Social protection models and the right to dental care for people with disabilities

Carneiro, Joana Danielle Brandão; Frazão, Paulo

doi:10.1590/S0104-12902024230658en

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Critical literature review • Saude soc. 33 (2) • 2024 • https://doi.org/10.1590/S0104-12902024230658en copy

Social protection models and the right to dental care for people with disabilities¹ 1 This work was financed by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) - Brazil - Financing Code 001.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Knowing and synthesizing expectations and recommendations on dental care as a right to oral health for people with disabilities (PwD) is essential to assist decision-makers. An integrative review was carried out, searching PubMed, Embase, LILACS, and VHL databases for articles published up to August 30, 2021. Term mining techniques were used via the Rayyan platform. Content analysis was based on welfare state theory. Sixteen articles were included. Expanding access was a need shared by all studies. The main expectations and recommendations were guaranteeing civil rights and reorienting the oral health care model (in the countries of liberal model); the need for professional qualification, systematic and free dental care, integration between services, multidisciplinary work and guaranteed financing (conservative model); qualification of infrastructure and workforce; and systemic articulation between care levels (social democratic model). We observed a complex and sometimes contradictory scenario of proposals, subject to indications with little potential for change, especially if we ignore contemporary challenges arising from economic crises and the welfare State that imply serious constraints to the models of social protection and the rights of PwD.

Keywords:
Public Policies; Guidelines; Oral Health; People with Disabilities

Data base	Descriptors	Total
Pubmed	(((((“health policy” [Mesh] OR “health policies” OR “policy, health” OR “healthcare policy” OR “healthcare policy” OR “healthcare policies” OR “policy, healthcare” OR “national health policy” OR “health policy, national” OR “national health policies” OR “policy, national health”) OR (“public policy” [Mesh] OR “policies, public” OR “policy, public” OR “public policies” OR “social protection” OR “protection, social” OR “population policy” OR “policies, population” OR “policy, population” OR “population policies” OR “social policy” OR “policies, social” OR “policy, social” OR “social policies”))) AND (“oral health” [Mesh] OR “mouth rehabilitation”)) OR (“dental care” OR “dental service, hospital” OR “dental health service”)) AND (“disabled persons” [Mesh] OR “disabled person” OR “disabilities, people with” OR “people with disability” OR “persons with disabilities” OR “disabilities, persons with” OR “disability, persons with” OR “persons with disability” OR “physically handicapped” OR “handicapped, physically” OR “physically disabled” OR “disabled, physically” OR “physically challenged”)	888
VHL	(mh:(“política de saúde”)) AND (mh:(“assistência odontológica”)) AND (“pessoa com deficiência”)	438
Embase	‘health care policy’ AND ‘dental procedure’ AND disability	19
Ovid	(“health policy” and “oral health care” and “handicapped”)	12

