(Dr. Hangorsky) Welcome to today's module. According to the World Health Organization, over one billion people are 15% of the world population is living with some form of disability, and that group is increasing drastically. The number of people experiencing disability is expanding due to a rise in chronic health conditions and aging population. As do all health care professions, dentistry and specifically dental schools, are becoming aware of the need to educate the next generation of dentists who are competent in addressing the oral health care needs of patients with special needs. The ability of academic institutions to train the next generation of dentists who will be capable of not only treating patients with disabilities, but also cognizant of the various attitudinal, physical, and financial barriers, is one of the formidable challenges facing our profession. To discuss these and other related issues, we have invited one of the experts in this area, Dr. Miriam Robbins. Dr. Robbins is the Director of the Care Center for Persons with Disabilities, Professor of Clinical Oral Medicine, and Professor of Clinical Restorative Dentistry at Penn Dental Medicine. She obtained her DDS from the State University of New York at Buffalo in 1987 and went on to complete a Dental Residency at Columbia Presbyterian Medical Center and Fellowship in Dental Oncology in the Department of Surgery at Memorial Sloan Kettering Cancer Center. Prior to her appointment at Penn Dental Medicine, Dr. Robbins served as Chair of the Department of Dental Medicine at New York University in Long Island and Chair of Department of Family Dental Medicine at NYU Long Island School of Medicine. Dr. Robbins brings extensive experience working with special health care needs patients, having led the NYU College of Dentistry Special Needs Clinic as Director, as well as serving on the New York State Task Force for Special Needs since 2005. She's a Diplomate of American Board of Special Care Dentistry, a Fellow of the American Association of Hospital Dentists, and a Fellow of the American Academy of Oral Medicine. She's very active within organized dentistry, serving as the President of both the Special Care Dentistry Association, and the American Academy of Oral Medicine. Welcome, Dr. Robbins, and thank you for joining us today. Dr. Robbins, could you please tell us basically, define the scope of the problem, why this is becoming such an important issue in educating our students and future dental professionals. (Dr. Robbins) Disability is the most rapidly growing segment of the patient population. It's estimated there are 61 million adults in the US with a disability. That translates into one in four or about 25%. One in three adults with disabilities do not have usual health care providers or have unmet health care needs over the past year. Certainly, we've seen with COVID an increase in inability of patients with disability to access health care. With age, as people get older, disability becomes more common so that we see in population over 65, two out of six people over the age of 65 will have disability. One in six, 17% of children ages 3-17 have one or more developmental disabilities, meaning they are born or had developed the disability before the age of 21. Dental care is the number one health care issue for patients with neurodevelopmental disorders and patients with special health care needs. (Dr. Hangorsky) Perhaps you can tell us what do you exactly mean by patients who have disabilities? How it may be different things to different people? (Dr. Robbins) A disability is defined, there are several different definitions, but in general, disabilities is defined as an impairment or limitation, either physical or cognitive, that disrupts the person's ability to either perform a major life activity, or an activity of daily living such as self-care, going to school, being able to work, take public transportation, or something that inhibits somebody's ability to participate in normal life. Disabilities can be mental, they can be intellectual, they can be physical. They can be the result of congenital situation where somebody is born with a disability or they can be acquired, either through chronic illnesses, age, and other physical infirmities. (Dr. Hangorsky) Okay. What are some of the challenges that these patients are facing when it comes to clinical treatment or oral health care delivery? (Dr. Robbins) Multiple, there are multiple barriers. Yeah, there are multiple barriers. Patients may have difficulty finding practitioners that can have accessible offices, meaning offices where if somebody's in a mobility device, let's say somebody is in a large wheelchair, they may have difficulty finding practitioners who have offices that can accommodate a large wheelchair. Very often fear is a huge barrier on the part of the health care providers. Because they have not received training or maybe they've had limited exposure, they're fearful that they're either going to hurt the patient or they're not going to be able to provide the proper care. That's one of the reasons that educating our health care providers right from the start on how to assess these patients, manage these patients, and educating them on how to modify the delivery of care, if that's necessary, will hopefully increase the access to care for patients with disabilities. (Dr. Hangorsky) Can you perhaps tell us, where does the current dental education fall short in terms of educating future dentists in addressing the needs of this