Da Rosa Barriers in Access To Dental Services Hindering The Treatmentpdf
Da Rosa Barriers in Access To Dental Services Hindering The Treatmentpdf
Da Rosa Barriers in Access To Dental Services Hindering The Treatmentpdf
Research Article
Barriers in Access to Dental Services Hindering the Treatment of
People with Disabilities: A Systematic Review
Copyright © 2020 Saulo V. da Rosa et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background. People with disabilities tend to have greater oral health problems compared to those without disabilities. This may be due
to barriers they come across in accessing dental services. Objectives. The objective of this systematic review was to provide a critical digest
of the scientific literature concerning barriers and facilitators of access to oral health services for people with disabilities. Methods. The
electronic databases PubMed, Scopus, Web of Science, Latin American and Caribbean Health Sciences Literature (LILACS), and
Brazilian Library of Dentistry (BBO) were searched using keywords relevant to the subject. The search was not restricted to specific
languages or years of publication; all relevant studies were translated and reviewed. Results. Sixteen studies including 14 articles, a
doctoral thesis, and a monograph were selected, and their quality was analysed using the Downs and Black assessment tool. Barriers to
dental services were divided into physical or nonphysical based on the dentist’s perspective, as per the perception of parents/guardians or
by the persons with disabilities. The barriers that emerged included the dentist’s lack of preparation to assist people with disabilities,
structural problems of access to dental offices, communication difficulties, and lack of awareness regarding the need for dental treatment
for the disabled person. Conclusion. It is concluded that people with disabilities continue to run into complex physical, behavioural, or
multidimensional barriers in accessing dental services. Improved training of dentists for the care of this population is hereby em-
phasized. The legal framework enabling access to dental care for people with disabilities must also be respected in each country.
When individuals with disabilities take initiative to ac- manually searched to add all the relevant publications that
cess health services and gain access, they subsequently may not have been included in the main search. At this stage,
choose to continue care in services that have empathetic, the grey literature was also accessed through the ProQuest
compassionate, and responsible professionals [11]. Yet, Dissertations and Theses Full-Text databases, CAPES Theses
access to care is deemed to be the first barrier to the initiation Periodicals, the Grey Literature Report, and Google Scholar.
of a health service, wherein the patient’s problem should be Abstracts from the annual conference of the International
known and their therapeutic itinerary in the service network Association for Dental Research (IADR) and its regional
be traced so as to solve the health problem [12]. Access to divisions (1990–2018) were also searched.
health services by persons with disabilities should consider The search strategy was appropriately modified for each
(but not exhaust themselves with) their most basic and database; two reviewers (SVR and LCT) performed the
specific health needs [5, 13, 14]. search in order to identify eligible studies. Table 1 depicts the
Knowledge of the main barriers that hinder oral health details of the search conducted with the search date and
care in people with disabilities needs to be discussed. Access number of articles found in each database.
to care is determined by the geographical location of the
patients and services, the convenience and ability to organize
services in order to accommodate the individual, their 2.2. Eligibility Criteria. Though observational studies (cross-
adaptability to the service provided, and the reciprocal ac- sectional, cohort, and case-control) were included, editorial
ceptability of professionals and end users [15]. Access is letters, historical reviews, in vitro studies, controlled trials, case
determined by the type of health system in each country and reports, comments, and qualitative studies were excluded from
the local context. In order to enable access to health care, the the present study. No language or publication date restrictions
health service must meet the needs of the user, be available, were imposed; all relevant studies were translated and revised.
and be appropriate to the population.
Thus, universal access to health services comprise (i) a 2.3. Data Collection and Analysis Process. After the exclusion
political aspect involving decision-making and agreement by
the different levels of the government in a country, thereby ®
of duplicates, using the Mendeley reference manager,
studies were initially screened on the basis of titles and
prioritizing and programmatically arranging the services and abstracts. Articles that appeared in more than one database
the intervention devices in context; (ii) economic and social were considered only once. The full-text versions of the
aspects that cover financing issues and mitigation or elimination articles were evaluated by a pair of reviewers (SVR and LCT)
of barriers encountered by the user; (iii) system organization who determined study eligibility; disagreements were de-
starting from the user’s entry into the service up till the reso- cided by a third reviewer (JSR). Each eligible article was
lution of their health problem; and (iv) technical-scientific assigned an identification code (first author/year) to facili-
training and cultural competence, through comprehensive tate its classification. Inter-rater reliability was calculated by
actions and respect for individuals, understanding the health- Kappa statistic; a value of 0.87 was considered optimal.
disease transitions, beliefs, values, and traditions [16]. Relevant information on study design, participant charac-
Based on the above, the objective of this systematic teristics, exposure, and outcomes was extracted through a
review was to critically gather from the scientific literature customized pretested data extraction form (Figure 1).
the main barriers and facilitators of access to oral health
services for people with disabilities.
