Introduction

Oral health and access to regular dental care remain ongoing concerns for individuals with disabilities and complex health issues [1–3]. In many cases, these individuals are at higher risk of oral conditions, such as dental caries and periodontal disease, due to the confounding effects of their general health, polypharmacy, other impairments, and dependence on carers and family to assist with activities of daily living including oral hygiene care. These patient factors are further complicated by the lack of willingness of many general dentists to manage individuals with these more complex needs [2, 4].

A barrier for many oral health professionals is their perceived lack of knowledge or training in managing those with special needs [2, 4–6]. The ability to find suitably-trained and experienced dentists has been identified as a key barrier to accessing regular and ongoing oral health care by individuals with disabilities and their carers [2] and dental specialists in this field [7]. Oral health professionals have discussed their limited exposure to treating individuals with special needs as part of their training and difficulty with accessing ongoing professional development in this area as concerns [5, 6]. However, many have also suggested that receiving additional support may improve both their willingness to treat these individuals and reduce their reliance on referral to specialists where these patients often encounter long waiting lists [5, 6].

The dental and wider health literature have primarily focused on the need for competencies that reflect the growing necessity for health professional graduates to be trained in managing individuals with special health care needs [8–10]. However, improvements of this manner do little to address perceived deficiencies in training and experience amongst qualified health professionals. One support that oral health clinicians have suggested is the ability to work closely or alongside specialists at their local clinics, feeling that this may facilitate opportunities for mentorship, observation, consultation, and advice to overcome some of their own reservations about treating patients with special needs [5, 6].

Mentoring has become a vital part of addressing the complexities and demands of contemporary health care. In dentistry, mentoring programs are commonplace to help newly-graduated oral health professionals adjust from the formal education to clinical practice [11, 12], with it providing young clinicians opportunities to consult more senior colleagues about complex cases in addition to receiving psychosocial support with difficulties experienced. Although its use with more experienced clinicians in the dental setting is limited, it has been described within the academic environment as effective in developing skill sets crucial for clinical teaching and research [13, 14].

The use of mentoring is more commonplace in the medical and nursing fields. In particular, peer mentoring is embedded as a crucial part of junior doctor and nurse support in acquiring and refining new skills and competencies within a hospital or general practice setting [15–18] and for support mental health and resilience [19–21]. Likewise, as a result of the hierarchical nature of hospital environments, mentoring is often a component within specialty fellowship training in medicine [22–25], providing guidance in developing new knowledge and skills. Despite its limited use in the dental setting, potentially due to the less team-based approach in much of dental practice compared with other parts of healthcare, it seems apparent that many of the benefits seen in other health settings could be translatable and beneficial for oral health professionals.

Consequently, several dental clinics have explored mentoring as a supportive measure for clinicians and to reduce the necessity to refer to specialist services, particularly for managing patients with special healthcare needs, but no research has been completed to understand the potential impact of such programs on clinician perceptions and views. The aim of this study was to determine whether having a specialist in special needs dentistry work closely alongside other clinicians and provide opportunities for support and mentoring would affect the willingness of these clinicians to treat individuals with special needs. It was hypothesised that specialist mentoring would positively influence and improve the willingness of the clinicians receiving support to attempt treatment rather than immediately referring to specialist services.

Materials and methods

Qualitative methods were used to explore perceptions of the support provided by specialists or clinicians with additional training in special needs dentistry to other clinicians in relation to managing individuals with heightened health care needs [26]. In particular, this study was focused on weekly clinical placements of specialists-in-training in special needs dentistry from the University of Melbourne at Carrington Health and Link Health and Community, two community dental clinics in Victoria, Australia, and the fly-in fly-out support and advice offered by a specialist in special needs dentistry to Top End Oral Health Services in the Northern Territory, Australia.

Consequently, a qualitative approach was determined to be most appropriate to understand the experiences of clinicians and to explore their perceptions and how these may have changed as a result of the additional support provided to them. In addition to being able to appreciate the individual experiences of participants, inductive thematic analysis of these views and the sentiments and themes that arose from the responses was used to develop an understanding of the collective response to these mentoring relationships.

