Oral and dental health utilization among patients with special health care needs: a qualitative study in Iran

Abstract

Background

Patients with special health care needs (SHCN) are considered a vulnerable group due to their complex physical and mental conditions, which often limit their utilization of oral and dental health services (ODHS). So, this study examines the utilization of ODHS among patients with SHCN in Iran.

Methods

This qualitative study was conducted in Iran from September 2024 until January 2025. Informants were selected using purposive and snowball sampling. A semi structured interview guide was used to explore the perspectives of three groups: service providers, policymakers, and families of patients with SHCN. Data were analyzed using thematic analysis with MAXQDA 10.

Results

Data from seventeen semi-structured interviews were thematically analyzed. Four overarching themes were identified: governance and policy landscape, professional competence and service readiness, sociocultural and familial dynamics, and care delivery processes. These themes encompassed both systemic and individual-level factors that either enabled or barred the utilization of ODHS among patients with SHCN. Informants emphasized that financial factors, clinical guidelines, insurance coverage, preventive healthcare systems, systematic approaches, and integrated information systems were major governance and policy-level factors. Within the second theme, training, motivations and attitudes, screening/specialized centers, and infrastructures and equipment were seen as significant measures to service provision. Sociocultural and familial dynamics-related subthemes included parents’ and caregivers’ knowledge and awareness, socioeconomic status, attitudes and stigma. In care delivery processes, geographic access and procedures and waiting lists emerged as key subthemes. Each of these factors could act as either a barrier or an enabler depending on how they are addressed in practice.

Conclusion

The findings of this study underscore the complex and multifactorial nature of factors influencing the utilization of ODHS among patients with SHCN. According to the results, both systemic and individual-level barriers and enablers play significant roles in shaping access to and utilization of ODHS. Addressing these challenges requires comprehensive, targeted policies that not only focus on improving the availability and accessibility of ODHS but also foster an environment that supports the continuous training of providers, enhances awareness among patients and their families, and ensures sufficient financial and infrastructural support.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-025-06392-6.

Background

In the past, oral health was often defined simply as the absence of detectable disease. However, this narrow perspective overlooked subjective factors such as individual values, personal perceptions, and expectations regarding oral well-being [1]. The World Dental Federation (FDI) emphasizes that oral health extends beyond physiological functions to include psychosocial aspects and overall well-being, positioning it within the broader context of general health [2]. In this regard, the literature describes oral and dental health as a multifaceted concept encompassing speech, smiling, olfaction, gustation, tactile sensation, mastication, and deglutition. Additionally, it involves the ability to express emotions confidently through facial expressions, free from pain, discomfort, or pathological conditions affecting the craniofacial complex [1–3].

Utilization of oral and dental health services) ODHS (is shaped by various factors, including age, education, dental treatment costs, household income, supplemental insurance, and employment [4, 5]. Among these, certain vulnerable groups encounter greater challenges. One such group comprises patients with special health care needs (SHCN) [6].

SHCN involve any physical, developmental, mental, sensory, behavioral, cognitive, or emotional impairment or condition that requires medical management, health care intervention, and/or specialized services. These conditions can be congenital, developmental, or acquired, and may limit daily self-care activities or major life functions [7].

According to statistics, approximately 1.3 billion people experience significant disabilities, representing 16% of the global population, or one in six individuals worldwide [8]. Additionally, the 2024 National Survey of Children’s Health reported that one in five children (20%) in the United States—over 14.5 million in total—have SHCN [9]. In the United Kingdom, more than 200,000 adults have profound learning disabilities or complex medical conditions [10]. Another study estimated that 13–18% of individuals under 18 in developed countries fall within the category of patients with SHCN [11]. In Iran, based on the 2011 census, the prevalence of disability in Iran is approximately 13 individuals per 10,000 people, which amounts to about 1,017,659 people [12].

Given the definition of SHCN, this group encompasses a wide range of physical, intellectual, and developmental conditions, each associated with distinct oral health needs and care-related challenges. Recognizing this heterogeneity is essential for understanding the complexities involved in their access to ODHS. For instance, key barriers identified in various studies include the cost of services, provider attitudes, accessibility challenges, underlying health conditions, and inadequate service provision [13, 14]. Therefore, there is a need to emphasize effective strategies that enhance the ability of individuals with SHCN to access ODHS. Studies have proposed several approaches, including improving health literacy among families, providing training for dentists, establishing financial support mechanisms, and expanding insurance coverage [14, 15].

Numerous qualitative studies have explored the challenges faced by individuals with SHCN in accessing oral health services. Balkaran et al. examined these challenges in Trinidad and Tobago, identifying issues like high service costs and limited access to care, while also proposing solutions such as provider training and policy interventions [16]. Similarly, Friedlander et al. investigated barriers to dental care among individuals with rare diseases, highlighting physical limitations, inadequate provider knowledge, and poor care coordination as major obstacles. They emphasized the importance of interdisciplinary collaboration and patient empowerment in improving access [17].