2.4. Bias Risk Assessment. The quality of the articles was
2. Materials and Methods assessed by two independent reviewers (SVR and LCT) using
the Downs and Black scale [21]. This instrument is used for
2.1. Search Strategy. This systematic review was carried out quality assessment of observational studies and randomized
according to the Cochrane Collaboration Guidelines clinical studies and comprises 27 items totalling up to 32
Combined [17, 18], Meta-analyses Of Observational Studies points (higher scores indicating superior quality). In this
in Epidemiology (MOOSE) [19], and according to the model review, a modified version [22–28] of this instrument was
Preferred Reporting Items for Systematic reviews and Meta- used which consisted of 17 items (1–3, 5–7, 9–11, 16–18,
Analysis guide (PRISMA) [20]. Prior to its initiation, the 20–22, and 25–26), totalling up to a maximum of 17 points.
protocol for this review was registered at the PROSPERO The relevant domains for the instrument included de-
database (protocol number: CRD42018107571). scription, external validity, and internal validity (confusion/
The guiding question of the review was defined as follows: selection bias). Disagreements in the quality of the articles
How do people with disabilities access oral health services? were resolved by a third reviewer (JSR).
The keywords were selected based on the study question For each aspect of quality assessment, the risk of bias was
and study population. scored according to an adapted version of the Cochrane Col-
Online databases were consulted from August 24, 2018, to laboration tool [17], which included the top four domains from
August 27, 2018, based on the date of online availability and the Downs and Black quality assessment tool. Studies were
included PubMed, Scopus, Web of Science, Latin American considered to have a “low” risk of bias when the domains
and Caribbean Health Sciences Literature (LILACS), and the external validity, internal validity, and description attained their
Brazilian Library of Dentistry (BBO). In addition, the ref- maximum scores. A single study presented a risk of “unclear”
erences cited in all the primary studies included were bias when the criterion description was not fulfilled and/or was
International Journal of Dentistry 3
unclear in the other key domains. A “high” risk of bias was accessed, type of dental procedures, and types of disabilities),
considered when a study did not meet the criteria internal and and source of the study population. Because of the het-
external validity, and when more than two items reflected a high erogeneity of the studies, a meta-analysis was not performed.
risk of bias in the domain description. The target audience of the questionnaires were people with
Kappa was also performed to measure inter-rater disabilities; however, the dentist was interviewed. Also, the
agreement and to analyse the risk of raters’ classification diversity among the studies was due to the age or the age
bias. A Kappa value of 0.86 was attained, which is considered groups of the target population, the difference in the health
optimal as per the relevant literature. systems in the countries studied, and differences in the type
of disability.
3. Results
3.1. Summary of Results. Data were analysed using the 3.2. Characteristics of Included Studies. A total of 2,190 ar-
extracted information which included the study title, author, ticles were derived from all the databases after removal of
year, country, sample size, study design, study results duplicates (Figure 1). However, the number reduced to 59
(barriers encountered in dental care, types of services articles following careful reading of titles and summaries.
4 International Journal of Dentistry
Articles found
Articles found Articles found Articles found Web of
Identification
PubMed Scopus LILACS e BBO Science
(n = 1805) (n = 311) (n = 4) (n = 421)
health (1)
(vi) Speaks about a specific
Articles included for
program (1)
quality review and final
(vii) Not found in full (22)
review (n = 16)
Figure 1: Flowchart of the study selection process according to the PRISMA guidelines.
