Dental care in children with medical complexity: A retrospective study

Abstract

Background and Objectives

Children with medical complexity (CMC) are defined by complex, chronic multi-system disease with significant medical fragility. Limited research exists on dental care in CMC, which is an important part of oral health and overall health. Objectives of this study were to (1) determine the frequency and type of dental visits at a tertiary paediatric hospital of all CMC between 2015 and 2020 and (2) identify the factors associated with dental visits.

Methods

A retrospective chart review of the electronic records of CMC who were seen at a paediatric hospital from 2015 to 2020 was completed. The number and type of dental visits, demographic and clinical information were reviewed. Poisson regression models were used to test the association between the outcome (number of dental visits) and potential factors associated with receiving dental care.

Results

Four hundred and eighty-seven CMC (mean age=7.3 ± 4.6 years, 43.7% female) were included in this study. CMC were seen by dentists at the hospital 4.4 ± 3.8 times since 2015, which is approximately once per year over a 5-year period. Dental visits were mostly preventative (66.4% of all visits). CMC had more dental visits if they had dental care funding compared to no funding if they were living in a community with a population >100,000 people and if they were being followed by a greater number of sub-specialists.

Conclusions

This study highlights the importance of funding, access to paediatric dental specialists, and care coordination support to improve access to dental care for CMC to optimize oral health.

What Is Known on This Subject: Regular dental care is important for oral health; however, it may be overlooked in children with medical complexity due to competing medical demands and limited access to paediatric dental specialists. Limited research exists on frequency, type, and the predictors of dental visits in children with medical complexity, which is important knowledge for clinical teams providing holistic care to this patient population.

What This Study Adds: The predictors of dental visits and access to dental care for children with medical complexity include government funding or private insurance, living in a large urban centre, which could be a proxy measure of access to care and availability of paediatric dentists, and having care coordination support. Given the fragility of this population, it is important to improve access to dental care to optimize oral health.

Children with medical complexity (CMC) are children and youth with multiple chronic medical conditions associated with medical fragility, significant functional limitations, increased health service and intensive care needs, and increased health care costs (1).

CMC are at a greater risk of dental caries, gum and oral diseases or infections than typically developing children (2). Poor dental health in CMC is related to a variety of factors such as inefficient control of salivary function which may be due to neuromuscular dysfunction (3) and gastroesophageal reflux adding to poor oral hygiene (4,5). Furthermore, CMC are often dependent on their caregivers for routine oral hygiene, which may be overly burdensome for parents. Limited data show that 45% of parents with CMC report their child had multiple dental concerns including pain, cavities, halitosis, broken teeth, and teeth discoloration (6) and 70% did not have a routine dentist visit in the past year (6). Dental concerns can have a negative impact on quality of life due to pain, potential infection and possible surgical intervention (7). If left untreated, poor dental health can lead to significant complications including aspiration pneumonia or systemic infections and inflammation (7,8).

Dental care is often overlooked in CMC because clinical teams and families have competing demands, and must manage multiple diagnoses, treatments, and technologies (9). Additionally, CMC may not be able to receive treatment in traditional dentistry settings because they have difficulty tolerating dental procedures and may need general anesthesia to ensure patient safety (7). There is limited research on dental care in CMC, and most studies include children with a single diagnosis (e.g., trisomy 21), who would not be classified as CMC. The nature of dental visits and barriers to accessing dental care are unclear in CMC.

The primary objective of this study was to determine the frequency and type of dental visits of all CMC who are followed at a tertiary-care paediatric hospital in Toronto, Canada between 2015 and 2020. The secondary objectives were to identify the predictors of total number of dental visits at the hospital to help identify barriers to accessing dental care.

METHODS

This was a retrospective study approved by the Research Ethics Board (REB# 1000065479). The Hospital for Sick Children is a tertiary care paediatric hospital in Toronto Canada with the largest Complex Care program in Canada with 487 children within the program. The Complex Care program maintained a registry of all CMC followed by the hospital. The medical and dental records of CMC who were seen at the hospital from 2015 to 2020 were reviewed by two trained research team members (AP and KS).