Another study focused on oral health care for adults with SHCN, identifying key relational factors, such as provider empathy and communication, as essential for effective care. It also highlighted the importance of adequate provider training and healthcare infrastructure, while recognizing financial constraints and limited access to specialized services as significant barriers [18]. Additionally, a study on behavioral guidance techniques for dental care in individuals with SHCN found that tailored behavioral approaches, negotiated with patients and caregivers, are crucial for successful treatment [19].

Given the importance of oral health, the high vulnerability of patients with SHCN, and their limited access to services, a significant gap remains in understanding the barriers and enablers affecting this population in Iran. Furthermore, since qualitative research can provide in-depth insights, lived experiences, and contextual differences that may be overlooked in quantitative approaches, and because no study has yet explored the experiences of providers, policymakers, and families in this context to uncover the perceived structural challenges and subjective meanings, the present study aims to explore the barriers and enablers to the utilization of ODHS for patients with SHCN in Iran based on the perspectives of these three key stakeholder groups.

Methods

Study design

This study, conducted in 2024–2025, employed a qualitative research design with a thematic analysis approach to investigate the utilization of ODHS among patients with SHCN in Iran. Thematic analysis (TA) is a set of techniques used to identify and analyze recurring themes or patterns of meaning within qualitative data [20]. Researchers applied thematic analysis to develop a conceptual model of their findings through a series of steps, including the selection of keywords and quotations, coding, theme identification, interpretation, and model development [21].

Informants and interviews

The data were collected through semi-structured interviews to explore the main barriers and enablers of utilization of ODHS for patients with SHCN in Iran. Informants included dentists, policymakers, and family members of patients with SHCN from various cities across Iran. A combination of purposive and convenience sampling methods was used for informant selection. Purposive sampling aimed to select informants who could provide the most relevant information based on the research questions, such as dentists who have treated patients with SHCN up to this point. Following data analysis and the development of initial categories, snowball sampling was employed to continue the process by engaging with individuals and circumstances that could yield new insights. The research team initially contacted potential informants based on their professional background and experience. Subsequently, participants referred other individuals from similar professional backgrounds, which ensured the inclusion of a diverse range of perspectives. To ensure data richness and comprehensiveness, the data collection continued until saturation was reached, where no new themes or insights emerged from additional interviews. It should be noted that the aim was not to predetermine equal numbers of participants from each group but rather to reach saturation within each category. Since several concerns related to patients and their families were also reflected by providers and policymakers, saturation in the service recipients’ group was achieved earlier. In contrast, the complexity and diversity of perspectives among providers and policymakers required a greater number of interviews to reach saturation in these groups.

Inclusion criteria included having sufficient knowledge, expertise, or relevant work experience directly related ODHS for patients with SHCN. Specifically, informants were required to have at least two years of professional experience either in delivering care to patients with SHCN, in shaping or implementing related policies, or in using care. Participants also needed to be communicative and willing to share their insights through interviews. Lack of experience in providing services to this group among providers, as well as a lack of utilization of ODHS by patients and their families, were considered exclusion criteria. It is worth noting that, the ‘service recipients’ referred to the family members of individuals with SHCN, who were interviewed as proxies to report the experiences of the patients due to the patients’ limited ability to engage in long interviews.

To schedule interviews with the selected informants, contact was made either by phone or in person to agree on the time and location. The interviews were recorded with the informants’ informed consent, both verbal and written, and they were assured that their information would remain confidential. For informants who were unable or unwilling to attend in person, interviews were conducted via phone or Skype as an acceptable alternative. In the case of phone calls, only voice communication was used. For Skype interviews, both the authors and the informants had their cameras on, allowing for visual interaction during the interviews. This helped ensure clear communication and allowed the researcher to observe non-verbal cues, such as facial expressions and body language, which were documented alongside verbal responses. Informants were reassured that they could withdraw or pause the interview at any point.

The interview guide included four main questions regarding the mechanism for identifying the SHCN group in Iran for dental treatment, the necessary infrastructure for accessing services, the challenges they face, and the training of service providers to care for this group. The interview guide was developed through an iterative process based on the research objectives and a thorough review of the literature. An initial version of the guide was created, which was then piloted with a small group of participants to assess the clarity and relevance of the questions. Feedback from the pilot interviews, along with reflections on the interview process, led to revisions of the guide, ensuring that the questions were both clear and directly aligned with the research objective. After several listens, the researcher transcribed the recorded interviews verbatim for analysis. Throughout the interviews, the researcher also documented the informants’ non-verbal behaviors and movements, while taking field notes concurrently. These non-verbal observations were recorded by a research assistant to help ensure rigor and completeness in data collection, although no specific codes were extracted from them during analysis.