Clinicians working at clinics with these support initiatives were invited to participate in a semi-structured interview to discuss their experiences of managing the oral health care of individuals with special needs. A promotional flyer was distributed to clinicians by the senior dentist or clinic manager and interested individuals asked to contact the research team. Specialists and specialists-in-training in special needs dentistry, dentists, oral health therapists, dental hygienists, dental therapists, and dental prosthetists who were either involved in the delivery of, or exposed to, these mentoring programs were eligible to participate.

The interviews were conducted in person or by phone or similar media, depending on the preference of the participants. A question guide was developed by the research team (Table 1) which used open-ended questions to determine the views of participants towards the additional supports provided and if it impacted on the willingness or ability of clinicians to treat patients with special needs. Participants provided written informed consent for their involvement. All interviews were digitally-recorded (audio only) using two separate devices to ensure audio clarity. All interviews were conducted by a single member of the research team to ensure consistency in the interview process. Interview recordings were regularly audited by the interviewer and principal investigator of the project to ensure consistency.

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Table 1. Question guides for interviews.

https://doi.org/10.1371/journal.pone.0266879.t001

Prior to undergoing analysis, the clearer digital recording of the interview was chosen and professionally transcribed. The transcription of the recording was then checked for accuracy against the recording with the second recording used to check in instances where further clarity of the response was required.

Analysis involved an initial reading of the responses prior to coding of emerging themes and sentiments using inductive thematic analysis and the qualitative data analysis software, NVivo (QSR International, Melbourne Vic, Australia) [26]. Initial themes that emerged from the first coding process were then reviewed and discussed by members of the research team. The research team had a range of backgrounds including specialists in special needs dentistry, specialists from other dental specialties, and a general dentist. Grouping of sentiments and themes that emerging from the views of participants of the study (Figs 1 and 2), and determination of data saturation based on the emergent themes, were thus the result of these discussions and consensus of the research team collectively.

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Fig 1. Coding tree for clinician interviews.

https://doi.org/10.1371/journal.pone.0266879.g001

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Fig 2. Coding tree for specialist interviews.

https://doi.org/10.1371/journal.pone.0266879.g002

Ethics approval was granted by the Melbourne Dental School Human Ethics Advisory Group (Ethics ID: 1544156.2) and the Human Research Ethics Committee of the Northern Territory Department of Health and Menzies School of Health Research (HREC Ref No. 2019–3364).

Results

A total of 10 clinicians agreed to participate in this study. Three participants were classified as ‘specialists’ because of their involvement in providing the support to other clinicians. This included one specialist in special needs dentistry and two training specialists in special needs dentistry. Remaining participants were ‘clinicians’ (6 dentists and 1 oral health therapist) with a range of experience (average years since graduation: 13.7, range: 3–23 years). Three of these clinicians had combined clinical and managerial roles (Clinicians 1–3).

Discussion

Improving the oral health of individuals with disabilities and complex medical issues needs to be considered as a high priority. Unfortunately, because other medical issues have often taken precedence over oral health, preventable dental conditions and oral health are neglected resulting in undue suffering from dental pain [27]. Furthermore, when these individuals finally seek dental care, their treatment needs are often greater, more complex, and may be more difficult to manage. The resultant delay in receiving this treatment can often result in unnecessary pain and tooth loss, creating a cycle that results in further debilitation and compromised masticatory function, swallowing, speech, and aesthetics [27].

Whilst part of the issue is a need for oral health to be given the same priority as general health, there is also need for concerted efforts from the health care system to ensure all patients are able to receive timely care. In the dental profession, this continues to be a problem with individuals with special needs reporting difficulties identifying dentists willing to treat them because of a lack of perceived training, knowledge, and skills [2, 4]. Likewise, specialist services for those with special needs are primarily within the public dental system in Australia and often have long waiting lists due to an ever-increasing demand placed on a small specialist workforce and limited resources to provide these services [28, 29].

