10.59987/ads/2016.3.52-59
Background. The prevalence of oral diseases including dental caries and periodontal conditions is remarkably higher in people with disabilities. The provision of accessible oral health services for people with learning disabilities may be challenging. Objectives. The objectives of the review were to identify barriers in accessing oral health care that persists within society, enabling or disabling people with learning disabilities.
Methods. Using the Arksey O’Malley framework, a scoping review was conducted on PubMed/Medline, OVIDSP, and EMBASE. Studies were evaluated and short-listed based on the inclusion criteria, which consisted of: (1) study participants or population with learning disabilities, (2) aged 16 years or over, (3) reporting on access to oral health services, (4) published in the English language. Those that justified the inclusion criteria were carefully chosen after a blind peer-reviewed process when relevance and quality were debated.
Results. Nine studies were eventually included from searches. Tabulation of data was done under the heading of study type, outcomes, the year of publication and patient selection. The majority of studies provided a biomedical overview of access for adults with learning disabilities.
Conclusions. The concept of access for people with disability is still ill-defined and obscure. Access to oral health care and needs of people with learning disabilities are complex and multi-facet.
application/pdf
1971-1441
66
3
en
H. S. Khalil 
https://creativecommons.org/licenses/by-nc-nd/4.0
Annali di stomatologia
coping review
Access to oral health care services among adults with learning disabilities: a scoping review
Text.Serial.Journal
https://www.annalidistomatologia.eu/ads
7
Review article
2022-08-10
2022-08-10
2016-09-01
2023-12-04
52-59
Ann Stomatol (Roma)
H. S. Khalil 
2016
10.59987/ads/2016.3.52-59
52
1971-1441
3
coping review
en
59
Access to oral health care services among adults with learning disabilities: a scoping review
https://www.annalidistomatologia.eu/ads/article/download/66/55
7
                                                                                                    Review article



    Access to oral health care services among adults
    with learning disabilities: a scoping review




                                                                                                                i
                                                                                                              al
    Mustafa Naseem1                                         Objectives. The objectives of the review were to
    Altaf H Shah1,2                                         identify barriers in accessing oral health care that




                                                                                                n
    Muhammad Faheem Khiyani3                                persists within society, enabling or disabling peo-
    Zohaib Khurshid4                                        ple with learning disabilities.




                                                                                             io
    Muhammad Sohail Zafar5                                  Methods. Using the Arksey O’Malley framework, a
    Shabnam Gulzar6                                         scoping review was conducted on PubMed/Med-
    AlBandary H. AlJameel7                                  line, OVIDSP, and EMBASE. Studies were evaluat-




                                                                az
    Hesham S. Khalil8                                       ed and short-listed based on the inclusion criteria,
                                                            which consisted of: (1) study participants or popu-
                                                            lation with learning disabilities, (2) aged 16 years
    1 Department of Preventive Dental Sciences, College     or over, (3) reporting on access to oral health ser-




                                                              rn
    of Dentistry, Dar Al Uloom University, Riyadh,          vices, (4) published in the English language. Those
    Saudi Arabia                                            that justified the inclusion criteria were carefully
    2 Fellow, Pacific Academy of Higher Education and Re-   chosen after a blind peer-reviewed process when
    search (PAHER) University, Udaipur, Rajasthan, India    relevance and quality were debated.




                                                            te
    3 Oral Health and Rehabilitation Research Unit,         Results. Nine studies were eventually included
    Biomedical Sciences Faculty of Medicine, Universite     from searches. Tabulation of data was done under
     de Montreal, Montreal, Canada                          the heading of study type, outcomes, the year of
    4 Department of Prosthodontics and Implantology,
                                                     In     publication and patient selection. The majority of
    School of Dentistry, King Faisal University, Al-Ahsa    studies provided a biomedical overview of access
    Saudi Arabia                                            for adults with learning disabilities.
    5 Department of Restorative Dentistry, College of       Conclusions. The concept of access for people with
                                          ni
    Dentistry, Taibah University, Medinah Munnawarrah,      disability is still ill-defined and obscure. Access to
    Saudi Arabia                                            oral health care and needs of people with learning
    6 Division of Pediatric Dentistry, Department of        disabilities are complex and multi-facet.
                                  io


    Preventive Dental Sciences, College of Dentistry,
    Dar Al Uloom University, Riyadh, Saudi Arabia           Key words: learning disability, access, oral
    7 Department of Periodontics and Community Dentistry,   health, health service utilization, scoping review.
                          iz