The interviews lasted between 25 and 65 min on average. All interviews were conducted by one of the researchers (Z. Z.). While an interview guide was used, the order and nature of the questions evolved as data collection progressed, with a focus on maintaining open-ended questioning throughout the process.

Trustworthiness

The qualitative study’s validity and rigor were enhanced by applying the four criteria introduced by Guba and Lincoln: credibility, transferability, dependability, and confirmability [22]. Prolonged engagement, continuous data comparison, and systematic categorization were employed to ensure credibility. Confirmability was reinforced by reviewing the data coding process and consulting qualitative research experts to validate the interview content. Dependability was strengthened through a trial audit conducted by research team members and external experts. Lastly, a detailed explanation of the concept and informant characteristics and a thorough account of data collection and analysis were provided to support transferability, supplemented with illustrative informant statements.

Data analysis

The data analysis followed the approach outlined by Graneheim and Lundman [23]. To ensure familiarity with the data, all audio recordings were listened to multiple times, and the transcripts were repeatedly reviewed. Meaningful text units were identified based on the study’s objectives, and initial codes were generated and labeled. These codes were then refined and finalized through a systematic review process. The final codes were categorized in the next step to identify sub-themes and main themes. To enhance the consistency of data analysis, two researchers conducted the process independently, and coding discrepancies were resolved through discussions within the research team. Ultimately, the key factors influencing ODHS utilization in patients with SHCN were identified. Data analysis was performed using MAXQDA 10 [24].

Results

Seventeen interviews were conducted with the aim of identifying the barriers and enablers for utilizing ODHS among patients with SHCN, with the characteristics of the participants presented in Table 1. Findings from these interviews, analyzed through content analysis, findings were categorized into four main themes: “Governance and policy landscape”, “Professional competence and service readiness”, “Sociocultural and familial dynamics”, and “Care delivery processes”.

Table 1.

Characteristics of the informants

No	Informant group	Gender	Work experience (Years)	Informants ID
1	Dentist	Female	16	D1
2	Dentist	Male	13	D2
3	Dentist	Female	15	D3
4	Dentist	Female	8	D4
5	Dentist	Female	10	D5
6	Dentist	Male	7	D6
7	Dentist	Male	12	D7
8	Policy maker	Male	3	P1
9	Policy maker	Male	5	P2
10	Policy maker	Male	5	P3
11	Policy maker	Female	6	P4
12	Policy maker	Female	3	P5
13	Policy maker	Male	7	P6
14	Service recipient	Male	-	S1
15	Service recipient	Female	-	S2
16	Service recipient	Female	-	S3
17	Service recipient	Female	-	S4

These findings were further divided into 15 sub-themes, each analyzed under two categories: “Barriers” and “Enablers”. This classification reflects the dual nature of each factor, which can function as both a barrier and an enabler in influencing utilization to ODHS for individuals with SHCN. Table 2 presents a summary of the key findings.

Table 2.

