ORIGINAL RESEARCH


https://doi.org/10.5005/jp-journals-10077-3290
Journal of South Asian Association of Pediatric Dentistry
Volume 7 | Issue 2 | Year 2024

Assessment of the Clinical Barriers Faced by the Practicing Dentist to Diagnose and Treat Children with Special Health Care Needs in Gujarat, India


Yash M Lalwani1https://orcid.org/0000-0001-9637-029X, Bhavna H Dave2https://orcid.org/0000-0001-9301-2948, Seema Bargale3https://orcid.org/0000-0003-4110-7990, Anshula Deshpande4https://orcid.org/0000-0003-3467-2123, Poonacha KS5https://orcid.org/0000-0002-5367-3685, Pratik B Kariya6https://orcid.org/0000-0001-8240-3142

1–6Department of Pediatric and Preventive Dentistry, K M Shah Dental College & Hospital, Sumandeep Vidyapeeth Deemed to be University, Vadodara, Gujarat, India

Corresponding Author: Yash M Lalwani, Department of Pediatric and Preventive Dentistry, K M Shah Dental College & Hospital, Sumandeep Vidyapeeth Deemed to be University, Vadodara, Gujarat, India, Phone: +91 9558815458, e-mail: dryash19087@gmail.com

Received: 05 December 2023; Accepted: 04 January 2024; Published on: 06 September 2024

ABSTRACT

Aim and background: Children with special health care needs (CSHCN) are one of the world’s underserved dental patient populations. Poor oral hygiene may be caused by an underlying disability, decreased manual dexterity, or an adverse effect of certain drugs. Conducting frequent professional dental visits to promote preventative oral health habits and ensure early detection and therapy of dental abnormalities is one strategy to preserve oral health status. Numerous studies have regularly demonstrated that the CSHCN continues to face significant challenges and barriers in accessing medical and dental treatment. To identify the clinical barriers that general dentists confront when diagnosing and treating CSHCN in Gujarat, India.

Materials and methods: A cross-sectional survey was conducted among the Indian Dental Association (IDA) members of Gujarat. A validated electronic questionnaire was sent to the participants through e-mail. The data collected was entered into a computer and analyzed using the Statistical Package for the Social Sciences (SPSS) software.

Results: About 93.8% of the participants were aware of the term CSHCN, but only 28.1% of them participated/attended a course on diagnosis and treatment of CSHCN (p < 0.001). Despite being not specially trained 54.4% of practitioners have treated a CSHCN with an untrained nonclinical staff (56.9%). Lack/difficulty in communication (72.5%) with the child was the biggest barrier.

Conclusion: This study presented a reliable picture of the barriers to access for CSHCN within the dental practice system. Recommendations for changes to the undergraduate dentistry curriculum should be made in order to better prepare future graduates to work with this group of special children.

Keywords: Barriers, Children with Special Health Care Needs, Dental care for disabled, Dental health services

How to cite this article: Lalwani YM, Dave BH, Bargale S, et al. Assessment of the Clinical Barriers Faced by the Practicing Dentist to Diagnose and Treat Children with Special Health Care Needs in Gujarat, India. J South Asian Assoc Pediatr Dent 2024;7(2):67–71.

Source of support: Nil

Conflict of interest: None

INTRODUCTION

India is one of the world’s greatest democratic societies and ranks second in terms of population (17.84% of the total global census). It is a fast-growing nation making significant progress in finance, information technology, health, and living standards. Despite this, it is disheartening to learn that very few individuals hold to regular dental care.1 According to World Health Organization (WHO) estimates, disability affects 14% of mankind in developed nations and 22% in underdeveloped countries. The health care system in India is being strained by an ever-increasing population. According to the 2011 Census, India’s overall population is 1.23 billion, with around 2.1% (nearly 21 million individuals) suffering from some form of impairment. Children aged 0–19 years make up almost one-third of India’s impaired population.2

The American Academy of Pediatric Dentistry (AAPD) defines “Special Health Care Needs” (SHCN) as any physical, mental, sensory, developmental, behavioral, cognitive, or emotional disability or limiting condition that necessitates health care intervention, medical management, and/or use of specialized services or programs. The condition may be developmental, congenital, or acquired as a result of trauma, disease, or environmental factors, and may impose limits in everyday self-care activities or significant limitations in a major life activity.3

Children with special health care needs (CSHCN) is one of the most neglected dental patient group in the world. Several studies have found that their (CSHCN) dental health is worse than that of the general population, which can be caused due to underlying disability, decreased manual dexterity, adverse effects of certain drugs, guardians’ failure to assess their child’s oral state, and/or the child’s incapacity to adequately express their pain or discomfort, or by a lack of access to dental treatment.1

