By Stephanie Stemmler
FIERCE ADVOCACY: DENTAL CARE FOR THE UNDERSERVED
CASSANDRA HOLLAND WAS THE FIRST TO RECEIVE TREATMENT FROM A DENTISTRY PROGRAM DESIGNED TO HELP PEOPLE WITH SPECIAL NEEDS. Photo by Matt Miller
Brushing. Flossing. Regular dental checkups. Many of us take these actions for granted to keep our teeth healthy and our smiles bright and intact. But what if you have a medical complication that makes it difficult, if not impossible, to receive routine dental services? “We fall through the cracks,” says St. Louis resident Sallye Holland. “And that has kept my daughter in pain for years and cost her almost half her teeth.”
Holland’s daughter, Cassandra, 42, was diagnosed with cerebral palsy and an accompanying seizure disorder at birth. Her muscle spasticity means that she might suddenly move and bite down hard, creating a risk for any dentist who tries to treat her. Beyond trying to brush Cassandra’s teeth at home, Holland was left scrambling whenever serious dental concerns arose. “For years, I kept a folder of phone numbers that I would call to try to get a dental appointment,” says Holland. “Every dentist I called was just not equipped to handle a patient like Cassandra. The closest place was probably Kansas City, and I couldn’t get there.”
Over time, Cassandra developed abscesses and infections in her mouth. Her teeth, decaying one by one, turned black. She was in daily pain. “I even brought her to a hospital emergency room, but the only thing the doctors there could do was give her medication to temporarily stop the pain,” says Holland. “They couldn’t do anything to help with the actual problem because hospitals don’t do dental procedures.”
Addressing the need
But now, at Barnes-Jewish Hospital, a team of specialists does just that. Thanks to a unique partnership forged by four health-care groups, people with conditions that had once made standard dental care impossible now can receive the care they need through the High Acuity Adult Special Needs Dental Program. Twice a month at the hospital, a collaborative team of specialists uses an operating room reserved for people with special needs. Before the work begins, general anesthesia is administered, which makes treatment possible.
“People weren’t getting the care they required,” says Jackie Martin, MD, MBA, vice president of perioperative services at Barnes-Jewish Hospital, “and if we weren’t able to help, then who? We’re here to serve the community, so we formed a team that aligns around a common vision.”
That vision—making essential dental care available to those without—is shared by all involved in the partnership: Affinia Healthcare, A.T. Still University – Missouri School of Dentistry and Oral Health, Barnes-Jewish Hospital and Washington University School of Medicine. These four teams worked through the inherent complexities in any such collaboration over the course of three years, then debuted the program as a pilot project in October 2021. Two months after start-up, the team declared it a success and, in January 2022, the High Acuity Adult Special Needs Dental Program became part of the official operating-room schedule at Barnes-Jewish Hospital.
“I believe this is the most significant relationship of its kind in the country,” says Alan Freeman, DMgt, FACHE, president and chief executive officer of Affinia Healthcare, a federally qualified health-care provider in St. Louis. “It’s a landmark achievement.”
A closer look at the problem
Before the high-acuity dental program was founded, administrators at Barnes-Jewish Hospital were aware of an increase in the number of patients seeking emergency dental services in its emergency department. Some of these people had special needs and were seeking care they couldn’t find elsewhere; others had limited access to dental care and, often, no dental insurance.
The Missouri Department of Health and Human Services noted in its 2020 Oral Health in Missouri report that in 2017 there were more than 56,000 dental-related visits to hospital emergency departments across the state. But an emergency room is not equipped to provide this kind of care, Martin notes, and patients with dental problems often are treated with short term pain relief and then referred to a dental clinic. Many of the those who arrive at an emergency room looking for dental care are there because they don’t have access to a dentist—because they lack dental insurance or don’t have a dental office nearby, or both.
In fact, the American Dental Association notes that Missouri has one of the highest levels of unmet need in the country. For people with special needs, the difficulty in accessing dental care is further complicated: The majority of dentists practicing in the state are not equipped to care for those with multiple medical, behavioral and physical complications.
