Boundless Abilities: Autism and More

Ep 18: Dental Care Is Healthcare

• Boundless • Season 2 • Episode 13

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Why does the I/DD community struggle with access to dental care and what are some of the challenges facing the next generation of dentists? All of this and more as Dr. Stephen Beetstra, program director for Ohio State's Nisonger Center for Dental Services and Boundless Health's interim dental director, sits down with Scott Light. 

Scott Light:

Welcome to Well-being a podcast brought to you by Boundless and it's made possible by a grant from the city of Worthington. Boundless is a nonprofit that provides residential support autism services, day programs and counseling and a whole lot more to children and adults. Our mission is to build a world that realizes the Boundless potential of all people. I'm your host, Scott Light. Our guest today is Dr. Stephen Beetstra, who leads the Boundless Health dental practice and is also Program Director of Ohio State's Nisonger Center for Dental Services, Dr. Beetstra, welcome to you.

Dr. Stephen Beetstra:

Well, thank you, Scott, I'm glad to be here.

Scott Light:

It's good to have you here. We are talking about new and really needed dental services for people with intellectual developmental disabilities, and also autism. If you would, let's start this way. Tell us about this program and also this partnership between Nisonger and Boundless.

Dr. Stephen Beetstra:

Well this has been It started about a year ago when Boundless came to OSU Nisonger program to see if we could help them create a dental component to their FQHC that they're developing. And we all know that this population, patients with intellectual and developmental disabilities have very limited access. And when we heard that Boundless was undertaking this initiative, it was a perfect marriage between OSU Nisonger and Boundless to help create the program to hopefully increase access for patients with intellectual developmental disabilities to oral health services.

Scott Light:

You are coming up on your second anniversary as director of dental services over at Nisonger. Broadly here, what have you learned, what have you observed here in central Ohio, about what we need in our community here?

Dr. Stephen Beetstra:

Well, this is not just a central Ohio issue, it's actually a national issue in which we have very limited access to oral health services for persons with intellectual and developmental disabilities. Those individuals often take a little more effort more time and experienced providers who have a compassion to take care of this population. Another thing that we need to really focus on with this population is the total health aspect of providing the oral health services. It's not just fixing a tooth, it's not just doing a cleaning, it takes it's a lot more, I mean, you need to be a healthcare provider. And that's one of the things that I really liked about Boundless and OSU Nisonger center is how we focused on the total well being of the patient and not just on a single tooth. Our goal is to make sure that individuals with intellectual and developmental disabilities have some say in the care that they receive, but also have some say in their total health. And as we develop the program here, and we expand the program at OSU, Nisonger, we're just opening the door up to additional services for this population who's been underserved for generations.

Scott Light:

Let me follow up with exactly where you ended. Why has this population been so underserved?

Dr. Stephen Beetstra:

It's multifaceted one of them. One reason is, this patient population takes providers who have additional skills and behavior management that often does not, you know, it's not taught in dental school education. Some of our providers that we who are very successful, there's a lot of on the job training. There's other residency programs that help train the providers, but generally, the person who goes to dental school doesn't receive the behavior management education that they need to to safely manage this population. And Dentistry has always been a carve out from healthcare. Ever since the 1965. Medicare plan Dentistry has been carved out of medicine, and healthcare. So it's Dentistry has been mostly a small business. And in order to be able to be profitable, and to manage a business, you had to be very efficient taking care of this population is not very efficient, because it takes more time it takes more staff, and it takes someone who has the desire to really manage this population.

Scott Light:

And speaking of taking that time taking more time. I've got a couple of data points here. 80% of the patients who come to you to have this right, they need to be sedated or told they need to be put under.

Dr. Stephen Beetstra:

Yeah.

Scott Light:

For basic dental care?