Social protection model in the study country
Author/Year	Authors’ expectations/recommendations
Objective (territory)	Authors’ expectations/recommendations
LIBERAL MODEL; represented by the USA, a country in which healthcare depends on the user’s ability to pay; it is regulated by the health insurance market, with part of the population eligible to receive subsidies from specific government programs (Medicaid, Medicare, and the Children’s Health Insurance Program).
Dart, 1988	The need to establish protection of civil rights by law; to take vigorous measures to ensure the enforcement of such laws; to ensure the availability of legal services for the defense of PwD, communication, transportation, and other support services; to promote education and empowerment initiatives, so as not to depend on paternalistic systems or be led astray by misinformation; to implement an effective and comprehensive oral health care service system, with a high degree of administration and professionalism involving partnerships between public (federal, state and local) and private entities, consumers, families, lawyers, and service providers; to ensure that the service system is accessible to all people through a single point of entry for information, referral, and counseling, based on a national computerized information network integrating services at the local, state, and federal level, in order to reduce costs and delays, eliminate gaps, provide reliable and up-to-date statistical information, and increase the power and productivity of professional service providers, as well as the quality and use of these services; for federal agencies to support research; to eliminate the regulatory and bureaucratic barriers that hinder access; and to develop international relationships with PwD advocacy organizations in other countries.
To share a proposed agenda to guarantee the rights of people with disabilities (USA).
Waldman & Perlman, 1997	Since Medicaid is a government-funded program that guarantees health care to certain groups, such as children, as long as they are below the poverty line, the authors recommended increasing dental services for adults with disabilities. This includes increasing the Medicaid budget and reimbursement amounts for paying for dental care.
To reflect on the lack of assistance that occurs with children with disabilities covered by Medicaid who lose coverage in adulthood but continue to have disabilities and needs (USA).
Glassman, 2005	Organized by the University of the Pacific School of Dentistry, with support from the California Dental Association Foundation, in California (USA), a new model of oral health care delivery for PwD was recommended: focus on prevention; greater financial incentive for promotion/prevention actions; integration between oral health and other community health and social services; case management approach for solution-based referral; oral health matrix support for other health and social service professionals; care system with increasing levels of complexity; caregivers closer to individuals with planned incentives; evaluation and monitoring of oral health services; increase the training of all dental professionals in the care of people with special needs; coordinating data systems across state programs; cataloging and disseminating successful models/experiences; financing research into models of oral health provision and prevention for PwD.
To present the conclusions of the conference on oral health for PwD, analyze the implications for the dental profession and society, and recommend systems and strategies that can lead to better oral health for these populations (USA).
Keels, 2007	Educational and professional accreditation entities play an important role in the qualification of service providers for PwD. Legislative agendas at the national and state level have impacted dental care for PwD. Efforts have been made through different governmental and non-governmental entities to defend PwD, who must be seen, first and foremost, as people. AAPD should be aware of these activities and develop activities in conjunction with these and other organizations whenever possible.
To identify policies and guidelines proposed by organizations other than the American Academy of Pediatric Dentistry (AAPD) that influence oral health care for PwD (USA).
Nowak, 2007	Include recommendations on clinical dental signs (oral manifestations) of child abuse and neglect; frequency of dental follow-up; list of preventive dental services (menu of care offer; early guidance on oral health and guarantee of dental treatment; pediatric restorative dentistry; management of acute dental trauma; fair and adequate compensation for the treatment of complex patients and other special needs.
To analyze the extent to which AAPD policies and guidelines include mention of PwD (USA).
Edelstein, 2007EDELSTEIN, B. L. Conceptual frameworks for understanding system capacity in the care of people with special health care needs. Pediatric Dentistry, Chicago, v. 7, n. 2, p. 108-116, 2007.	Institute a holistic approach to benefit the capacity of the dental care system to provide services to children with special needs, considering oral health as a health need and not just an individualized need with dental services that respond only to this demand. Defend an accessible, safe, competent, individualized, compassionate (humanized), integrated, high-quality, and educational health system. Focus on Primary Health Care (PHC): effectiveness, efficiency, punctuality, safety, user-centeredness, equity. This model may hold strong promise for incremental improvements in dental care for special needs children. The suggestions were: 1. to improve the supply and skills of dentists; 2. to establish sufficient funding streams (especially through Medicaid); 3. to integrate the medical and dental care team via: a. collaboration: b. co-training; and/or c. mobile installations. In order to facilitate implementation, this may require matching funds from states, foundations, health plans, hospitals, professional associations, or other interested parties.