Before their collaboration, the entities that formed the high-acuity program were working to offer dental services to those who, for a variety of reasons, don’t have easy access to care. Dwight McLeod, DDS, MS, dean of the A.T. Still – Missouri School of Dentistry, notes that the school was founded in 2013 to help meet the needs of the underserved. Two years after it opened its doors to students, it partnered with Affinia Healthcare—the largest community health center in Missouri—to create the St. Louis Dental Education and Oral Health Center, also known as the St. Louis Dental Center. A.T. Still students spend the last two years of their dental education working at this clinic, which offers affordable dental services for people of all ages. Before collaborating with A.T. Still to open the dental center, Affinia was working to meet the need by operating dental services clinics in the region—and providing services through a mobile dental clinic to children in under-resourced areas.
Despite these efforts, the number of dental-related visits to emergency rooms indicated the need for more intervention. In response, the Centene Charitable Foundation, working with A.T. Still and Affinia, funded the creation of the Centene Charitable Foundation Urgent Dental Care Center in 2017. This center treats people who don’t have dental insurance. In 2018, Barnes-Jewish Hospital made a $1.5 million grant over five years to A.T. Still to support expansion of the Urgent Dental Care Center’s hours. To date, the center has treated more than 20,000 people.
Additionally, the St. Louis Dental Center established a special-needs dentistry clinic within its existing program. It was designed to treat people with intellectual, physical and behavioral differences that make standard dental care difficult. “We offer these patients teeth cleanings, sealants, fillings, crowns, bridges—even oral surgery,” says Robert Schmidt, DDS, MS, former director, Special Care Unit - Special Needs Dentistry, and a professor of clinical education. “But some high-acuity patients can’t or won’t open their mouths or sit down.” These patients, he notes, “need to be fully sedated during procedures, an option the St. Louis Dental Center can’t provide.” The High Acuity Adult Special Needs Dental Program was created to help solve that specific problem.
A tailor-made solution
General anesthesia—and the safety protocols it requires—make dental procedures possible for people who otherwise couldn’t receive care. Beginning in 2019, Washington University and Barnes-Jewish Hospital administrators met regularly with A.T. Still and Affinia partners to develop protocols for dental procedures to be performed in the hospital’s operating room. “We use the same safety procedures and quality-of-care measures for all our patients, whether they are being treated in the OR for dental problems or needing some other procedure,” says Washington University anesthesiologist Ivan Kangrga, MD, PhD, one of the specialists involved in establishing the program.
That commitment to safety means that all dentists, oral surgeons and dental assistants treating patients in a Barnes-Jewish operating room have received credentials from the Washington University School of Medicine’s Department of Otolaryngology. To further ensure and maintain quality, all dental and X-ray equipment was purchased by the hospital and donated to the program. “We left no stone unturned,” says Kangrga. “Equipment, pharmacy services, patient transport, training of certified nurse anesthetists, emergency contingencies: We carefully considered each aspect of the program before the first patient was scheduled.”
How the program works
People requiring high-acuity dental care—and general anesthesia to receive that care—are first evaluated at the St. Louis Dental Center; preadmission paperwork is completed at Barnes Jewish Hospital. The hospital provides a dedicated operating room two days each month to help make scheduling easier. “We’re a busy hospital,” says Kangrga, “so having an established schedule helps ensure we meet the ongoing need.” Martin adds: “Every person we treat through this program has value. Every partner supporting the program is committed to making our patients’ needs a priority.”
Schmidt notes that, currently, the High Acuity Adult Special Needs Dental Program has nearly 100 people on its waiting list. He adds: “By the time those patients receive treatment, we’ll have added 100 more to the list.”
Treating the first patient
“I remember it well,” says Schmidt, referring to the day Cassandra Holland, the first person treated within the high-acuity program, arrived at Barnes-Jewish Hospital for dental care. “We didn’t know what to expect because we weren’t able to examine her until after sedation.”
For Holland, treatment required 13 extractions and nine fillings. But the team managed to eliminate the source of her pain—and preserve much of her smile. “I was actually surprised she didn’t lose more of her teeth,” recalls Sallye Holland. After the procedure was done, she says, “I was singing everyone’s praises and thanking the Lord because my daughter was no longer suffering like she had been for years.”
Freeman sums up the effort to develop the high-acuity dental program this way: “Fierce advocacy recognizes that some people have less than others. Collaborative efforts by willing partners can make a difference. This program is a superb example of fierce advocacy by everyone involved.”