Providing Dental Care for Disabled Patients

A teenage girl arrived at a dental office grimacing with pain. She pointed to one of her teeth but couldn’t answer the receptionist’s questions about when the problem began, what medications she was taking, or how she would pay for treatment. She had been profoundly deaf since childhood and couldn’t communicate without a sign language interpreter.

Her plight is but one example of what can happen when someone with a disability arrives at a dental office for treatment. Even though the federal Americans With Disabilities Act since January 1992 has required dentists to serve people with disabilities, the young girl was refused service because the dentist refused to pay for an interpreter.

Since dental offices are considered public accommodations under the Act, dental office, like any other public business, must be made accessible to people with disabilities.

"Certainly dentistry is among the categories identified in the statute to which people have a civil right to access," said Josephine Black, executive director of the Independent Living Resource Center, a nonprofit agency that provides assistance for people with physical and sensory disabilities in California’s central coast region. "This is a civil rights access issue, not a privilege. Dental and medical offices have an obligation under the law to provide accommodation."

Black’s regional office, based in Santa Barbara, provides services to about 1,400 people with disabilities each year and helps them with removal of barriers in the community, including architectural, communication, and attitudinal. Amy Hedberg, an advocate and communications assistant specialist in Black’s office, said the teenager who was refused service was one of two deaf sisters who needed an interpreter to go to doctor and dental appointments.

"I was referred to two dentists in the area by the girls’ high school interpreter," Hedberg said. "I called both of them and explained that I needed to get authorization for an interpreter. They both said they never had to pay for this before and saw no reason to start. One of them hung up on me," she said.

According to information provided by the American Dental Association’s legal division, the Americans With Disabilities Act also requires dentists to make reasonable modifications to their practices to facilitate access. The modifications may include rearranging part of the office, as well as changing policies that may have the effect of excluding disabled people from receiving care. The Act also requires dentists to provide auxiliary aids and services at their expense to disabled patients. In the case of the young woman who was deaf, the auxiliary aid could be a sign language interpreter, a note taker, or a qualified reader.

"There are also a number of issues related to physical access to dental offices if the patient is a wheelchair user," Black said.

According to Black, some dentists say that Medi-Cal doesn’t cover their expenses, so paying for extra services to provide access for the disabled causes them to lose money.

"The Americans With Disabilities Act isn’t looking to bankrupt any small business like a dental office," Black said, "but the practice can probably afford a $40 interpreter fee."

To ensure that their practices are ready to provide access to the disabled, dentists should allow for accommodation in their office budgets. Forms may have to be printed in large print format or read to someone who is blind. Some expenses are one-time only, like installing a wheelchair ramp, but there may be recurring expenses such as supplies that have to be planned for.

"This is about making access for disabled people like a normal person would, protecting and making decisions about their health," Black said. "It’s hard to deal with door slamming. We have often cut our fees for interpreters, but some dentists don’t even want to deal with it. It’s a lack of awareness and a lack of sensitivity that is modifiable."

CDA President Kent Farnsworth believes that the reason members fail to adhere is not because they don’t want to comply.

"I think it’s more that they aren’t always aware of what their responsibilities are under the Americans With Disabilities Act," he said.

Farnsworth said that if compliance requirements seem onerous, there are ways to appeal.

"But it has always been in dentistry’s best interest to accommodate those who are less fortunate and have obstacles to receiving care," he said. "It’s incumbent on us as small-business people to conform to the law of the land."

Members who want to find out more about what they’re required to do under the Americans With Disabilities Act can log onto the Department of Justice’s Americans With Disabilities home page at http://www.usdoj.gov/crt/ada/adahom1.htm. Telephone support is available from both the Department of Justice at (800) 514-0301 and from regional technical assistance centers for small businesses at (800) 949-4ADA.

Black said that for disabled people, the Act means trying to level the playing field. "They want to finally go where everyone else has gone before." she said.

First Survey of Human Genome Completed

The international Human Genome Project has completed initial sequencing of the human genome. This mapping of the molecular blueprint for human beings is expected to lead to a new era of molecular medicine for the prevention, diagnosis, treatment, and cure of disease.

