Preliminary findings from the 2001 Surgeon General’s Conference on Health Disparities and Mental Retardation identified four health care issues for people with mental retardation that need to be addressed and improved on:

– increasing their access to quality care;

– improving health care provider education and training;

– providing a comprehensive approach to the delivery of care across the life span;

– reducing the stigma associated with mental retardation in conjunction with an increase in public awareness.⁶

The surgeon general also noted a lack of oral health care research devoted to the disparity of health care among people with disabilities.

In line with these reports, we conducted a study to determine the extent to which dental students are formally prepared to care for patients with special needs, their attitudes and beliefs toward people with mental retardation, their comfort levels with working with people with mental retardation, and whether experience and previous contact with people with mental retardation affect their beliefs and attitudes about people with mental retardation.

	METHODS

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A total of 312 third- and fourth-year students at five dental schools from different geographic regions participated in the study. The dental schools were University of Texas Health Science Center at Houston Dental Branch; Southern Illinois University School of Dental Medicine, Edwardsville; University of Medicine and Dentistry of New Jersey, New Jersey Dental School, Newark; State University of New York at Stony Brook School of Dental Medicine; and University of Missouri-Kansas City School of Dentistry.

We used a demographics questionnaire, or DQ, to assess the students’ reactions to their instruction in the care of people with mental retardation. We also used the DQ to assess and measure students’ experiences and previous contacts with people with mental retardation and the amount of didactic time and clinical experience that was devoted to people with mental retardation. In addition, students reported their confidence in, preparedness for and knowledge about working with people with mental retardation. The DQ asked students to indicate whether they believed that after they were graduated from dental school they would treat people with mental retardation.

We used a prognostic beliefs scale, or PBS, to measure students’ expectations about people with mild, moderate or severe mental retardation.⁷ The first part of the PBS assessed which tasks students feel people with mental retardation would be capable of completing. Their choices were 27 capabilities, ranging from simple tasks to very complex tasks, that fall into four major skill categories: self-help, social interaction, vocational and independent living. The second part of the PBS measured students’ perceptions of the appropriate residential and vocational placement for people with mental retardation. The residential placement category asked students to indicate the most appropriate living environment for a person with mild, moderate or severe mental retardation.

	RESULTS

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We distributed the questionnaires to 175 third-year and 137 fourth-year dental students. All of the students responded to the questionnaires. Questionnaires from six third-year students and 11 fourth-year students were incomplete and unusable; these questionnaires had a usable response rate of only 96.4 percent and 92 percent, respectively. We analyzed the surveys using independent t tests in a statistical software package (Statistical Package for the Social Sciences graduate pack, Version 10.0 for Windows, SPSS, Chicago).

The average age of the respondents was 26.2 years. There were 170 men and 124 women, and one person did not respond to the sex category. Sixty-five percent of the respondents were white, 14 percent were Asian-American, and eight percent did not respond to the question on ethnicity. Less than 5 percent of the respondents were in each of the following ethnic categories: African-American, Hispanic, American Indian, Indian and Egyptian. There were no sex or ethnic differences relative to the data reported herein.

Experience. A little more than one-half (50.8 percent) of the fourth-year dental students said they never provided any clinical treatment for patients with mental retardation. A total of 22.2 percent said they received less than one hour or didactic presentations devoted to the care of people with mental retardation, and 46.8 percent said they spent less than one hour providing clinical services for this population (Table 1). A total of 68.2 percent said they received five hours or less of didactic presentations, and 68.2 percent spent five hours or less providing clinical services devoted to people with mental retardation.

Comfort level. Eighty-three percent of the fourth-year dental students indicated that they would definitely or possibly provide treatment for patients with mental retardation after they were graduated from dental school (Figure 1). Nearly 60 percent, however, reported they were not confident or were a little confident that they could provide care for people with mental retardation (Figure 2). Almost three-quarters (74.6 percent) said they were "not at all" prepared or were "a little" prepared to provide needed care (Table 2). Nearly 58 percent did "not at all" understand or understood "a little" the dental needs of people with mental retardation (Table 2).

View larger version (25K): [in this window] [in a new window]   Figure 1. Fourth-year dental students’ willingness to treat patients with mental retardation after graduation from dental school.

View larger version (27K): [in this window] [in a new window]   Figure 2. Fourth-year dental students’ confidence levels in providing treatment to people with mental retardation after graduation from dental school.