Inclusion criteria

1. Patients followed by the complex care program must fulfill the following criteria as per the provincial definition (10):

   • a. Chronic diagnosis

   • b. Complexity

   • c. Fragility

   • d. Technology Dependent

2. CMC followed by the complex care program (ages 1 to 17 years of age)

Exclusion criteria

1. CMC > 18 years of age

2. Discharged from the complex care program

The following data was recorded from eligible patients:

Child demographics and medical history: Please see Table 1 for details on data collected.

Table 1.

Patient demographic and clinical characteristics

	All CMC (N=487)	CMC with dentistry records at the hospital (N=262)	CMC without dentistry records at the hospital (N=225)	P-value
Age (Years)	7.4 ± 4.6	8.0 ± 4.3	6.6 ± 4.8	<0.01
Sex (% Female)	43.7	44.7	42.7	0.73
Number of diagnoses	9.3 ± 3.5	10.0 ± 3.6	8.5 ± 3.2	<0.01
Number of medications	9.4 ± 5.8	10.4 ± 5.9	8.3 ± 5.4	<0.01
Number of technologies	4.9 ± 3.3	5.6 ± 3.3	4.2 ± 3.1	<0.01
Number of sub-specialists	6.6 ± 2.5	7.0 ± 2.5	6.1 ± 2.4	<0.01
Number of days hospitalized since 2015	65.1 ± 95.4	70.1 ± 102.9	59.1 ± 85.7	<0.01
Immigrated to Canada <5 years ago (%Yes)	4.7	6.5	2.7	0.08
Living in a small community (%Yes)	34.9	26.0	45.3	<0.01
Types of dental care funding (%)
Government∗		29.4	Not available	--
Private		33.6
Mixed (Private and Government)		9.2
None		27.9

All values reported as mean and standard deviation unless otherwise specified. Values in bold are statistically significant.

CMC Children with medical complexity.

Government funding includes The Ontario Cleft Lip and Palate/Craniofacial Dental Program, Healthy Smiles Ontario and the Native Indian Health Benefit.

Dental Visits: The types of dental visits patients attended were also documented and were classified into the following groups:

1. Preventative dentistry visit: A scheduled visit where patients receive a dental check-up and procedures such as plaque and calculus removal, fluoride varnish, and pit and fissure sealants.

2. Restorative dentistry visit: A scheduled visit focused on managing of diseases affecting teeth (e.g., dental caries) through procedures such as cavity fillings and crowns.

3. Dental Examination: An unscheduled or scheduled visit where patients are examined for both urgent (e.g., dental pain) and non-urgent (e.g., cleft palate assessment) concerns.

Statistical analysis

Descriptive statistics of patient characteristics and selected outcomes are presented as means and standard deviations for continuous variables; counts and proportions for categorical variables. T-tests and chi-square tests were used to compare differences between patient characteristics separated by those who had dental visits in the last 5 years and those who did not have visits.

As a secondary analysis, Poisson regression models were used to assess whether total number of dental visits (continuous variable) were associated with potential factors associated with receiving dental care which include: number of technologies the patient is using, diagnoses the patient has, subspecialists the patient is being followed by, patient age (assessed as a continuous variable), patient and family immigrated to Canada <5 years ago (yes or no), living in a small community (<100,000 people) (yes or no) and type of dental funding (government, private insurance, mix of government and private, none). Rate ratios along with their 95% confidence intervals and P-values corresponding to the effect of the patient characteristics are presented with values of P<0.05 considered to be statistically significant. Data were analyzed with R 3.6.3 statistical software.

RESULTS

Four hundred and eighty-seven CMC (mean age=7.3 ± 4.6 years, 43.7% female) were followed by the complex care program and were included in this study. Of these, 262 CMC (53.8%) were seen by the dental service in the hospital and 164 CMC (33.7%) were seen by a dentist in the community. Sixty-one CMC had no mention of dental care in their medical record and a dental record could not be found at the hospital. The 262 CMC seen by the dental service in the hospital were seen, on average, four times since 2015 (4.4 ± 3.8 times) and 72.1% of these patients had funded dental care. The CMC seen by the dental service in the hospital were significantly older age, had a greater number of diagnoses, medications, technologies, subspecialists, and days hospitalized since 2015. A significantly greater percentage of CMC living in a small community were seen by dentists in the community rather than the dental service in the hospital. Further details on dental funding, demographics and clinical characteristics of the study cohort can be found in Table 1.