    College of Dentistry, King Saud University, Riyadh,
    Saudi Arabia
    8 Department of Oral and Maxillofacial Surgery,         Introduction
             Ed




    College of Dentistry, King Saud University, Riyadh,
    Saudi Arabia                                            Access to affordable and acceptable health care, in-
                                                            cluding access to oral health services is a basic and
                                                            fundamental human right (1). Unfortunately, an in-
    Corresponding author:                                   verse relationship exists in this context, and people
    Mustafa Naseem                                          who have greater health needs are the ones who re-
 IC




    Department of Community and Preventive Dentistry        ceive the least amount of care (2). This is also evi-
    Dar Al Uloom University, KSA Riyadh                     dent when it comes to the oral health of marginalized
    Exit 7 Alfalah                                          groups, like those with mental, intellectual or behav-
    75540 Riyadh, Saudi Arabia                              ioral challenges, and physical disabilities (3-5).
C




    E-mail: m.naseem@dau.edu.sa                             It is observed that similar to other marginalized groups,
                                                            people with learning disabilities also have poorer oral
                                                            hygiene status and a higher prevalence of dental caries
    Summary                                                 and periodontal disease (6, 7). As a consequence, poor
@




                                                            oral health not only affects the physical well-being of
    Background. The prevalence of oral diseases in-         these groups but also has a marked impact on their
    cluding dental caries and periodontal conditions        quality of life, overall health and self-esteem (8). In a
    is remarkably higher in people with disabilities.       recent study, it was proposed that groups with special
    The provision of accessible oral health services        needs may present with complex needs that can be
    for people with learning disabilities may be chal-      met through prevention and which require extensive fo-
    lenging.                                                cus towards further research (9).

    52                                                                          Annali di Stomatologia 2016;VII (3):52-59
    Access to oral health care services among adults with learning disabilities: a scoping review


    Models of disability and access to care                            health, social care, and general medicine. Although
                                                                       evidence of good practice has been reported under
    The term “disability” has been defined and utilized in             these areas, yet more research is needed in this do-
    various forms in recent years. The medical model and               main (23). Although Authors found a systematic re-
    the social model of disability present two contrasting             view (24) of the oral health of people with intellectual
    concepts that define disability in completely different            disabilities and access to healthcare for disabled peo-
    context and setting (10). While the medical model                  ple (25), yet the Authors did not find any review ana-




                                                                                                                            i
                                                                       lyzing disparity in access to oral health care for peo-




                                                                                                                          al
    proposes that disability physical or behavioral should
    be seen as individualistic, the social model sees dis-             ple with learning disabilities. Therefore, the aim of
    ability through a social lens and considers it as a                this scoping review was to review access to oral
    challenge for the society as a whole. It focuses on                health care for people with learning disabilities, along




                                                                                                            n
    systems structure that enables the society to access               with identifying barriers to accessing oral health care
    and utilize health care, thus preventing disability from           that persists within society.




                                                                                                         io
    becoming a handicap (11). Oliver and Zarb critique
    that health systems based on the biomedical model
    of health promotion influence the objectification, clas-           Methods




                                                                           az
    sification and categorization of people, thus promot-
    ing discrimination, labeling and victim blaming (12,               The study followed the framework presented by Ark-
    13).                                                               sey O’Malley for scoping reviews (26). The review fol-
    Access to services for people with learning disabili-              lowed five stages: (1) Identifying the research ques-




                                                                         rn
    ties appears multi-dimensional and multi-faceted (14,              tion; (2) Literature search; (3) Study selection; (4) Da-
    15). The poor oral health status of people with learn-             ta extraction; and (5) Summarizing and reporting the
    ing disabilities reflects the barriers to access faced by          results. A broad research question was selected in
    them and is evident as the marked variation seen in                order to scope the extent of research available on the