As stated by Edwards and Merry in 2002, identifying such challenges might be the first step in fixing these inadequacies. Penchansky and Thomas operationalized the concept in terms of the “Five A’s—affordability, availability, accessibility, accommodation, and acceptability—as the common factors influencing the utilization of health care services.”4

Making frequent oral health care visits to promote preventative oral health practices and guarantee early detection and therapy of dental abnormalities is one strategy to preserve oral health status. Despite improvements in dentistry, CSHCN has poor overall oral health [untreated caries (84.6%) and periodontal disorders (74.7%)].5

Numerous studies have regularly demonstrated that the CSHCN continues to face challenges and barriers in accessing medical and dental treatment. Despite legislative efforts, there appears to be no appropriate answer for dental treatment among these chronically challenged individuals who cannot leave their homes. Thus, with the aim to expand the accessibility and minimize these hurdles, a thorough awareness of the clinical challenges to diagnose and treat oral health for CSHCN experienced by practicing dentists is essential.1

MATERIALS AND METHODS

In this research, an 18-point self-administered questionnaire was developed (part I: Four questions related to demographic details; part II: 14 questions related to determination of clinical barriers) by conducting a thorough review of the existing literature. The questionnaire was designed to assess knowledge, attitude, aptitude, practice, and overall barriers related to the dental diagnosis and treatment of CSHCN (Tables 1 and 2). To ensure its validity, the questionnaire underwent expert validation and was subsequently modified according to their recommendations. The content reliability of the questionnaire was assessed using Cronbach’s alpha value (α = 0.651).

Table 1: Demographic and descriptive data of the participants
Variables Number Percentage
Gender
ߓMale 38 23.8%
ߓFemale 122 76.3%
Qualification
ߓBDS 107 66.9%
ߓMDS 53 33.1%
Years of experience
ߓ<3 years 124 77.5%
3–5 years 19 11.9%
ߓ>5 years 17 10.6%
Region
ߓNorth Gujarat 13 8.1%
ߓEast Gujarat 12 7.5%
ߓWest Gujarat 34 21.3%
ߓSouth Gujarat 36 22.5%
ߓCentral Gujarat 65 40.6%
Table 2: Comparison among various variables of the questionnaire with level of significance
$Q1 p-value
Yes No Total
$Q2 Yes 45 0 45 <0.001*
No 105 10 115
Total 150 10 160
$Q1 p-value
Yes No Total <0.001#
$Q4 Yes 134 5 139
No 16 5 21
Total 150 10 160
$Q4 p-value
Yes No Total <0.001*
$Q5 Yes 93 12 105
No 46 9 55
Total 139 21 160
$Q4 p-value
Yes No Total <0.001*
$Q6 Yes 78 9 87
No 61 12 73
Total 139 21 160
Q1 Are you aware of the term CSHCN?
Q2 Have you participated/attended any course for diagnosis and treatment (dental) for CSHCN?
Q3 On an average in a week, how many CHSHCN visit your clinic/institute?
Q4 According to you, is there any need for special clinic design or specific equipment required to diagnose and treat CSHCN?
Q5 Is your clinic/institute accessible to CSHCN?
Q6 Have you ever treated a CSHCN in your clinic/institute?
Q7 Is your nonclinical staff trained for CSHCN?
Q8 How would you like the caretaker/parent to approach you with CSHCN?
Q9 Where would you prefer to treat the CSHCN?
Q10 What is your approach to treating a CSHCN?
Q11 How would you manage a CSHCN?
Q12 what would be your standard protocol while treating a CSHCN?
Q13 What is your approach for follow-up post treatment?
Q14 What are/would be the greatest barriers you have faced or might face while treating a CSHCN? (choose multiple options)

*, McNemar’s test; #, Pearson’s Chi-squared test ; $, Reference for the questionnaire

Following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for the cross-sectional study, it received approval from the Institutional Ethics Committee SVIEC/ON/DENT/SRP/NOV/22/40. A sample size of 160 was determined by a statistician. Google Forms: The Online Form Creator was used to create the electronic form of the questionnaire. Dental professionals registered with the Indian Dental Association (IDA) of the Gujarat state branch were included in the study and were reached by e-mail and WhatsApp. Informed consent was obtained from the participants before directing them to the electronic form. Participants who were unable to be contacted or did not give their consent were excluded from the study.

