Living with a disability can significantly complicate your healthcare needs for a variety of different reasons. In addition to the challenges of finding suitable treatment and accommodations for their conditions, many people with disabilities also have greater difficulty finding primary care doctors and accessing many other basic healthcare services that we all depend on.
According to the Centers for Disease Control (CDC), one in three working-age adults (aged 18 to 44) with disabilities do not have a primary care physician, and that same proportion has also had a healthcare need go unaddressed due to the cost of care within the last year. Further, one in four adults with disabilities reported that they hadn’t had a routine checkup over the past year.
This disparity is especially prominent in oral care outcomes, partly because of the way dental care is treated by insurance providers. Medicare, one of the largest healthcare coverage providers for people with disabilities, does not cover oral care in most cases, and many people have great difficulty finding dentists that accept Medicare at all. Additionally, Medicaid programs in many states offer little or no coverage for dental care.
This lack of coverage can lead to major long-term problems for people with disabilities, as many common disabilities can have significant impacts on oral health. A variety of unique barriers may prevent people with disabilities from finding and receiving adequate care.
The relationship between disability and dental health
There are a variety of disabilities and chronic conditions that can negatively impact oral health and make it more complicated to find care. Conversely, maintaining good oral health can reduce the chance of some serious illnesses and support better outcomes for people with many types of disabilities.
Intellectual and developmental disabilities
Intellectual and developmental disabilities (IDDs) such as autism, Down syndrome and cerebral palsy can adversely affect oral health outcomes in several ways. Individuals with these conditions can experience anxiety, uncontrolled body movements or sensory sensitivities that can make it very challenging to cooperate with their dentist while receiving care in a traditional setting — and many dental offices are not equipped to make necessary accommodations for them.
Additionally, the behavioral complications caused by IDDs can make it more difficult for patients with these conditions to follow their dentist’s instructions and consistently maintain good oral care habits at home, such as brushing and flossing daily. Over time, this can increase the risk of problems like cavities and gum disease. Other dental issues associated with IDDs include the formation of harmful oral habits like grinding and clenching of teeth, which can accelerate tooth decay and lead to a variety of other issues.
Epilepsy
There are several oral health concerns associated with epilepsy. Seizures cause convulsions, which can lead to a number of oral issues, including chipped and cracked teeth, cheek and tongue biting, trauma-induced temporomandibular joint (TMJ) disc dislocation and jaw fractures. Epilepsy treatments can also cause oral health issues in certain cases. Some common anticonvulsants, such as phenytoin, can cause gingival hyperplasia (bleeding gums) when taken orally, which can lead to issues like swelling, pain and detached teeth.
Autism spectrum disorders
Autism spectrum disorders (ASD) can contribute to poor oral health in several ways. Due to sensory issues, patients with ASD may be deterred from visiting the dentist and may also have greater difficulty following oral care routines at home. Common sensory challenges reported by people with ASD in dental offices include sensitivities to bright lights, the feeling of their faces being touched and the high-pitched sounds produced by motorized dental instruments like drills.
Many people with ASD also experience sensory issues during their home dental care routines. These issues can include aversion to the texture or taste of toothpaste, as well as the feeling of bristles in the mouth. Sensory sensitivities like these can cause patients with ASD to become uncooperative during dental visits and compel them to neglect their oral care at home. Additionally, many people with ASD, particularly children, may struggle to clearly express their discomfort when experiencing a dental issue, which can prevent them from receiving care promptly.
Chronic conditions with oral health concerns
Several additional chronic health conditions can impact oral health, and/or be exacerbated by poor oral health habits.
- Diabetes: People with diabetes tend to have higher-than-normal concentrations of sugar in their saliva, as well as in their blood. This can lead to dry mouth and accelerate the growth of plaque, contributing to problems like inflammation, tooth decay and gum disease. Because diabetes also causes slow wound healing, oral problems like infections and sores can take patients longer to recover from and must often be treated with special care.
