Dentistry, Managed Care, and Your Special Child
September 27, 2000
Hello everyone and welcome to our webcast from the Quality Community Managed Care project from the University of Illinois School of Public Health. This is Faye Eldar, your moderator.We have another webcast in our Kids and Managed Care series today. Our show today is about managed care, oral health and children with special health care needs. We have three speakers. Two of them are dentists; Dr. Fred Margolis and Dr. Scott Miller, and a parent speaker; Alyce Selman. We're going to be talking about managed care, oral health care and how families and dentists can work together to meet the special needs of children who have disabilities. I'd like to introduce our speakers and we will get on with our show. For each of the speakers, I'd like to just briefly introduce yourself and tell us where you are located and what kind of dental practice you have, and Alyce, tell us a little bit about who you are and your family and your child with special needs. We'll start with Dr. Margolis. Thank you, Faye.
I'm Fred Margolis. I'm a pediatric dentist. I'm in private practice in Buffalo Grove, Illinois, and I'm an assistant professor of dentistry at the University of Illinois College of Dentistry. I'm on the faculty at Loyola University where I teach in their general practice residency course. My subspecialty is dentistry for the disabled. I see both children and adults with disabilities. And I'm proud to say that I'm the author of a textbook called Beautiful Smiles for Special People, which will be included in the sources in this program, along with this program on the website. And the book is a source manual and course manual for dentists on how to care for disabled patients. I have had the pleasure of being the staff dentist for (inaudible) Cook campus for children with developmental disabilities for over 14 years, and I'm currently the staff dentist for the Center on Deafness, located in Northbrook, Illinois. Thank you, Faye, for having me on this webcast.
Thank you, Dr. Margolis. I know that you'll have a lot of useful information to share with us. And Dr. Miller. Yes thank you, Faye.
I'm a general dentist. I practice in Chicago. I've been practicing for 18 years, family practice. Currently the president of the Chicago Component of the Academy of General Dentistry. And I am also pleased to be here. Thank you.
Thanks a lot. And Alyce Selman.
Thank you, Faye. I'm a parent of three children and a wonderful husband. And my youngest child who just turned four was born with what's called apraxia developmental delay. And he goes to a special education class and I'm pleased to be here today. Thank you very much.
Q. Now Dr. Margolis, as a dentist, how would you define a child with special needs?
A. My definition would be any child with mental, physical or emotional problems. So this covers a wide gamut of children and a large percent of the child population in today's society.
Q.What are some of the things that are different about dental treatment and oral health care for children who do have special needs?
A. Well many of the children have problems with manual dexterity. That, of course, would come into play as far as oral hygiene, as far as holding the toothbrush, manipulating the toothbrush, flossing. We often teach the parent how to clean the child's teeth and how to floss the child's teeth so that this manual dexterity problem can be overridden. Another problem that we run into is the diet. Many of these children, because of their special needs, are on soft diets. And therefore, many times the food clings to the teeth and the hard foods are not chewed and help with cleansing action of the teeth such as eating an apple or chewing sugar-free gum to clean off the extra food debris. Medications. Many of these children are on medications. That becomes a problem because some of the medications are very high in sucrose and sucrose is made up of glucose fructose, which can cause the tooth decay from the plaque, the bacteria in the mouth, digesting the acid digesting the sugars producing the acids. So medications. Another type of medications that would come into play would be medications that dry the mouth. Saliva has a natural buffering action and this natural buffering action isn't there in patients with dry mouth. And therefore, they're more prone to dental decay we call dental carries. Gingivitis is also more prevalent because if we can't clean the plaque, the germs around the gums that cause the gum disease, then gum disease is going to be more prevalent.