                                                                       te
    the utilization of these services (16). This eventually            subject and to avoid early exhaustion of literature
    results in detrimental oral health outcomes (17). The              during the search process.
    most commonly identified barrier to health or oral                 An initial search of broader concepts using various
    health service utilization is physical access (18, 19).
                                                             In        search terms was conducted on PubMed and a log of
    While physical access to roads, transportation, hospi-             relevant terms was maintained. Three major concepts
    tal buildings and clinical facilities is crucial, the ability      were used: learning disability, oral health, and access
    to access a workforce which is conducive and trained               to care. The pilot search developed the final research
                                                   ni
    to cater to the special needs of marginalized groups               question and dictated the inclusion and exclusion cri-
    is of equal importance (20).                                       teria.
    Various models of access including various criteria                Research question: what are the barriers to the ac-
                                                                       cess of oral health care services for adults (16 years
                                         io


    have been proposed by different Authors (17, 19, 21).
    However, there seems to be a variation in utilization              and over) with learning disabilities?
    of services. These variations in the uptake of services            A detailed search strategy was then developed using
    are due to attitudes, research, and policies based on              relevant MeSH terms and keywords, with the assis-
                               iz



    the biomedical model of access rather than the social              tance of an expert librarian (Tab. 1). The final search
    model (22).                                                        strategy, with database specific modifications, was
               Ed




    Most of the work done on access for people with                    executed on Medline via OvidSP, PubMed, and EM-
    learning disabilities has taken place in the field of              BASE.


    Table 1. Search Strategy on Medline.

    1.    *developmental disabilities/ or *intellectual disability/ or exp learning disorders/ or exp Communication Disorders/
 IC




    2.    (Intellectual disabilities or learning disability or communication disorder or developmental disability or developmental
          disorder).mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word,
          protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
C




    3.    exp Dental Care for Disabled/ or exp Dental Health Services/ or *Oral Health/
    4.    (Oral health services or dental health services).mp. [mp=title, abstract, original title, name of substance word, subject
          heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept
          word, unique identifier]
@




    5.    exp “Delivery of Health Care”/
    6.    (((health service access or delivery of health care or access to health care or health) adj3 utilization) or access).mp.
          [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol sup-
          plementary concept word, rare disease supplementary concept word, unique identifier]
    7.    (1 or 2) and (3 or 4) and (5 or 6)
    8.    limit 7 to “all adult (19 plus years)”


    Annali di Stomatologia 2016;VII (3):52-59                                                                                    53
    M. Naseem et al.


    Studies meeting the following inclusion criteria were                Endnote Citation Manager X7 was used to catalog
    subsequently included in the scoping review: (1)                     the studies according to database, duplicates, initial
    study participants or population with learning disabili-             screening and final inclusion. An of the scoping re-
    ties, (2) aged 16 years or over, (3) reporting on ac-                view process according to PRISMA guidelines is pre-
    cess to oral health services, (4) published in English               sented in Figure 1.
    language. The exclusion criteria to filter out the stud-
    ies were (1) any gray literature, (2) non-peer re-




                                                                                                                                i
    viewed articles, (3) articles which were not focusing                Results




                                                                                                                              al
    on oral health and focused on children disability (4)
    articles other than English were excluded. There                     Around 195 studies were retrieved from the search
    were no date limitations applied for study designs or                strategy and 3 studies were shortlisted through other




                                                                                                                 n
    year of publication, and all studies published until                 resources. Following duplicate removal (n=31) 167
    February 2016 were considered for eligibility. An age                studies were screened for title and abstract and 88




                                                                                                              io
    limit was applied restricting the results to studies pub-            studies were selected for full-text review. Following
    lished on an adult study population “All adults-16 plus              review and discussion, nine studies were included in
    years” in Medline and “18 to 64 years” in EMBASE).                   the study (Fig. 1) Prisma Flow diagram.




                                                                              az
    Table 2 illustrates a list of databases, search engines              Table 3 shows the general characteristics of studies
    and library resources used for the literature search.                considered in this scoping review. A total of nine arti-
    Screening and study selection: two reviewers (Author                 cles were included in the final synthesis. These arti-
    1 and 2) conducted literature screening, and study                   cles had been published between years 1991 to




                                                                            rn
    selection independently, following duplicate removal                 2011. Among the nine reviewed articles, three studies
    after initial title and abstract screening, relevant stud-           were quantitative studies (27-29) with cross-sectional
    ies meeting the research question theme were select-                 study design. Two were verifiable CPD papers (17,
    ed for full-text review. Following the full-text review,             30) based on the existing literature and two were




