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dentistry.ucsf.edu dentistry.ucsf.edu Presentation Transcript

  • General Dentists’ Approaches to Treating Challenging Children with Public Insurance Erin E. Masterson, BA; Kristin S. Hoeft, MPH; Judith C. Barker, PhD; Sarah B. Horton, PhD Center to Address Disparities in Children’s Oral Health University of California – San Francisco (Supported by NIDCR grant # U54 DE 14251)
  • Challenging Patients
    • Children respond in many different
    • ways to an encounter in the dental
    • clinic
      • Influenced by age, fear and anxiety,
      • previous experiences, pain, lack of
      • preparation
    • Unable to sit still, hysterical and uncontrollable (Guideline on behavior guidance for the pediatric patient 2006 AAPD)
      • Compromises safe and effective delivery of treatment
      • Dealing with such children takes extra time and does not necessarily generate revenue
    www.nature.com
  • Behavior Management Techniques
    • Interpersonal Techniques
      • Communicative techniques (tell-show-do, voice control, nonverbal communication, positive reinforcement, distraction)
      • Parental presence/absence
    • Advanced Techniques
      • Nitrous Oxide
      • Physical Restraint (protective stabilization)
      • Chemical Restraints (oral conscious sedation, general anesthesia)
  • Public Insurance
    • Low-income children are at higher risk for
    • dental disease, particularly early childhood
    • caries (ECC), than are other children
    • (Dye, et al. 2007 Vital Health Statistics 11(248):1-92; A Report of the Surgeon General 2000 NIDCR)
    • Nationally, only half of general dentists accept children with Medicaid (Seale & Casamassimo 2003 JADA 134(12):1630-40)
      • Parents report difficulty in finding providers and scheduling appointments (Mofidi, et al. 2002 Am J Public Health 92(1):53-8)
    www.dental.columbia.edu
  • Challenging Children with Public Insurance
    • General dentists are often not equipped or not willing to treat challenging children using advanced techniques, but rather refer such patients out (Stewart, et al. 1990 Aust Dent J 35(3):294-8; Klooz & Lewis 1994 J Can Dent Assoc 60(11):981-6)
    • Publicly insured children are more likely to be referred out than are children with private or no insurance (McQuistan, et al. 2005 Pediatr Dent 27(4):277-83, McQuistan, et al. 2006 JADA 137(5):653-60; Seale & Casamassimo 2003 JADA 134(12):1630-40)
  • Study Rationale
    • In the existing literature, characteristics of general dentists who are most likely to often/always refer patients out have been identified (McQuistan, et al. 2005 Pediatr Dent 27(4):277-83, McQuistan, et al. 2006 JADA 137(5):653-60; Cotton, et al. 2001 Pediatr Dent 23(1):51-5)
      • Undergone advanced clinical training
      • Little experience handling children during training
      • Patient base made up of more than 5% Medicaid
      • Low percentage of children in practice
    • However, the point at which dentists decide to refer a challenging child for specialist care has not been extensively explored
  • Study Design
    • To explore qualitatively urban and rural dentists’ provision of care and interactions with their low-income patients, particularly those under five years of age
    • Specifically, to understand the actions and experiences of general dentists that comprise their decisions to maintain or refer challenging patients
  • Sample Recruitment
    • Convenience sample (N=25)
      • Served low-income patients, particularly children
      • Accepted public insurance
      • Practiced in clinics located in an urban city in northern California or a small rural region in California’s Central Valley
    • Recruited by direct approach of the interviewer
  • Procedures & Data Analysis
    • Data was collected by semi-structured interviews
      • Interviews were recorded and transcribed
      • Codes were developed around dentists’ attitudes and actions in relation to uncooperative patients
      • The researchers independently read, coded and analyzed the transcripts using the NVivo ® Software Package
  • Dentist Demographics TOTAL (N=25) Geographic Location 64% urban 36% rural Gender 72% male 28% female Ethnicity 60% Asian 24% Latino 16% Caucasian Years practicing dentistry Mean: 10.9 ± 9.0 years Range: 0.5-37 years Clinic type 56% public 44% private Years at the current clinic Mean: 6.4 ± 6.5 years Range: 0.25-20 years
  • MANAGEABLE UNMANAGEABLE
    • Referral
    • Advanced Techniques
    • Nitrous Oxide
    • Protective Stabilization
    • Oral Conscious Sedation
    • General Anesthesia
    • Challenging
    • Patients
    • Age
    • Need
    • Behavior
    • Trial Exam
    • Interpersonal Techniques
    • Parental Presence/Absence
    • Communicative Techniques
    Results No Follow-up/ Treatment Successful Treatment
  • MANAGEABLE UNMANAGEABLE
    • Referral
    • Advanced Techniques
    • Nitrous Oxide
    • Protective Stabilization
    • Oral Conscious Sedation
