SPECIAL CARE SPECIAL PATIENTS
Maureen Romer, D.D.S., M.P.A., Demystifies Special Needs Dentistry
How would you define patients with special needs?
Patients with special needs could have a physical or intellectual disability; they could also have psychiatric disorders. Additionally, patients that are medically complex would also be applicable, e.g. hemophilia, end-stage renal disease, Alzheimer’s disease, cardiac patients, transplant patients as well as geriatric patients. Basically, anyone that’s going to take more time, energy, effort and knowledge to provide effective treatment could be considered a person with special needs.
Can you see why dentists might be hesitant in promoting that they can handle patients with special needs?
Well, this should at least be encouraging: for patients with intellectual disabilities, about 85 percent of them can be seen in a regular dental office. These types of patients with special needs don’t exhibit symptoms that are very profound or severe, in fact, I would be confident that most dentists with a little patience, understanding and behavioral management skills should be able to treat them in a private office. The remaining 15 percent of patients that really are profoundly affected by a disability typically come to a clinic like ours (the Special Care Clinic at ASDOH), where people that are specifically trained to deal with complex patients are available.
Where would dentists look to receive special care training?
Our students do receive a lot of this training because we have a special care clinic onsite. In reviewing dental statistics regarding special care training, they indicate a lot of doctors (already in practice) haven’t had this type of training; however, it’s now a CODA Standard to have this type of training, so dental students are now being exposed to it.
I’ve found that most doctors receive training if they do a general practice residency, and a large percentage of pediatric dentists have this type of training (since it’s behavior management). Dentists can also often receive special care training during other kinds of post-doctoral training. There are fellowships in special care dentistry, but they aren’t well-funded or available in great numbers, so it’s difficult to get formal training. Dr. Romer jokes, “Most doctors that offer treatment to patients with special needs ‘just started doing it’. They assert that, ‘One patient told another patient, and before they knew it, word had gotten around.’”
Lastly, many dentists that didn’t receive training while in school end up picking it up at CE courses, others ironically end up starting to learn special needs dentistry due to immediate necessity – they have a new patient that requires it. It’s not uncommon for dentists who are new to special needs patients to anxiously think, “I have to look this up, or call someone to help me figure this out!”
Does phoenix see more patients with special needs than most cities in the United States?
Since we have such a large geriatric population in the Valley, we tend to see older patients with chronic problems that have really progressed to end-stage diseases. With advances in technology that are able to help prolong life, we’re seeing patients that are much older and sicker than we might have twenty years ago. Here at this clinic, we do see a lot of patients that are medically complex: cardiac stents, patients on warfarin and patients on dialysis. Yes, the Valley does have a higher rate of people with special needs; primarily because of its growing older population.
What if you have a patient that is unable to be treated using behavioral management skills?
Well, we offer advanced behavioral management here at the school to help equip doctors to treat patients that are unable to cooperate. In rare occasions, when I have exhausted all of the techniques and approaches to encourage a patient to cooperate, we turn to pharmacology; we also use nitrous oxide and IV sedation with a dental anesthesiologist.
What are some of the less invasive tactics are often used to desensitize patients?
It’s interesting you ask that, I am currently doing a project on this now. One technique is called, systematic desensitization where the dentist helps to place the patient in a comfortable, non-threatening environment. The dentist (in a gentle voice) asks the patients to perform simple tasks and providing encouragement once the task is completed. As this cycle repeats it enables the dentist to establish trust with the patient and it also allows them to request progressively harder or perhaps intimidating tasks. For example, the dentist or staff member may ask the patient to leave her/his seat in the lobby and go into an operatory room. Once the patient completes this task they are praised and then asked, “Let’s see if we can look into your mouth with just a mirror. It won’t hurt a bit.”
It’s a profoundly effective technique. At the same time, the challenge that all health care providers, including dentists, have with this approach is that it’s time-consuming. As providers we’re all “under the gun”, and many of us have a “Let’s get them in, let’s get this done” mentality. Unfortunately that doesn’t work well for a lot of these patients (geriatric patients, Alzheimer’s patients, patients with intellectual disabilities or even patients that are medically complex). As a footnote on medically complex patients, they see providers on a regular basis and feel they need to explain their issues and how it is affecting their life, even if they are not dental related. Patients feel the need to expound upon 19 medications and 12 diagnoses, but if dentists rush them through this process, it will often cause the patient to feel distrust and frustration, which will make them more difficult to treat. In general, dentists need to take more time…but I do understand them feeling, “How do I get reimbursed for all of that?”
Why did you choose to work in special care?
Actually I didn’t choose it; it chose me. I did a general practice residency and I was working in the hospital that had a special care fellowship, but I wanted to become an endodontist. I ended up getting wait listed for endo school and I thought, “I’ll just take the fellowship position and hang out here for a year,
” - that was 17 years ago. I found that I really liked special care, so I never left it.
Is it more rewarding to work with people with special needs?
There are very few procedures in dentistry where a patient will be able to appreciate the level of expertise their treatment required. A dentist may have cut a really good crown and thinks to herself, “Wow, this is great work
”, but the patient most likely won’t care. I’ve often found that if the patient can’t see it, they don’t often appreciate the level of care that was provided in their treatment. Most patients just like pretty, white teeth. But with special care, it is so difficult for most patients to receive treatment, that they are very appreciative of the work that’s been done. Patients give us hugs; they make us odds and ends like pillows or necklaces. We’ve (ASDOH) tried to create a dental home for these patients, and I am happy to report that many of them are actually happy to see us.
As it relates to teaching special care training to students, what is most rewarding?