                                                                          te
    studies meeting the inclusion criteria were included in              qualitative studies based on interviews and opinions
    the scoping review. Data extraction for each study in-               (5, 16). Two studies were review articles (19, 29).
    cluded in the final selection was carried out, using a               One-third of the studies used quantitative study de-
    data extraction form, recording information on the
                                                              In         signs to explore access to services with broader sam-
    main characteristics and findings of each study.                     ples. The total number of responders (sample)
    Disagreements were resolved by discussion with a                     ranged 485 to 1984 for quantitative researches. In
    third reviewer (Author 3) and a consensus was                        the qualitative study the sample of the study partici-
                                                ni
    achieved. The online search was further complement-                  pants ranged from 10 to 40.
    ed by hand searching and sifting through the bibliog-                In general, CPD papers (17, 30) highlighted ways to
    raphy of studies shortlisted for inclusion.                          address unmet needs and improve access to the
                                      io


    Table 2. List of data bases, search engines, libraries resources used for literature search.
                             iz



                                       
                Ed




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    54
     
                                                                                                Annali di Stomatologia 2016;VII (3):52-59
    Access to oral health care services among adults with learning disabilities: a scoping review



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    most vulnerable sections of society i.e. disabled indi-           plain access to dental services for people with dis-
                 Ed




    viduals. Similarly, in quantitative studies both internal         abilities, they lean towards the biomedical model with
    and external barriers were identified, which compro-              minimal emphasis on the social aspect of care and
    mised utilization of dental services among adults with            access. Only those aspects of access are taken into
    disabilities. In all nine studies, access was poorly de-          account which may pose as physical barriers to oral
    fined and the term remains ambiguous for people                   care for adults with learning disabilities, while little at-
    with learning disabilities.                                       tention is given to other multi-dimensional aspects of
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                                                                      access.
                                                                      Similarly, Koneru and Sigal (27) and Cumella et al.
    Discussion                                                        (5) also cite access as the “ability to obtain and use
                                                                      services”. The definition moves towards an indicator
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    The present study was based on the hypothesis that                of access without describing what “access” really
    access to oral health care for adults with learning dis-          means for people with disabilities (31).
    abilities is similar to the general population. To our            This was observed throughout the studies reviewed.
    understanding from indexed literature, this is the first          Policy makers, professionals and Authors when at-
@




    scoping review that systematically reviewed access                tempting to suggest effective health care reforms,
    to Oral health care among adults with learning dis-               tend to assign different meanings to the term “ac-
    abilities.                                                        cess” based on the feasibility and suitability of the
    Interestingly, the majority of studies included in this           profession without justifying comprehension and com-
    review define access on the basis of the single con-              plexity of issue (21, 32).
    cept of “utilization of services”. While both papers by            Recently, a renewed emphasis was given for access
    Dougall and Fiske (17), Gallagher and Fiske (30) ex-              to oral care by Owens et al. (16) who presented a


    Annali di Stomatologia 2016;VII (3):52-59                                                                                               55
                                                             @




56
                                            Table 3. List of studies and their general characteristics included in the review.


                                                              
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Annali di Stomatologia 2016;VII (3):52-59
                                                                                                                                                                                                 n              al          to be continued




                                                                                                                                                                                                                  i
                                  Access to oral health care services among adults with learning disabilities: a scoping review


                                                                                                                                                                                                                                                                                                          framework of access based on the social model of
                                         

                                                            
                                                                                                                                                                                                                                                                                                        disability. The proposed model has been inspired by


                                                                                      
                                                                                                                                                                                                                                                                                                          the works of Penchansky and Thomas (15, 21) and




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                                                                                                                                                                                                                                                                                                          perience and professionally driven practice to access
          




                                                                              




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                                                                                                                                                                                                                                                                                                          societal discrimination against various forms of dis-




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                                                                                                                                                                                                                                                                                                          ability (12, 20). It divides access into six categories:




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                                                                                                                                                                                                                                                                                                                                             n
                                                                                                                                                                                                                                                                                                          nately, it appears that the social model of disability is
                                                       
      




                                                                                                                                                                                                                                                                                                          not practiced in its true sense within dentistry. Evi-
                                                       



          




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                                                                                                                                                                                                                                                                                                          dence suggests that attitudes of the dentists and den-




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                                                                                                                                                                                                                                                                                                          tal staff, lack of interdisciplinary collaboration among
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                                                                                                                                                                                                                                                                                                          different health services and lack of acknowledge-
                                                 
              
 




                                                                                                                                                                                                                                                                                                          ment of the rights of people with disabilities create
  


          




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                                                                                                                                                                                                                                                                                                          barriers to service utilization (16).
                                                                                                                                                                                                                                                                                                          A study by Koneru and Sigal (27) reported that while
          




                                      




                                                                                                                                                                                                                                                                                                          people with learning disabilities were able to access
                                                                                                                                                                                                                                                                                                          dental services, the greatest difficulty was experi-