The initial sequence represents only the first step in the full decoding of the genome, because most of the individual genes and their specific functions must still be deciphered and understood. Tens of thousands of genes have already been identified, including some related to deafness, kidney disease, breast cancer, hereditary skeletal disorders, hemorrhagic stroke and diabetes

Information from the initial sequence alone, however, is expected to generate significant contributions to health care. Scientists hope to use the working draft of the human genome to:

* Alert patients that they are at risk for certain diseases. Once scientists discover which DNA sequence changes in a gene can cause disease, healthy people can be tested to see whether they risk developing conditions such as diabetes or prostate cancer later in life. In many cases, this advance warning can be a cue to start a vigilant screening program, to take preventive medicines, or to make diet or lifestyle changes that may prevent the disease.

* Reliably predict the course of disease. Diagnosing ailments more precisely will lead to more reliable predictions about the course of a disease. For example, a genetic fingerprint will allow doctors treating prostate cancer to predict how aggressive a tumor will be. New genetic information will help patients and doctors weigh the risks and benefits of different treatments.

* Precisely diagnose disease and ensure the most effective treatment is used. Genetic analysis allows classification of diseases, such as colon cancer and skin cancer, into more defined categories. These improved classifications will eventually allow scientists to tailor drugs for patients whose individual response can be predicted by genetic fingerprinting. For example, cancer patients facing chemotherapy could receive a genetic fingerprint of their tumor that would predict which chemotherapy choices are most likely to be effective, leading to fewer side effects from the treatment and improved prognoses.

* Develop new treatments at the molecular level. Drug design guided by an understanding of how genes work and knowledge of exactly what happens at the molecular level to cause disease will lead to more effective therapies. In many cases, rather than trying to replace a gene, it may be more effective and simpler to replace a defective gene’s protein product. Alternatively, it may be possible to administer a small molecule that would interact with the protein to change its behavior.

The Human Genome Project makes its sequencing data available to public and privately funded researchers worldwide at no cost.

Soda Drinking by Teen Girls Linked With Bone Fractures

Consumption of colas and other carbonated beverages is associated with bone fractures in teenaged girls, according to an article in the June issue of the American Medical Association’s Archives of Pediatrics & Adolescent Medicine.

Grace Wyshak, PhD, from Harvard Medical School, Boston, analyzed self-reported survey data from 460 9th- and 10th-grade girls concerning physical activities, beverage consumption, and bone fractures to determine the possible association between carbonated beverage consumption and bone fractures among teenage girls.

Nearly 80 percent of the girls reported drinking carbonated beverages, 49.8 percent cola beverages only, 11.5 percent noncola beverages only and 15 percent both cola and noncola beverages. Approximately 20 percent of girls reported having had a fractured bone. The author found that the girls who drank carbonated beverages had about three times the risk of bone fracture than the girls who did not drink carbonated beverages.

The girls who reported high levels of physical activity and drank cola beverages had nearly five times the risk of fracture as those who did not drink carbonated beverages.

According to background information in the article, teen consumption of soft drinks is on the rise while their consumption of milk has plummeted. While considering past research, Dr. Wyshak speculates that the phosphorus contained in soft drinks may change the physiology of the body including a deleterious effect on bone due to the change in the phosphorus-calcium ratio or possible bone resorption from high levels of phosphorous.

UOP to Use $2 Million Grant to Assist Developmentally Disabled

The California Endowment, the state’s largest health foundation, recently awarded the University of the Pacific School of Dentistry a three-year, $2 million grant to expand and strengthen a successful community-based oral health treatment and prevention program for people with developmental disabilities.

"This award represents an exciting opportunity for people with developmental disabilities in California," said Dr. Paul Glassman, project co-chair and director of UOP’s Advanced Education in General Dentistry Program. "We know that dental problems are among the greatest unmet needs and this grant represents an opportunity to form community-based coalitions to address this significant problem."

UOP School of Dentistry, working in partnership with state-funded regional centers, has established the following grant objectives:

* Institute dental health care coalitions in eight communities throughout California;

* Implement community-designed and community-based networks for oral health care and prevention;

* Organize prevention training and services for agencies, consumers, and caregivers;

* Train and support local dental professionals in treating patients with developmental disabilities; and

* Establish a statewide task force for persons with special needs.

AHA Releases New Statement On Oral Health and Heart Disease

In a newly released advisory that it hopes will clarify current confusion, the American Heart Association notes that although oral health is a factor in reducing the risk of bacterial endocarditis, ordinary dental treatment has not been shown to prevent chronic coronary heart disease. Following is the text of the full statement:

American Heart Association Science Advisory:

American Heart Association Statement On Oral Health and Cardiovascular Disease

Good oral health is important in reducing the risk for acute cardiovascular disease such as bacterial endocarditis. There is limited and inconclusive evidence that oral bacteria may play a role in chronic cardiovascular disorders such as coronary artery disease. Whether this relationship will eventually prove to be significant, as one of the many factors in the development of cardiovascular disease, or of no significance is presently unknown. Regular professional and home dental care can reduce acute cardiovascular risk from oral microorganisms; neither routine nor extraordinary dental treatment procedures have been documented to prevent chronic coronary heart disease. The 1997 American Heart Association guidelines for the prevention of bacterial endocarditis in at-risk dental patients remain in effect as recommended.

