Barriers to Oral health care in patients with special needs-A Cross-sectional study

 

Dr. Nandhini Subramaniam¹*, Dr. Arvind Muthukrishnan²

 

ABSTRACT:

Aim- This cross-sectional study aimed to identify the barriers to receive oral care among patients with special health care needs. Materials and methods: This cross-sectional study was conducted among 50 patients seeking dental treatment in the special care unit of Oral medicine department. A self-administered questionnaire was employed for data collection. Results: It was found that nearly 56% of respondents listed fear towards dental treatment as an important barrier which in turn prevents them from gaining access to dental care. Around 52% of patients considered their underlying medical problem as a reason for not seeking dental care as their comorbid condition would increase their fear of dental treatment, 43% of patients considered physical barriers or in need of caretakers as a barrier to Dental care. 10% of the population stated that they do not have barriers to access Dental care. Conclusion: The major barriers to oral health care utilization among patients with special needs were fear-related and hence these patients need attention towards fear alleviation and make dental care painless and simple.

 

 

 

INTRODUCTION:

Background:

Oral diseases are a major health problem worldwide. It is recognized as a major issue on patients who are specially challenged. The existence of difference in the prevalence, incidence, mortality of oral diseases and other adverse health conditions as well as the use of health care services, among specific populations referred to as oral health disparity. Access to oral care refers to the ability of the patients to obtain or to make use of oral health care. Good oral health is essential to general health and well being. Persons with special health care needs can be at increased risk for dental diseases which can be attributed to, as well as exacerbate, existing medical conditions¹. Despite increased dental problems, there is limited utilization of dental services. This could be due to various barriers that limit oral health utilization².

 

Currently, there is a wide difference between the need for oral health care and the demand for it. External factors like transportation, cultural peculiarities, language barriers and internal factors like age, gender, education, ethnicity, perception of need, anxiety needs and feeling of vulnerability and other factors like cost of treatment, the health status of individuals, disability, lack of access to the patient also act as the hurdle to access the dental care^1,3–5. So understanding the various barriers that prevent the patients from seeking oral health care and providing appropriate dental care for patients would bridge the gap between the need for oral care and demand for it.

 

Important access to special care dentistry is communication. Special care dentistry includes patients with anxiety and communication problems, sensory disability- hearing impairment, visual impairment, deaf blindness., neurological deficits (aphasia, dysarthria), autistic spectrum conditions. In managing this special group of patients in a dental unit, communication plays a crucial role. The communication triangle has been proposed adding percentages to the elements of communication⁶. The elements of communication include- Facial expression and body language- accounts for about 60 %

Vocal tone – accounts for about 33 %

Words – accounts for about 7 %

 

Thus, communication is a shared system of signals that requires systematic encoding appropriate decoding of signals. Good communication facilitates building a proper rapport and trust with this special group of patients when providing dental care.

 

 In patients with hearing impairment, they may rely on language service providers (LSP) hearing aids so ensure that the device is switched on for communication, they may also rely on lip leading so the dentist should remove the face mask or face shield while communicating, minimize background noise, allow extra time for the patient to respond, speak clearly but not too slowly, do not exaggerate the lip movements, use gestures for visual feedback, write down, be patient and communicate properly, make appointments and communicate with the patient through texting.

 

In patients who are visually impaired tactile feedback such as a handshake, keep informed about each step in the dental procedure especially when there is about to be sudden noise or sensation.

 

In patients with aphasia (inability to process language has a negative physical emotional social impact on the individual) ensure eye contact before the starting to speak, use a short sentence, give one information at a time, ask closed-ended questions, repeat statement whenever necessary. The commonly recognized type of aphasia includes global aphasia- severe form, no longer can read and write, Broca’s aphasia – due to damage to the frontal lobe of the brain, there is understanding o conversation but speech output is severely reduced. Wernicke’s aphasia – these patients will be able to speak a long sentence that has no meaning.

 

In autistic spectrum conditions - there is qualitative impairment of social interaction, qualitative impairment of communication, qualitative differences in the imagination. While treating these groups of patient’s language needs to be precise, exact, sign language or visual symbols may also aid. Always prefer one-sided talk rather than back and forth conversation.

 

The current study was designed to identify the barriers to access dental care in patients with special health care needs. Patients who are medically compromised, physically challenged, mentally challenged, learning disabilities, visually challenged, anxious and petrified, geriatric population, pregnant women, patients undergoing treatment for cancer are categorized as patients requiring special needs and are treated in the special care unit. Also providing oral care to these patients with special needs is a challenge to the dental professional because of these patients more likely to have complex medical conditions and dental treatment plans.

 

Thus, this cross-sectional study aimed to identify the barriers to receive oral care among patients with special health care needs.

 

MATERIALS AND METHODS:

This cross-sectional study was conducted among 50 patients seeking dental treatment in the special care unit of Oral medicine and radiology department, Saveetha Dental College, Chennai, Tamilnadu, from September 2018 to December 2019. A structured self-administered questionnaire with 15 questions was employed for data collection (Figure 1).

 

Figure 1: 15-closed ended questionnaire.

All the questionnaire items were explained to the patients before the treatment.

 

The questionnaire incorporated information on age, gender and underlying medical condition from the respondents. Previously reported barriers like fear, feeling of insecurity, expensive nature of the treatment, lack of access to dental care, lack of time, transportation difficulty, lack of interest, discomfort in opening the mouth for a long time, long waiting time, worried about the number of appointments, medical clearance, lack of knowledge about oral care were outlined in the given questionnaire. It was randomly distributed to patients with special health care needs requiring Dental treatment in the special care unit and was asked to score the 15 listed barriers from 0 to 3 (0- no difficulty, 1- low, 2- moderate, 3- high level of concern about the listed barriers) and they were also encouraged to include other factors which deter them from oral health care services.

