General Dentists Approaches to Treating Challenging Children with Public Insurance

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 Childrens
Oral Health University of California San
Francisco (Supported by NIDCR grant U54 DE
14251)
2
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
3
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)

4
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
5
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)

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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

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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

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Sample Recruitment

• Convenience sample (N25)
• 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
  Californias Central Valley
• Recruited by direct approach of the interviewer

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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

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Dentist Demographics
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Results

• Challenging
• Patients
• Age
• Need
• Behavior

• Trial Exam
• Interpersonal Techniques
• Parental Presence/Absence
• Communicative Techniques

UNMANAGEABLE

• Referral
• Advanced Techniques
• Nitrous Oxide
• Protective Stabilization
• Oral Conscious Sedation
• General Anesthesia

MANAGEABLE
Successful Treatment
No Follow-up/ Treatment
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• Challenging
• Patients
• Age
• Need
• Behavior

• Trial Exam
• Interpersonal Techniques
• Parental Presence/Absence
• Communicative Techniques

UNMANAGEABLE

• Referral
• Advanced Techniques
• Nitrous Oxide
• Protective Stabilization
• Oral Conscious Sedation
• General Anesthesia

MANAGEABLE
Successful Treatment
No Follow-up/ Treatment
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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

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• Challenging
• Patients
• Age
• Need
• Behavior

• Trial Exam
• Interpersonal Techniques
• Parental Presence/Absence
• Communicative Techniques

UNMANAGEABLE

• Referral
• Advanced Techniques
• Nitrous Oxide
• Protective Stabilization
• Oral Conscious Sedation
• General Anesthesia

MANAGEABLE
Successful Treatment
No Follow-up/ Treatment
15
Trial Exam

• Interpersonal Techniques
• 1. Communicative Techniques
• 2. Parental Presence/Absence

www.pdalakewood.com
http//butterflypdds.com
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• Challenging
• Patients
• Age
• Need
• Behavior

• Trial Exam
• Interpersonal Techniques
• Parental Presence/Absence
• Communicative Techniques

UNMANAGEABLE

• Referral
• Advanced Techniques
• Nitrous Oxide
• Protective Stabilization
• Oral Conscious Sedation
• General Anesthesia

MANAGEABLE
Successful Treatment
No Follow-up/ Treatment
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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

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Nitrous Oxide

• laughing gas
• Reduces anxiety
• Does not require certification to administer
• Rarely used

www.rch.org.au
19
Physical Restraints

• Protective Stabilization
• Parental assistance/restraint
• Papoose Board
• Most commonly used

www.quickmedical.com
20
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
21

• Challenging
• Patients
• Age
• Need
• Behavior

• Trial Exam
• Interpersonal Techniques
• Parental Presence/Absence
• Communicative Techniques

UNMANAGEABLE

• Referral
• Advanced Techniques
• Nitrous Oxide
• Protective Stabilization
• Oral Conscious Sedation
• General Anesthesia

MANAGEABLE
Successful Treatment
No Follow-up/ Treatment
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Discussion

• Why do some referrals NOT result in successful
  treatment?

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The Influence of Public Insurance

• Challenging
• Patients
• Age
• Need
• Behavior

• Trial Exam
• Interpersonal Techniques
• Parental Presence/Absence
• Communicative Techniques

UNMANAGEABLE

• Referral
• Advanced Techniques
• Nitrous Oxide
• Protective Stabilization
• Oral Conscious Sedation
• General Anesthesia

MANAGEABLE
Successful Treatment
No Follow-up/ Treatment
24
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

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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

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Summary

• This investigation suggests that Challenging and
  Unmanageable children, particularly those with
  public insurance, often never obtain successful
  treatment for their oral health needs.

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Acknowledgements

• Supported by NIDCR grant U54
• DE 14251 and the Center to Address Disparities
  in Childrens 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