Addressing an Unmet Need: Providing Oral Health Care for Adults with Disabilities

As a clinical assistant professor and dentist at the University of Florida (UF) College of Dentistry, Bryan Smallwood, DMD, MPH, CPH, has cared for thousands of patients. One in particular stands out to him. 

“I have a patient who had been to the operating room many times because other dentists couldn’t treat him,” Smallwood says. 

That patient was an adult who had developmental differences and was very anxious when he received dental care. 

“I had a long chat with [one of his family members], and it turns out that he just wanted to see what was going on in his mouth,” Smallwood says. “And as long as he could see, he would sit there forever.” 

Smallwood says his patient is just one of many adults with an intellectual or developmental disability who struggle with accessing oral health care — a struggle exacerbated for people in northern Florida after the state government stopped funding outpatient dental services at Tacachale Developmental Disability Center in 2022. The center provided residential care and outpatient dental services for adults with developmental disabilities. Patients and caregivers were driving more than two hours to Orlando or Jacksonville just for a dental cleaning and facing long wait lists.

“That created an even greater unmet need locally, and actually regionally, because there were so many people that were served there,” says Dan McNeil, PhD, the chair of the Department of Community Dentistry and Behavioral Science at the UF College of Dentistry. “But this is a pressing need across the country as well.” 

McNeil decided it was time for action. He applied for a CareQuest Institute grant, aimed at organizations working to address systemic barriers to oral health for people with disabilities. McNeil began assembling a team that includes Smallwood; Olga Ensz, DMD, MPH, clinical assistant professor and director of community-based outreach with the UF College of Dentistry; and Reeva Morton, PhD, BCBA-D, NCSP, and a board-certified behavior analyst and licensed and certified school psychologist at the UF College of Medicine and College of Dentistry. The team also includes Tim Garvey, DMD, a UF faculty dentist who has provided care to people with disabilities for decades; Whitney Haley, RDH, BASDH, a dental hygienist in the Department of Community Dentistry and Behavioral science who works in a UF-based statewide program for people with disabilities funded by the Special Day Foundation; and Frank Catalanotto, DMD, faculty dentist, and former dean and chair, who supports the team regarding its public health impact. 

“The CareQuest Institute grant helped us organize a group of people at UF and in the community to come together to say, ‘Okay, there’s this problem. Let’s work together,’” McNeil says. 

The $125,000 grant has allowed the College of Dentistry to collaborate with the Arc of Alachua County, an organization that supports adults with special health care needs. The Arc helps connect those adults with community services and make sure they have housing. Through UF’s new program, the Arc now also connects patients to dental services. And dentists have the time to dedicate to their patients there. 

“It takes that pressure off so we can really focus on providing the best care for these patients,” Smallwood says. “And we’re doing it on their timeline, not ours.” 

Taking the Time to Treat Special Populations 

Adults with intellectual and developmental disabilities face numerous challenges to accessing care. One of them is cost. Once they turn 21, public insurance payments typically are more limited. Many of them end up in the emergency room or operating room for dental emergencies. 

With the help of the CareQuest Institute grant, Smallwood and the rest of the UF team started bringing in mobile dentistry equipment to the Arc in mid-April to treat those patients in that predicament. 

Each patient and parent/caregiver has a teledentistry appointment first, including an initial phone screening, where the dental team members can identify the patient’s dental treatment history and get a good idea of what to expect during an office visit. The dental team then sees the patient at the Arc on specified days to do an assessment of the patient’s mouth, address behavioral concerns by creating a task analysis, and figure out how to provide safe dental care. The team hopes to see between four and eight patients a day. 

“It’s a great technique for us to go out into the community, into places where specialty patients are comfortable, and see them,” Smallwood says.

Training Dental Students for Special Care 

But it’s not just getting adults with an intellectual or developmental disability to the dentist — it’s also about finding a dentist that will care for that patient. 

That’s where Ensz and Morton come in, along with McNeil. 

Ensz and Morton, who focus on public health and behavioral health, are advisors on the grant. They say individuals with intellectual and developmental disabilities may communicate using nonverbal communication strategies, some may have sensory sensitivities, and others may have mental health diagnoses, such as anxiety, about going to their dental appointment. Ensz says there are many ways dentists can help patients have a better experience in the chair. 

“Providing things like social stories that show visual cues of what to expect,” she says. “Using things like rhythmic counting, providing distractions with different sensory items, weighted blankets, dimming the lights, seating them in a quieter room, playing soft music.” 

Ensz says part of the work she does is educate dental students to be able to treat patients of all ages with disabilities. 

“It is challenging for many oral health providers — dental school is four years, and you have a lot of stuff jam-packed into that,” she says. “Sometimes the clinical training in working with special populations might involve very few of these sorts of opportunities, or it might be purely observational versus hands-on. So this is something that when I have dental students or dental hygiene students on a community-based dental outreach rotation, I want them to experience and learn.” 

Morton and McNeil are also able to use their experiences and education to show dentists how to care for special populations. 

“As a board-certified behavior analyst and licensed school psychologist, I’m able to implement some of the behavioral strategies that we are taught in the ABA classes, in combination with using the behavioral consultation models that we learned in psychology, to service the need of the patient,” Morton says. “The behavioral strategies vary for each patient including verbal statements that praise their cooperation, weighted blankets, taking breaks, visual schedules, or social stories. Then, after seeing how some positively respond to those behavioral strategies, I’m able to motivate the dentists to continue to incorporate those practices [every day] while they’re providing oral health care.” 

McNeil, a clinical health psychologist, emphasizes the importance of desensitization, helping patients gradually cope with those aspects of dental care that they find anxiety-provoking. 

“Teaching dental students and providers about the psychological basis of desensitization, and how to implement it in the dental operatory with patients with disabilities, gives them a powerful method to help patients learn to be more comfortable with the novelty of dental care,” McNeil says.

Smallwood says dental students rotate through a UF pediatric dentistry clinic, where they learn about treating children with special needs, but those patients can’t be seen after they age out. Dental students also need this training with adults with special needs. With this program the grant is providing, the goal would be to have every dental student spend a few weeks treating adults with special needs at the Arc. 

“We are a teaching institution, and everything we do we want to have some level of education involved with it,” Smallwood says. 

Ensz agrees. 

“I feel like as the only state-funded dental school, we have a responsibility to the community,” Ensz says. “Sometimes we’re the only place where people can go, and I think it’s important that we have a dedicated space because that’s what’s needed to provide care.” 

Expanding Better Care for Individuals with Disabilities 

The issue of finding care for adults with intellectual and developmental disabilities is not just a problem in Alachua County; it’s national. But Smallwood says this program the UF team has started is a step in the right direction to help people who live in and around the county. 

“This is the beginning of our answer to dealing with that problem,” Smallwood says. 

He and the rest of the UF team aspire to grow the program into a permanent place in Alachua County. 

“I hope that this grant is the foundation for building something that becomes a clinic that allows us to educate not just future dentists but also hygienists and other people on how to treat patients with special needs,” Smallwood says. “And hopefully one day it increases the access to care as oral health providers enhance their knowledge and skills in caring for patients with special needs.”