 

The data were tabulated and analyzed using SPSS for Windows version 16. A Chi-square test was done to compare the proportion between age groups and the category of patients.

 

RESULTS:

The distribution of participants according to age and patient category are as follows. There were 3 participants (6%) were below age 30, 33(66%) were between 30 and 60 and 14(28%) were above 60 years. The mean age of the participants was 42.6. There were 44% of males and 56% females. Out of 50 participants, 52% were medically compromised, 10% were with learning and physical disability and pregnant, 4% were mentally challenged, geriatric, anxious and petrified, 16% were oral cancer patients requiring prophylaxis before radiotherapy. The various barriers to access Dental care and the level of concern of the respondents to the listed barriers are shown (figure 2).

 

Figure 2: Graph shows participants level of their concerns over Dental care

 

 

It was found that nearly 56% of respondents listed fear towards dental treatment as an important barrier which in turn prevents them from gaining access to dental care. Around 52% of patients consider their underlying medical problem as a reason for not seeking dental care as their comorbid condition would increase their fear of dental treatment, 43% of patients considered physical barriers or in need of caretakers as a barrier to Dental care. 10% of the population stated that they do not have barriers to access Dental care.

 

Chi-square test was performed and there was no significant difference between the patient category and their levels of concern (p=0.144).

 

DISCUSSION:

Oral medicine is a specialized discipline within dentistry that focuses on the provision of dental care for medically complex patients, diagnosis and management of medical disorders involving jaw, mouth, and salivary glands.

People who require special health care needs are at high risk of dental disease than the general population. This is due to side effects of long-term medication use, xerostomia leading to dental caries, decreased manual dexterity especially geriatric population causing difficulty in oral hygiene, also other factors like dietary habits, caregivers' attention influences the oral hygiene.

 

A study that assessed dental fear and anxiety to access oral health care among patients with special health care needs reported that 27.9% of samples reported fear/ anxiety about dental treatment⁶.

 

A study assessing dental fear in a special needs clinic population of patients with disabilities reported 43.2% of respondents to indicate dental fear⁷.

 

Demographically like other studies reported in the literature, the percentage of female patients (56%) was more compared to males (46%) in our study similar to previous studies^8,9. Patients below 30 years age constituted the least proportion (6%) which is contrary to the previously reported studies^10–12. This might be because the majority of the population develop comorbid conditions only during late adulthood period^3,11.

 

We found that fear and pain phobia for dental treatment is the most commonly cited barriers among special needs population of which the fear of being injured constituted the barrier with highest ranking followed by the numerous dental visits and procedures they require which is similar to previous studies^6,10,12,13. Their underlying medical problem could be a possible reason for postponing or not seeking dental care^14-16. Avoidance of oral care due to fear is a well-recognized phenomenon^17,18. Dental fear and anxiety levels amongst patients have not decreased despite the advances in dental technology and preventive procedures^19–21. Association has been found between dental fear and less frequent dental procedures and poor oral health²².

 

Dental fear (dental phobia) is the fear of dentistry and or receiving oral care. This dental fear can occur either by direct experience or by indirect experiences like vicarious learning, stimulus generalized, mass media, helplessness and perceived lack of control. This dental fear can be diagnosed using fear measurement scale-like Corah’s dental anxiety scale or modified dental anxiety scale.

 

In a study to assess barriers to dental care for older minority adults which included 20 participants with 65 years of age or above, residents of low-income housing funds that the most frequently stated barriers were cost, fear/mistrust, and transportation¹².

 

A study on 44 HIV infected individuals, identified following as barriers to oral care- Dental anxiety and fear, cumbersome administrative procedures, long waits at the dental unit, problem-focused care-seeking behavior, transportation issues, dentists reluctance to treat these people, psychological issues. This study also identified a few facilitating factors like being treated with respect and acceptance, appropriate dental care from dentists for these groups of patients²³.

 

In our study, nearly 43% of patients considered a physical barrier, dependence of caretakers as a barrier to dental care²⁴. This might be because the majority of older patients need bystanders for their access to dental treatment. Like previous studies around 52% of patients considered the underlying medical problem as a reason for not seeking dental care as their comorbid condition would increase their fear of dental treatment^6,20. A maximum of 60-65% of patients scored transportation time and lack of interest with the least score, around 52% considered fear of injections and anesthetic complications as their moderate level of concern towards dental management. Only 30% of the population considered cost as their barrier to access dental care.

 

Previous studies^1,5 found the cost as the common barrier among the study population. On the contrary in our study, only 30% of the population had a high level of concern towards the cost. The reason for this could the feasibility of the cost of dental procedure in the special care unit for the low and middle-income populations.

 

CONCLUSION:

The major barriers to oral health care utilization among our patients were fear of being injured and hence these patients need special attention towards dental management. It is important to raise the level of dental awareness among our people, to educate them on preventive oral care habits. Knowledge amongst public and medical fraternity about the availability of the special care dentists could lead to a better understanding of the problem and implementation of appropriate care for these patients.

 

CONFLICT OF INTEREST:

Nil

 

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Received on 27.04.2020            Modified on 30.05.2020

Accepted on 23.07.2020         © RJPT All right reserved