Altaf H Shah*, Ahmed A Fateel**, Osamah Al-Nakhli***
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J Pak Dent Assoc.2011; 20 (2): 98-104
The aim of this study was to evaluate the opinion of dental students and dentists regarding the dental treatment of patients with Special Needs and if the teaching provided during the undergraduate course concerning such patients is adequate.
A Questionnaire including 10 main items was developed and distributed at the College of Dentistry; Male (Darriyah Campus) and Female (Malaz Campus) in Riyadh, King Saud University. The results were analysed using Statistical Package for Social Sciences) SPSS version 16. The questionnaire included socio-demographic variables, opinion regarding current knowledge and experience in treating Special Care Dentistry patients. Finally, opinion regarding starting a new course for Special Care Dentistry at King Saud University was sought.
Out of the 300 questionnaires 250 were returned, giving a response rate of 83.3%. Regarding opinion about the theoretical information provided during the course with respect to dentistry for Special Needs patients, most of the respondents either reported it as ‘Inadequate’ or ‘Very Inadequate’. However, there was no statistically significant difference of opinion among the gender. Although exposure to such patients in clinical practice was reported to be ‘very few’ or ‘occasionally’ by most of the respondents (71.2 %) more than three quarter of the respondents (76.4% ) agreed that the treatment of such patients is ‘Challenging’ as compared to the general population. However the majority of the respondents (86.4 %) agreed that a specific Course on Special Care Dentistry would be beneficial for the treatment of such patients; out of which 53 % expressed their opinion to ‘Provide more practice’ for Special Care Dentistry course.
Among the Special Care group fewer patients are seen at College of Dentistry, Riyadh, King Saud University; when compared to the general population. Most respondents feel that the present amount of theoretical knowledge and practical experience in treating Special Needs patients is insufficient. Majority of the respondents thought that a course designed to deal with the treatment needs of special care dentistry patients would be beneficial in the treatment of such a group.
Special Needs Patients, Dental Treatment, Dentists’ Opinion.
Special Care Dentistry known in some countries as Special Needs Dentistry1-2 is the branch of dentistry concerned with providing care for people who have physical, sensory, intellectual, mental, medical, emotional or social impairment or disability or, more often, a combination of a number of these factors.3
Patients who require Special Care Dentistry include a diverse group.4 Their additional needs may be directly due to their impairment or disability, or due to some aspect of their medical history that affects their oral health. It could also be related to their social, environmental or cultural context that disables them with reference to their oral health.5
The various definitions of Special Care Dentistry convey that Special Need populations have a variety of disabilities.6-7 Evidence exists that they are at high risk of developing oral diseases and conditions and they experience significant barriers to accessing dental care.6, 8-9
A need to improve undergraduate dental education concerning the treatment of special needs patients has been found in several countries, all over the world. 10-17 In the United States of America the Surgeon General’s report, 2000, found that there was clearly a lack of formal training for dentists both in undergraduate and postgraduate dental curricula in the field of dentistry for people with special needs.18-19 One research has also found that general dentists who were not exposed to patients with special needs during their training were less likely to treat these patients in their practice compared to those who had such experience.20-21
Dental education in the treatment of Special Care patients has an effect on practitioners’ professional behaviour and dental students’ willingness to consider providing care for such patients.22-24 Furthermore; unmet oral health needs among Special Care group appear to be greater than the general population.25, 26 A study of the development of positive attitudes in dental students towards persons with disabilities concluded that increase in exposure with special needs patients alone will not ensure that the students will develop positive attitudes, but that “contact must be planned carefully so as to occur in a social climate”. 27
Some dental schools have designed virtual programmes to address the need for student dentists to increase their skills and decrease their perception of difficulty in caring for children with disabilities.28 Several studies that evaluated the knowledge and behaviour of dentists found them vulnerable in treating patients with Special needs.29-32 No survey has been carried out before at the College of Dentistry, King Saud University, on the educational needs of students or graduates with respect to the dental treatment of patients with Special Health Needs. The aim of this study was to evaluate the opinion of students and dentists at College of Dentistry, King Saud University regarding the dental treatment of patients with special needs. The study also evaluated the difficulty faced by students and graduates including interns in terms of application of their knowledge, skill and confidence
A Survey based study, using a self administered questionnaire, was conducted in the College of Dentistry, King Saud University. The study included Fifth year students, Interns, Postgraduate students and Faculty
members in both (Male Darriyah University Campus) as well as Female (Malaz University Campus) campuses. A questionnaire made up of ten main items, was developed including demographic information and opinion-based closed ended questions. The questionnaire was pre-tested on 15 dentists, who were not included in the main study, to check for the clarity and ease of answering. The compatibility of the questions with statistical analysis was also evaluated by a statistician.