    • General Anesthesia
    • Challenging
    • Patients
    • Age
    • Need
    • Behavior
    • Trial Exam
    • Interpersonal Techniques
    • Parental Presence/Absence
    • Communicative Techniques
    No Follow-up/ Treatment Successful Treatment
  • CHALLENGING Patients
    • 1. Age
      • under approximately five years of age
      • deemed such patients “UNMANAGEABLE” immediately (no trial exam)
    • 2. Severity of Need
      • extensive treatment (e.g., ECC, difficult extractions)
    • 3. Behavior
      • Age appropriate behavior (unable to sit still)
      • Dental fear and anxiety
  • MANAGEABLE UNMANAGEABLE
    • Referral
    • Advanced Techniques
    • Nitrous Oxide
    • Protective Stabilization
    • Oral Conscious Sedation
    • General Anesthesia
    • Challenging
    • Patients
    • Age
    • Need
    • Behavior
    • Trial Exam
    • Interpersonal Techniques
    • Parental Presence/Absence
    • Communicative Techniques
    No Follow-up/ Treatment Successful Treatment
  • Trial Exam
    • Interpersonal Techniques
      • 1. Communicative Techniques
      • 2. Parental Presence/Absence
    www.pdalakewood.com http://butterflypdds.com
  • MANAGEABLE UNMANAGEABLE
    • Referral
    • Advanced Techniques
    • Nitrous Oxide
    • Protective Stabilization
    • Oral Conscious Sedation
    • General Anesthesia
    • Challenging
    • Patients
    • Age
    • Need
    • Behavior
    • Trial Exam
    • Interpersonal Techniques
    • Parental Presence/Absence
    • Communicative Techniques
    No Follow-up/ Treatment Successful Treatment
  • UNMANAGEABLE Patients
    • Only six of the 25 (approximately one fourth) general dentists were equipped to utilize an advanced technique in his or her own clinic
      • Nitrous Oxide
      • Protective Stabilization
      • Oral Conscious Sedation
      • General Anesthesia
    • Most of the general dentists (19/25, 76%) discussed eventually referring some of their CHALLENGING patients elsewhere
    • “ laughing gas”
      • Reduces anxiety
      • Does not require certification to administer
      • Rarely used
    Nitrous Oxide www.rch.org.au
  • Physical Restraints
    • Protective Stabilization
      • Parental assistance/restraint
      • Papoose Board
      • Most commonly used
    www.quickmedical.com
  • Chemical Restraints
    • Oral Conscious Sedation
      • A depressed level of consciousness
      • Requires certification from the state
      • to administer
    • General Anesthesia
      • A controlled state of
      • unconsciousness
      • Requires certification from
      • the state to administer
    www.falmouthpediatricdentistry.com www.lasleepdentist.com
  • MANAGEABLE UNMANAGEABLE
    • Referral
    • Advanced Techniques
    • Nitrous Oxide
    • Protective Stabilization
    • Oral Conscious Sedation
    • General Anesthesia
    • Challenging
    • Patients
    • Age
    • Need
    • Behavior
    • Trial Exam
    • Interpersonal Techniques
    • Parental Presence/Absence
    • Communicative Techniques
    No Follow-up/ Treatment Successful Treatment
  • Discussion
    • Why do some referrals NOT result in successful treatment?
  • MANAGEABLE UNMANAGEABLE
    • Referral
    • Advanced Techniques
    • Nitrous Oxide
    • Protective Stabilization
    • Oral Conscious Sedation
    • General Anesthesia
    • Challenging
    • Patients
    • Age
    • Need
    • Behavior
    • Trial Exam
    • Interpersonal Techniques
    • Parental Presence/Absence
    • Communicative Techniques
    The Influence of Public Insurance No Follow-up/ Treatment Successful Treatment
  • Public Insurance
    • Small percentage of general dentists who accept public insurance
        • Even fewer pediatric specialists will treat children with public insurance
        • Long waiting lists
    • Publicly insured children, who are already at high-risk for dental disease and ECC, find it difficult to locate a provider and then to remain in that practice because:
      • Extensive needs for treatment, especially at young ages
      • Uncooperative behavior demands extra time
  • Public Insurance
        • Few dentists who accept public insurance offer an advanced management technique, but instead refer Challenging patients out
      • Reimbursement per service
      • Radiographs for reimbursement difficult to obtain with an uncooperative child
  • Summary
    • This investigation suggests that Challenging and Unmanageable children, particularly those with public insurance, often never obtain successful treatment for their oral health needs.
  • Acknowledgements
    • Supported by NIDCR grant # U54
    • DE 14251 and the Center to Address Disparities in Children’s Oral Health
    • (CAN DO Center) at the University of
    • California at San Francisco ( Jane A.
    • Weintraub, DDS, MPH, Principal Investigator)
    • Thank you to the participants in this study
    • Research Team
      • Judith C. Barker, PhD (PI) Kristin Hoeft, MPH
      • Sarah Horton, PhD Erin Masterson, BA