Themes and subthemes

Main themes	Sub-theme	Barriers (Most repeated/meaningful quotes)	Enablers (Most repeated/meaningful quotes)
Governance and policy landscape	Financial factors	Currently, the government does not provide specific support, and we do not even have insurance or assistance for typical individuals, let alone for this group. The out-of-pocket dental expenses exceed 80%. From a financial perspective, the government does not allocate any budget for them. (D6)	The main issue is the economic burden. Without government subsidies or insurance company intervention, parents can’t afford the costs for these patients. The dental treatment costs for individuals with special needs are higher due to the complexity and special considerations involved. In a society where even, typical individuals struggle with dental expenses, it is even more challenging for those with greater needs, higher costs, and more complex treatment requirements. (P5)
	Clinical guidelines	This group has not been adequately recognized within the dental care system. The dental guidelines are solely designed for the general population, and this group is treated just like typical individuals, without any specific considerations or adaptations for their unique needs. (P4)	Developing comprehensive and standardized clinical guidelines specifically for dental care in this group should be a priority to ensure consistency in delivering high-quality services. (P2)
	Insurance coverage	There is generally no insurance coverage for dental services, and this issue poses a significant barrier for us. (S2)	One of the foundational aspects that comes to mind is insurance coverage in the field of dentistry. This would alleviate the financial burden on families and address financial issues to some extent, allowing them to pursue their children’s treatment on a regular basis. (D7)
	Preventive healthcare system	Fluoride therapy is crucial to prevent significant tooth decay in these children. However, fluctuations in fluoride levels in drinking water pose a problem. If the fluoride concentration is too high, it can cause additional issues for this group. If it’s too low, it won’t effectively prevent decay. (D5)	Brushing teeth is extremely important, and we can even move towards designing tools that these individuals use to be different from standard tools. (D3)
	Systematic approach	The country’s health network lacks a systematic approach to ODHS for these individuals. Existing initiatives are not specifically focused on their oral health needs. Instead, these individuals are classified under general public health categories, addressing their oral health only as part of broader public health considerations, rather than having a dedicated approach. (P5)	Integrating the oral health of this group into national health policies and establishing a dedicated protocol in policymaking is essential for improving their access to care. (P4)
	Integrated information system	Currently, we lack categorized and specific information about these groups in dentistry. For example, there are no patient records, treatment histories, or patient data that providers can utilize. On the other hand, their families also lack information about dentists and how they work with these groups. (D3)	If there were a center that clearly specified which facilities provide services specifically for our children, or which have more expertise in working with them, and even provided information on timing and pricing, we would be able to make better-informed decisions about pursuing their treatment. (S4)
Professional competence and service readiness	Training	The fact that dental students do not receive sufficient practical training in working with SHCNs exists. This lack of skills prevents dentists from properly addressing the behavioral and treatment challenges these patients present, and as a result, they are unable to provide services because they simply do not know how. (D3)	The second key factor that can provide significant benefits for these individuals is technical training. This involves continuous education in dentistry or the introduction of training programs designed to focus on this group, helping dentists understand and address the specific needs of these patients. (D1)
	Motivations and attitudes	Healthcare providers face various challenges when treating individuals with syndromes. They often experience fear and uncertainty about managing potential complications, which are less straightforward than with typical patients. Despite the increased difficulty and complexity of their work, their compensation remains equivalent to that for treating regular patients, leading to decreased motivation among providers. (D5)	In my view, one of the most crucial factors in improving access to these services is the attitude of healthcare providers. Establishing a supportive environment, building patient trust, and ultimately enhancing treatment outcomes all depend on this. (P6)
	Infrastructures and equipment	Many of the clinics currently lack the specialized equipment needed for these individuals. Simply put, the infrastructure for providing adequate services to this group is insufficient. (P1)	If we want to provide comprehensive care and effective treatment, we need the right tools. At a minimum, this includes specialized garments to help manage their movements and the necessary infrastructure for anesthesia-assisted treatments. (D2)
	Screening/Specialized centers	In fact, there is currently no place that offers specialized services for these groups, where individuals can receive care for their oral and dental issues. (D4)	In my opinion, there should be centers where reports of these individuals’ problems are sent upon their identification. These centers and institutions can then decide on preventive measures to take for these individuals. (P2)
Sociocultural and familial dynamics	Parents’ and caregivers’ knowledge and awareness	Many parents lack awareness of their children’s dental issues and mistakenly believe that since their children cannot express pain or discomfort, there is no need to visit a dentist. This oversight can lead to more serious problems regarding their child’s oral health. (D1)	Families who are aware of these issues and understand that a child with physical and mental disabilities, or those whose oral and dental conditions present more challenges than others, need more care, are more likely to refer them for treatment sooner. Therefore, it is essential to provide education to these families so that they can address their children’s needs more promptly. (D7)
	Socioeconomic status	We are a low-income family in this society, and we are always worried about the treatment costs for our child. When my child needs dental treatment, the situation becomes even more difficult, and I have to spend hours thinking about how we will manage to pay for the dental care. (S1)	Families with greater financial access or higher education levels are more likely to pursue dental treatment. (D2)
	Stigma and social attitudes	Every time we go to dental clinics or other crowded places for these services, we feel uncomfortable due to the way people around us look at us. It can be embarrassing, and it often feels like they are judging us. This is why we feel a sense of loneliness, and ultimately, we can only connect with families who have children similar to ours, who understand our situation. (S4)	While society’s attitudes toward this group may not always be positive, this issue can be addressed through education and awareness campaigns within the community. (P3)
Care delivery processes	Geographical access	The access of this group to dental services is very limited; for instance, in the western part of the country, there are only two specialized clinics, one of which is exclusively for autism. This situation has led us to face many challenges. If there were a center in every city, the services would be much better. Currently, we have patients coming from Ilam, Kurdistan, and Lorestan to a center located in Kermanshah. (D6)	I believe that offering services through centers in both urban and rural areas would significantly increase accessibility and utilization. This would prevent individuals from forgoing treatment due to distance or the absence of nearby centers. (D2)
	Procedures and waiting lists	One of the reasons that parents or caregivers may avoid going to the dentist is the waiting time they have to endure before receiving services. The experience of sitting in a room filled with annoying noises and chaos can be particularly distressing for these individuals, leading to anxiety and restlessness. Even if the environment is quiet, keeping a child in the clinic for several hours can be very challenging (D4)	Utilizing advanced techniques and technologies to minimize waiting times, along with policy decisions that offer families benefits for dental treatment, seems like a suitable approach. (P6)

Governance and policy landscape

The first theme identified through the thematic analysis is governance and policy landscape. Policymaking in the field of oral health plays a pivotal role in shaping access to services for patients with SHCN. Several critical elements emerged within this theme, including financial factors, clinical guidelines, insurance coverage, preventive healthcare system, systematic approach, and integrated information system.