Questionnaires were distributed along with a participant information letter explaining the aim and purpose of the study in dual languages (Arabic-English). The descriptive variables included questions regarding age, gender, level of study and years since graduation. Other questions like; if the respondents had ever treated a patient with special needs, difficulty in treating such patients, most common way of management of such patients, rating of management of such patients and reasons for not treating such patients were designed to obtain the most desirable choice. The last question sought the opinion of the respondents about a need for a course in special care dentistry, including an open suggestion for such a course. The data were entered into a computer using Statistical Package for Social Science version 16 (SPSS.v.16). Chi square test of association was applied with the significance level set at P < 0.05.
Out of 300 distributed questionnaires, 251 were returned one questionnaire was invalid giving a total response rate of 83.3%. Majority among the respondents 134 (53.6 % ) were males and 116 (46.4% ) were females (Fig 1). The majority of the respondents (63.2%) were in the age group of 20-25 years (Fig 2).
More than half (68.4 %) of the respondents were undergraduates of final year and fresh graduated interns. The majority of the respondents (76.8 %) reported that the
practical experience (87.6 %) provided during the full course of Bachelor of Dentistry (BDS) was either ‘Inadequate‘ or ‘Very Inadequate‘ with respect to the treatment and management of patients with special health needs. Table III and IV show no significant difference of opinion in terms of gender. A higher percentage (50.4 %) respondents have reported Practical Experience as ‘Very Inadequate’ as compared to the Theoretical Information (30.0%) provided during the course.
There was no significant difference of opinion in terms of age, level of study or years since graduation; with majority reporting theoretical information as ‘Inadequate’ and practical experience as‘ Very Inadequate’. However, there was a statistically significant difference in opinion in Terms of practical experience with respect to age and years since graduation (table IV).
When the respondents were asked if they had ever come across patients with special health needs, 49.6 % reported ‘Very few’ and 16.4% of the respondents reported that they had never come across a patient with Special Health need. Statistically significant difference (P < 0.05) was found between the level of study and if the respondents ever came across patients with special health needs. The post graduates and the faculty reported 'occasionally' and 'frequently' more as compared to final year students and Interns.
When asked if the respondents had ever treated a patient with special health need, 64 % of the respondents reported ‘Yes’ and 34 % reported ‘No’. No Statistically significant difference was found between gender but there was a statistically significant difference (P < 0.05) with respect to the level of Study/Position as 92.2 % of the faculty reported 'Yes' while 63.4% among the final year students reported 'No'. Those respondents who reported 'Yes' for the above question; rated 'Manage with supervision from a senior staff'' as the most common way of managing of these patients. Regarding the rating of the management of such patients, the majority (59.6 %) rated it either as 'Very Challenging' or 'Challenging'. (Table V). In terms of the reasons for not treating these patients, 'never came across such a patient' and 'Insufficient knowledge about the patient's condition' were cited as the most common reasons. When asked if treated special care Patients is challenging as compared to the general population, 76.4% reported 'Yes' and 11.6% reported 'No' while 12% reported it as 'Can't Say’'Cooperation problem with the patient' was cited as the most common cause for encountering difficulty in treatment of patients with special health needs. More than 80 % of the respondents stated that a specific course in Special Care Dentistry is required (Figure 4).
Most of the respondents desired the course to be designed to gaining more practical experience in treating Special Care Dentistry patients. (Figure 5)
This study highlights the opinion of the dental students and dentists at college of dentistry, King Saud University, being inadequate in terms of theoretical knowledge and practical experience in treating Special Care Dentistry patients. This study emphasizes the need for more experience and exposure of dental students with patients who have special needs. By gaining more experience and having more exposure to patients with special needs the students will get more confidence in treating these patients in terms of their oral health. Wolff et al20 (2004) also Showed that students indicated that they had received inadequate experience and training in dental school for the care of patients with disabilities. They concluded that many U.S. dental students are prepared inadequately to provide services for people with mental retardation. Spending time with these patients provides a more positive understanding of the capabilities of these people. They implicated increased dental school training and continuing education programs are needed to meet this need. Similarly, Loan et al23 concluded that dentists who felt well prepared were more likely to treat special needs patients and provide services for patients with more diverse special needs than dentists who did not feel well prepared. In our study the dental students expressed their opinion to be better prepared in order to serve the special needs group. Reports in dental literature show dentists’ reluctance in caring for the disabled patients ranged from low reimbursement to inadequate dental school training.33
The participants in our study felt that although the facilities in treating special needs patients were adequate yet they did not have enough exposure to such patients. Dental education system has been suggested as the vital link in providing a workforce capable of improving oral health for people with Special needs.34 This study might encourage planners to organize course in Special Care Dentistry to prepare students to handle such situations.