Dental services have taken different approaches to trying to address this issue with many providing additional support to their clinicians to try and reduce a reliance on specialist referral. A common theme from discussions with oral health professionals has been a desire to work closely or alongside specialists in special needs dentistry or for opportunities for mentoring [5, 6, 30]. This was the approach taken by the clinics involved in this study. In particular, two community dental clinics in Victoria, Australia (Link Health and Community and Carrington Health) collaborated with the Melbourne Dental School at the University of Melbourne to have training specialists in special needs dentistry work alongside dental teams consisting of general dentists, oral health therapists, and dental prosthetists once a week as a clinical placement. Similarly, the Top End Oral Health Services in the Northern Territory, Australia developed a formal relationship with a specialist in special needs dentistry from interstate to visit Darwin and Alice Springs several times a year to provide additional support to local clinicians. Between these periods, this specialist offered clinicians remote support by providing advice and input on individual cases based on the needs of individual practitioners.

The results of the current study indicated that despite some of the inherent differences between these two initiatives, overall they had a positive effect on clinicians working at each of the respective sites and improved their willingness to try to manage these patients rather than referring them onwards. A key benefit was that clinicians were able to interact directly with the specialists in whatever manner reflected their own needs. Many participants and specialists discussed seeking advice on cases, observing or learning from specialists with respect to how they managed patients, the ability for joint consultations and treatment planning sessions, opportunities for role modelling, and aspects of moral support from the specialists in the possible situation of an adverse event.

A significant opportunity of working alongside specialists or specialist trainees, over other forms of interactions, was the ability for clinicians at the community clinic to experience direct mentoring and see how more-experienced clinicians worked in their local setting. From other initiatives discussed in the literature, a reported limitation has been a sense that specialists may not appreciate the challenges faced by clinicians at the community level because of limitations in local infrastructure, such as clinic design, equipment, and facilities with these commonly identified by oral health professionals as a barrier to treating individuals with special needs [5, 6, 30]. However, in this study, and particularly for those in Melbourne clinics working with training specialists, being able to see specialists work with them and with equal constraints allowed the local clinicians to see how they could adapt their own ways of managing patients; something more difficult to achieve through remote support.

In addition, the ability for these visiting specialists to improve access to care was essentially two-fold. Not only did their support improve the willingness of other clinicians to attempt treatment for these patients, but having the specialist work locally allowed patients to access specialist level care closer to home. Given that most specialist clinics in Australia are centralised in major cities, this may offer a significant advantage for many patients by reducing the burden of travel often placed on patients, families, and carers as a form of outreach or intermediate level service [2, 28].

Although many of the reflections of the general clinicians were somewhat anticipated, some interesting themes emerged from the views of specialists involved in providing this support. Although their reflections were generally positive and complementary towards many of the clinicians they supported, some discussed their role as one of ensuring quality and accountability. In doing so, they raised concerns about the ability of the clinicians they were supporting to appreciate the true complexity of cases and their management and discussed the need for them to intervene and ensure patients received an appropriate level of care. Previous studies into support provided by specialists in special needs dentistry have raised similar concerns about finding an appropriate balance between encouraging clinicians to attempt treatment when they may not fully appreciate the complexity, ensuring that these vulnerable patients are receiving the standard of care they deserve, and ensuring adequate access to this case [30].

In addition, specialist services often encounter the problem of being placed under additional pressure because of ‘unnecessary’ referrals or those that are perceived by specialists to lack complexity and could be managed by general dental practitioners [28]. The United Kingdom, in particular, has explored the use of case mix models to determine the complexity of patients treated by different clinicians and postulated its use for determining appropriate allocation of referrals to clinicians in specialist services [31, 32]. The problem with many such tools is they continue to rely on specialists, or those with additional training and experience, assessing the complexity of patients wherein the more significant problem lies with clinicians at the community level not being able to fully appreciate the interaction of social and medical factors in these patients. As a result, whilst tools that dentists may be able to use to assess the case complexity of patients with special needs are developed and validated, perhaps initiatives such as visiting specialists and mentoring, could also be used by specialist services to assist with assessment and triage of patients to determine the most appropriate provider for their care based on their needs.