In this context, informants consistently emphasized the importance of adequate financial factors as a foundational requirement for improving service utilization. They highlighted the lack of structured financial backing from health authorities as a key obstacle to utilization of ODHS. As one policymaker explained:

“In our organization (welfare), a general credit is allocated to this group. However, they require very different services, including treatments. Ultimately, if any funds remain, we can select only a very small number of individuals with severe dental issues and provide them with a discount voucher for dental services. But overall, there is no financial support for dental services for this group.” (P1).

Another enabler highlighted by informants was the need for clear, specific, and evidence-based clinical guidelines tailored to patients with SHCN. Such guidelines were seen as essential for standardizing care, ensuring continuity, and improving treatment quality. One expert noted:

“This group has not been considered within the dental care system in general. The dental guidelines are only for the general population, and this group is completely overlooked and treated the same as others.” (D2).

The theme also included concerns about insurance coverage. Informants reported that many families refrain from seeking care due to the absence of coverage for preventive and therapeutic services. One caregiver stated:

“As families working with these children, having insurance is extremely important to us. At least with insurance, we may sometimes be able to take our child to the dentist.” (S2).

In relation to preventive healthcare systems, interviewees advocated for the prioritization of oral disease prevention in SHCN patients. Suggestions included implementing fluoride therapy through drinking water and healthcare centers, as well as designing specialized tools to accommodate physical limitations. As one provider suggested:

“Toothbrushes with larger handles should be designed, as these individuals lack fine motor control and cannot use small handles. This option is currently not available on the market, or it could be designed in an oval or ball-like shape, allowing for more natural, less damaging movements.“(D7).

Additionally, the lack of a systematic approach to oral health within national health strategies was perceived as a contributing factor to service neglect. Policymakers noted that oral health often ranks low in priority compared to other public health concerns. One participant reflected:

“I could say oral and dental health has been overshadowed by other health concerns, which could be a reason why this group doesn’t benefit from the services.” (P3).

Finally, informants raised concerns about the integrated information system to support informed decision-making by families and caregivers. Such a system could improve transparency about available services, locations, and associated costs. As one caregiver pointed out:

“If there were a center that clearly indicated which facilities offer services for us, specifically for our children or those with more expertise in working with our children, and provided information on timing and costs, we would make more informed decisions and seek out their treatment more easily.” (S3).

Professional competence and service readiness

The second key theme derived from the data is professional competence and service readiness. Informants across stakeholder groups emphasized that the knowledge, attitudes, and structural capacity of oral healthcare providers directly influence access to services for individuals with SHCN. This theme comprises four interrelated sub-themes: training, motivations and attitudes, Screening/specialized centers, and infrastructural and equipment.

A central concern expressed by participants was the lack of specialized expertise and practical skills among service providers is a major barrier to accessing ODHS for individuals with SHCN. They noted that dental education programs often overlook the specific needs of this group, and the limited hands-on training for dental teams significantly impacts service accessibility.

“It’s unfortunate that dental students receive no practical training. Their education is entirely theoretical, and only pediatric specialists receive hands-on experience.” (D2).

Others emphasized that even outside of dental schools, general health professionals often lack awareness of ODHS pathways, leading to missed opportunities for early referral and intervention. In this regard, one expert observed:

“Currently, patients can be excluded from the treatment process because their initial contact was with someone who could not properly guide them.” (P3).

Interviewees also emphasized that having trained and skilled professionals in the ODHS team is one of the most critical factors in enabling individuals with SHCN to access services. Due to the unique physical and psychological conditions of this group, their treatment requires comprehensive training and hands-on experience. The lack or insufficiency of such training creates significant challenges in providing effective care for SHCNs.

“Proper training for dentists is essential—not only to equip them with the expertise needed to provide quality care but also to enable them to oversee the work of others. This is a fundamental requirement for delivering oral and dental services to this group.” (P4).

In addition to technical skills, a significant barrier to utilization of ODHS for individuals with SHCN is the low motivation among some providers to treat this group. Interviewed dentists attributed this to fear of managing complex cases, as well as the high workload and treatment complexity without additional financial compensation. As one dentist explained:

“Treating these patients involves serious risks. For instance, I worry that a patient with a neurological condition might have a seizure, or that a heart condition could lead to sudden cardiac arrest after receiving anesthesia. These concerns create fear and hesitation.” (D1).