Q. What is gingivitis, Dr. Margolis?
A. It's the inflammation of the gum tissue. And many times it leads to what we call periadontitis or destruction of the bone around the teeth. The teeth are held into the jawbone by the bone surrounding individual teeth. The other problem we run into are maliclusion or bite problems. For example, Downs syndrome patients, I saw one in my practice this morning, a little girl in for her first visit and I forewarned the mother that because of the enlarged tongue that Downs syndrome patients have, many times the tongue protrudes and pushes on the teeth and pushes them in unfavorable positions. So we have orthodontists that we work with and many pediatric dentists such as myself do some minor tooth movement to help allay some of these problems.
Q. Now when parents find out that their child has either been born with a disability or has been diagnosed with some type of special needs, are there any special measures or treatments that you advise the parent to do at home to help in the care of their teeth and mouth?
A. Well I'm glad you asked that, Faye, because the American Academy of Pediatric Dentistry and now also the American Academy of Pediatrics does suggest that all parents of "normal and special needs children" bring the children to the dentist by age one or when the first tooth erupts. Now why would a baby need to go to the dentist? So that we can instruct the parent in how to clean the child's teeth, talk about fluorides, which type of fluorides the child's receiving, if they are receiving too much or not enough, what types of toothpaste should be used, if at all and answer a lot of the questions as far as the individual child's needs, especially, of course, for children of special needs.
Q. And do you think most parents know that babies need to start seeing the dentist at age one?
A. No they don't. That's one of the reasons obviously for us doing the webcast so that we could inform more people that this is the case. Hopefully, the pediatricians and practitioners and nurses will let the parents know. All they have to do is hand them a brochure and say take your child to the dentist by age one or when the first tooth comes in so you can be more informed as to how to have your child go through life without any cavities or gum disease. You know, I think all of us need to be aware that tooth decay is the most common infectious disease among children in our country. That's correct.
Q.So that is an issue that we all need to be aware of. And are there any other kinds of treatments or medicines that put children at a high risk for dental problems?
A Yes. For example, some children are on anti-seizure medication and Dilantin to be specific. And this causes in many cases the overgrowth of the gums. The gingivitis we were talking about would be more severe where the gum tissue actually grows up sometimes over the teeth can become very serious and what we do is we dentists work with the neurologists, pediatric neurologists, to see if there aren't other medications that work as well and not causing the seizures to come about, but yet not affecting the gum tissue. There are also some anti-rejections medications for persons who have had transplants. For example, I've had patients who have had liver transplants and kidney transplants. And these patients are on certain medications that may cause also the hypertrophy or the overgrowth as we call it of the gum tissue.
Q. Okay well then it's important for us to be aware of that so we can get the information out to everybody. Now Dr. Miller, I have some questions for you about dental managed care. Our previous shows in this series have been dealing with managed health care, and now we'd like you to talk about managed dental care. We know that fewer people in our country have dental insurance as opposed to health insurance, but some, there is dental insurance and there is traditional type of dental insurance and then there are some different kinds of managed care. Could you explain that to us, please? Sure.
A. First we'll talk about the dental HMO. This is one type of dental insurance plan. Usually the family pays a lower premium through his through their employer than with regular insurance. Regular insurance we also call indemnity or fee for service. There are dentists who sign up to be providers under the HMO network, and they're paid a fixed dollar amount per patient per month. This we call capitation. And this is to provide all services under the plan. The payment makes the plan in essence a pre-paid plan. And then the family pays greatly reduced fees for the services and sometimes nothing at all. So the benefits to the family are reduced premiums and co-payments and no deductibles or annual maximums. The more services needed, the greater the savings in total. On the other hand, you can only choose a dentist from the providers listed with the plan and their may be reduced accessibility and/or coverage services under these plans.
The dental PPO is another type of insurance plan which differs from an HMO in that it does not involve a monthly capitation payment to the dentist. Therefore, it's not a pre-paid plan and resembles more the fee for service insurance plan, except there is still a network of contracted dentists and they've agreed to accept reduced fees according to a PPO fee schedule. Now the advantages to the family are that the premiums are somewhat lower than the fee for service and that they may still go to the dentist of their choice, even if they are not listed under the plan. The benefits paid are better for an in-network provider than for an out-of-network provider, but there are still some coverages opposed to the HMO setup.