Subsequent to reading the full-text versions, 43 articles were Only two studies were derived from a secondary data-
excluded for the reasons such as (i) use of a qualitative base [72, 74], and the other fourteen discussed data from
approach (n � 7) [29–35]; (ii) included subjects other than primary sources that had a cross-sectional observational
people with disabilities (n � 4) [36–39]; (iii) did not discuss study design.
access, barriers, or facilitators of care (n � 6) [40–45]; (iv) did
not specifically address oral health (n � 1) [46]; (v) were
highly restricted and dealt with only a specific program 3.3. Bias Risk Assessment. The results of the bias risk as-
(n � 1) [47]; and (vi) were not available in full text for reading sessment are shown in Table 3. One study showed a low risk
(n � 22) [48–69]. of bias for all the assessed items [74]. Though, three studies
Table 2 depicts a summary of the characteristics of the 16 depicted an unclear risk of bias [70, 72, 84], seven of them
studies that were finally included. It is noteworthy that one showed a high risk of bias due to ambiguity in the de-
was a doctoral thesis and another a monograph (grey lit- scription of confounding factors and their adjustment
erature). The studies originated in several countries and during the selection of the study participants
continents; six studies were from North America with four [5, 71, 76, 79–82]. With respect to external validity, three
from the United States [70, 72, 74, 77] and two from Canada articles presented a high risk of bias [70, 82] and one pre-
[71, 76]. There were six studies from Brazil in South America sented an unclear risk [75]. At this stage, the extent to which
[5, 79, 80, 82–84]. Two selected studies were from Europe, of the study conclusions could be extrapolated to the studied
which one was from England [73] and the other from the population was evaluated. On assessing internal validity
Netherlands [75]. A single article was selected from Malaysia (systematic error), only one article showed a high risk of
[81] and another from Australia [78]. bias, the main outcomes of which were not accurate and the
Table 2: Characteristics of the studies.
Study Statistical Most frequent dental
Author/year Country Type Sample Sample features Types of services Types of disabilities
design analysis procedures
Persons with Treatment paid by
disabilities from the federal government Emergency treatment,
Burtner
United Cross- 362 Florida Department of Not funds. Private examination and
et al, 1990 Article —
States sectional respondents Health and adjusted payment through prophylaxis, other
[70]
Rehabilitation, United private plans or services.
States. Primary data. funds.
Examinations, oral
Asthma, autism, cancer,
radiographs, panoramic
cardiac arrest, cerebral palsy,
radiography, topical
International Journal of Dentistry
+ , low risk; ? , unclear risk; – , high risk. ∗Adapted from Cochrane Collaboration. ∗∗Adapted from Downs and Black, scores from zero to 17
access to care facilities, such as surgeries being performed on many countries such as Brazil, as access to dental care is a
the upper floors of buildings that did not have elevators and right of the disabled.
not remembering that dental extraction is a common re- Family involvement in access to care for people with
quirement among people with disabilities [75, 81]. Inade- disabilities is very essential, as family support and emotional
quate dental facilities are also barriers that affect access bond play a fundamental role in their health. Expecting a
[70, 76, 80, 84]. The compromised mobility of people with child with disabilities can inflict emotional distress and guilt
disabilities affecting their ability to reach the place of care is in parents, who are required to prepare appropriately and
yet another critical barrier and has been reported in three introject situations of difficulty that they may encounter,
studies included in this review [76, 82, 83]. Difficulties in given the social, structural, and programmatic inequities that
access due to lack of adaptation to health care facilities and place a disabled person in a vulnerable situation [88]. The
offices has been mentioned in four studies [76, 77, 79, 81]. To family of children with disabilities may be in denial upon
overcome such barriers, dental offices and dental centres identification of the condition, as they lack preparedness to
must follow and abide by accessibility laws as enforced in care for a child with a disability. They tend to adapt as they
10 International Journal of Dentistry
seek information in order to meet the care needs of their with disabilities. It has doctrinal principles: universality,
loved ones. Subsequently, they enter a phase of acceptance, equity, and comprehensiveness [94, 95]. Primary care is the
when they establish an emotional bond with their child and gateway to the SUS; there are family health teams (FHS)
understand their health care needs [89]. which aim at comprehensive multidisciplinary care of the
People with disabilities often have a number of associated people [96]. In the year 2000, dentists were included in this
health problems such that oral health care takes a back seat in team with the objective of oral health actions and services as
the family [10]. This barrier to oral health care was also a part of primary care [96]. Among the barriers observed in
detected by Nelson et al. [77]. Koneru and Sigal [76] also the studies conducted in Brazil, the lack of trained profes-
encountered a perceived lack of dental treatment in parents or sionals for the dental care of people with disabilities was
caregivers. The dearth of time to take the affected child or the prominent, given that these surveys were conducted among
guardian to the dentist was reported by Nelson et al. [77] and people who attended the SUS [5, 79, 80, 82–84].