Another added:

“Providing care for these patients is extremely challenging, yet the compensation is the same as for treating a typical patient—despite the significantly greater effort and complexity involved. This lack of incentive is discouraging.” (D7).

Interviewees also emphasized communication barriers as a major challenge. They noted that providers’ inability to effectively communicate with SHCN patients can significantly limit access to care.

“Behavioral challenges can also hinder access to care. Unfortunately, many healthcare providers lack the skills to communicate with or manage SHCN patients effectively.” (P6).

In response to these challenges, policymakers believe that fostering empathy between the medical community and the public can enhance providers’ understanding and improve coordination in managing the treatment challenges of this group. They suggest that offering both material and non-material incentives by the government could be another solution to overcome this barrier.

“The medical community must understand the needs of individuals in special healthcare groups and recognize that they, too, are fellow human beings in need of dental services. Despite the known difficulties in treating this group, efforts should be made to ensure they are included among those who receive care, with ethical and humane considerations taken into account.” (P2).

The absence of specialized centers was also cited as a major structural gap. The absence of screening centers specifically designed for SHCN individuals further compounds this issue. Therefore, one potential solution to improve access to care could be the establishment of specialized service centers with the necessary equipment and initial dental assessment centers.

“Currently, there are no centers that offer specialized care for this group. These individuals are not covered for oral and dental issues.” (D4).

“For individuals who require more complex treatments, such as those with SHCN, specialized centers are essential. While some exist, they are few in number. It may be necessary to increase the number of hospital-based dental service centers.” (P2).

Several informants stressed the need to increase the number of such centers and ensure they are equipped for early identification and tailored intervention.

“In my opinion, there should be centers where the issues of these individuals are reported upon identification, and these centers and institutions would then determine the appropriate preventive measures.” (D5).

Finally, adequate infrastructure and modern, specialized equipment are crucial for providing ODHS to the patients with SHCN. Both dentists and policymakers have acknowledged the current lack of these resources and emphasized the importance of establishing such infrastructure to improve utilization of ODHS.

“When we are equipped with the right tools and have the necessary infrastructure for their treatment, we will undoubtedly be able to offer higher-quality services more easily.” (D3).

Sociocultural and Familial dynamics

This theme focuses on factors related to patients, parents, and caregivers that may either hinder or facilitate their utilization of ODHS. According to the results of the thematic analysis, these factors were categorized into two groups: socioeconomic status, and stigma and social attitude.

According to the informants, socioeconomic status plays a significant role in determining access to and utilization of ODHS in Iran. Since most individuals with SHCN belong to lower socioeconomic classes, their access to dental services is significantly affected, leading to reduced utilization. As one caregiver explained:

“Economic challenges are so overwhelming that we often struggle to meet our children’s basic needs. Taking them for dental treatment, which is already a costly task, becomes even more difficult for us.” (S1).

Another interviewee pointed out that the issue extends beyond financial means alone; cultural and social disadvantages also contribute to a reduced ability to navigate the healthcare system effectively.

“Most of the time, when you work with them, you realize they come from much lower socioeconomic backgrounds. Even if they don’t have a low socioeconomic status, culturally, they still require support.” (D1).

Beyond financial strain, stigma and social attitude were frequently mentioned as powerful deterrents to seeking care. The majority of families and caregivers of patients with SHCN cited the attitudes and behaviors of others, especially those in healthcare settings, as a major reason for not seeking dental care.

“Every time we go to dental offices or other crowded places for these services, we feel uncomfortable due to the way people look at us. It’s as if they embarrass us or treat us in a way that makes us feel judged.” (S4).

Another described how even interactions with healthcare staff could reinforce this discomfort:

“Unfortunately, the staff at the centers I’ve visited don’t understand us. Instead, they have a prejudiced attitude. The atmosphere feels tense, and the looks from others are uncomfortable, making me feel like I should apologize for my daughter’s illness.” (S3).

Care delivery processes

The final theme centers on the processes surrounding the actual delivery of ODHS for individuals with SHCN. While previous themes focused on structural and sociocultural enablers or barriers, this theme captures the logistical and practical realities that shape how—and whether—families can access care. informants emphasized two primary subthemes within this theme: geographical access and procedural and waiting lists.

Geographical access was repeatedly cited as a fundamental barrier, particularly for families living outside major urban centers. Informants explained that specialized clinics capable of delivering tailored dental care—especially under anesthesia—are few and far between. This lack of geographic distribution leads to costly and exhausting travel for many families. As one policymaker observed:

“Access to specialists is not available everywhere, so we need professionals at all levels who can gather these patients and provide the necessary services.” (P3).