Thierer & Meyerwitz 35 noted that it is not clear if educational initiatives in the care of patients with special needs will translate into a larger oral health workforce willing to treat these patients. Moreover there has been a recurrent assertion that the dental school curriculum is already too crowded and adding additional training will need to come at the expense of other areas.36 This study could not look into whether a new course in Special Care Dentistry can be accommodated by students who have a seemingly tight schedule already.
Most of the respondent in this study reported that they had come across or treated fewer patients with special healths needs as compared to the general population. Since the majority of the sample group were young at experience, they are expected to come across more Special Care patients over the years. A significantly higher number of people reported such patients as their years since graduation increased. The special care group is one of the neediest and yet most underserved group of dental patients. With people living longer and with better medical facilities that improve chances of living, this group of underserved special needs patients is expected to increase.37 Hence, it becomes more important to initiate an organised oral health service for this group.
In this study those who reported treating Special needs patients cited ‘Manage with the supervision of a senior staff’ as the most common way of managing these patients. This might be evident as the majority are working under the supervision in a teaching institution. Although, researchers have suggested more educational initiative in dealing with patients who have special needs, yet there is no consensus whether this initiative should concentrate on Pre-doctoral or Post- doctoral level of dental education.35
Most of the respondents who had treated patients with Special Needs mentioned the treatment of such patients as challenging. In the literature, some practitioners who work with disabled patients propose that most disabled patients can be treated by general dentists. However, with only little experience in handling these patients, fear about how to manage their Special Needs is a pivotal factor in whether care is provided at all.37 The difference in the type of treatment needed between the disabled population and the general population is not as great as the concomitant medical and behavioural problems that complicate the dental treatment.38
Fenton39 noted that the graduates who haven’t encountered a sufficient number and variety of patients with special needs during their formal training will not feel confident inviting these patients into their practice. Thus experience and exposure to such patients can build up confidence in the students to treat such patients.
In the present study, those respondents who reported not treating patients with Special Needs reported the most common reasons either as ‘Never come across such a patient’ or ‘Insufficient information about the management of patient’s condition’. This is in agreement with the findings of Fenton and other researchers.39
Kleinert et al28 have proposed improving student dentist competencies and perception of difficulty in delivering care to children with developmental disabilities by using a virtual patient module with a CD-ROM. Lawton40 observes that while the prospect of accommodating the needs of patients with disabilities may seem daunting initially, such treatment actually can be incorporated into a general dental practice easily. He further states that dentists treating patients with disabilities are likely to find that he or she needs special equipment less than compassion and tolerance. Majority of the respondents noted the treatment challenging due to communication problems with the patients. As pointed out earlier, it is important to build confidence in treating such patients, which would be attained by more exposure to such patients thereby improving the communication with such patients. Most of the respondents agreed that there should be a specific course in the dental curriculum for the management of people with Special Health Care Needs. There has been a need to introduce specific programmes in the dental curriculum to prepare graduating students for better care of Special Care Dentistry patients all over the world.10-17 Majority of the respondents who wanted a specific course for Special Care Dentistry would like it to be in the form of having more practical experience. Waldman et al16 note that the most important aspect of student clinical practice involving patients with disabilities is learning to apply previously learned procedures to the particular situation. The patient is therefore fundamental to developing the student’s proficiency and experience in treatment of the disabled individuals.
• Students and graduates feel that the present level of dental education is not sufficient in preparing them to deal with special care patients in their practice as they don’t have a sufficient amount of exposure to these particular conditions.
• Although the majority of respondents come across few or occasional patients who have special health needs, yet most of them rated their management as challenging.
Most respondents among the sample felt that a specific course in Special Care Dentistry would be beneficial for them in treating such patients. The majority also feel that practical experience provided in dealing with such patients would be most beneficial.
Special Care Dentistry can be included as a separate course; most probably, in the final year towards the completion when the students have acquired other skills in the field of dentistry. Special Care Dentistry should be part of continuing dental education seminars especially during the internship. The interns can also be included in active transfer of knowledge during treatment of such patients. Moreover Special Care Dentistry should be either a separate department or a division within a department to deal with the needs of this group.
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