- HIV/AIDS: Because of the way that they weaken immune function, HIV (human immunodeficiency virus) and AIDS (acquired immunodeficiency syndrome) can both increase the risk of serious oral health problems such as cavities, gingivitis, periodontitis (bone loss around teeth), canker sores, oral warts and hairy leukoplakia (rough white patches that appear on the tongue).
- Heart disease: While many people don’t think of oral health and heart health as directly related, bad dental habits can significantly increase the risk of heart disease in several ways. This may be because the bacteria found in gum disease can spread throughout the body via the bloodstream, leading to inflammation and increasing the risk of infections in the heart.
- Kidney disease: Chronic kidney disease (CKD) is also associated with an increased risk of oral health problems. Over time, CKD can lead to uremia, or an elevated level of urea and other waste compounds in the blood, which can cause a variety of dental issues. Research has found that people with uremia have higher rates of decayed, missing and detached teeth than the general population.
- Depression: While it won’t directly contribute to tooth decay, the effects of chronic depression can cause patients to neglect good oral care and nutritional habits, which can significantly increase their risk of cavities, gum disease and other dental problems over time.
Barriers to oral health care for people with disabilities
People with disabilities face several notable obstacles to accessing oral health care. These barriers can be caused by both medical and systemic factors:
Providers’ inability to assist people with disabilities
One of the most prominent issues facing people with disabilities is that many oral healthcare providers are simply not equipped with the tools and knowledge needed to properly treat them. Staff members in many dental offices may be either unaware of how to assist people with disabilities, unable to provide them with the accommodations they need or both. This may be due to financial concerns or a general lack of training. Some care providers may find it too difficult to interact with patients with disabilities, while others may feel unqualified or ill-equipped to treat them safely.
Lack of access to care
Because most dental offices are not adequately equipped to treat people with disabilities, many people with mobility and sensory impairments have difficulty finding dentists with accessible facilities that suit their needs. The lack of accessible care can adversely impact patient experiences and may deter people with disabilities from seeking treatment altogether.
Some potential accessibility barriers for people with disabilities include lack of reliable transportation to and from appointments, undersized offices or facilities, unsuitable equipment, lack of support staff, trauma triggers and providers who are unwilling to accept insurance plans like Medicaid and Medicare.
Communication problems
Communication is another major barrier to oral health care for people with disabilities. People with conditions like ASD and IDDs may struggle to interpret medical instructions, and may have difficulty explaining their needs and concerns to their care provider without assistance.
Additionally, many types of disabilities can make it substantially more challenging for people to understand and complete the paperwork needed to receive care. These issues can adversely impact the quality of care that patients with disabilities receive and can potentially make care inaccessible in some cases.
How providers can accommodate people with disabilities
Providers must take several steps to improve access to oral healthcare for people with disabilities. There are several ways that dentists and their staff can modify their practices, facilities and equipment to accommodate patients with different types of disabilities.
Hearing impairments
Visiting the dentist can be an uncomfortable and trying experience for people with hearing impairments. Some steps that dentists can take to accommodate hearing impaired and deaf people include:
- Minimizing background noise during visits.
- Utilizing written and illustrated materials to help explain procedures and diagnoses.
- Training staff members in American Sign Language (ASL).
- Switching to windowed masks that allow for lip reading.
Patients with hearing assistance devices should also be given the opportunity to adjust or turn off their devices before treatment begins. Taking these steps can help care providers improve outcomes and minimize stress for patients with impaired hearing.
Visual impairments
Visual impairments and blindness can also make receiving oral health care substantially more complicated. Fortunately, there are several ways that providers can improve access to oral care for people with impaired vision:
- For printed materials, utilize large type that stands out against the paper and is easy to read.
- Make sure the lighting in your facility is adequate.
- Speak clearly when addressing patients.
- Narrate the steps you take during treatment.
- Offer patients assistance when filling out forms.
- Escort patients to and from the treatment area if necessary.