Capabilities. The respondents said they believe that there is a direct relationship between the severity of a person’s mental retardation and the limitations of his or her performance capabilities. The mean capability scores reported by respondents was 18 capabilities (out of a possible 27 capabilities on the PBS) for people with mild mental retardation, nine for people with moderate mental retardation and three for people with severe mental retardation.

Respondents who had experience with people with mental retardation reported significantly higher capability scores for people with mild (P < .003) and severe (P < .02) mental retardation compared with respondents who had no experience.

Respondents who had a relative with mental retardation indicated that they better understood the dental needs of patients with mental retardation (P < .04) compared with respondents who had no relatives with mental retardation.

Residential and vocational placement. The majority of respondents indicated that living in a group home or institution was most likely for people with severe mental retardation (Table 3). A majority of respondents indicated that people with severe mental retardation would be incapable of employment (Table 4). The majority of respondents indicated that living in supervised living residences and having supervised full-time employment was most appropriate for people with mild mental retardation.

	DISCUSSION

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– the greater their awareness of the capabilities of people with mental retardation is (students who had experience with people with mental retardation reported significantly higher capability scores for people with mild and severe mental retardation than did students with no such experience);

– the more positive their attitudes toward people with mental retardation are;

– the better their appreciation of the dental needs of people with mental retardation is.

Compared with findings from a study that used a similar beliefs scale to review the perceptions of physicians, educators, psychologists and social workers, dental students reported the lowest level of expected capabilities for people with mental retardation.¹¹ Limited dental school didactic hours and clinical contact with people with mental retardation and other disabilities may be contributing factors.

While the students we surveyed are a convenient sample and not necessarily representative of all U.S. dental students, our findings are similar to those of earlier national studies⁴ and a more recent study. The 2002 American Dental Education Association survey of dental school seniors reported that almost 41 percent of responding students indicated that they were less than or not well enough prepared to provide care for patients with disabilities.¹² Second to the preparation for practice management category, the preparation for care of patients with disabilities category had the highest proportion of respondents who perceived they had inadequate experience and training in dental school. Dental students are receiving minimal didactic and clinical opportunities in how to care for people with mental retardation, they do not feel confident about their ability to treat people with mental retardation, and they have limited awareness of the capabilities of people with mental retardation.

The Commission on Dental Accreditation is considering a proposal made by Dr. Waldman and Dr. Perlman through Special Olympics to ensure that "at minimum, graduates must be competent in providing oral health care within the scope of general dentistry, as defined by the school, for the child, adolescent, adult, geriatric, medically compromised and mentally/physically disabled patient" (Steve Corbin, Special Olympics, oral communication, June 2001).

The challenge is to change practitioners’ attitudes toward and increase their awareness of the abilities of people with mental retardation. Only then can we ensure a willingness to provide the needed dental care. A necessary step in this direction is to increase dental school didactic and clinical opportunities in how to care for this patient population.

	CONCLUSIONS

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Increasing numbers of people with mental retardation no longer live in institutions. They are dependent on private practice dentists in their communities for dental services. The findings of this study, however, emphasize the limited educational opportunities in dental schools to prepare new practitioners to provide needed services to this population. As a consequence, a majority of students reported a lack of preparation for, and little knowledge of, the dental needs of people with mental retardation. The reality is that many people with mental retardation are members of families being treated by private practice dentists. Dental students and practitioners increasingly need opportunities to prepare them to provide the needed services for people with mental retardation.

View larger version (112K): [in this window] [in a new window]   When this article was written, Dr. Wolff was a pediatric dental resident, University of Texas Health Science Center Houston Dental Branch. He now is in private pediatric practice, Salem, N.H. Address reprint requests to Dr. Wolff at 389 Main St., Salem, N.H. 03079, e-mail "awolff_{at}hotmail.com".

View larger version (102K): [in this window] [in a new window]   Dr. Waldman is a professor, Dental Health Services, Department of General Dentistry, School of Dental Medicine, State University of New York Stony Brook.

View larger version (131K): [in this window] [in a new window]   Dr. Milano is the program director, Post Graduate Pediatric Dentistry, Department of Pediatric Dentistry, University of Texas Health Science Center Houston Dental Branch.

View larger version (117K): [in this window] [in a new window]   Dr. Perlman is global clinical director, Special Olympics Special Smiles, and an associate clinical professor of pediatric dentistry, The Boston University Goldman School of Dental Medicine.