Dr. Stephen Beetstra:

Exactly. At the Nisonger center, and even somewhat here at Boundless. All of our patients that we see at the Nisonger center were referred to us for treatment under sedation and of those 80 to 85 percent of them, we're able to treat them without sedation in our dental clinic. And it just takes the experience it takes the behavior management skills, it takes an understanding of the communication, you need to be able to communicate with the patient at their level. I mean, you need to be able to be clear with your communication in order to be able to provide services. Let's face it, I mean, going to the dentist is a horrible, horrible experience for everybody. And what we tried to do is to try to make it tolerable and we try to educate and train our patients to be able to tolerate dental care. On occasion, we do need to take patients for treatment under sedation, but it's it is not the majority, it's probably about 10 or 15%.

Scott Light:

Also, along with fewer oral health resources, the data shows that people with I/DD generally have increased dental disease, right?

Dr. Stephen Beetstra:

Yes and the reason for that is there's multiple reasons. One is they tend to have poor oral health care. A lot of patients with intellectual developmental disabilities are dependent upon other people to provide those oral health those home care services to them and, and sometimes it can be difficult. Another thing is some of the medications that they take cause dry mouth, which increases the amount of caries that they have increases build up, they tend to be mouth breathers. Every time I see a patient who has a mouth breather, I know that there's possibly a higher likelihood that they're going to have some sort of dental disease, either dental cavities or periodontal diseases. All of them, most of them sleep with their mouth wide open. And we all know from research that mouth breathers especially when they sleep have a higher incidence of health problems, not just dental problems.

Scott Light:

You're in your OSU scrubs joining us today, you're an educator as well teaching that next generation of dental clinicians as an assistant professor at Ohio State. Tell us about your passion for this. Give us a little bit about your background.

Dr. Stephen Beetstra:

Well, I have been on faculty of medical schools before I came to Ohio State for about 25 years. One was at the University of New Mexico and I how I helped start a dental program for patients with intellectual and developmental disabilities there. And for the past 16 years. I was at Arkansas Children's and University of Arkansas for medical sciences where I was the chair of the department of pediatrics and special needs dentistry. I have been focusing on taking care of this population for the for the next 25 years. And as I get older, I realized that in order for us to maintain services for this population, we need to train or train the next generation. And that's one of the reasons why I was attracted to Ohio State is to be able to train the next generation and find those one or two dental students in each dental class that has the passion and the commitment to care for this population.

Scott Light:

You led me right to an easy follow up, which is this does that next generation of clinicians and get that they're really needed in this space of care.

Dr. Stephen Beetstra:

Yes and no.

Scott Light:

Okay.

Dr. Stephen Beetstra:

Yes, that they know they're really needed. But no, in the reason why it's no is because student debt is such a big issue with dental students, that the reimbursement rates that we currently have for this population, and the added time for them, makes it cost prohibitive, prohibitive to to actually go and take care of this population just because of all the student debt that they have. On average, it's not uncommon for a dental graduate to have a half million dollars worth of worth of student debt when they graduate dental school. And because of that, sometimes is really limited to where they can practice because they need to be able to pay off some of that debt. Fortunately, we have some governmental programs that allow them to pay off a percentage of the debt over 10 years. But depending on your student loans, not all loans are eligible for that type of repayment plan.

Scott Light:

My goodness 500,000? How did the collaboration begin between Nisonger and Boundless?

Dr. Stephen Beetstra:

500,000. And fortunately for us, Ohio State is one of the less expensive dental schools but it's still I still I have contact with the dental students on a daily basis and it's not uncommon for $500,000 worth of student debt. I've even had some that have come out with 700 to$800,000 worth of student debt So that's one of the things that in order to make an impact with that we need to look at maybe identifying students earlier who want to do this and provide scholarships and maybe some sort of payback in which they are able to pay back some of the their debt and pay back some of their scholarship based upon time taking care of this population. There's always been a little interaction between the two programs. Nisonger is a University Center of Excellence for the care of, of the developmentally disabled. And Boundless basically has a very similar mission more on the service and we're basically on the education side and, and research side and you guys were on the service side, we've been providing services for this population and it was just a, it was a marriage that fit well to allow Nisonger to to further commit towards educating providers and moving slightly away from the patient. Not totally away from the patient care aspect, but slightly away from the patient care aspect and let Boundless actually begin and expand their program. There is plenty of patients out there I mean, I look at my schedule here at Boundless and it's I mean I've been here for a month and I'm already filled up until September. I look at my look at my schedule at OSU Nisonger and and I know there's like 100 new patients that need to be seen. And I'm booked until October already and and a lot of a lot of times so the need is out there and with the expansion of the Boundless program it it is a win win situation for everybody here it's a win win for Boundless it's a win win for OSU Nisonger, it's a win win for the patients. Being able to have access to quality oral health services and to quality health services is is what we're trying to do when we incorporate oral health services into both the OSU Nisonger program and Boundless Health.

