Introduction
India ranks number two in the list of countries by population. The population of India is equivalent to 17.84% of the total world population.[1
In 2001, it was reported that over 21 million people in India were suffering from one or the other kind of disability and this constitutes about 2.1% of the population of the country. According to United Nations Enable, around 10% of the world's population live with disabilities. The United Nations Universal Declaration of Human Rights (1948) emphasizes equal rights to good health and well-being even for persons with disability. Children with special healthcare needs (CSHCN) is one of the underserved dental patient groups throughout the world.
The poor oral hygiene can be attributed to underlying disability, reduced manual dexterity, or sometimes as a side effect of certain medications.[2
Despite advances in dentistry, general oral health of people with special needs remains poor. The prevalence of dental caries might be or might not be similar to the general population but other aspects like periodontal health may be more demanding.[3 2 , 4
Untreated dental conditions leading to an overall compromised oral health may be because of the inability of carers to evaluate the child's oral condition and/or by the child's inability to express their pain or discomfort or due to poor access to dental care.[5
The barriers to provision of necessary dental care range from physical barriers in practices,[6 , 7 8 9
Edwards and Merry in 2002 pointed out that identification of such barriers can be the first step in addressing these deficiencies.[10
Hence, this study was undertaken with the aim of investigating the perception of general dental practitioners in Kerala regarding the treatment needs and the hitches and challenges clinicians face in providing dental care to children with special needs.
Methods
The study was approved by the Ethical Committee, KMCT Dental College, Kerala, India.
A 16-item self-administered questionnaire was developed and made available in paper and electronic (online) formats. The validity of the questionnaire was confirmed with similar articles with some modifications. The questionnaire was distributed among 149 randomly selected general practitioners from various parts of the state. The difficulty faced by practitioners in delivering adequate care to this group of children was elicited by including variables on the location of the dental practice, accessibility to the clinic, suitable equipment for patient management, and willingness of practitioner and supporting staff in the clinic to treat such individuals. Questions about respondents' demographic data included the number of years as a practicing dentist and number of special needs patients visiting them every month. Questions concerning respondents' practice patterns and confidence levels in treating CSHCN included inquiries about whether practitioners were willing to treat all categories of special needs patients, how they rate their training in undergraduate dental school to provide care for CSHCN, and whether they desired additional training in the field. The special needs children were broadly classified into children with physical disabilities, mental health disorders, and medically compromised children. A question was asked to the respondents to identify various factors which they perceived to be a barrier to their willingness to see CSHCN. Respondents were asked about specific treatment procedures rendered to these children and also about various laws of the country demanding equality in care for all citizens including special needs patients.
Statistical analysis
The data were obtained and entered into a Microsoft Excel spreadsheet and analyzed using the SPSS version 20.0 (Statistical Package for the Social Sciences). Association between variables was found using Chi-square test. Pearson correlation coefficient correlated the various variables. A logistic regression model was developed to assess the lack of perceived oral healthcare in the special needs children. All the analyses were set at confidence interval of 95% and P < 0.05 was considered significant and P < 0.001 was highly significant.
Results
Out of the 149 general practitioners to whom the questionnaire was administered, 126 returned the paper-based survey and 6 responded through the online version. Of the total 132 response forms received, 100 were deemed valid based on the completion of questions in the response sheets. Data revealed that 70% dentists encountered <3 special needs patients every month in their practice. Although 45% of the respondents claimed that the undergraduate training received in this particular field was good, 57% of them stated that they were not confident of managing children with special needs. Fifty-five percent of the auxiliaries in the dental office were found to be comfortable providing assistance for the dentist. Inaccessibility to the dental clinic (not being located on the ground floor, absence of ramp/lift facilities for wheelchair, etc.) was reported to be the main physical barrier to access to dental care in as high as 71% cases. Eighty-six percent of the clinics were found to lack specialized amenities and equipment for managing special needs patients. On the brighter side, when asked about their opinion on reducing disparity in treatment delivery for children with special needs and those without special needs, 96% respondents felt that the former group should be given equal consideration. The level of training of practitioner (32.6%) and inadequately motivated caretakers (20.8%) were found to be the greatest barriers and challenges to a practitioner's willingness to treat disabled children. Patients' behavior and the inability to establish proper communication with the patient were stated as the greatest barriers by 13.3% and 14.5% of the respondents. A confounding 82% of the dentists were unaware of the various Indian laws for disabled people including Persons with Disabilities Act, 1995, and Right of Persons with Disabilities Bill, 2014.