The majority of dental visits were preventative and scheduled (66.4% of all visits). Other dental visits included both urgent (e.g., dental trauma or pain) and non-urgent (e.g., cleft palate assessment) oral examinations (26.2% of all visits). Restorative dentistry visits (e.g., crowns, cavity fillings, root canals) made up 7.4% of all visits, and the majority of these visits were completed under general anaesthesia in the operating room (74.1% of all restorative visits). Further details on the type of dental visits can be found in Table 2.

Table 2.

Dentistry for children with medical complexity

Type of visit with dentist at the hospital	N	% of total dental visits since 2015
Preventative Dentistry (Scheduled Visits)	729	66.4
Restorative Dentistry	81	7.4
Dental Examinations (Urgent/Non-Urgent)	288	26.2
•General consultation by dentist to examine dental health	176
•Dental plaque/tooth discolouration	12
•Rule out dental pain	10
•Dental caries	10
•Cleft palate assessment	20
•Rule out dental infection	8
•Gingival swelling or bleeding	8
•Dental trauma and pain	14
•Bruxism/teeth grinding	8
•Retained primary teeth	4
•Tooth erupted, mobile or avulsed	7
•Other	11
TOTAL	1098

Other includes the following: Delayed tooth eruption (3), Tooth alignment/malocclusion (2), obstructive sleep apnea (1), oral aversion (1), prosthodontic assessment (1), secretions (1), extraction and preventative dentistry (2).

The regression model shows that the rate of dental visits increased by 88% in CMC with government funding for dental care compared to CMC with no dental funding support. The rate of dental visits increased by 68% in CMC with private insurance funding compared to CMC with no funding support. The rate of dental visits by CMC who lived in a small community was 72% less than the CMC who did not live in a small community. The rate of dental visits for CMC also increased by a factor of 7% as the number of subspecialists increased by one. Further details on the regression analysis can be found in Table 3.

Table 3.

Predictors of dental care at the hospital: Poisson multiple regression model

	RR	95% CI (Lower)	95%CI (Upper)	P value
Age (years)	1.1	1.1	1.1	<0.01
Number of technologies	1.0	1.0	1.0	0.12
Number of diagnoses	1.0	1.0	1.0	0.58
Number of subspecialists	1.1	1.0	1.1	<0.01
Immigrated to Canada <5 years ago - Yes	0.9	0.7	1.2	0.45
Living in a small community - Yes	0.7	0.6	0.8	<0.01
Dental care funding - Government	1.9	1.6	2.2	<0.01
Dental care funding - Private	1.7	1.4	2.0	<0.01
Dental care funding – Mixed (Private and Government)	1.2	0.9	1.5	0.24

CI Confidence interval; RR Relative risk.

DISCUSSION

This study explores the frequency and types of dental care in CMC followed by a complex care program at a tertiary paediatric hospital. In this study, 87.5% of CMC saw a dentist either at a tertiary paediatric hospital or in the community. In this cohort, CMC were seen by dentistry at the hospital approximately once per year over a 5-year period. The majority of dental visits in the hospital for this cohort were scheduled preventative services (66.4%). The frequency of dental visits by CMC in this cohort, however did not meet what is recommended for typically developing children, which is twice every year for preventative care/a dental check-up (11).

This study also shows that the greater number of subspecialists a patient had, which can be a surrogate marker of medical complexity, was predictive for receiving dental care at the hospital. This may be because more subspecialists may be associated with more appointments at our centre, and thus more opportunities for dental care to be coordinated with other services. At our centre, care coordination by the complex care team can allow for dental visits to be scheduled with other clinical services and may even be done under general anaesthesia in combination with another surgical procedure. Other research shows that children with special needs had a greater probability of using dental care when they had care coordination support from their clinical team (12,13). Another study in children with special needs reported multiple medical appointments are a barrier to accessing dental care because coordination of appointments was difficult for the family as they were not followed by a complex care team (14). The medical home of children with special health care needs is typically their primary care paediatrician, who may have limited care coordination support and focus primarily on acute care needs and ongoing health care maintenance. Strengthening the connection between medical and dental teams can be an effective way to improve care coordination for CMC, which can improve access to dental care and subsequently improve their oral health.