population? (Dr. Robbins) So, often, as I mentioned, people with cognitive developmental or physical disabilities have trouble finding a dental team willing and able to meet their needs. We believe the solution is building confidence and competence in managing the needs of patients with disabilities, as I said from the very beginning of dental training. If you educate providers about the various conditions, if you can educate training to handle the unique needs of individuals with disabilities, then the hope and the thought is that when people go out into their practices they will be more willing and feel more confident about treating patients with disabilities. (Dr. Hangorsky) So, Dr. Robbins, you are currently the director of a clinic, which is referred to as Personalized Care Clinic, but it's really a clinic that addresses patients with special needs. Could you tell us what specific aspects of this clinic enable you to address those patients' needs? (Dr. Robbins) So actually Personalized Care Clinic, which is a name that was chosen by Dean Mark Wolff, is actually very telling because what it says is we personalize, we individualize, the delivery of care for each patient based on what they need. We have a facility that has a variety of operatories that are designed to accommodate different needs. We have sensory rooms that have blackout shades and sound baffling for patients who have sensory processing disorders, people who have difficulty with bright lights and loud sounds. We have operatories that are large enough to handle patients with wheelchairs and large mobility devices. We have a wheelchair lift so that a patient can remain in the wheelchair, and we can put the wheelchair in a position where we can provide care. But probably more importantly, is that we're really looking at addressing the root cause of dental disease in a way that's I think a little unique. Most dentists were taught to drill and fill. Find a hole, make a hole, fill it up. If we can address the root, we know that all, most dental diseases infectious in nature and it's preventable. We're working very hard on one, educating both the patients and their caregivers, their families on how we can prevent dental disease, and then looking at ways that are non-surgical in nature in order to aggressively remineralize and prevent the advancement of dental disease. The traditional model always was, if you had somebody who was intellectually impaired, had difficulty cooperating for dental care in a traditional setting, they would be taken to the operating room. They'd be put under general anesthesia. All of their dental work would be done in a three or four hour block, and then that would be it for five years. Then they wouldn't receive any oral care for another five years, and then the cycle will repeat. (Dr. Hangorsky) Which is not a sustainable model. (Dr. Robbins) It's not sustainable at all. It's becoming increasingly unsustainable because unfortunately, access to operating rooms is becoming more and more difficult for a number of reasons. But it's not a sustainable model. We're looking to try to get more at the root of the problem, and how do we address, how do we teach dental students a different way of approaching the treatment of these patients that doesn't necessarily involve the traditional surgical model. (Dr. Hangorsky) Could you perhaps elaborate a little bit more? What is unique about the approach you have in this special clinic that could perhaps be then copied and adopted by other dental institutions to train dental students? (Dr. Robbins) So, one thing is that we have several auxiliary personnel. We have a patient navigator. Patient navigator is very unique. It's not unique in medicine, but it's unique in dentistry. Our patient navigator is responsible for helping patients navigate to our clinic, helping to remove any potential barriers so the patient is getting to us. So for example, arranging for transportation, if the patient has difficulty getting to us. The other thing that we have is we have a full-time nurse practitioner. The nurse practitioner works closely with the dental students so that we try to gather as much information. Before the patient ever steps foot in our facility, we call the home, we have conversation with the family members. We have sometimes with the patient depending on whether the patient is the one who's going to be able to communicate the information or a family member or a caregiver, so that we know before the patient ever even comes what we need to have prepared for that patient. Does the patient have sensory issues? Do we need to put the patient into a room that will accommodate the wheelchair? Do we need to reach out to their physician to get information about an underlying medical condition? So that when that patient comes for that first visit, instead of spending that visit collecting data, we already have the data so that we can actually provide care on the very first visit that the patient comes in. Another thing is that we really work at the patient's pace. We spend a lot of time with desensitization for some of our patients. That means that a patient may come in and the only thing we do is to have the patient walk around the operatory, maybe get them to sit in the chair, show them the light, show them the handpiece, show them all of the different components. It may take several appointments before we can actually have the patient sit in the chair and open their mouth. Sometimes the patient doesn't sit in the chair, sometimes the