dentistry.ucsf.edu

431 views

Published on

  • Be the first to comment

  • Be the first to like this

dentistry.ucsf.edu

  1. 1. 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)
  2. 2. Challenging Patients <ul><li>Children respond in many different </li></ul><ul><li>ways to an encounter in the dental </li></ul><ul><li>clinic </li></ul><ul><ul><li>Influenced by age, fear and anxiety, </li></ul></ul><ul><ul><li>previous experiences, pain, lack of </li></ul></ul><ul><ul><li>preparation </li></ul></ul><ul><li>Unable to sit still, hysterical and uncontrollable (Guideline on behavior guidance for the pediatric patient 2006 AAPD) </li></ul><ul><ul><li>Compromises safe and effective delivery of treatment </li></ul></ul><ul><ul><li>Dealing with such children takes extra time and does not necessarily generate revenue </li></ul></ul>www.nature.com
  3. 3. Behavior Management Techniques <ul><li>Interpersonal Techniques </li></ul><ul><ul><li>Communicative techniques (tell-show-do, voice control, nonverbal communication, positive reinforcement, distraction) </li></ul></ul><ul><ul><li>Parental presence/absence </li></ul></ul><ul><li>Advanced Techniques </li></ul><ul><ul><li>Nitrous Oxide </li></ul></ul><ul><ul><li>Physical Restraint (protective stabilization) </li></ul></ul><ul><ul><li>Chemical Restraints (oral conscious sedation, general anesthesia) </li></ul></ul>
  4. 4. Public Insurance <ul><li>Low-income children are at higher risk for </li></ul><ul><li>dental disease, particularly early childhood </li></ul><ul><li>caries (ECC), than are other children </li></ul><ul><li>(Dye, et al. 2007 Vital Health Statistics 11(248):1-92; A Report of the Surgeon General 2000 NIDCR) </li></ul><ul><li>Nationally, only half of general dentists accept children with Medicaid (Seale & Casamassimo 2003 JADA 134(12):1630-40) </li></ul><ul><ul><li>Parents report difficulty in finding providers and scheduling appointments (Mofidi, et al. 2002 Am J Public Health 92(1):53-8) </li></ul></ul>www.dental.columbia.edu
  5. 5. Challenging Children with Public Insurance <ul><li>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) </li></ul><ul><li>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) </li></ul>
  6. 6. Study Rationale <ul><li>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) </li></ul><ul><ul><li>Undergone advanced clinical training </li></ul></ul><ul><ul><li>Little experience handling children during training </li></ul></ul><ul><ul><li>Patient base made up of more than 5% Medicaid </li></ul></ul><ul><ul><li>Low percentage of children in practice </li></ul></ul><ul><li>However, the point at which dentists decide to refer a challenging child for specialist care has not been extensively explored </li></ul>
  7. 7. Study Design <ul><li>To explore qualitatively urban and rural dentists’ provision of care and interactions with their low-income patients, particularly those under five years of age </li></ul><ul><li>Specifically, to understand the actions and experiences of general dentists that comprise their decisions to maintain or refer challenging patients </li></ul>
  8. 8. Sample Recruitment <ul><li>Convenience sample (N=25) </li></ul><ul><ul><li>Served low-income patients, particularly children </li></ul></ul><ul><ul><li>Accepted public insurance </li></ul></ul><ul><ul><li>Practiced in clinics located in an urban city in northern California or a small rural region in California’s Central Valley </li></ul></ul><ul><li>Recruited by direct approach of the interviewer </li></ul>
  9. 9. Procedures & Data Analysis <ul><li>Data was collected by semi-structured interviews </li></ul><ul><ul><li>Interviews were recorded and transcribed </li></ul></ul><ul><ul><li>Codes were developed around dentists’ attitudes and actions in relation to uncooperative patients </li></ul></ul><ul><ul><li>The researchers independently read, coded and analyzed the transcripts using the NVivo ® Software Package </li></ul></ul>