Q. How do the dental HMOs and the dental PPO's play a role in dental care for children who have special needs? Well if the child is an HMO or PPO patient, and the general dentist cannot treat the child due to physical, dental or emotional problems, a referral to a pediatric dentist is appropriate. If there are contracted pediatric dentists, they would be the preferred referral. However, some plans may not have contracted pediatric dentists. Then one could be sought as an out-of-network provider under the PPO and there would be some benefits payable. Under the HMO, however, the parent would likely be responsible for the costs of going to a non-contracted provider.
Q. And what would be reasons that it would be better for a child to be seen by a pediatric dentist instead of the general dentist in your dental HMO?
A. Well I guess it would be, I wouldn't say it would be better, but I would say proper when when the general dentist feels that that the problems of the special needs child, that he would not be able to solve all of the problems of that child.
Q. Then you refer to the specialist. Now we know that in medical care, many of the managed care plans have a gatekeeper system where you have to see the primary care physician first in order to get a referral. Is that also the case in managed dental care that you have to go first to a general dentist before essentially getting permission to see the pediatric dentist?
A. Yes. In an HMO and also in the PPO, there is more or less a gatekeeper arrangement. You need to see somebody to be referred. That's correct.
A. Faye?
A. Yes.
A. If I might, Scott excuse me for interrupting, I happen to be a dental specialist as a pediatric dentist under several of these plans. And what I have found is that as as Dr. Miller has stated, that if the general dentist doesn't feel comfortable in treating the patient either because of the severe dental problem, unusual dental problem or difficult management-wise because of the child's disability or they feel more comfortable because of the child's systemic condition, they refer the patient to me after seeing them. But usually they they do try to screen the patient so to speak and try to do as much as they can for the patient and then they decide with the parent, gee you know I think your child would be better off going to a specialist because of this reason
Q. You know, there are dentists like Dr. Margolis and other pediatric dentists who specialize in seeing these types of patients. So it makes everyone comfortable. I would say that the biggest problem is finding the pediatric dentist to go to. I think Dr. Miller is right. Because there aren't very many pediatric dentists, there are only 4000 in the United States, sometimes the parent will have to travel a good distance in finding one.
Q. Okay now Alyce could you tell us if your family has had any experience with dental HMO's and PPO'sand if so, could you tell us a little bit about it?
A Well I've never had experience with a dental HMO. We do belong to a PPO through my husband's insurance to my husband's employer. And our option that we chose, I wanted Scotty very much to see a pediatric dentist. I did not feel with his special needs that he would do well. One of his special needs is sensory deprivation where he doesn't like anything touching his mouth. So I felt strongly that I needed to take him to somebody who would be able to deal with this situation and I chose to go to a dentist. In Fact, Dr. Margolis, who is not in this particular PPO, but to my husband and myself, this was our good option because it was the best possible situation for Scotty.
Q. You know, when you were looking at your insurance for dental care, first of all, did you have a choice in the type of dental insurance?
A. We did have a choice as far as my husband's past company offered us COBRA when he left and went to a different position. We opted to go with the COBRA plan, even though it does cost us money out of pocket which is a disadvantage to us. We opted to go with that because of the services both medically and dentally we would be able to get for Scott that were not available to us in the other PPO. We realized that by making this choice and going to a dentist who doesn't belong to this particular PPO that we are involved with, there is an extra fee involved. But that is our our choice and my basic philosophy as a parent is I'm I'm going to do what's best for my child even if it means I take another job or whatever it might be. And that was the choice we made, you know, for Scotty to do.
Q. Okay Dr. Miller, could you tell us when somebody is offered a choice of dental plans, what are things that they should think about before deciding which type of dental managed care plan to go into.