Scott Light:

Well and let's talk about again, in you mentioned this earlier, oral health isn't just about oral health, it's not siloed, right? It's a part of a person's overall general health.

Dr. Stephen Beetstra:

Correct me and it's both general health and it's also some of the social things. Like for example, we all know that periodontal disease goes hand in hand with diabetes and heart disease. We also know that if you happen to be missing front teeth, chances are it has a huge economic impact on your overall life. You How often do we see somebody without front teeth who are working in a nice restaurant being the it just doesn't happen? There's an economic impact and in our patient population, they all want to work. They really do. I mean, if you have an intellectual and developmental disability, you want to be productive in society. And we need to be able to help those individuals who who want to work who want to be doing things and being productive, being be productive. And and that means providing a lot of health services. And in doing evaluating their health when they come to the dental office. I mean, one of the things that we are trying to do at Nisonger center now is do a one C tests on all of our patients when they come in in order to identify those pre-diabetic patients. So that way we can make the referrals off to primary care. I see something very similar to that happening here at Boundless in which there's a total integration of the of health services in which both primary care, psychiatric, and dental services work as a team and work as a collaborative. And that's something that I really think sets the Boundless program apart from a lot of programs, stuff, especially here in central Ohio.

Scott Light:

You were talking about this being brand new, am I right that you're right now you're offering dental services once a week?

Dr. Stephen Beetstra:

One day a week? Yes.

Scott Light:

Talk about the build out from there. Where do you want to get to in terms of number of chairs, exam rooms and things like that?

Dr. Stephen Beetstra:

Well, currently, there's going to be a brand new clinic with six chairs. And I envision that that program will be quite busy fairly quickly. Once Once a new facility is built, the facility is going to be very patient friendly. For example, where I worked at Arkansas Children's Hospital, we noticed that if you put a TV over the dental chair and a screen over the dental chair, the amount of sedation and the amount of behavior management you needed to use went down dramatically. So the new clinics gotta have TVs over the chairs. So and decide like a side note. You can never guess what the favorite channels are patients liked at Arkansas Children's Hospital.

Scott Light:

I'm gonna guess Cartoon Network?

Dr. Stephen Beetstra:

No, it was HGTV and the Food Network.

Scott Light:

Get out really?

Dr. Stephen Beetstra:

Yes. And it's funny. Once a patient gets over to 8, 9, 10 years of age, it was HGTV and the Food Network where the really where the channels that were most requested by patients with autism.

Scott Light:

Interesting, interesting, okay. And even color choices on the walls and the types of furniture all that's going to be considered in this whole build out, right?

Dr. Stephen Beetstra:

It is, it is patient-centered. And I mean, for example, the equipment that's selected is going to be behind the patient. Because if you've ever been to the dental chair, and they bring that tray over the top of you, it can be it can make you feel claustrophobic. And we want to make sure that patients feel comfortable when they walk in. We want to make sure patients understand why they're there and in train them to be able to tolerate dental care. And that's the main goal of this because I've I've had operating room privileges for close to 30 years now over 30 years. And let me tell you, it's very risky taking a patient to the operating room of all the things that I've ever done. That's the most risky thing that I do. And if we can manage and take care of the patients in the clinic, it's so much safer for them. And we're able to provide quality dental care and oral health services and healthcare service for services for these popular for this population. That's what our plan is to do here at Boundless.

