Accessible care for all at a new dental center

From the perspective of Mark Wolff, the Morton Amsterdam Dean of the School of Dental Medicine, having a physical or intellectual disability should not alter one’s access to high-quality dental care. And his firm belief is that every dentist should be able to provide that care, no matter what accommodations may be necessary.

“A mentor I trained with 40 years ago believed this, and so when I started practicing, I always had a number of patients with disabilities or medical complications,” says Wolff. “I didn’t realize this was a novel way of doing things for a decade or decade and a half.”

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That personalized care approach—part of Wolff’s practice from his earliest days as a dentist—also represents the underlying philosophy of the newly opened Care Center for Persons with Disabilities at Penn Dental Medicine, a 3,500-square-foot facility in the School’s Robert Schattner Center. Designed with an eye toward meeting the needs of people with physical and intellectual disabilities, the Care Center will also allow dental students to learn how to meet the needs of their patients and even provide opportunities for innovation in how that care is delivered.

“A lot of this is demystifying care for this population,” says Miriam Robbins, clinical professor of oral medicine and restorative dentistry, who was recently hired to serve as the center’s director. “There are multiple reasons these patients may have challenges with access to dental care, but part of it is fear of the unknown on the part of dental care providers. Our dental students will have the opportunity to develop a comfort level with these patients that they’ll take into their clinical practice.”

New paradigm of care

Opening such a facility was part of Wolff’s plan since taking the helm of the School in 2018. In addition to early mentors, he owes some of his thinking in this area to his wife, who, during their newlywed years, worked at a state-run center for people with intellectual and developmental disabilities. Spending time there and observing their people-centered approach, he shaped his practice around caring for children with developmental disabilities as well. At his previous institution, New York University, his passion for treating patients with disabilities contributed to a new facility, able to treat patients who required sedation to receive oral care. At Penn, he set his sights on developing a more comprehensive approach to caring for a broad patient population with disabilities based on evidence-based preventive and management programs.

The revamping of the space in the Schattner Center was only slightly delayed by pandemic-related closures. Construction wrapped up in November with the finishing touches put on through December, when patients began to arrive.

A foremost priority for the center is accessibility. In the patient-care area, the Personalized Care Suite, entranceways and corridors are wide and its 12 operatories can accommodate wheelchairs or other supportive devices. In addition, four operatories include wheelchair lifts, which can support and recline patients in their chairs, enabling clinicians to perform cleanings and other procedures. One extra-large room is designed for treating a patient on a gurney or even on the floor.

Every operatory is equipped with nitrous oxide, better known as laughing gas, a sedative that can help manage pain and anxiety and keep patients comfortable during a dental visit. A low-stimulation room has lower lights and soundproofing for patients with sensitivities to bright lights and loud noises. And dental chairs do not have instruments attached to prevent patients from reaching for and touching equipment; instead, clinicians use instruments on carts that can be kept at a distance and transported between operatories.

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“I’m very excited to instill the love I have for treating this population into students,” says Alicia Risner-Bauman, assistant clinical professor of oral medicine and restorative dentistry, who joined Penn Dental Medicine in January as an associate director of the center. “We can do that by exposing them, getting them comfortable, and making them understand that this isn’t as difficult as some people make it out to be. I think the way the center is designed and the plans and ideas we’re putting into place to make it operate well will make it happen.”

Throughout the suite, video cameras will enable faculty to monitor students’ care in real-time, as well as observing how patients and caregivers are able to practice needed oral care that they will continue at home.

Outside the clinical care area, consultation rooms were also designed to fit patients who use wheelchairs and caregivers comfortably. And throughout the center, wayfinding guide strips can help visually impaired persons navigate the space.

The Care Center is also the new clinical care home at the School for medically complex patients—those individuals who may have bleeding or lung disorders, infectious diseases, cancer, or other medical conditions that can make the management of their dental care more complicated. Leading this segment of the patient care is Temitope Omolehinwa, assistant professor of oral medicine, serving as the Care Center’s other associate director.

“This is a dream realized for me,” says Wolff, who notes that the School hopes to treat 10,000 patients a year in the center. “Through the good fortune of fantastic donors, through the great fortune of having faculty who are engaged and motivated on this, we’ve been able to make this a reality, even amidst the pandemic.”