A. Okay. If you're given a choice of plan types, I think the parents should ask how much care they should expect their child to need over the years. If if the teeth are fairly well positioned or if the child has the dexterity to brush affectively or is cooperative with the parent's efforts you know to clean their teeth, then you know I think you can you can see the care would be minimal. If the teeth are malposed, they're you know if they're in different places or they're tight or there's you know cooperation problems, then, of course, care may be extensive. The more care necessary, then the more savings that you would realize under the HMO plan. Now the key is finding a capable dentist or specialist under the HMO. If if there is none, then the PPO would provide more options and the traditional plan even more options. And II think it's important to ask about the availability of any particular dentist in any case. Finally they can ask what the differences are in cost from plan to plan for that particular set of treatments.
Q. Okay and Alyce, can you tell us about decisions made in your family about whether your son, Scotty, who has special needs should go to the same dentist as your other children or did he need to see a specialized dentist and how did you arrive at this decision?
A. Well actually my two older children who are nine and eleven were going to a general dentist in the area and he he was a wonderful dentist and they did well with him, but watching my children with him, I realized that Scott was not going to be easy. He would not even take the chance and sit in the chair just for a ride and based upon the different problems he has with his mouth being that he has apraxia which is focused around the mouth and the speech and the sensory deprivation, I truly felt it was best to start the right way for me as oPPOsed to taking him somewhere, having a poor experience and then having trouble getting him to go elsewhere. I did decide afterwards after Scotty having such a great experience to switch my other children over to Dr. Margolis, my reasoning being that my other children do have some situations where they might not be cooperative and as they got older, I did predict that there might be times where there was decay, orthodontic work needed, etc. or teeth extracted and I just could not see my two older children being able to manage things other than a routine cleaning without somebody who was extremely experienced with behavior problems etc. So I opted just recently to to switch them and I found that they did extremely well under the circumstances and they seemed to be very happy.
Q. Well good. Thank you for sharing that with us. Now could you tell us a little bit about how you helped to prepare Scotty for the first time he went to the dentist? What did you tell him? How did you help him understand what is a dentist and what will happen in the dentist's office?
A. Well one of the things I always did which I do with our medical doctor too is I take Scotty with when my older children are going for appointments, whether it be to get their routine immunizations at the pediatrician or whenever I took my children for their routine dental cleanings so he was able to watch what was happening with them. he is extremely close to his brother and sister, so he he tries to be an "adult" just like they are. We told him that we're going to go meet Dr. Fred and he was going to peek at his teeth. He was going to count them just like they do with his brother and sister when they go to the dentist and we told him he might be lucky and have his teeth brushed today. I'm not going to tell you he was extremely enthusiastic because as a whole, Scott's not overly fond of doctors. But he went willingly. He played. He seemed to be fine and he adjusted. He adjusted fine. We also looked at a book about going to the dentist.
A. You know, if I can interject here, this is Dr. Margolis. Alyce, you brought up a couple things here. One of the things that Dr. Miller and I use as dentists for children that may be a little reluctant is forms of desensitization. For example, what Alyce described having her son watch her other two older children is called modeling. Now, of course, we have to make sure that the older children are good patients and so forth. But modeling works very nicely. Another type of desensitization is reading books to the child. In fact, we use a service called Dentisaurus which is kind of unique in that the it's a computerized book and it has the child's name and my name throughout the book and it introduces them in a non-threatening way with a little dinosaur going to the dentist to the dental experience. So this is another way. Reading books to the children. You can get books at the library that'll be very very good in desensitizing or getting the child use to what's going to happen before it happens. So these are things that I could recommend. I know Fred Rogers Mr. Rogers, has a great book on going to the dentist and there are quite a few others
Q. You know, we would appreciate it if you could make a list of some of these childrens books so we can put them in our resource section and share them
A. Sure.
Q. Now Alyce, I have another question for you. How did you explain to the dentist and hygienist about your son's special needs and how this could impact on what they would need to do to his teeth?