Scott Light:

And coming back to something that you were talking about the how underserved these populations are. And to our listeners out there, if they're thinking well, you know, six chairs, but wait a minute, I mean, six chairs, you multiply that again, once the build out happens, you're talking about eventually affecting hundreds and 1000s of lives a year, over the course of time. That's a lot of health care outcomes that are improved,

Dr. Stephen Beetstra:

Right and being being centrally incorporated within primary care and psychiatric health. It just just magnifies it. Maybe the dental clinic will be a conduit to improve conduit to primary care. I mean, we can't be treating these patients in a silo, we need to think about their overall health. When we and Boundless is thinking about their overall health when they started the construction and renovation of the new building.

Scott Light:

One of the last questions I'd like to get to and when we get leaders like you on our podcast, it's it's what we like to call a magic wand question. If you had that wand to, let's say address three acute shortcomings in oral health, what would they be?

Dr. Stephen Beetstra:

The first is I want the oral health providers to understand the social determinants of health and how they impact this population. They need to understand that transportation is such a big issue. They need to understand how difficult it is to make it make an appointment. They need to develop and create. They need to have the empathy to take care of this population because walking in our patients shoes sometimes is very, very difficult. And they need to understand all the effort that it takes for both the families, caregivers and the patients in order to actually come in and receive services. A second thing that I would like to happen is I would love oral health provide I would like to have dental education be a lot more reasonably priced, but to allow for more individuals who really want to go into this area to be able to we're working on a national level to possibly create a specialist to care for this population. We're working on creating a standardized curriculum that can be utilized throughout dental Schools and residency programs to be able to better manage and care for this population. Currently, the dental school curriculum is getting so compressed with so much information that it's very, very difficult to get all the information into four years, our medical colleagues, they know they go to medical school, and then they go for another three, four or five years of residency training. And I believe dental education needs to go into that model as well. We need to really be able to expand the training of the of the provider after they finished dental school. And I always wish the third thing is I always wish that we had some sort of vaccines or something to prevent dental caries and prevent periodontal disease, because this population would really really benefit from that. I wish we could have some magic Bill bullets where we could improve the overall oral health of this population. But right now there isn't and, and as we see this population grow and grow. I mean, the number of autistic patients is growing, the number of patients with intellectual and developmental disabilities is increasing the number of patients with medical issues is increasing just because our medical care has has improved so greatly over over the past 30 years. I remember when I first started, I never saw patients in their 60s. Now we see Pete patients in there, we see lots of patients in their 60s 70s 80s. I even had a 90 year old. And it's just because healthcare has gotten so much better that we need to, we need to refocus our mission of improving the overall or oral health of this patient population well beyond the 60s, their 60s and 70s, to really look at improving outcomes, and expect them to have their teeth when they're in their 80s and 90s. My dad is 91 years old. And you may not know this, but I grew up on a dairy farm and I grew up milking cows and my dad is 91 years old and he has all of his teeth.

Scott Light:

Well, that's because he's had to use his dentist.

Dr. Stephen Beetstra:

I have never treated my father in my life. I mean, hey, I've lived all over the country. And once I left the dairy farm in Wisconsin, I go back to say hello, but I've never lived in Wisconsin since then. But I want everybody to have the oral health care that my father's had. And he's 91 and still has all of the all of his teeth. And that's what I hope for all of our patients.

Scott Light:

Dr. Beetstra thank you for being here.

Dr. Stephen Beetstra:

I appreciate it. I mean, anything I can do to improve the overall health of this population. Sign me up.

Scott Light:

We will have you back for sure. And to our listeners, thank you as well. If you'd like more information on our conversation, all you have to do is head to boundless health.org That's where you can sign up for an appointment as well. You can be part of episodes in the future to email us your questions or comments at podcast at I am boundless.org This is the Well-Being podcast brought to you by Boundless.