Data collection, entry, and statistical analysis were performed using a Microsoft Excel spreadsheet and Statistical Package for the Social Sciences (SPSS) version 20.0, respectively. To determine associations between different variables, Pearson’s Chi-squared and McNemar’s test were applied at a 95% confidence interval. Additionally, a logistic regression model was developed to assess the lack of perceived oral health care in children with special needs.

OBSERVATION AND RESULTS

During a 30-day period (1st to 31st December 2022), 160 participants responded to the survey. The data obtained was put into a Microsoft Excel 2007 spreadsheet. The responses were then analyzed using SPSS software.

The demographic data revealed that among the participants, 23.8% (38) were male and 76.3% (122) were female. Regarding experience, 77.5% had a duration of 3 years or less, and only 10.6% had >5 years. As for qualifications, 66.9% were Bachelor of Dental Surgery (BDS) and 33.1% were Master of Dental Surgery (MDS), geographically, 40.6% of dentists practicing Central Gujarat, 22.5% in South Gujarat, 21.3% in West Gujarat, 8.1% in North Gujarat, and 7.5% in East Gujarat (Table 1).

Regarding awareness of the term “CSHCN,” 94.39% of the BDS participants and 92.45% of the MDS participants were familiar with it. Notably, a significant association was observed between those who knew the term CSHCN and the fact that 70% of them had not attended or participated in a course on the diagnosis and treatment of CSHCN (p < 0.001) (Table 2).

A further significant association was found among the 89.5% (n = 134) who were aware of the term CSHCN and the 85.21% who had not attended any course, as they believed that special clinic design or specific equipment was needed to diagnose and treat CSHCN (n = 139) (p < 0.001). Among these 139 participants, 66.9% (n = 93) had their clinic/institute accessible to CSHCN (p < 0.001) (Fig. 1), and 59.05% had experience in treating a special child (Fig. 2). Interestingly, 45.45% of dentists who did not have their clinic/institute accessible to CSHCN had still treated special children (Fig. 2 and Table 2).

Fig. 1: Pie chart showing comparative assessment of participants those who have their clinic/institute accessible to CSHCN

Fig. 2: Bar graph showing percentage of participants who have treated a child with SHCN vs is there clinic/institute accessible to them

Concerning the availability of trained staff, 56.8% of participants reported not having trained staff, and among them, 45.97% had treated a special child without trained nonclinical staff. When it came to scheduling appointments, 50.6% preferred parents and caregivers to call first and provide the child’s medical and dental history, while 40% preferred a prior appointment with the parents and caretakers. About 19.4% of practitioners felt that they required general anesthesia, 38.8% preferred conscious sedation, and 41.9% believed they could manage the child’s behavior without any pharmacological interventions. Furthermore, 50% of the dentists preferred a multispecialty hospital setup, 46.9% preferred a dental clinic with emergency medical services, and 3.1% required only a dental clinic. The majority (81.9%) of dentists aimed to provide both definitive and preventive treatment to CSHCN and only 11.3% required referral to a specialist for treatment, while 77.5% attempted to treat CSHCN with regular follow-ups.

Regarding the challenges faced by dentists in practice, the primary obstacle was a lack of communication with the child, experienced by 72.5% of the participants. Other barriers included patient behavior (60%), parent or caregiver behavior (45%), time-consuming nature of treatment (38.8%), and financial burden on the child’s parent or caregiver (32.5%) (Fig. 3).

Fig. 3: Bar graph showing the percentage of most common clinical barriers faced by the dentist to diagnose and treat CSHCN

DISSCUSSION

The present study focused on assessing the clinical barriers faced by practicing dentists in Gujarat, India, in diagnosing and treating CSHCN. The significance of this study lies in the fact that CSHCN is an underserved dental patient group worldwide, and their oral health status tends to be poorer compared to children in the general population. Despite advances in dentistry, a large proportion of CSHCN continue to suffer from untreated dental conditions, including caries and periodontal problems.1,5

The demographic data obtained from the survey provided valuable insights into the characteristics of the participating dentists. Most of respondents were female (76.3%) and had a BDS qualification (66.9%). Furthermore, a significant proportion of dentists (77.5%) reported having <3 years of experience. Geographically, Central Gujarat had the highest representation (40.6%) among practicing dentists, followed by South Gujarat (22.5%) and West Gujarat (21.3%).