To identify the strengths and weaknesses of the US healthcare system in relation to oral care for PwD, to provide a framework for understanding the system’s capacity, to describe the context in which dental care is provided (USA).
Glassman & Subar, 2008GLASSMAN, P.; SUBAR, P. Improving and maintaining oral health for people with special needs. Dental Clinics of North America, Amsterdam, v. 52, n. 2, p. 447-461, 2008. DOI: 10.1016/j.cden.2007.11.002 https://doi.org/10.1016/j.cden.2007.11.0...	Growing workforce shortages, inadequate training and a reimbursement system that does not reward the types of services needed contribute to the failure of the current system. Training and education of professionals compatible with the needs that PwD require when seeking dental care; to understand the appropriate use of language and know how to work in a multi-professional and interdisciplinary team, taking into account the different needs of PwD (social, health, cultural); territory-centered care practice (understanding the community arrangements, equipment and services available); to establish communication for compatible care with the user being assisted; broadening the scope of dental hygienists’ duties; and a multi-level care model in which increasingly complex care is carried out by those with the most extensive training, and less complex care is provided by those with less extensive training.
Given the expansion of the population with disabilities, to describe the challenges of providing oral health care services to this population and discuss the implications of these challenges within the dental profession and the organization of the oral health system (USA).
Edelstein, 2013	In order to be successful in changing policy (or including oral health in other policies), oral health advocates need to: (1) articulate their issue with clarity, urgency, and articulate the significant consequences; (2) link their issue to some political agenda that is “in motion”; (3) achieve significant levels of consensus within the oral health and general health communities and related communities of interest to avoid dissension and competing voices; and (4) commit to doing the “heavy lifting” of daily involvement in the policy-making process. As Congress recasts itself every 2 years, advocates must adjust to the political philosophies and economic realities of the time by modifying their “request,” reframing their issues, and renegotiating the political process.
To describe federal legislation for public oral health coverage for children with disabilities in contrast to the absence of such coverage for dependent adults (USA).
Tegtmeier et al., 2016TEGTMEIER, C. H.; MILLER, D. J.; SHUB, J. L. The Impending Oral Health Crisis. The New York State Dental Journal, Albany, v. 82, n. 3, 2016.	Despite the growing recognition that good oral health has an impact on general health, hospital dentistry programs and centers of excellence for patients with special needs are in financial difficulties and threatened with closure. It is necessary to ensure adequate payments for hospital dental services, special needs services and a well-trained and skilled workforce; to control costs with prevention; to advocate for a public policy, which means attracting the interest of policymakers; to advocate for oral health, which means reducing injustice and social inequalities; to advocate for a collaborative model of oral health (user, service, provider, company).
To reflect on the future of Special Needs Dentistry, Hospital Dentistry, and Dental Education, and formulate recommendations to ensure that PwD have access to adequate oral health care in the years to come (USA).
Cruz et al., 2016	A closer look at the resources available for children under 6 with special needs is necessary, especially since they are less likely to receive preventative dental care than those of school age. Other recommendations include use of fluoride; partnership between community organizations and dentists from the ABCD (Access to Baby and Child Dentistry) program to provide services to children with special needs; including oral health education in the agenda of organizations’ professionals (physiotherapists, occupational therapists, speech therapists) as part of the care of special children, including the education of those responsible for them.
To identify the types of oral health services offered by community-based organizations to children under 6 with special health needs and the barriers and facilitators to their provision in a community without access to fluoridated water (USA)
CONSERVATIVE MODEL: represented by countries where health care is based on mandatory social insurance and universal coverage regulated by the State, financed by work-related social contributions and taxes. Competences and resources can be transferred to health regions as arranged in each country.
Haavio, 1995	In these countries, the right to dental care is guaranteed by local public services, generally until the end of adolescence, with the age range varying depending on the country. Since 1984, the Oral Health Law in Norway prioritizes mental PwD, older adults, chronically ill people and PwD in institutions or home care. In addition, it guarantees these groups free dental care. The social and economic situation had worsened and could deteriorate the structure of the welfare state. Increasingly, PwD are experiencing reduced health and services. The Nordic Society for Dentistry for the Disabled has recommended education for oral health professionals providing services to PwD. Both theoretical knowledge and practical training should be included in the training of dentists, dental DHA and DHT; all intellectual PwD must be guaranteed free, systematic dental care, including health promotion and preventive dentistry; as well as referral systems, multi-professional cooperation. It is expected that mental PwD will be guaranteed free systematic dental care, also including health promotion and preventive dentistry. In addition, active search systems, multi-professional cooperation, and the special expertise of the dental team were considered necessary.