  10. 10. 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
  11. 11. MANAGEABLE UNMANAGEABLE <ul><li>Referral </li></ul><ul><li>Advanced Techniques </li></ul><ul><li>Nitrous Oxide </li></ul><ul><li>Protective Stabilization </li></ul><ul><li>Oral Conscious Sedation </li></ul><ul><li>General Anesthesia </li></ul><ul><li>Challenging </li></ul><ul><li>Patients </li></ul><ul><li>Age </li></ul><ul><li>Need </li></ul><ul><li>Behavior </li></ul><ul><li>Trial Exam </li></ul><ul><li>Interpersonal Techniques </li></ul><ul><li>Parental Presence/Absence </li></ul><ul><li>Communicative Techniques </li></ul>Results No Follow-up/ Treatment Successful Treatment
  12. 12. MANAGEABLE UNMANAGEABLE <ul><li>Referral </li></ul><ul><li>Advanced Techniques </li></ul><ul><li>Nitrous Oxide </li></ul><ul><li>Protective Stabilization </li></ul><ul><li>Oral Conscious Sedation </li></ul><ul><li>General Anesthesia </li></ul><ul><li>Challenging </li></ul><ul><li>Patients </li></ul><ul><li>Age </li></ul><ul><li>Need </li></ul><ul><li>Behavior </li></ul><ul><li>Trial Exam </li></ul><ul><li>Interpersonal Techniques </li></ul><ul><li>Parental Presence/Absence </li></ul><ul><li>Communicative Techniques </li></ul>No Follow-up/ Treatment Successful Treatment
  13. 13. CHALLENGING Patients <ul><li>1. Age </li></ul><ul><ul><li>under approximately five years of age </li></ul></ul><ul><ul><li>deemed such patients “UNMANAGEABLE” immediately (no trial exam) </li></ul></ul><ul><li>2. Severity of Need </li></ul><ul><ul><li>extensive treatment (e.g., ECC, difficult extractions) </li></ul></ul><ul><li>3. Behavior </li></ul><ul><ul><li>Age appropriate behavior (unable to sit still) </li></ul></ul><ul><ul><li>Dental fear and anxiety </li></ul></ul>
  14. 14. MANAGEABLE UNMANAGEABLE <ul><li>Referral </li></ul><ul><li>Advanced Techniques </li></ul><ul><li>Nitrous Oxide </li></ul><ul><li>Protective Stabilization </li></ul><ul><li>Oral Conscious Sedation </li></ul><ul><li>General Anesthesia </li></ul><ul><li>Challenging </li></ul><ul><li>Patients </li></ul><ul><li>Age </li></ul><ul><li>Need </li></ul><ul><li>Behavior </li></ul><ul><li>Trial Exam </li></ul><ul><li>Interpersonal Techniques </li></ul><ul><li>Parental Presence/Absence </li></ul><ul><li>Communicative Techniques </li></ul>No Follow-up/ Treatment Successful Treatment
  15. 15. Trial Exam <ul><li>Interpersonal Techniques </li></ul><ul><ul><li>1. Communicative Techniques </li></ul></ul><ul><ul><li>2. Parental Presence/Absence </li></ul></ul>www.pdalakewood.com http://butterflypdds.com
  16. 16. MANAGEABLE UNMANAGEABLE <ul><li>Referral </li></ul><ul><li>Advanced Techniques </li></ul><ul><li>Nitrous Oxide </li></ul><ul><li>Protective Stabilization </li></ul><ul><li>Oral Conscious Sedation </li></ul><ul><li>General Anesthesia </li></ul><ul><li>Challenging </li></ul><ul><li>Patients </li></ul><ul><li>Age </li></ul><ul><li>Need </li></ul><ul><li>Behavior </li></ul><ul><li>Trial Exam </li></ul><ul><li>Interpersonal Techniques </li></ul><ul><li>Parental Presence/Absence </li></ul><ul><li>Communicative Techniques </li></ul>No Follow-up/ Treatment Successful Treatment
  17. 17. UNMANAGEABLE Patients <ul><li>Only six of the 25 (approximately one fourth) general dentists were equipped to utilize an advanced technique in his or her own clinic </li></ul><ul><ul><li>Nitrous Oxide </li></ul></ul><ul><ul><li>Protective Stabilization </li></ul></ul><ul><ul><li>Oral Conscious Sedation </li></ul></ul><ul><ul><li>General Anesthesia </li></ul></ul><ul><li>Most of the general dentists (19/25, 76%) discussed eventually referring some of their CHALLENGING patients elsewhere </li></ul>