The study findings revealed that a substantial proportion of participants in BDS and MDS knew about the term CSHCN (94.39 and 92.45%, respectively). However, despite this awareness, a considerable number (70%) had not attended or participated in a course on the diagnosis and treatment of CSHCN. This lack of specialized training could be one of the contributing factors to the clinical barriers to dentists when it comes to providing dental care to CSHCN. These findings are supported by Adyanthaya et al.5 in which they reported that the level of the training of practitioner (32.6%) was found to be the greatest barrier, also 45% of the participants received training in their under graduation (UG) but 57% among them were not confident of managing CSHCN. Similar findings were also reported by Rao et al.6 and Dao et al.7 According to Casamassimo et al.,8 only one-fourth of dental students had hands-on learning experiences with CSHCN in dentistry school, and >40% deemed further training relevant to treating CSHCN highly desired or desirable. Fasale et al.9 reported that 50.5% of dentists have insufficient knowledge and training to treat CSHCN. According to Wasnik et al.,10 around 53% of dentists believe their UG dental education preparation is inadequate for handling CSHCN, and the majority of dentists (78%), prefer contacting Pediatric Dentists for treatment of CSHCN.

The study also highlighted the association between awareness of CSHCN and the perceived need for specialized clinic design or specific equipment to treat these patients. Among those who were aware of CSHCN, a significant majority (89.5%) believed in the importance of such specialized facilities. Interestingly, a significant proportion of dentists (45.45%) who did not have accessible clinics or institutes for CSHCN still managed to treat special children. This finding points to the resourcefulness and dedication of some dentists in overcoming barriers to providing care to this vulnerable patient group. These findings are in accordance with Adyanthaya et al.,5 where 86% of clinics were inaccessible and lacked specialized amenities required to treat CSHCN. Baird et al.11 also investigated the availability of facilities for CSHCN in Leicestershire and found that these facilities were inadequate and absent.

The availability of trained staff was identified as another critical aspect of managing CSHCN in dental practice. Approximately, 56.8% of participants reported not having trained staff, and a significant percentage (45.97%) of them had treated special children without the support of trained nonclinical staff Adyanthaya et al.5 also reported that 45% of the auxiliaries were found to be unskilled in providing assistance for the dentist. This highlights the need for enhancing training and support for dental staff to cater to the unique needs of CSHCN.

The preferred appointment scheduling methods varied among the participants, with 50.6% opting for parents and caretakers to call first and provide medical and dental histories, while 40% preferred prior appointments. Dentists also demonstrated different preferences for sedation methods, with 19.4% requiring general anesthesia, 38.8% preferring conscious sedation, and 41.9% opting for nonpharmacological behavior management techniques, which is also in agreement with Adyanthaya et al.5 They observed that 73.2% of practitioners considered that CSHCN could be handled using various behavior management strategies, 17% advised treatments under general anesthesia, and 9.8% advocated the use of conscious sedation. Fasale et al.9 also reported that 37.5% of the participants preferred nonpharmacological behavior management techniques and about 5% of dentists chose to utilize pharmaceutical behavior control approaches. Wasnik et al.10 also came to a similar conclusion, 77% of respondents preferred nonpharmacological behavior management techniques.

The clinical barriers faced by practicing dentists in Gujarat were further elucidated by identifying the primary obstacles in the provision of dental care for CSHCN. A significant percentage of dentists (72.5%) cited lack of communication with the child as the main challenge; this is in consistent with Fasale et al.9 where 61.8% of dentists reported lack of communication as a challenge. This highlights the importance of developing effective communication strategies to engage and build relationships with young patients who may have difficulty expressing their oral health needs and concerns.

Patient behavior (60%) and the behavior of parents or caregivers (45%) were identified as additional barriers, emphasizing the need for comprehensive patient and caregiver education and support from patients to caregivers. Additionally, the time-consuming nature of treatment (38.8%) and the financial burden on parents or caretakers (32.5%) were recognized as challenges that need to be addressed for CSHCN to have better access to dental treatment.

Furthermore, the majority of dentists (81.9%) aimed to provide both definitive and preventive treatment to CSHCN, and a significant proportion (77.5%) attempted to treat these patients with regular follow-ups. Despite the limitations, these numbers show that dentists are committed to improving the dental health of CSHCN.

Bastani et al.12 conducted a scoping review on dental services for CSHCN and identified various access barriers, which were categorized into three classifications—geographical and physical access, cultural and behavioral access, and financial access. Financial access emerged as a significant factor affecting CSHCN’s ability to access dental services. In particular, inappropriate insurance coverage was highlighted as a major barrier.

With limitations such as (1) limited generalizability—the findings may not be fully representative of the challenges faced by dentists in other regions or those who are not members of the IDA; (2) self-reported data and social desirability bias—data in this study were collected through a self-administered questionnaire, which based on the respondents’ accuracy and honesty of the respondents in reporting their experiences and practices; (3) lack of patient and caregiver perspectives—the study focused primarily on the perspectives of practicing dentists. Including the perspectives of CSHCN and their caregivers would provide a more comprehensive understanding of the barriers to dental care and could highlight areas for improvement from the patient’s point of view, this study emphasizes the multifaceted nature of access barriers for dental services among vulnerable groups like CSHCN. Addressing these barriers requires a comprehensive approach that considers not only financial aspects but also factors related to resources, administration, and the availability of skilled dental professionals.