Herein lies the dilemma faced by special needs dentistry as a specialty in many countries: how best can the needs of these patients be met without compromising the quality of care they receive? The solution is not increasing the reliance on specialist services, given the limited resources dedicated to these services and the limited specialist workforce. Instead, it is about ensuring that the dental workforce, and particularly those in the public dental system, are adequately equipped to manage the needs of this growing population.

The current study provides an example of how both the specialist and training specialist workforce may be used beyond direct patient care to encourage wider access to care. Whilst such initiatives may not necessarily change the perceptions of all clinicians and improve their willingness to manage this group of patients, it will go some way to addressing current deficiencies in training and experience that remain as significant barriers to access of care for these programs while training programs address these issues in future generations of oral health professionals.

Unfortunately, what is currently lacking is adequate resourcing which must include appropriate funding and priority dedicated to these patients, use of an integrated team of oral health professionals to manage preventive care for those more vulnerable to risk of oral disease, and ensuring this workforce has not only the adequate training and skills, but also appropriate investment into the specialty to benefit from ongoing support from specialists in this environment. In addition, efforts to improve the oral health awareness amongst other health professionals and carers in the disability and aged care communities is vital to supporting these preventive messages and increasing the priority of oral health in these populations.

There were several limitations of the current study. Firstly, due to the limited sample size, there was an inability to provide more in-depth comparison between the weekly support provided by the training specialists and the less regular support provided by the fly-in-fly-out specialist. Inherent differences between the support provided by the two models emerged from the responses of participants and certainly warrants further research of both models to allow health services to determine if such supports may be beneficial to their clinicians and availability of specialists. Furthermore, there was a risk of bias given that participants volunteered their time and views and that these may not have been reflective of the wider group of clinicians in these clinics. This reinforces the need for further research in this area to validate the initial results presenting in the current study.

Regardless of these issues, the results of the current study suggest that having more experienced clinicians, whether they are trainee or qualified specialists, to mentor other health professionals can have a positive influence and potentially improve the willingness of clinicians to treat individuals with special needs. Furthermore, these initial and promising results warrant further investigation into these and other supports that clinicians feel may improve their confidence, ability, or willingness to treat these patients. Although discussed primarily in the context of special needs dentistry, such models may have implications for other dental specialties in considering how specialists can continue to support oral health professionals, particularly in areas where access to specialists may be more difficult. Nevertheless, these findings reinforce the need for improved training of oral health professionals in the area of special needs dentistry and demonstrate the vital role specialists play in continuing to advocate for, and improve access to dental care and better oral health for individuals with special health care needs, not just in specialist clinics but also the wider community.

Conclusions

The results of this study indicate that specialist mentoring improved the willingness of clinicians to treat patients with special needs. In particular, having opportunities to work alongside each other often offered mutual benefits. From a specialist perspective, the support provided improved the quality of care received by patients at these clinics and ensured a greater level of accountability given the reliance of clinicians to recognise case complexity. In addition, where treatment was beyond the scope of clinicians, patients benefited from increased access to specialists treating them locally. Specialists raised concerns about possible inappropriate use of supports to mitigate medicolegal concerns and productivity pressure but for specialist trainees, it offered a unique opportunity to understand the barriers and challenges faced by clinicians they received referrals from. Likewise, working alongside specialists was positively received by clinicians and resulted in them feeling they were able to provide better access to care as well the opportunity to learn from specialists. Further research and investment is required into such initiatives to support clinicians working in the primary care setting to address existing barriers to accessing regular dental care experienced by individuals with special needs, particularly those related to the perceived lack of training and experience of oral health professionals in this area.

Acknowledgments

Mathew Lim would like to acknowledge the support provided by the Australian Government Research Training Scholarship and the Rowden White Scholarship from the University of Melbourne.