  18. 18. <ul><li>“ laughing gas” </li></ul><ul><ul><li>Reduces anxiety </li></ul></ul><ul><ul><li>Does not require certification to administer </li></ul></ul><ul><ul><li>Rarely used </li></ul></ul>Nitrous Oxide www.rch.org.au
  19. 19. Physical Restraints <ul><li>Protective Stabilization </li></ul><ul><ul><li>Parental assistance/restraint </li></ul></ul><ul><ul><li>Papoose Board </li></ul></ul><ul><ul><li>Most commonly used </li></ul></ul>www.quickmedical.com
  20. 20. Chemical Restraints <ul><li>Oral Conscious Sedation </li></ul><ul><ul><li>A depressed level of consciousness </li></ul></ul><ul><ul><li>Requires certification from the state </li></ul></ul><ul><ul><li>to administer </li></ul></ul><ul><li>General Anesthesia </li></ul><ul><ul><li>A controlled state of </li></ul></ul><ul><ul><li>unconsciousness </li></ul></ul><ul><ul><li>Requires certification from </li></ul></ul><ul><ul><li>the state to administer </li></ul></ul>www.falmouthpediatricdentistry.com www.lasleepdentist.com
  21. 21. MANAGEABLE UNMANAGEABLE <ul><li>Referral </li></ul><ul><li>Advanced Techniques </li></ul><ul><li>Nitrous Oxide </li></ul><ul><li>Protective Stabilization </li></ul><ul><li>Oral Conscious Sedation </li></ul><ul><li>General Anesthesia </li></ul><ul><li>Challenging </li></ul><ul><li>Patients </li></ul><ul><li>Age </li></ul><ul><li>Need </li></ul><ul><li>Behavior </li></ul><ul><li>Trial Exam </li></ul><ul><li>Interpersonal Techniques </li></ul><ul><li>Parental Presence/Absence </li></ul><ul><li>Communicative Techniques </li></ul>No Follow-up/ Treatment Successful Treatment
  22. 22. Discussion <ul><li>Why do some referrals NOT result in successful treatment? </li></ul>
  23. 23. MANAGEABLE UNMANAGEABLE <ul><li>Referral </li></ul><ul><li>Advanced Techniques </li></ul><ul><li>Nitrous Oxide </li></ul><ul><li>Protective Stabilization </li></ul><ul><li>Oral Conscious Sedation </li></ul><ul><li>General Anesthesia </li></ul><ul><li>Challenging </li></ul><ul><li>Patients </li></ul><ul><li>Age </li></ul><ul><li>Need </li></ul><ul><li>Behavior </li></ul><ul><li>Trial Exam </li></ul><ul><li>Interpersonal Techniques </li></ul><ul><li>Parental Presence/Absence </li></ul><ul><li>Communicative Techniques </li></ul>The Influence of Public Insurance No Follow-up/ Treatment Successful Treatment
  24. 24. Public Insurance <ul><li>Small percentage of general dentists who accept public insurance </li></ul><ul><ul><ul><li>Even fewer pediatric specialists will treat children with public insurance </li></ul></ul></ul><ul><ul><ul><li>Long waiting lists </li></ul></ul></ul><ul><li>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: </li></ul><ul><ul><li>Extensive needs for treatment, especially at young ages </li></ul></ul><ul><ul><li>Uncooperative behavior demands extra time </li></ul></ul>
  25. 25. Public Insurance <ul><ul><ul><li>Few dentists who accept public insurance offer an advanced management technique, but instead refer Challenging patients out </li></ul></ul></ul><ul><ul><li>Reimbursement per service </li></ul></ul><ul><ul><li>Radiographs for reimbursement difficult to obtain with an uncooperative child </li></ul></ul>
  26. 26. Summary <ul><li>This investigation suggests that Challenging and Unmanageable children, particularly those with public insurance, often never obtain successful treatment for their oral health needs. </li></ul>
  27. 27. Acknowledgements <ul><li>Supported by NIDCR grant # U54 </li></ul><ul><li>DE 14251 and the Center to Address Disparities in Children’s Oral Health </li></ul><ul><li>(CAN DO Center) at the University of </li></ul><ul><li>California at San Francisco ( Jane A. </li></ul><ul><li>Weintraub, DDS, MPH, Principal Investigator) </li></ul><ul><li>Thank you to the participants in this study </li></ul><ul><li>Research Team </li></ul><ul><ul><li>Judith C. Barker, PhD (PI) Kristin Hoeft, MPH </li></ul></ul><ul><ul><li>Sarah Horton, PhD Erin Masterson, BA </li></ul></ul>

×