patient sits in the operator chair, sometimes the patient sits on the floor. We have a yoga mats that we put down and we've been known to the patient wants to sit on the floor, we sit on the floor where the patient is. The bottom line is being able to provide the care. We let the patient guide us in some ways to how they are going to be the most comfortable having that care provided. (Dr. Hangorsky) So, in other words, the key to success for running a clinic like this is really having an interdisciplinary health care team. (Dr. Robbins) Absolutely. It's utilizing all the different pieces. It's understanding the pathogenesis of dental disease and then an appreciation of what steps can be utilized to interrupt or to change the development of the disease. To that end, we use a lot of fluoride. Every patient, every visit, gets fluoride varnish, which is not the way, it's an off-label use. If the patient's caries level speaks to that. We use a lot of silver diamine fluoride. Silver diamine fluoride is a solution that is painted on the teeth that arrests caries or stops the cavity from getting worse. We will do that very often in patients where we may not be able to go in surgically with a handpiece to drill out the cavity. We're using a combination of silver diamine fluoride and fluoride varnish to arrest the cavity and use what's called atraumatic restorative technique, where we might remove part of the carious tooth using a hand instrument and then place the glass ionomer restoration just to stop the process. If we can preserve the function of the tooth, but not necessarily place a traditional filling, then we will do that. (Dr. Hangorsky) So you've been in existence with the center of almost a year now. Have you seen any impact this has on the education of dental students that you are being able to witness? (Dr. Robbins) Well, it's been interesting. A lot of students came in, they were extremely fearful, very nervous. We try to prepare them. We gave them information beforehand. We work very closely with them. We have a very good student to faculty ratio. We can be chairside if we need to be chairside. Some students are still maybe a little more reserved, but a lot of students have really embraced this. They actually get excited when they have a patient that maybe they'd been working with a patient for two or three sessions and then the patient actually lets them do something or perform what they need to be done. They get really excited about it. Because we are brand-new, We did a pre-clinic survey. We're doing a mid-semester survey and we're going to do an exit survey. So we'll see. If we could get every student in our class to just see one or two special needs patients. That would go a long way to helping the issue, and 85% of these patients can be treated with minimal modifications. For most of these patients, for 85%, it's really business as usual with very minor changes. The other remaining patients may need a specialized facility like our facility. But our hope is that we are going to be training our students. Then when they go out into their practices, they'll be comfortable treating this population. (Dr. Hangorsky) So, if you had to predict to the future, which is the difficult. Where do you see this education of students and training of dental professionals is heading as far as taking care of patients with disabilities? (Dr. Robbins) Ideally, we would have a center like ours in every dental school in the U.S. Maybe every dental school in the world. This population is growing. As people get older, more and more people are living with chronic illnesses. This is a population that dentists are going to be seeing when they get out into practice. Their population is going to be made up of patients with a variety of disabilities. I think, as there are advances in addressing the infectious disease nature of oral disease. Maybe one day we'll have a vaccine against cavities. But I think looking outside the traditional models of providing care, again, addressing the root cause, whether it be diet. That's something else that I forgot to mention that we actually do diet analysis. If you have a low cariogenic diet, if you have a low carbohydrate diet, you're less likely to get get cavities. I think looking outside of the traditional drill and fill model and looking more holistically at dentistry or dental diseases and infectious disease and addressing some of those root causes. (Dr. Hangorsky) Dr. Robbins, I would be remiss if I didn't ask you about technology. Is technology changing the way you practice and if so, how? (Dr. Robbins) Yes. So we've begun to incorporate digital dentistry into our practice, which is I'm been around for awhile, but the ability to scan instead of having to put a tray with impression material and expect the patient to sit for three minutes or four minutes without moving is really changed the way that we're able to do things because we can scan and if we have to give the patient a break, we can give them a break and then we can start scanning again. We recently just started doing our first case of digital dentures for a young woman who has Down syndrome, who I think would have had great difficulty cooperating for all of the impression. She has a very small mouth, very limited opening. But we're able to use the scanner to scan her and we're making her a set of dentures digitally. I'm very excited about that. (Dr. Hangorsky) Thank you very much for a fascinating discussion. I appreciate it. (Dr. Robbins) Thank you, Dr. Hangorsky.