‘In their box’

The Care Center is about much more than just fancy equipment and facilities, however. “It requires breaking out of conventional dental ideas,” Wolff says. And often, that simply means looking at each patient as an individual and plotting out their oral health care accordingly.

“I like to say, ‘Don’t get out of the box, get in their box,’” says Risner-Bauman. “Figure out what they need to succeed.”

Robbins describes caring for patients with disabilities as requiring “a fundamental foundation shift” for dentists, who in previous generations may have been taught that the only way to provide thorough oral care would be under general anesthesia.

“We can look at ways that we can change people’s oral health status without involving that,” she says. “Prevention is key. If you have a patient prone to caries, you can put them on a limited-carb diet or a stringent regimen of fluoride. Instead of treating the end result, you take a couple of steps back and address the root cause and see what really aggressive prevention and modification can do to find a pathway for these patients to have good oral health.”

Wolff also notes that since certain disabilities are progressive, clinicians must treat them accordingly, taking into account the demands on caregivers.

“If you are a patient without teeth in one arch, they may be restored to function with six implants and 12 crowns, we can do that, that’s wonderful today, but if you start developing progressive Alzheimer’s disease, becoming unable to clean it—or are unable to allow others to clean it for you—that may be a disservice to the patient, because they will develop a lot of disease and inflammation around it,” Wolff says. “We might instead consider changing to a removable denture that a caregiver can clean in five minutes. This requires a change in our thoughts about what is ideal dentistry to find out what is the ideal accommodation for the patient.”

To reinforce these ideas, every DMD dental student will get hands-on experience working under close faculty supervision in the Center—about 5% of their fourth year—managing patients with a wide range of disabilities as well as seeing medically complex patients. Through their clinical training, students will spend time treating patients with sensory impairments, behavioral problems, psychosocial issues, and other conditions requiring sensitive and comprehensive care.

“They’ll already have competencies, they’ll have learned basic techniques,” Wolff says, “so in the Care Center we’ll have them refine those skills.”

Residents in the School’s postgraduate program in oral medicine are also rotating through the Center, focusing predominantly on medically complex patients but also seeing patients with disabilities. Plans are in development to launch an Advanced Education in General Dentistry program at the School in 2022, with the residents in this new program anticipated to rotate through the Center as well.

Research and innovation

The new Center not only provides a home for treating patients and educating students, but will also be a site for developing new products and approaches to care that will continue to reap benefits into the future. Embedded within the space is the Colgate Innovation Laboratory, designed to encourage Penn experts to collaborate with Colgate scientists on the design and implementation of products to enhance oral care in people with disabilities.

“We were very interested in partnering with the Penn dental school to build this lab,” says Juliana Gomez, a clinical research manager for Colgate-Palmolive Company. “It meshes well with our goals of making the lives of underserved populations easier and healthier.”

The Innovation Laboratory, adjacent to the clinical care spaces in the Center, will allow researchers to interact with patients, recruiting them for studies or testing of prototype devices, for example. With patient and caregiver consent, scientists will also have the opportunity to observe how their products are used and receive feedback that can inform design tweaks or new inventions.

Gomez notes that her team has previously worked in Penn Dental Medicine’s pediatric clinic, interactions that have led to testing of a “smart” toothbrush that helps children learn good brushing habits. Such a device as well as others—from a toothbrush grip that makes it easier for those with mobility challenges to maneuver, to high-fluoride therapies that reduce the risk of decay—may be deployed and tested in the new Center.

“It’s a very exciting area to be working in,” says Gomez.

The Care Center for Persons with Disabilities builds on other efforts by the School to enhance accommodations to match patients with first-rate care, including a clinic for survivors of torture, expanded community-based clinics, and the PennSmiles bus to treat students in neighborhoods around Philadelphia. This focus on meeting dental patients where they are, both geographically and based on their needs, is a priority for training the next generation of dentists.

“The way I see it, whether you’re sick, elderly, have an inherited or an acquired disability, you should be treated as an individual and have your needs met,” Wolff says. “Providing care for all should be a core value to be a good human, and it’s a value we want to impart in our students as they become dentists as well.”

Homepage image: Despite the pandemic, construction on the Care Center space wrapped up in early winter. Accessibility was a priority in every element of its design.