Interestingly, other markers of medical complexity such as number of medical diagnoses and number of medications were not predictors of dental care in this study, further suggesting that care coordination support from a complex care program may explain the association between greater number of subspecialists and a greater number of dental visits for CMC. Furthermore, this study also showed that the majority of restorative dentistry (e.g., cavity fillings and crowns) in this cohort of CMC occurred under general anaesthesia, which is similar to other studies with patients comparable to CMC (15,16). CMC are more likely to have restorative dental treatment under general anaesthesia because of their limitations in intellectual functions and interpersonal interactions (15). Additionally, the majority of CMC may have difficulty tolerating the discomfort of restorative procedures with a local anaesthetic, and general anaesthesia can help ensure the safety of both the patient and dentist during the procedure. However, it is interesting to note that 25.9% of restorative treatment was tolerated by CMC in this cohort with a local or no anaesthetic.

This study also highlights that the strongest predictors of receiving dental care at the hospital were government funding or private insurance. We believe this may be because a lack of insurance and high out of pocket costs are a known barrier to accessing dental services especially amongst CMC as families have competing financial priorities. Families with CMC often have out of pocket expenses for medical equipment (e.g., positive airway pressure machines, electronic wheel chairs) and other medical needs (e.g., physiotherapy, medication) thus potentially putting dental care as less prioritized. This is in line with other studies that have identified financial costs, affordability and insurance limitations, as the most significant barriers to accessing and receiving dental care (13,14,17). These barriers may be more significant for children with certain medical diagnoses including craniofacial abnormalities, cerebral palsy, autism, developmental delay, and trisomy 21 (18).

Another demographic predictor of dental visits for CMC at the hospital was not living in a rural community, suggesting that there are additional barriers to accessing specialized dental care for CMC living in rural communities, which may include difficulty travelling to a specialized paediatric tertiary care centre (14). Data from the USA also show that CMC living in rural areas have higher levels of unmet dental needs than their urban counterparts (19). Rural settings may also have limited availability of dental specialists with experience caring for CMC in the community setting.

Equitable access of specialized dental care for CMC is critical in order to optimize both physical health and quality of life for these children. Regular dental care is important because it can prevent common dental concerns such as dental caries, gingivitis, and periodontal disease, which develop from bacteria in the mouth (7). Additionally, children who have regular preventative visits with their dentists have better dental health and are less likely to need subsequent restorative services (20). Our results underline the importance of continued advocacy for improved funding and financial resources for these families. It also identified a particular group of patients, those living in smaller communities, who may need additional support to access specialized dental care. Initiatives to target improved advocacy for dental services for CMC specifically may include coordination of multiple medical appointments for the same day, knowledge of travel grants available to these families, and continued partnerships and education of community paediatricians and dentists to ensure that CMC are able to access the dental care that they need in order to achieve optimal health.

Our data have some notable strengths and weaknesses. The strength of this study is the large sample size of CMC included. Additionally, although there is published data on dental care in children with special health care needs, there is less research on CMC specifically, who tend to be more medically complex and technology dependent and have different challenges in accessing dental care. Limitations of this study include that data were collected retrospectively, so we had limited variables available and could not account for selection bias. We also did not have dental data on the CMC that were not seen by dentists at the hospital. Future research with data on dental care from providers in the community may help generalize the findings of this study to more CMC.

CONCLUSION

This study shows the majority of CMC in this cohort are followed by dentistry either at the hospital or in the community, largely for preventative services. The strongest predictor of having a dental visit at the hospital was having government funding, followed by private insurance. Other predictors included living in a larger community and being followed by more subspecialists—which is likely linked to more opportunities for care coordination. These predictors may guide future research on interventions on improving access to dental care in CMC, to improve oral health and overall quality of life.

Author Contributions

Arpita Parmar participated in the conceptualization and design of the study, collected data, analyzed and interpreted the data, drafted the initial manuscript and manuscript completion. Dr. Kelsey Shannon contributed to data collection and interpretation, drafting of the initial manuscript and manuscript completion. Dr. Michael Casas participated in the conceptualization and design of the study, data collection, and interpretation and manuscript completion. Dr. Julia Orkin participated in the conceptualization and design of the study, analyzed and interpreted the data, drafted the initial manuscript and manuscript completion. All authors critically reviewed and revised the manuscript for important intellectual content. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Clinical Trial Registration: Not applicable.

Funding: There are no funders to declare for this manuscript.

Potential Conflicts of Interest:

All authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.