A. Well to start out with and I might sound a little stuck up here, but I insisted that Dr. Margolis clean my son's teeth himself. I felt more comfortable with that because it was enough just explaining to Scotty that he was going to see the dentist as opposed to me trying to explain to him in the beginning what a hygienist was and then the doctor coming in. I felt he would feel less threatened this way. What I did with Dr. Margolis is I sat down and explained Scott's problem with apraxia and Scott also had an immune deficiency at the time. And I sat down and explained everything to Dr. Margolis as well as I knew it. I also believe I brought in some paperwork that I had gotten off of the internet from you know explaining what apraxia was. I explained to Dr. Margolis about the therapy Scott goes to and gave him the name of Scott's therapist should he need to talk to her regarding his sensory deprivation problems.
A. One thing that I have found, Faye, and this is very very helpful is I would suggest that the parent contact the dentist prior to the appointment. We now in the last two months, my associate and I, have started to call ever new patient's parents and ask specifically if they have any concerns, whether they're "special" or not, see if the parent has any concerns about previous visits to the dentist that perhaps were not as pleasant as they could have been or thumb sucking habits or anything that's on the parent's mind so we know in advance how to work best with the child and answer the parent's questions.
Q. Dr. Miller, do you see any children with special needs in your general dental practice? I have one patient yes. He is II don't know how to describe his his condition, but he when he was very young, he had a an infection and it left him pretty much you know without use of his limbs and very very slow in development. And did the parent explain to you and your staff a lot about the child's special needs or did the staff ask a lot of questions? How did you handle that?
A. Well I I knew she comes in regularly, the mother, and she explained to me about the child and eventually she brought the child in and he, in fact, has a younger brother now and you know we got him into the chair and we did, he was pretty cooperative. We did an exam and he seemed to be okay. The mother seems to take pretty good care of him so far.
Q. Dr. Margolis, could you tell us a little bit about giving dental care to children who have behavior and cognitive difficulties that would make it difficult for them to cooperate?
A. Well I'll tell you about one young lady. Her name's Kerissa. Kerissa was my patient when she was three years old til about age seven and then for whatever reason the family stopped coming to the dentist for a few years. And Kerissa came back to me a few years ago. Kerissa is mentally retarded. She does communicate very well though verbally and seems to understand quite a bit. But her coordination is a problem, so we do have the parent help Kerissa. She's now a teenager and help with her brushing. But one thing we noticed was that Kerissa would not let anyone, myself, her father, her mother get into her mouth. She was very very much of a gagger. And what I did was we did something where we had Kerissa come back every two weeks for a period of six weeks and we did conditioning. It's sort of like the Helen Keller story with Helen Keller having been conditioned. What we did was I had the parent buy it's called a toothette. A toothette it looks like a sucker stick and it has a sponge rubber on the end of it. They use these in nursing homes and in institutions where it's difficult for the patient to clean the mouth and the teeth and so forth. And we had the mother start with a toothette and Kerissa would clean one tooth and then the mother would clean one and finally after six weeks of coming into the office every couple weeks, we were finally able to discover that the gagging was more mental than physical type of gag. Where now I can actually go in and do dental work in her mouth. She had some she had a root canal done recently. We also are able to go ahead and use the air tooth brush with the rubber cup and clean her teeth and scale them and clean them properly. And this is something that a year ago she wouldn't tolerate. So we try to use this desensitization. We use modeling. We use the Tell Show Do technique. What does the Tell Show do? Well we tell the child or the patient what we're going to do. We show them on a model or we tickle their fingernail with a tooth brush or whatever or showing them and then we go ahead and do it. I also use a mirror when I'm working. The mirror is attached to the operatory light above the dental chair so that the child can watch. There are some things, of course, we do that we don't want the children to watch, but it's really good for having them watch what's actually happening instead of imagining what may be happening. And we find that fear, of course, creates a negative dental experience. Well I think as adults we can all relate to that also and I think it's wonderful that you are willing to make such extensive accommodations. Now in terms of the young lady, what met her needs was coming into your office every two weeks until she could be ready for standard