A caregiver shared her experience of having to travel long distances to reach a clinic capable of treating her child:

“In our city, there is no dental clinic that can treat my child with anesthesia. To get dental treatment for my child, we have to travel from our town to Shiraz, which is costly, time-consuming, and involves many other challenges.” (S2).

In addition, procedural obstacles and long waiting lists were described as major deterrents to service utilization. Families reported that long queues and rigid administrative procedures often clash with the needs and limitations of their children. These issues are compounded by unsupportive work environments that offer little flexibility for caregiving responsibilities. One caregiver described the strain:

“The dental clinic we go to is very crowded, and we have to wait for an extremely long time, to the point where my child can’t calm down. My daughter is under a lot of pressure, which makes her become aggressive.” (S1).

Others noted the difficulty of coordinating appointments with demanding work schedules and limited support from employers:

“Taking my child to the dentist and getting treatment is always a big challenge. I’m constantly trying to find a suitable time to take leave and figuring out how to convince my employer to approve it. I feel like I’m torn between my job and my family.” (S3).

In some cases, these logistical burdens became so overwhelming that families were discouraged from pursuing care altogether. As one mother explained:

“Every time we want to take her to the dentist; the first problem is that I can’t easily take leave from my work. Also, because of my child’s condition, my husband can’t do it alone… The pressure is so much that sometimes we regret even trying to go for treatment.” (S4).

Discussion

Utilization of healthcare services has always been a challenging issue for health policymakers. Oral and dental health, as a key factor influencing overall well-being and a potential cause of serious health complications [25, 26], is particularly important. This concern is even more critical for individuals with SHCN due to their vulnerability and specific physical and cognitive conditions.

In this study, informants identified various factors that can either enable or bar utilization of ODHS in patients with SHCN. The most frequently mentioned factors are discussed in the following sections.

Among the governance and policy-related factors affecting access to ODHS, financial factors and insurance coverage were the most frequently highlighted by interviewees. The high cost of dental care, coupled with insufficient government support for SHCN patients, often leads to treatment delays or neglect, ultimately worsening their oral health conditions. In this regard, El-Yousfi et al. identified inadequate government financial support as a significant policy barrier to utilization of ODHS for vulnerable individuals [27]. Similarly, Zahran et al. reported that high treatment costs are among the most common obstacles preventing patients with SHCN from receiving dental care [28].

Moreover, the lack of insurance coverage for dental services further aggravates this issue. Accessing supplementary insurance, which provides limited coverage for dental care, is particularly challenging for families of SHCN individuals, who are often from lower socioeconomic backgrounds. This, in turn, further reduces their access to oral health services. Sarkar et al. highlighted that patients with SHCN covered by public insurance programs had significantly greater access to ODHS and improved oral health outcomes [29]. Similarly, Zhou et al. confirmed that socioeconomic status is a significant barrier to accessing dental services for SHCN individuals [30].

Financial vulnerability was particularly pronounced among families without access to supplementary insurance or financial support, often compelling them to delay essential dental treatments. Furthermore, it seems that many families of individuals with SHCN come from lower socioeconomic backgrounds, which further constrains their ability to prioritize oral health care [31]. This structural deficiency intensifies existing barriers and sustains a cycle in which preventive care is overlooked and treatment is sought only in emergency situations.

The findings indicate that a lack of specialized skills among dental care providers, along with insufficient comprehensive training for dentists, is a significant barrier to service utilization. The dental education curriculum in Iran does not adequately address the unique needs of individuals with SHCN, leading to insufficient training, particularly in practical aspects. As a result, many dentists feel unprepared and hesitant, which can either limit access to care for individuals with SHCN or result in suboptimal service quality.

One study found that inadequate preparation among dentists to support individuals with disabilities can restrict their access to dental care [32]. Similarly, Balkaran et al. highlighted that the lack of experience among dental teams is a key challenge for patients with SHCN in receiving dental care. They also emphasized the need for improved training for dental students, which aligns with the findings of this study [16]. Other studies have also confirmed the inadequacy of dental education in preparing dentists to treat patients with SHCN [33, 34].

The findings underscore a gap in specialized training about SHCN patients in Iran dental education program. In addition to the need of incorporating well-structured, SHCN-focused modules into dental education curricula, practical training and clinical exposure are essential to bridging the gap between education and practice as well. Targeted educational interventions that enhance providers’ confidence and clinical competence are likely to foster more positive attitudes toward treating patients with SHCN, expand service availability, and support the provision of more equitable care. Additionally, short-term specialized courses can be developed for providers interested in working with this population, with participants awarded an official certificate upon completion.

Dentists’ attitudes and motivation toward treating patients with SHCN play a crucial role in the quality of provided care. Many dentists have negative perceptions or lack sufficient motivation to treat these patients, making it difficult to ensure consistent and ongoing care that could improve their oral health outcomes. This issue has also been confirmed in previous studies [35].