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                                                                                                                                                                                                                                                                                                          enced in accessing services when general anesthe-
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                                                                                                                                                                                                                                                                                                          sia was required. They also cited the poor availability





                                                                                                                                                                                                                                                                                                          of services, affordability, and beliefs of caregivers as
                                                                                                                                         
                                     +




                                                                                                                                                                                                                                                                                                          te
                                                                                                                                                                                                                                                                                                          barriers to access and utilization. However, the weak-
                                      
 




                                                                                                                                         +




                                                                                                                                                                                                                                                                                                          ness of the study was a weak sampling procedure re-
                                                                                                                                                                                                                                                                                                          sulting in recall bias. Similarly, in another study, it
                                                                                                                                                                                                                                                                                                          was observed that attention must be paid to creating
                                                                                                                                                                                                                                                                                                          In
                                                                                                                                                                                                                                                                                                          an adequate dental workforce to respond to the de-
                                                                                                                                                                                                                                                                                                          mand that enables patients and dentists to participate
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                                                                                                                                                                                                                                                                                                          in any programs that are aimed at improving access





                                                                                                                                                                                                                                                                                                          to care for underserved populations (34).
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                                                                                                                                                                                                                                                                                                           Cumella et al. (5) and Pradhan et al. (29) underlined
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                                                                                                                                                                                                                                                                                                          the factors that create barriers to access for dental
                                                                                                                                                                                                                                                                                                          services, however, their recommendations lack a
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                                                                                                                                                                                                                                                                                                          concrete definition of access. Both studies measured
                                                                         





                                                                                                                                                                                                                                                                                                          access in terms of service utilization. This uni-faceted
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                                                                                                                                                                                                                                                                                                          approach is often simply not enough and may not do
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                                                                                                                                                                                                                                                                                                          justice to the resources put to address the problem.
      




                                                                  




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                                                                                                                                                                                                                                                                                                          Cumella et al. (5) highlight that the poor oral health





                                                               
                                                             
      




                                                                                                                                                                                                                                                                                                          status of individuals with learning disabilities is not
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                                                                                                                                                                                                                                                                                                          adequately addressed and their oral health needs
                                                                                                                                                                                                                                                                                                          may continue to be unmet as compared to the gener-
                                                  






                                                 
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                                                                                                                                                                                                                                                                                                          al population.
                                              
      




                                                                                                                                                                                                                                                                                                          The studies included here, highlight the barriers to ac-
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                                                                                                                                                                                                                                                                                                          cess and service utilization, which include lack of
                                                                                                                                                                                                                                                                                                          knowledge or expertise on part of the dentist, hesitation
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                                                                                                                                                                                                                                                                                                          or lack of confidence to treat patients with disabilities,
                                                                                                                                                                                                                                                                                                          attitudes of the dental workforce and issues with remu-
                                                                                                                                                                                                                                                                                                          neration methods. From the other side, these barriers
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                                                                                                                                                                                                                                                                                                          include limited awareness of carers and family about
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                                                                                                                                                                                                                                                                                                          the services that may be available for their patients or
                                                                                                                                                                                                                                                                                                          loved ones. Cumella et al. (5) have classified these bar-
                                                





                                                                                                                                                                                                                                                                                                          riers into three broad categories:
                                                                                                                                                                                                                                                                                                          • barriers to individuals (35-38)
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                                                                                                                                                                                                                                                                                                          • barriers in relation to dental profession (10, 38)
                  Continued from Table 3




                                                                                                                                                                                                                                                                                                          • barriers with reference to policy makers (10, 37,
                                                                                                                                                                                                                                                                                                               38)
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                                                                                                                                                                                                                                                                                                          Looking from a wider context these barriers can be





                                                                                                                                                                                                                                                                                                          appropriately addressed if discussed under the
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                                                                                                                                                                                                                                                                                                          framework of access given by Owens et al. (16).
                                                                                                                                                                                                                                                                                                          Among the studies, the most common and widely re-





                                  Annali di Stomatologia 2016;VII (3):52-59                                                                                                                                                                                                                                                                                      57
    M. Naseem et al.


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                                                                        405-412.
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                                                                                                                              i
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                                                                                                                            al
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                                                                                                            n
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                                                                                                         io
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                                                                      az
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                                                                    rn
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                                                                  te
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    Annali di Stomatologia 2016;VII (3):52-59                                                                                            59
