Learning Practices in Community Oral Health with Vulnerable Groups

Disability is an objective and visible social phenomenon. Essentially it is a situation of physical, psychic or sensory impairment that affects specific people and is also reflected at the socio-cultural level. It is a dynamic condition which, in addition to its biological determinants, depends on socio-cultural, economic and other factors. According to World Health Organisation data, between 7 and 10% of the world's population is affected by some form of disability. Eighty per cent of disabled people live in developing countries, and in Argentina one third of the disabled are children under the age of 15.

Concern with overcoming the inequalities that continue to affect the disabled population has gradually gained momentum in the world and now has a significant impact on the design of health and social policies. In many areas, however, disabled people are treated as invisible citizens. Up to this point dental science has failed to address the dental health needs of this highly vulnerable group. This project is aimed at making a contribution towards solving the oral health problems of the disabled.

Providing dental care for disabled patients is still a ‘Cinderella’ issue when it comes to understanding and evaluating their health problems. Approaches and treatments that focus on biological and organic factors or are unidisciplinary in nature continue to be used; health policies do not address orofacial issues, and disabled people unfortunately do not seem to have the right to a healthy smile.

In July 1993, the Faculty of Dentistry of the National University of Cuyo in Mendoza (Argentina) and the Mendoza Dentistry Support Foundation (FADEOM) reached an agreement to create a space to provide care for the disabled: the Dental Care Centre for the Disabled.

At the same time, a curricular area was incorporated into the dentistry programme to explore the subject of disability in relation to dentistry. Up until this time, the subject had not been included in curricula in Argentina. This initiative reflected a clear need to train general and family dentists with an interdisciplinary vision that would enable them to deal with all primary care dental patients without distinction. Accordingly, the programme now includes a course entitled Dental Care for Disabled Patients, which is aimed at providing future dental professionals with an opportunity to learn about the problems associated with disability. This is accomplished by employing in situ strategies within institutions for the disabled and carrying out direct dental care actions in the teaching hospital (faculty). The project is based on the initiative of educators who are engaged with the social reality of vulnerable population groups—disabled infants, children, adolescents, adults and elderly people—and on an understanding of the need to provide university-level education that develops the basic knowledge and skills required to ensure attention to diversity.

Fourteen years after this important step was taken, after providing care for over 1000 infants, children, young people, adults and elderly patients, as health professionals we felt there was a need to broaden the initiative so that those with disabilities detected either at birth or later in their lives would be able to receive comprehensive health care and experience an improvement in their quality of life.

In the year 2000, the Dental Centre for Special-Needs Infants and Children was set up to provide early oral care for disabled infants and children from birth to age six.

Advances in the health sciences have led to improvements in care for the disabled and significantly extended their life expectancy. However, dentistry has not kept pace with this development in terms of maintaining their teeth, given that many disabled people have mutilated dentition.

A rise in the number of patients with chronic systemic diseases, disabilities and seriously compromised health requesting treatment in dental practices has led to a corresponding increase in the complexity of routine dental practice.

However, when disabled patients are treated and the focus is on the systemic disease, the oral cavity is the last issue to be considered. The actions of health teams are directed only towards dealing with the established disease, and performing an early dental examination is not a priority.

Consequently, a situation of inequality still exists in relation access to oral health services for children and adolescents with special healthcare needs.

The oral health of children and adolescents with special health needs is adversely affected by medication, treatments and special diets (some of which are high in sugars), difficulties with daily oral hygiene, parents who do not have enough information about the dentomaxillofacial growth and development of their children, and the attitude of professionals who think that the oral health of disabled people is not a matter of great importance.

A study on the demand for care and use of health services for special-needs children (1994-1995) detected a strong demand for dental health services. However, parents of disabled children said they had been turned away when they sought treatment and pointed to a shortage of dentists willing to treat disabled people.

Our work is based on a number of key principles: a focus on preventive dental care for special-needs patients, a recognition of the importance of working with parents and teachers, early referral to dental practices, respect for the time patients are able to tolerate procedures, and a recognition of the right of disabled people to be able to smile. By acting on these guiding principles, we have been able to reduce demand for emergency services, practices leading to mutilated dentition, and excessive use of general anaesthetic for clinical care.

The following factors were taken into account in our situational diagnosis of the target population we work with:

• The absence of oral health promotion, prevention and treatment programmes aimed at vulnerable populations (in this case disabled infants and children).
• The fact that oral health is not addressed in special educational institutions.
• The lack of preventive and rehabilitative clinical actions for the disabled, which results in high rates of tooth loss.
• The widespread refusal of public and private dentists to provide care for these patients.
• The fact that doctors do not refer these patients to dental practices.
• A lack of orientation and advice for parents.
• Dentists are not included on the multidisciplinary teams responsible for rehabilitation of disabled children.
• Shortcomings in the university training in this subject for future dentists.
• The lack of a local, regional or national dental care centre specifically adapted to address the problems of disabled children.

The course Dental Care for Disabled Patients is taught in the fifth year of the dentistry programme at the National University of Cuyo (Mendoza). It includes a series of actions and activities that combine classroom learning and fieldwork. The aim is to bring students into closer contact with the communities involved and provide a service to those communities.

The perspective we try to develop with students starts with the contact they have with disability in their own family environment, the way this problem is perceived, and the socio-cultural context. It reflects an inclusive care model in which disabled patients are provided with access to dental practices so that their quality of life can gradually be improved. Students must work out how to relate the knowledge they acquire over the course of their studies to the practical task of providing care for special-needs patients. Teaching staff face the challenge of creating educational situations that allow students, together with their instructors, to reflect on the reality of the disabled, think about theory and practice in this area, and develop strategies that facilitate effective health care.

After spending five years in the faculty learning about dentistry, students may find themselves dealing with patients who are not like the ones they are used to treating. During these first encounters they may find that the principles they learned during their university education are insufficient, that the techniques they have mastered cannot be applied in the same way, or that the dental materials they use are not effective.

Disability is a barrier that prevents them from applying their scientific knowledge. This is why—as we seek to provide students with a better understanding of disability by offering them an insight into the everyday lives of the disabled, engaging their creativity, and exploiting cultural resources—we employ and share a range of practices to help students overcome the barrier of disability. All of these practices have a common objective: to develop a clinical approach to dental patients that reflects mastery of content, a sense of security when addressing disability-related problems, and awareness that the difficulty of treating disabled patients can be reduced.

The activities students engage in provide them with opportunities to express themselves, participate and learn in an atmosphere that is natural and unconstrained despite its unfamiliarity. Instructors coordinate activities that arise out of discussions, improvise resources, solve problems, and support students as we engage in a process in which dentistry serves as a tool for improving the quality of life of disabled people.

To sum up, our team believes that this teaching-learning process opens up a multitude of possibilities that enrich teaching and learning: the classroom cannot be a substitute for concrete experiences that take place in the community.

1992; ongoing