NASA Research Leads to Laser With Dental Use

A laser device inspired by NASA research on atmospheric conditions could provide a one-laser system for use by dentistry on both hard and soft tissues.

Researchers at NASA Langley Research Center, Hampton, Va., have demonstrated that two of the laser wavelengths approved by the FDA for dental applications can be produced from a single, easy-to-use system. This development is expected to result in an increased interest in and use of lasers in dentistry.

Both wavelengths can be produced using the same hardware, reducing cost and complexity. Switching between the two wavelengths is accomplished by selecting the amount and rate of energy sent to the specially designed laser system. The resulting hardware is about one half the size of two distinct laser systems and does not require the laser system to be "tuned" by the operator, as with typical present-day systems, according to NASA.

"The dual system is simple because we’ve already done all the complex physics in the lab," said Langley laser researcher Keith Murray, one of three inventors of the dental laser technology. The other inventors are Norman Barnes, also of Langley’s Laser Systems Branch and Ralph Hutcheson of Scientific Materials Corp., Bozeman, Mont.

A typical hard tissue laser costs about $38,000, and a soft tissue laser costs around $25,000. The dual wavelength unit made possible by this new technology is expected to cost less than $30,000, according to NASA.

The discovery of the two-wavelength technology is a byproduct of work to develop high-power lasers for remote sending of the atmosphere, a key element in NASA’s atmospheric sciences mission.

Web Watch

Pages on herbal remedies

As herbs become increasingly popular as alternative remedies, dentists may want to educate themselves on the purported properties of these plant derivatives. Following are sites devoted to herbs and their effects. Their claims may very well be untested and unscientific, but patients may be reading this kind of information nonetheless.

For scientific information on possible interactions and precautions for herbs as they relate to dentistry, see "Herbal Supplements: Considerations in Dental Practice" by Richard P. Cohan, AB, DDS, MS, MA, MBA, and Peter L. Jacobsen, PhD, DDS, on page XXX of this issue.

http://www.botanical.com

News and information on food and food additives.

http://metalab.unc.edu/herbmed/

FAQs and other information on medicinal and culinary uses of herbs.

http://www.herbsociety.org/

http://www.wic.net/waltzark/herbenc.htm

The site of the Herbal Encyclopedia. Information on various plants and their uses.

Upcoming Meetings

2000

July 30-Aug. 2 Congress of the International Society for Lasers in Dentistry, Brussels, Belgium, +32 2 648 80 59.

Aug. 14-16 Association of Philippine Orthodontists National Congress, Manila, Philippines, (632) 890-2824

Aug. 30-Sept. 2 Surfaces in Biomaterials 2000, Scottsdale, Ariz., (612) 512-9103, http://www.surfaces.org/00pp.htm

Sept. 15-17 CDA Scientific Session, San Francisco, (916) 443-3382, Ext. 4470

Sept. 17-20 American Academy of Periodontology Annual Meeting, Honolulu, www.perio.org

Oct. 14-18 ADA Annual Session, Chicago, (312) 440-2500

Oct. 19-21 Academy of Surgical Research Annual Meeting (612) 545-1919, http://www.surgicalresearch.org/00sess.htm

Oct. 26-28 American Society for Dental Aesthetics, Millennium International Conference, San Francisco, (800) 454-2732, www.asdatoday.com

Nov. 15-18 American College of Prosthodontics annual session, (312) 573-1260, Ext. 15.

Nov. 29-Dec. 2 FDI World Dental Congress, Paris, http://www.fdi.org.uk/congress/index.htm

2001

April 19-22 CDA Scientific Session, Anaheim, (916) 443-3382, Ext. 4470

May 4-8 Australian Dental Congress, Brisbane, +61 (0) 7 3369 0477

Sept. 14-16 CDA Scientific Session, San Francisco, (916) 443-3382, Ext. 4470

To have a meeting included on this list, please send the information to Upcoming Meetings, CDA Journal, P.O. Box 13749, Sacramento, CA 95853 or fax the information to (916) 443-2943.