dental treatment. Is that something that would typically be supported by a dental managed care plan? No. No it wouldn't. It would not be covered. Fortunately, this doesn't happen too often. And that's why I used her specifically as an example. But I just wanted to use her as an illustration of what can be done with patients and understanding and, of course, the parent. The parent has to be willing to go along with the program. For example there's some things that Alyce comes in with her son. There's some understanding that Alyce and I have. A lot of these children if they're small, they sit on Mom's lap or Dad's lap and Mom or Dad can hold the hands or whatever as we're going ahead and proceeding to show the patient what we're going to do. And we use this you know Show Tell and Do technique. And it works out very nicely in most situations. Now Alyce can you tell us a little bit about following through with dental care at home for Scotty in terms of brushing his teeth, spitting out the water, using dental floss, eating the diet that's recommended by the dentist. What's that like? Well Scotty is is pretty difficult at home. The one advantage I do have is once again he likes to brush his teeth with his brother and sister, which now that they're back at school is not always a possible thing. We did try the toothette as Dr. Margolis explained and that did help him. The other thing that his therapist started doing is I'm not quite sure what it's called, but it's a type of vibrating machine that they put on his outer cheek to get him use to the sensory movement of having a tooth brush inside his mouth, and slowly but surely he has taken to that and and accepted it. He will go in and brush his teeth with water. He will not use tooth paste because he does not like anything like that material in his mouth. But he does do a very good job of trying. We try to do the chest to chest technique where I sit down and he sits on my lap facing me and we we try to brush his teeth. He's not overly fond of that because he he thinks of it more as me trying to restrain him in some aspect. But he does get motivated and go in and brush his teeth. I'm not going to tell you it's the best job in the world which is one reason that even though as I explained we have the PPO. I have opted to take Scotty in four times a year to have his teeth professionally cleaned as opposed to the recommended two times a year. That is my option and obviously is not covered those two extra times by insurance. But it assures me that the lack of teeth brushing he's doing at home is hopefully being made up and helping with his preventative care in the long run. And do you do flossing with him? At this time I don't. I really haven't talked to Dr. Margolis about this yet because I've been a little bit more concerned about at least getting the tooth brush in his mouth and particularly trying to reach back teeth. He will let you brush his front teeth, both upper and lower, but when you're starting to go anywhere backwards, he will start gagging and and he will pull away from you immediately. He doesn't like the feel of it by his tongue or on his teeth. You know since you brought up the back teeth, I would like the dentists to tell us a little bit about dental sealants, what they are and how they help children with special needs have better oral health. Doc, you want to start? Sure. Dental sealant is a fairly superficial sort of a filling material that you can place in the grooves of the teeth in order to prevent cavities from developing. Once the cavity goes past the enamal, you often have to do a regular filling and that involves much more willing and possibly some anesthetic for the child. So you can possibly avoid all that with a child whose diet or home care isn't so great for one reason or another by um when these teeth erupt, particularly the first permanent molars, putting a little sealant in the grooves. Let me also add just to clarify Scott, you mentioned that you don't have to do as much drilling. With dental sealants normally no drilling is necessary, no anesthetic is necessary because the material is simply painted on. A great way to think about it is just like the ladies and girls get nail polish on their nails, we put polish on the teeth. And as Scott said, we fill the what we call the pits and fissures the deep grooves and pitted areas of the teeth, especially the permanent molars. Sometimes 20 to 30 percent of the children I find have their baby molars have also deep pits and fissures and require sealants. The only trick to the sealants is you have to be able to keep the tooth nice and dry when you place the sealant so the material sets completely before the tooth gets wet. But otherwise, it's a great technique for prevention. We know that 83 percent of these teeth will eventually become decayed on the chewing surfaces and I would say that I use the sealants on 95 percent of my patients that come into the office. Are sealants something that you would recommend that families and children with special needs look into? Absolutely. All children. And does dental managed care plans do they usually cover having the sealants applied? Usually there is coverage. More than half the companies, the dental insurance companies, PPO's, HMO's