CONCLUSION

In conclusion, this original research article sheds light on the clinical barriers faced by practicing dentists in Gujarat, India, in diagnosing and treating CSHCN. The findings underscore the importance of specialized training, enhanced staff support, and targeted strategies to improve communication and patient education. By removing these barriers, dental professionals can help improve the oral health and general well-being of CSHCN, eventually leading to more inclusive and equitable dental treatment for this vulnerable group.

Clinical Significance

Present study truly portrays the hurdles to CSHCN access inside the dentistry practice system. It significantly contributes to our understanding of the obstacles encountered by dentists in the treatment of CSHCN, illuminating the challenges inherent in diagnosing and providing care to this unique demographic. Furthermore, the article underscores the necessity for modifications in dental curriculum for undergraduates and advocates for enhanced awareness and training within pediatric societies with respect to children with special health needs.

ORCID

Yash M Lalwani https://orcid.org/0000-0001-9637-029X

Bhavna H Dave https://orcid.org/0000-0001-9301-2948

Seema Bargale https://orcid.org/0000-0003-4110-7990

Anshula Deshpande https://orcid.org/0000-0003-3467-2123

Poonacha KS https://orcid.org/0000-0002-5367-3685

Pratik B Kariya https://orcid.org/0000-0001-8240-3142

REFERENCES

1. Fotedar S, Sharma KR, Bhardwaj V, et al. Barriers to the utilization of dental services in Shimla, India. Eur J Dent 2013;2(2):139–143. DOI: 10.4103/2278-9626.112314

2. Government of India Ministry of Statistics and. Programme Implementation. Persons with Disabilities (Divyangjan) in India - A Statistical Profile : 2021. Nic.in. 2021 https://www.nhfdc.nic.in/upload/nhfdc/Persons_Disabilities_31mar21.pdf

3. American Academy of Pediatric Dentistry. The Reference Manual of Pediatric Dentistry: Definitions, Oral Health Policies, Recommendations, Endorsements, Resources. Chicago, Illinois: American Academy of Pediatric Dentistry; 2020. p. 19.

4. Lakshmi K, Anusha R, Iyer K, et al. Development of a tool to assess barriers faced by children with special needs in utilizing dental care services. J Oral Health Comm Dent 2019;13(1):1–4. DOI: 10.5005/jp-journals-10062-0037

5. Adyanthaya A, Sreelakshmi N, Ismail S, et al. Barriers to dental care for children with special needs: General dentists’ perception in Kerala, India. J Indian Soc Pedod Prev Dent 2017;35(3):216–222. DOI: 10.4103/JISPPD.JISPPD_152_16

6. Rao D, Amitha H, Munshi AK. Oral hygiene status of disabled children attending special schools of South Canara, India. Hong Kong Dent J 2005;2:107.

7. Dao LP, Zwetchkenbaum S, Inglehart MR. General dentists and special needs patients: does dental education matter? J Dent Educ 2005;69(10):1107–1115. DOI: 10.1002/j.0022-0337.2005.69.10.tb04011.x

8. Casamassimo PS, Seale NS, Ruehs K. General dentists’ perceptions of educational and treatment issues affecting access to care for children with special health care needs. J Dent Educ 2004;68(1):23–28. DOI: 10.1002/j.0022-0337.2004.68.1.tb03730.x

9. Fasale DM, Rao DD, Panwar DS. Awareness and knowledge regarding treatment and management of children with special health care needs among dental professionals in India. Int J Sci Healthcare Res 2022;7(2):190–196. DOI: 10.52403/ijshr.20220428

10. Wasnik M, Sajjanar A, Kumar S, et al. Barriers to dentist in management of patients with special health care needs. J Res Med Dent Sci 2021;11:217–222.

11. Baird WO, McGrother C, Abrams KR, et al. Access to dental services for people with a physical disability: a survey of general dental practitioners in Leicestershire, UK. Community Dent Health 2008;25(4):248–252. PMID: 19149304.

12. Bastani P, Mohammadpour M, Ghanbarzadegan A, et al. Provision of dental services for vulnerable groups: a scoping review on children with special health care needs. BMC Health Serv Res 2021;21(1):1302. DOI: 10.1186/s12913-021-07293-4

________________________
© The Author(s). 2024 Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.