To describe the current situation and plans for the future of oral healthcare for PwD in the Nordic countries (Sweden, Denmark, Norway, Finland, and Iceland).
Gondlach et al., 2019GONDLACH, C. et al. Evaluation of a care coordination initiative in improving access to dental care for persons with disability. International Journal of Environmental Research and Public Health, Basel, v. 16, n. 15, 2019. DOI: 10.3390/ijerph16152753 https://doi.org/10.3390/ijerph16152753...	In France, competencies and resources have been transferred to health regions. A national expansion of the organization of oral health services is advocated from the perspective of health care networks, with accompanying financing and professional training programs. This advocacy involves developing primary care services that are local, inclusive, user/territory-centered, comprehensive, sufficient in quantity, quality, and accessibility.
To describe the results of the internal evaluation of the Réseau Santé Bucco-Dentaire et Handicap de la région Rhône-Alpes and discuss the health networks model as a response to improving access to dental care for people with disabilities (France).
SOCIAL DEMOCRATIC MODEL: represented by countries where health care is financed by the State and does not depend on the user’s ability to pay, having a universal character
Merry & Edwards, 2002MERRY, A. J.; EDWARDS, D. M. Disability part 1: The Disability Discrimination Act (1995) - Implications for dentists. British Dental Journal, London, v. 193, n. 4, 2002. DOI: 10.1038/sj.bdj.4801522 https://doi.org/10.1038/sj.bdj.4801522...	In the UK, the law was passed in 1995. Service providers are expected to make reasonable adjustments where it is impossible or unreasonably difficult for a PwD to use the service in three areas: (1) policy, procedure, and practice changes; (2) offering an ancillary service that enables or facilitates PwD access to the service’s logistical resources; (3) providing a reasonable alternative method of service provision when this is prevented or unreasonably hampered by a physical feature. These measures aim, above all, to overcome barriers to access to care for PwD. And dentists need to be aware of their responsibilities under the Disability Discrimination Act, whether as employers or service providers.
To describe the Disability Discrimination Act (DDA) and how it affects dental practice, taking as a starting point the results of a survey into access to dental services by PwD in Merseyside (England).
Dougall & Fiske, 2008	The need for an appropriate approach for a shared care, via a well-developed oral health network for PwD in the primary and specialist care sectors, which allows patients to move seamlessly between services and be seen by the right person, in the right place, at the right time. Adopting a patient-centered approach is essential to ensure that service users with disabilities have the same level of access, consented choice, and service user care as anyone else. Ensure the quality and quantity of the workforce in services for PwD in the United Kingdom.
To define Dentistry aimed at PwD and offer practical tips to encourage access and dental care, transfer to the chair, and access to the oral cavity by the professional (United Kingdom).
Qureshi & Scambler, 2008QURESHI, B.; SCAMBLER, S. The Disability Discrimination Act and Access: practical suggestions. Dental update, London, v 35, n. 9, p. 6, 2008. DOI: 10.12968/denu.2008.35.9.627 https://doi.org/10.12968/denu.2008.35.9....	Law in the United Kingdom recommends ‘reasonable adjustments’ to the physical structure of dental care services to increase accessibility and achieve an inclusive approach: internal and external ramps (temporary or permanent), handrails, parking, bathrooms with railings, elevators, decoration, doors, escalators, lighting, paving, ventilation, easy visual identification of the location at a certain distance (differentiated colors), carpets flush with the floor, Braille or tactile communication for general instructions, level surfaces whenever possible, non-slip surfaces, noise reduction as much as possible, repetition of key messages for care/consultation/treatment, availability of a variety of seats to meet different needs, and creating a lowered space at the reception desk.
To present the results of a study exploring access to dental care following the Disability Discrimination Act among general dentists based in the city center of Aylesbury (England).
Rocha et al., 2015	Health services that provide dental care in primary health care in Fortaleza, an influential capital located in the Northeast region of Brazil, were evaluated. It was recommended that practices be institutionalized, in a more articulated way, both in care routines (trained professionals, reception for scheduling, user participation) and in referring patients to more complex services; reduction of social, economic, communication, architectural and geographical barriers to enable the inclusion and comprehensive care for PwD.
To evaluate the accessibility of dental services in Fortaleza (CE) for PwD (physical, hearing, and visual) considering the presence/absence of geographic, architectural, organizational, cultural, economic, and communication barriers (Brazil).

Faculdade de Saúde Pública, Universidade de São Paulo. Associação Paulista de Saúde Pública. Av. dr. Arnaldo, 715, Prédio da Biblioteca, 2º andar sala 2, 01246-904 São Paulo - SP - Brasil, Tel./Fax: +55 11 3061-7880 - São Paulo - SP - Brazil
E-mail: saudesoc@usp.br

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[1] Correspondence Joana Danielle Brandão Carneiro Avenida Dr. Arnaldo, 715, Cerqueira César, São Paulo. CEP: 01246-904. Brazil.

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Social protection models and the right to dental care for people with disabilities1 1 This work was financed by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) - Brazil - Financing Code 001.

Abstract

Social protection models and the right to dental care for people with disabilities¹ 1 This work was financed by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) - Brazil - Financing Code 001.