and regular indemnity insurance fee for service would cover sealants. Okay these could be done in the dentist's office? Yes it's done in the office. Are there other times when children who have special needs need to get dental care in a hospital setting? Yes there are times when the child either because of their behavior being uncooperative or perhaps because of systemic problems. Perhaps they're hemapheliacs or have heart problems and the physician would recommend in consultation with the dentist that they feel the dental work care should be provided in a hospital setting. Most dentists are on the staff of a hospital and the anesthesiologist would provide the anesthesia for the patient and most hospitals in in the Chicago area and throughout the country have provisions for dental care to be done and have a dental staff. Is that something that either the managed care HMO or the PPO for dental care would consider as part of the treatment plan? Well I think I think that would cross over perhaps into into some of the medical coverage. What I have found is that they look into it on a case by case basis. And unfortunately, Illinois right now is not one of the states where dental services are considered the same as medical in a hospital setting. What I mean by that is many times the dental insurance companies will not pay for the dentist to go in and do his dental work under general anesthetic. They may they'll pay the dentist for doing the dental work, but they won't pay the hospital or the anesthesiologist. Again, there are exceptions to the rule, but on the whole, most insurance plans are not right now paying for this service. In over 20 states, thanks to organizations such as the American Academy of Pediatric Dentistry and the American Dental Association, American Academy of General Dentistry, has all been very very good in trying to get the legislators to go along in the hospitals and the insurance companies to say wait a minute. We put a child to sleep for a tonsilectomy and we won't put them to sleep to have their dental work done? That doesn't make sense. These are some of the issues that we're up against right now. What advice would you give to the family of a patient who has special needs and they're seeing you now I assume a small percentage of children may need some dental work in the hospital and the managed care plan, you know, the first time they ask does not approve them. What advice do you give to the families? Well fortunately there are several dentists and anesthesiologists in the state of Illinois for example, that we work with, and depending on the child's health conditions, we may be able to do some of these patients and we have done some of these patients in the dental office with the anesthesiologist present. The anesthesiologist would be the one who puts the patient to sleep or does I.V. sedation or sedates the patient and monitors the patient and has all the emergency equipment available in case the need arises. But we've done quite a few patients in the office. Fortunately, out of all my patients, we only have to use general anesthetic on approximately five to ten patients. Not percent. Patients per year. And Dr. Miller, if someone has to appeal a decision in their dental health plan, is that the same as a regular insurance appeal or is it different? I don't think they have the the setup that is so structured with the dental insurance. I think that you really have to enlist the help of your the gatekeeper to go in there and pitch for you. There are dental consultants that work for the insurance plans and I think the parent and the dentist and the dental consultant need to get together and talk about the case and perhaps get them on your side and maybe then they will decide to cover it in some way. faye, I have a recent report from a Dr. Wendy Mouradian. She's the project co-director from the U.S. Surgeon General's office and the conference on children and oral health and I would like to read you this quote. "The current health care system largely rations health care by ability to pay, a characteristic that is starkly evident in the oral health area. Many more families lack dental coverage than lack medical coverage. And for every child without medical insurance, there are 2.6 children without dental insurance. More than one third of all children in the United States lack dental coverage. Furthermore, current definitions of medical necessity typically exclude dental-related conditions. Another concern is the fact that programs specifically designed to provide dental coverage for the poorest children have failed to insure access. This is according to the Inspector General's report where fewer than one in five children insured under Medicaid, for example, receive dental exams." So I thought that you'd like that current information. I appreciate that information. This is something that we are very much aware of here and as a matter of fact, we recently have been involved with a group in Illinois called the I floss coalition which is a dental public health initiative of people who are dentists, people who are doctors, people from health departments, consumer advocates, people involved in the disabilities field to address the access issues. And that information will be posted