Dantas Cardoso [82]. Cardoso et al. [80] cited instances in In the United States, the most frequent barrier was the
which as per the perception of the parents or caregivers, the lack of experience among dentists and the cost of treatment
child with disability did not need care. Instances depicted by [70, 72, 74, 77]. The latter reflected the characteristic of the
Nelson et al. [77] reflect the lack of knowledge regarding the country’s health system, whereby there was no universal
need for oral health care. These included situations where the system followed, and one had to pay for health insurance or
child was deemed to be too young to see a dentist, the father use Medicare and Medicaid, which are subsidized by the
feared a visit to the dentist, or when the child had recently government for vulnerable groups of patients [97]. In
exfoliated his or her deciduous teeth. Therefore, access to Canada, the health system is provincial with variations in
information and health education for parents and caregivers each province; however, access to oral health services is
of people with disabilities can overcome these barriers [90]. mostly not covered by this system [98]. The type of health
The studies selected belonged to various parts of the system in a country is therefore a crucial determinant of the
world, with representation from the United States physical barriers and the cost of treatment [71, 76].
[70, 72, 74, 77], Canada [71, 76], Netherlands [73], Malaysia The difficulty to provide dental care and the lack of
[81], Australia [78], England [73], and Brazil trained professionals to care for people with disabilities has a
[5, 79, 80, 82–84]. Although these countries have diverse direct influence on their oral health. The procedures that
health systems, barriers to care reported in these studies were need to be performed are most often on patients requiring
similar. One of the most common barriers was the lack of urgent care where they are already in pain, mandating tooth
preparation and experience of the professional for dental extraction due to decay or prophylaxis due to bacterial
care of disabled persons [5, 70, 75, 77–80, 84]. Knowledge is biofilm accumulation. Procedures such as restorations and
fundamental for good dental practice, and innovation and preventive treatments can be performed in order to prevent
the use of instruments that can facilitate the time of care can tooth mutilation. The use of prostheses can also restore the
always help in the treatment of people with disabilities when well-being and quality of life of people with disabilities
we do not have a collaboration during the consultation [91]. [70, 71, 74, 76–78, 80–83].
This is a significant finding, which reflects upon the training The compilation of the barriers observed was derived from
received by the dentist or even the dental curriculum, which studies using quantitative methods which in turn may be a
does not consistently cover the theme of dental care for limitation of this systematic review, considering that qualitative
people with disabilities [92]. In such situations, continuing studies may approach barriers differently. For example,
health education programs can aid dental professionals to qualitative studies are ideally not limited to structured ques-
keep abreast of the techniques to meet the needs of people tions with closed options, and one’s view of access to services
with disabilities. can be further explored, thus opening horizons for another
Permanent health education allows professionals to re- systematic review (metasynthesis) for qualitative studies. An-
fresh their knowledge and practices through latest evidence other limitation to be considered was the inclusion of only
and the best treatment approach available, thereby enabling cross-sectional studies. Finally, it is alarming that facilitators of
the enhancement of technical skills, scientific knowledge, and access to dental services for people with disabilities have not
ethical development of the processes and also building re- been discussed or reported in these revised studies, which paves
lationships between the teams involved. The appropriate way for further studies in this field, aiming at solving the
distribution of professionals and services to the proximity of barriers that hinder access to dental services.
the population in need, irrespective of their location with an
aim to improve access to care and to enable continuing health 5. Conclusion
education, is a complex task, as there is a noticeable con-
centration of specialized professionals in large centres [93]. People with disabilities continue to encounter various
This imposes alternatives such as the virtualization of learning physical, structural, geographical, professional, or behav-
through nonpresent or semipresent modules. ioural barriers that hinder their access to dental services.