- Make sure all pathways remain unobstructed.
Sensory sensitivities
Caring for people with sensory sensitivities is a variable process that requires special consideration. There are several steps that dentists can take to accommodate these patients:
- Install adjustable lighting in their facilities.
- Offer mediating devices to patients who need/want them, such as sunglasses and earplugs.
- Provide patients with coping tools, such as support animals and music.
- Help patients find a toothpaste flavor they are comfortable with, if possible.
- Allow patients to schedule appointments during non-peak hours.
Trauma-informed care
Taking a trauma-informed approach to care can help providers better accommodate traumatized patients. There are several ways that dentists can implement trauma-informed care in their facilities:
- Before treatment begins, agree on a signal that the patient can use to pause the procedure if they need to.
- Have comforting objects available, such as toys and blankets.
- Involve patients in the treatment process by allowing them to hold tools.
- Always use consent-based language with patients: “I’m going to do X now, is that OK?”
- Make sure all levels of your staff are trained in trauma-informed care.
Mobility impairments
It’s critical for dental offices to make sure patients with mobility impairments are accommodated as well. There are several ways that they can do this:
- Make sure there is adequate accessible parking with easy access to the building.
- Make sure your facilities are large and spacious enough to accommodate mobility assistance devices.
- If need be, assist patients as they travel from the waiting room to the treatment area.
By taking these steps, oral care providers and their staff can successfully treat more patients with differing needs. However, because unequal access to care for people with disabilities is a widespread societal issue, correcting the problem for all will take a concerted effort from industry leaders and policymakers.
Policies for improving oral healthcare outcomes
While providers can take steps to improve access on a day-to-day basis, lasting policy changes are necessary to fully address the oral healthcare disparities for people with disabilities. There are several ways that governments and healthcare organizations can alter their policies to improve oral health outcomes for people with disabilities.
Medicaid expansion
One of the major factors preventing people with disabilities from receiving oral health care is the lack of dentists that accept Medicaid. In total, only 39% of dentists in the United States accept Medicaid and the coverage it provides for oral care is extremely limited in some states. Medicaid participation by dentists can vary wildly from location to location, and many people with disabilities may have difficulty locating a Medicaid dentist near them.
In states with lower rates of provider involvement, greater numbers of patients are forced to seek care from the same sources, which can make it more difficult for them to find appointments with covered providers. This disparity can be corrected if more healthcare organizations enroll as Medicaid providers, which would qualify them for federal Medicaid reimbursements and provide disadvantaged patients with more options for care.
State and federal governments can incentivize more dentists to enroll and ultimately expand access to care by increasing Medicaid reimbursement rates for dental services. Additionally, governments in some states can assist patients directly by expanding their Medicaid coverage of dental care beyond emergency-only. This has the potential to reduce healthcare expenditures for states over time as it can improve patient outcomes and eliminate the need for more costly emergency care.
Specialized training for hygienists and technicians
Another important step for healthcare organizations is to ensure that their staff is trained to treat patients with disabilities. Since 2019, the Commission on Dental Accreditation (CODA) has required all dental schools to train their students in managing treatments for patients with intellectual and developmental disabilities (IDDs), including students in dental hygiene and dental assistant programs.
While this is a positive step toward equalizing access to care, many older dental professionals have not received this training and many dental offices still don’t have staff members who are trained. Dental care providers can address this issue by prioritizing this type of training in their hiring process and making sure that trained staff members are consistently present in their offices.
Additionally, educational and regulatory organizations can improve accessibility by expanding their training requirements to cover a wider range of disabilities and conditions including trauma, hearing and vision impairments, autism spectrum disorders, epilepsy and chronic diseases such as diabetes and heart disease
There is much work that still needs to be done to address disparities in oral health care for people with disabilities. Until lasting changes can be made by governments, practitioners and healthcare organizations alike, people with disabilities and their families must conduct research and take careful steps to find quality care for themselves or their loved ones.