up in our resource section as well as well as some national link so we can all do some more work on this important problem. Now as we close, Alyce, I wonder if you have some advice about dental care for other families who have children with special needs. Well my my big thing that I believe is that when you are talking to your child about going to the dentist, regardless of what the dental procedure is they're going to do, I believe in a short simple explanation for a young child or really for any child. I think the more detail you go into, the more scared you're you're making your child of the dentist. Some examples that I've seen lately that have sort of scared me have been I was sitting at Dr. Margolis' office one day and listening to a woman tell her children who were there, if you don't behave, the dentist is going to hurt you and pull out your teeth. And I think it's so important that we encourage our children that the dentist is a wonderful thing and that they're going to help your teeth so they're not scared, because special needs children have many things already with their doctors, their pediatricians and their specialists that they go to probably on a week to week basic. I know that for a long time Scotty went every two weeks to an immunologist and had blood drawn and many other invasive procedures and the last thing he wanted was another doctor. So we've tried to make it as comfortable as possible and explain in the short simple explanations as to why it's important for him to go and what's going to happen. And he accepts the short explanations. If I go any further into that, I think it scares a child. As a parent, I can really identify with what you're saying. I told you that I have a daughter who's a young adult now who has special needs. She's dead-blind and has cerebral palsy. She's a senior in high school. Now that I remember at age three, anytime she would met a woman she didn't know, she would ask are you a nurse? Are you going to give me a shot? When she went to the beauty shop the first time when she was five years old, is the lady a doctor for hair? That's what she experienced. You have to sit in the elevated chair. You have to put on a gown. There's a big light and you can't touch the instruments. Faye, the other thing that a lot of dentists do and we do this in our practice, is besides sending the book to the child, we send a welcome package to the parent. And in the welcome package, and this is for all parents, special needs and "normal" patient population also. And we instruct the parents as to what to say and what not to say. And we try to impart the feeling of just like when they visit Dr. Miller, you know your child's going to be visiting a new friend. And that's why I think the Mr. Rogers book is so good also because that's the way he talks and and that's his style also. In fact, my patients call me uncle Fred for that reason because of the friendliness imparted in the uncle. Well that's very nice.
Q. Now Dr. Miller, a final question for you. Since you have a general dental practice and see a lot of adults, do you give them reminders about when they have a baby they have to start at a year old in bringing the baby in and taking care of their teeth? Do dentists talk about that. It's been a while since I've been in that situation. I don't remember.
A. Absolutely. We tell them what to do from early on and in fact they're quite, the parents are usually quite interested in knowing exactly when it is that they're going to have to bring the child in for the first time. I say well it can be for an exam. It can be for a chair ride. It can be for a cleaning, whatever the child will tolerate at that point. One of the things I wanted to add in things not to say is I hear parents say to their kids or I know they've said something to their kids about it's okay to go to the dentist. He won't hurt you. And just by injecting that word into the phrase and to even use the word, if something's not going to happen. So I find that to be a common problem where the parents actually use the word pain or hurt or something like that and give the kid an idea. In other words, we need to think positively.
A. Yes I would say so. Always talk positively and also Faye, we should also not say too much. In other words, if the child says am I going to get a shot? Well he or she may need to have an injection of novacaine or local anesthetic as we call it. So I would rather have the parent say you know, I don't know. We'll have to ask the dentist and see what's best for you. But I will tell you that the dentist is your friend and that's why Mommy and Daddy are taking you to see him he or she, so that you can have nice healthy teeth and a great smile. So I think again, a positive approach is what we're trying to emphasize.
Okay. Well I want to thank you all very much for your contributions. You've given us a lot of really important information that will be helpful to many families and many medical and dental specialists also all over the country and I think we have a group of three experts. So I'm very very grateful for your help and this now concludes our webcast in the KMCO series on managed care and children with special health care needs.
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