Such attitudes can also create communication barriers between patients and healthcare providers, further limiting access to care for SHCN individuals. Research indicates that limited communication skills among providers, combined with a lack of experience in effectively interacting with SHCN patients, can result in missed opportunities for proper treatment [15, 36]. Similarly, Campos et al. found that most dentists struggle to communicate with deaf patients, a subgroup of SHCN patients, which aligns with the findings of this study [37]. Additionally, a study by Lim et al. showed that specialized training and counseling for dentists improve their preparedness to treat SHCN patients, ensuring timely and appropriate care for this population [38].

In addition to the previously discussed issues, the findings revealed that geographical access is another significant barrier that requires targeted policy planning to improve the utilization of ODHS for patient with SHCN. Many areas, particularly rural and remote regions, lack specialized dental clinics. Traveling long distances to access services in cities can be a significant challenge. Moreover, the indirect costs faced by families, such as time, accommodation, and additional expenses—especially for those with limited transportation options—further limit access to services. Additionally, the clinics available in urban areas are often not equipped with the advanced tools and facilities necessary for providing specialized care to this group. In a study on barriers to dental access for SHCN individuals, Alfaraj et al. found that over half of the informants identified geographical access, unsuitable clinic environments, and transportation challenges as significant barriers to accessing services [39]. This finding was also confirmed in Star et al.‘s study [40].

Additionally, the lack of flexibility in work environments, the difficulty of visiting medical centers, and the long waiting times in healthcare settings—especially considering the complexity of SHCN patients’ conditions—can lead to increased frustration among families, ultimately deterring them from seeking regular treatment. Several studies have highlighted the lack of access to dental care among vulnerable populations, asserting that this lack of access often leads to long waiting times [41–44]. Moreover, the reduction in utilization of dental services among SHCN individuals due to long waiting times has also been confirmed in other studies [35, 45].

Limitations

This study has several limitations. First, due to the qualitative nature of the research, the findings are not generalizable. Although efforts were made to include a diverse group of participants—initially categorized into three main stakeholder groups (service providers, policymakers, and families of patients)—the possibility of sampling bias cannot be entirely ruled out. The use of purposive and snowball sampling methods, while common in qualitative research, may have unintentionally excluded certain perspectives. Furthermore, the researcher’s active involvement in the design, data collection, and analysis phases may have introduced some degree of interpretive bias, as personal assumptions and experiences could have influenced data interpretation. Nevertheless, measures such as repeated review of the interview transcripts, consultation with experts, and documentation of analytical decision-making were undertaken to minimize potential biases. A key limitation is that service recipients who had never utilized ODHS were excluded from the study. This decision was made because the focus was on exploring the barriers and challenges faced by individuals who had attempted to access these services but encountered difficulties. Although, the perspectives of non-users could also provide valuable insights into the broader factors that prevent people from utilizing ODHS, the study offers valuable insights into the factors influencing the utilization of oral and dental health services among individuals with special healthcare needs in Iran, grounded in the detailed narratives of various stakeholders.

Conclusion

The present study identified the multifaceted factors that affect utilization of ODHS for SHCN patients in Iran, as viewed by healthcare providers, policymakers, and the patients’ families. The most significant factors highlighted by informants include training, motivation and attitude, financial factors and insurance coverage, geographical access, the socioeconomic status of families, as well as procedures and waiting lists. Since all these factors not only have a direct impact on utilization but also influence each other, a comprehensive and systematic approach is needed to address the barriers and transform them into enablers, ultimately bridging the utilization gap for this group. In this context, policymakers and healthcare authorities can create a supportive and inclusive environment through targeted interventions and policies, ensuring oral health, overall health, and well-being for these individuals.

Electronic supplementary material

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Abbreviations

SHCN

Special Health Care Needs

ODHS

Oral and Dental Health Services

Author contributions

Conceptualization: ZZ, ZKData curation: ZZFormal analysis: ZZ, ZKMethodology: ZZProject administration: ZKSupervision: ZZ, MAB, FI, ZKWriting – original draft: ZZ, MAB, FI, ZKWriting – review & editing: ZZ, MAB, FI, ZK.

Funding

This study is part of a PhD thesis, which was partly financed by the Research and Technology Deputy affiliated with the Shiraz University of Medical Sciences (SUMS) with grant no 1401.082 The funding bodies were not involved in the study design, study execution, or the writing of this manuscript.

Data availability

All data generated or analyzed during this study are included in this published article.

Declarations

Ethics approval and consent to participate

This study received ethical approval from the Ethics Committee of Shiraz University of Medical Sciences (ID: IR.SUMS.NUMIMG.REC.1401.082). The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. All participants provided informed consent prior to participation.

Consent for publication

Not Applicable.

Competing interests

The authors declare no competing interests.