Webcast
KMCO Archives
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.
Thank you for logging onto our webcast production. We're
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address is kmcouic.edu. Our telephone number is 312-996-2233
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