Most of the studies included in the review were centred Furthermore, there is a need to improve the training ren-
primarily in countries such as Brazil, the United States, and dered to dentists pertaining to care for this population in
Canada. Brazil has a universal Unified Health System (SUS) various national and regional contexts. It would be ideal to
enshrined in its federal constitution of 1988. It is a free enforce and implement accessibility laws in every country.
system accessible to all Brazilian citizens, including people Therefore, a lot remains to be achieved by the society with
International Journal of Dentistry 11
Table 4: Continued.
Barriers
Physical Nonphysical
Author/year Country
Dentist’s Caregiver/responsible Caregiver/responsible
Dentist’s perception
perception perception perception
(1) Difficult to take time
off from work to bring
child to the dentist
(2) Difficult to find
dentist willing to treat
child because of their
medical condition
(3) Dental care is very
expensive
(4) Difficult to find a child
dentist nearby
(5) Difficult to travel to
the dental office
(1) Difficult to find an (6) The dental team is
Nelson et al., United
— affordable dentist’s office for — anxious or nervous
2011 [77] States
the disabled treating children
(7) Child is afraid of the
dentist
(8) Child does not like to
do anything to his mouth
(9) The child is too young
to see a dentist
(10) Dad is afraid to go to
the dentis
(11) The child has only
recently fallen milk teeth
(12) The child has other,
more urgent health care
needs
(1) Lack of dentists with
adequate skills in
managing people with
disabilities
Pradhan
(2) Cost of treatment
et al., 2009 Australia — — —
(3) Inconvenient location
[78]
of clinic
(4) Lack of dentists
willing to treat people
with disabilities
(1) Difficulties in getting to (1) Does not have dentist
the service due to lack of in health unit
adaptation of access routes to (2) Fear; the patient
the health unit for people refuses to go
Aragão et al.,
Brazil — with walking difficulties — (3) Difficult to get
2011 [79]
(2) Difficulties in service vacancy
entrance due to lack of (4) Long service
adaptation of the building (5) Does not like the
structure service
International Journal of Dentistry 13
Table 4: Continued.
Barriers
Physical Nonphysical
Author/year Country
Dentist’s Caregiver/responsible Caregiver/responsible
Dentist’s perception
perception perception perception
(1) Low dentist offer for
special needs patients
(2) Delay in scheduling
(3) Unavailability to
perform under general
anesthesia
(4) Do not find the
Cardoso service
(1) Location
et al., 2011 Brazil — — (5) The child has no need
(2) Lack of structure
[80] for care
(6) The child does not
collaborate
(7) Lack of humanization
of the dentist
(8) Time
(9) Lack of professional
preparation
(1) They do not feel qualified
to work with people with
(1) Difficulty in receiving
special needs due to the
dental care
difficulty of clinical
Rocha et al., (2) Dentists had no
Brazil — — management of these patients
2015 [5] special training to work
(2) Difficulties
with patients with
communicating with disabled
disabilities
patients, especially with deaf
people
(1) Physical
(1) Difficulty in managing
barriers to access
patient behavior
your clinics
(2) Communication
(2) There was no
(3) Time restriction
Bindal et al., ground floor
Malásia — (4) Lack of training —
2015 [81] operating room
(5) Did not have adequate
(3) Inaccessible
exposure during
bathrooms
undergraduate dental studies
(4) Lack of
for special needs
equipment
(1) Lack of vacancies
(2) Professional denied
attendance
(3) Does not have time
available
Dantas
(4) Lack of will on the
Cardoso, Brazil — — —
part of the patient
2015 [82]
(5) Does not have dental
services near the
residence
(6) High shipping cost to
carry the patient
Damiance,
Brazil — (1) Transportation — (1) Financial
2016 [83]
14 International Journal of Dentistry
Table 4: Continued.
Barriers
Physical Nonphysical
Author/year Country
Dentist’s Caregiver/responsible Caregiver/responsible
Dentist’s perception
perception perception perception
(1) Low dentist offer for
special needs patients
(2) Delay in scheduling.
(3) Unavailability to
perform under general
anesthesia
(4) Do not find the
service
Paulo et al., (1) Location
Brazil — — (5) The child has no need
2017 [84] (2) Lack of structure
for care
(6) The child does not
collaborate
(7) Lack of humanization
of the dentist
(8) Time
(9) Lack of professional
preparation
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Acknowledgments
para mães de crianças especiais: um espaço para a prática dos
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