When I see students come in at the beginning of their rotation I can see a look of trepidation on their faces. I tell them (in a joking tone), “I understand this may be new to you, but you can’t catch autism, cerebral palsy, etc. by being around patients with special needs
.” By the time these students are D4s, they are so comfortable and confident in being able to work with patients with special needs – that’s what is most rewarding to me. I know that these students will be able to go out into the field and do this.
What is the biggest misconception dentists already in the field have with special care?
I’d have to say that it is an overwhelming majority of dentists feeling that only a specialist will be able to treat people with special needs, which is often untrue. There’s often a misconception that every person with special needs is the extremely difficult individual that’s going to disrupt the office and create an uproar. With a little bit of patience and effort, I personally believe that most dentists have the skill set to treat these patients. If dentists have the willingness and heart, I believe they can do it.
What would you say to dentists concerned that treating patients with special needs will slow down their practice?
There are some studies that show that if every practicing dentist saw one or two people with a disability that it would make a profound difference in access to care issues. It’s interesting to point out that in some cases, dentists might be seeing these patients and might not be aware of it. For dentists that have some initial fears of treating people with special needs, I would just encourage them to explore it a little bit before coming to a conclusion. I would suggest going to a continuing education course, getting the information and then deciding how to move forward.
If a practitioner hasn’t worked with patients with special needs and has been in practice for over twenty years, she/he is not going to wake up and think, “I should work with people with special needs today
.” In many cases, dentists are careful about doing something they haven’t done before, which is probably a good thing for the public! The bottom line is that it’s not for everyone, and if you’re really not comfortable you’re patients will pick up on it and it won’t be an enjoyable relationship. For those dentists that have explored special care training and found it wasn’t for them, I would suggest they refer these patients to another practitioner in their community.
What organizations or resources are available for those interested in special care dentistry?
The largest organization (which has about 1,000 members nationwide) is the Special Care Dentistry Association (Dr. Romer is the current President-elect). Their web site: www.scdaonline.org
, has a host of links and resources that can be explored. The other active group is the American Academy of Developmental Medicine and Dentistry (www.aadmd.org
). These are the two primary organizations that would have the best resources for dentists. Additionally, dentists practicing in the Phoenix metro area can even contact us here at the dental school; we know most of the practitioners that will see people with special needs and will be happy to help them. Additionally, The Special Care Patient
(ISBN 13: 978-1-4377-0467-9, author: Burt Wasserman, DDS, DABSCD) is also a good resource for dentists.
How can dentists identify other practitioners they can refer people with special needs?
I’d say the easiest option is accessing the Special Care Dentistry Association’s web site at www.scdaonline.org
. In addition to links and resources, the web site has a list of members that can treat patients. Note: AzDA members can use the Find-a-Dentist link on azda.org, to find a dentist that treats special needs in their community.
How will the announcement that the gompers special needs for special smiles dental center is closing (in regards to dentistry), affect patients in arizona with special needs?
There’s going to be large group of patients (hundreds and hundreds) that will need to find dentists, and many of these patients have private insurance. The dental school cannot possibly absorb all of patients that will be looking for care, but will absolutely need the Arizona Dental Association’s help in recruiting members who are willing to see patients.
Would you share a memorable story about a patient with special needs that you treated?
Yes. I’ve been treating a young man (mid-thirties) that travels all the way from Flagstaff to see us. Unfortunately, when he began treatment, he didn’t have any teeth that we could save, and we had to remove all of them. Going through this procedure was emotional for everyone involved, and we could all see that this severely affected his confidence. Well, over the course of his treatments we got to know the patient; he’s a sweet kid. On the day he was to receive his new teeth, everyone here at the clinic was in celebration mode, in fact, his mom made us brownies. Though what I remember most about this day was when the patient put his new teeth in for the first time, looked at himself in the mirror and said, “Boy, do I look handsome
Now that he has his teeth, he’s working, he’s confident and he’s living his life (as well as contributing to society); for us, that’s what it’s all about. This was life-changing for the patient as well as the students that provided treatment.
You serve as a faculty member on an outreach mission in alaska, what can you tell readers of it?
For about ten days we travel above the Arctic Circle to Fort Yukon, which serves as our home base. The trip is a collaborative effort that includes 8-10 students and residents from both ASDOH and New York University (NYU). The trip focuses on prevention, so we see a lot of children. Our goal is to see every child in each village that we visit. We do all the restorative and preventive and then we do preventive therapies with the village health aid or even with the teachers and principal – we teach them how put on fluoride varnish so they can do it when we’re not there. Emergency dentistry is also offered for adults.
It’s extremely rewarding, but I have to say that it’s difficult to believe we’re still in the United States sometimes; often times the school is the only building in the village that has running water and electricity. It’s a life-changing experience for everyone, although I am not sure why I was offered the chance to go. I am from New York City and have virtually no nature survival skills…I never even slept in a sleeping bag before I went on these trips! It’s exhausting work, but I love it.
What final thoughts do you have?
It’s just not that complicated (special care dentistry); you can do this. Believe me; if you’re a practicing dentist, you have a much broader skill set and experience than the third year dental students that are doing this at ASDOH. If you want to do this, you definitely can.
Observations from the Managing Editor
Beyond the nuts and bolts information I learned from our Q&A session, I walked away feeling Dr. Romer is a practitioner who thoroughly loves what she does, as well as the students that she teaches and patients she treats. She’s passionate about special needs dentistry and genuinely feels that AzDA members could provide treatment for a large percentage of patients with special needs if they wanted.
Dr. Romer’s background
Maureen Romer, D.D.S., M.P.A., has served as the inaugural director of special care dentistry at ATSU’s Arizona School of Dentistry & Oral Health since December 2006. She is also an associate professor and serves as co-director of the Advanced Education in General Dentistry residency program and the ASDOH special care clinics. She was named a 2010 Health Care Hero in the dental category by The Phoenix Business Journal