About 73.2% of the practitioners believed that such children can be managed in the dental office by means of the various behavior management techniques, whereas 17% suggested procedures under general anesthesia and 9.8% recommended the use of conscious sedation. Emergency treatments (29.5%) and oral hygiene instructions including preventive measures (30.1%) were the most commonly delivered treatment modalities followed by restoration, extraction, periodontal treatment, multi-visit procedures including dentures in the decreasing order of frequency. Of all the category of children with special needs, more than 50% dentists preferred treating physically challenged children and the least preferred category was autistic children. About 61.2% of the respondents felt that to improve the quality of care to children with special needs, Special Care Dentistry should be part of undergraduate curriculum and also undergraduate students must be given opportunity to provide various levels of treatment and assistance in Special Care Dentistry. Eighty-four percent of the private dental practitioners showed interest in pursuing further training in managing patients with special needs. Regarding updating their current knowledge and expertise by attending Continuing Dental Education programs or conferences, 53% replied as attending such programs once per year, 35% twice a year, and 12% only once in 2 years.
Table 1 considering p < 0.05 as significant and p < 0.001 as highly significant shows that there is a significant association (P = 0.001) between undergraduate dental training and the frequency of children visiting dental clinic. Dentists who were practicing for more than 5 years encountered barriers more frequently, and this was statistically significant (P = 0.01). More frequent the child with special need visits the clinic, there are increased challenges for delivery of dental care, and this was statistically significant (0.003). Treatments rendered to children with special care were significantly associated with years of practicing (P = 0.005).
Table 1: Association between the experience of dentist, their frequency of treating children with special needs, barriers they face, and various treatments rendered
Table 2 depicts the correlation matrix which establishes that correlation exists between undergraduate dental training and the treatment of patients with special healthcare needs. Frequency of children visiting the dental clinic associated with the years of practicing was found to be statistically significant.
Table 2: Correlation model depicting the correlation between various variables
Correlation matrix establishes that correlation exists between undergraduate dental training and the treatment of patients with special healthcare needs.
Table 3 depicts Exp(B) as the odds ratio with corresponding P value. When practitioners were asked about the perceived barrier, lack of communication had 3.72 odds of being a perceived barrier (P = 0.01), inadequately motivated caretakers had 2.38 odds of being a perceived barrier (P = 0.05).
Table 3: Logistic regression model for accessibility to patients against perceived barriers and challenges
Figure 1 is the graphical depiction of perceived barriers by general dentists when treating special needs patients.
Figure 1: Perceived barriers by general dentists when treating special needs patients
Discussion
The present study was conducted on 149 randomly selected general dental practitioners in Kerala, India, to determine their perceived barriers in providing optimal dental care for children with special needs.
The results showed that almost all the practitioners wanted to eliminate the disparity between dental care delivered to children with and without special needs, but the majority of the respondents found the job challenging. The finding was similar to the conclusion made by Mueller in the US in 1998[11 et al .[12
About 32.6% of the professionals stated lack of training and experience as a difficulty for managing disabled children which is in accordance with studies of Rao et al .[13 et al .[14
About 20.8% of the participants suggested inadequately motivated caretakers to be a relevant barrier. This observation is similar to that of findings conducted by Vignehsa et al .,[15 16 17
Results of this study offer a confusing picture regarding the effect of training received at the undergraduate level for the practitioners. Even when 45% rated the training they had received as undergraduates to be good, in another question regarding their confidence in providing treatment for children with special needs, 43% answered on the negative side. These results reinforce the findings of Casamassimo et al .[18
An imperative inference in this regard would be in the same lines as Casamassimo [19
Assessing the many aspects considered in this study, it can be summed up that a dentist's decision in providing care for a CSHCN is governed by multitude of factors including financial, time, attitudinal, and educational constraints along with physical barriers in accessibility to a dental office which maybe worsened by inadequately motivated primary caretakers.
Conclusion
Based on the findings of this study, we propose few potential strategies to combat the perceived barriers and help the professionals meet the treatment needs of children with special needs:
Training programs in special needs dentistry to enhance and improve the quality of patient care. Considering the encouraging response from practitioners regarding their aspiration to eliminate any disparity in treatment given to the children with special needs, a revision of curriculum for undergraduate training can be considered to equip future dental graduates in dealing with this group of patients better
To address the oral healthcare needs from the elementary level, parents, caregivers, and teachers of these children should be adequately educated and trained about dental problems, oral hygiene instructions and dietary practice, prevention of orofacial trauma, and first aid
Since the location and equipment of the dental offices were found to be one of the major hindrances in accessing dental care for these children, barrier-free environments with suggested use of open space in clinic for maneuvering wheelchair, stabilizing devices, and disabled-friendly toilets and lifts are recommended.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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Acknowledgment
We would like to express our gratitude to Dr. Arun Paul E.M, senior lecturer, Department of Public Health Dentistry, KMCT Dental College, Calicut, Kerala, for providing us necessary help with the statistical analysis of data obtained.
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