An Assessment of Oral Health Care Delivery to Children with Special Needs at Dental Schools in South Africa

Abstract

Background: Children with special healthcare needs (CSHCN) including adolescents may experience disproportionately poorer oral health and greater access barriers to dental care than those with no special care need (NSHCN). There is limited knowledge pertaining to the oral health status and delivery of dental care to CSHCN in South Africa (SA). Objective: The aim of the study was to assess oral healthcare delivery to CSHCN at academic dental hospitals (ADHs) in SA. The specific objectives were to: - compare the dental treatment provided to CSHCN and NSHCN at ADHs, describe the dental care services provided for CSHCN at ADHs, explore the perceptions of oral health professionals (OHPs) towards provision of dental care to CSHCN at ADHs and identify factors influencing the delivery of oral healthcare to CSHCN at ADHs in SA from the perspectives of OHPs. Methods: A sequential mixed methods study design was utilised. The inter-related methodological components to answer the research objectives included the quantitative phase of a narrative of literature review (2002-2023) on the oral health status of CSHCN in SA; a record review (2017-2023) of dental treatment provided under general anaesthetic (GA) to CSHCN and NSHCN aged 1-16 years at ADHs; a cross-sectional online survey conducted among OHPs at ADHs to assess their perceptions towards provision of dental care for CSHCN. The qualitative arm involved in depth interviews with clinical heads in Paediatric Dentistry at ADHs and a focus group discussion with OHPs from some respondents of the survey. Quantitative data was presented using frequencies and percentages. The Chi-square test and Fischer exact test were used for statistical analyses, and all tests were done at 95% confidence level. Thematic framework analyses were used to assess the qualitative data. Results: Twenty-six articles were retrieved for the narrative literature review and six studies that met the eligibility criteria were analysed. A total of 2,402 CSHCN were included in the review, 59.7% (n=1,433) of whom were male and 40.3% (n=969) were female. The age of the children ranged between 0 and 20 years. The types of CSHCN varied across the studies, and included, inter alia, intellectual/mental disability, cerebral palsy, learning disabilities, autism spectrum disorders, hearing impaired, physical disabilities, Down Syndrome, epilepsy, ‘complex/multiple disabilities’ and other health disorders. The prevalence of dental caries ranged from 22.5% to 85.2% and 68%-100% of the caries was untreated. v Four hundred records were retrieved from the ADHs for the record review study. Of the children treated under GA, 29% were CSHCN and 71% were NSHCN. The median age at assessment was 5 years (IQR: 3-6.5). The medical conditions of CSHCN who presented for dental treatment under GA included inter alia, cerebral palsy, various chronic medical conditions, craniofacial anomalies and other developmental disorders. The CSHCN were older than NSHCN, (p< 0.001). More CSHCN (52.6%) compared to NSHCN (25.4%) were referred from primary health care centres (PHC), (p<0.001). Caries was the main dental diagnosis. Overall, both groups received mainly extractions (43.5%), while 20% had restorative care and <10% had preventative care. Fifty OHPs completed the survey, and eight participated in the interviews. The majority of the OHPs were female (n=36; 72%), above 35 years (n=40; 80%) and two-thirds had more than 10 years of clinical experience (n=33;66%). Furthermore, the dental services provided to CSHCN comprised mainly of basic tooth extractions, restorative care, fissure sealants and oral prophylaxis. Oral surgery and orthodontics were the limited specialty services for children with cleft lip and palate. Four themes emerged from the perceptions of OHPs towards provision of dental care for CSHCN: - service provision, resource constraints, patient affordability and organisational factors. Other challenges experienced by OHPs at ADHs included inadequate infrastructure, theatre and sedation facilities, inadequate resources such as time, dental assistants, limited inter-disciplinary collaborations, and challenges with the children’s medical/behavioural problems. However, the OHPs felt positive and found their work fulfilling. They suggested proposals to alleviate the challenges they faced. Conclusions: The study findings revealed that CSHCN in SA were a diverse and heterogenous group. Poor oral health and high unmet treatment needs were prevalent among these children from the limited data available. Patients who received dental treatment under GA at ADHs in SA were CSHCN or NSHCN typically under the age of 6 years, presenting with extensive caries. The treatment provided consisted mainly of extractions with little restorative and preventative treatment. The OHPs at ADHs experienced challenges related to service provision, resource constraints, low patient affordability and organisational factors that in turn affected the availability of quality dental services for CSHCN. These challenges can be addressed by advocating for enhanced multi-disciplinary collaborations, creation of more public-private partnerships, increasing training opportunities for OHPs especially in PHC settings, properly vi equipping the PHC facilities to be able to provide basic dental services for CSHCN; thus, the travelling costs of patients and referral load to ADHs would be alleviated. Recognition of paediatric dentistry as a specialty in SA is long overdue so that the specialists can support the general dentists in the dental management of CSHCN and hence improve access to dental care.