A better condition of care
The new Phil and Karen Hunke Special Care Clinic is making dentistry accessible and approachable for special care dental patients and students
By Kristen Zapata
“Hablo Español muy bien,” said Jennifer Farrell, DDS, DABSCD, with a satisfied smile. As a middle schooler growing up in Massachusetts, Farrell’s parents were told she would struggle in school, never be capable of attending college and certainly never learn a foreign language, which she desperately wanted to do.
“I am the product of special education,” Farrell announced proudly. As a child, she had a hearing condition that doctors didn’t believe required hearing aids. At school, she was given the accommodation of sitting in the middle of the classroom so the sound of her teacher’s voice could bounce off the walls to amplify it.
“Even then, I just wasn’t doing so well in school,” she said. “I would always look at my classmates and think, I want to be smart like them.”
To keep up with her peers, Farrell would attend tutoring and be assigned double the work. She was finally given clearance to enroll in a Spanish course.
“They didn’t think I could handle it, but my mother was always in my corner,” Farrell said.
As it turned out, she handled the course quite well, went on to graduate from college and then earned a dental degree from Northwestern University Dental School.
She did a preceptorship in special patient care dentistry and completed a residency program in dental anesthesiology at Advocate Illinois Masonic Medical Center in Chicago, where she subsequently directed the Special Patient Care Dental Program for 13 years.
“I had to work really, really hard, but I’m always up for a good challenge, so here I am,” said Farrell, who today is the founding director of the Phil and Karen Hunke Special Care Clinic at UT Health San Antonio’s School of Dentistry.
Indeed, with over 28 years of special patient care experience, Farrell is ready to make a difference in South Texas. “Speaking Spanish comes in handy in these parts,” she said.
The challenge
The School of Dentistry celebrated the opening of its special care clinic with a ribbon-cutting ceremony on Feb. 7, 2024. The clinic, named for the San Antonio-area philanthropists who provided seed money for the space renovation, provides comprehensive dental care or adults and children with intellectual, developmental, cognitive or physical disabilities and those with complex medical conditions.
“There really isn’t a whole lot of difference between treating these folks and the general population,” Farrell said. “The biggest differentiator would be chairside manner, 100%.”
Farrell should know. She has the unique perspective of being a dental provider and mother to four children, each with unique challenges.
“I’m facing the exact same challenge that my patients face. It’s not just with dental care but all health care,” she said.
The challenge Farrell and other caregivers face is access to health providers experienced and willing to treat their loved ones in need of accommodations for care.
According to a report by the National Council on Disability, due to a lack of training, “dental care is often more difficult to find than any other type of service for people with [intellectual and developmental disabilities].” Because of this, the council stated that this patient population is less likely to have had their teeth cleaned in the past five years or at all compared to those who are not considered disabled.
These findings resulted in the council making a recommendation to the Commission on Dental Accreditation (CODA) to require all U.S. dental schools to ensure their students receive proper training to manage the treatment of patients with intellectual and developmental disabilities.
In 2019, CODA passed the decision to require schools to update their curricula to be inclusive of special care patients in the predoctoral dental, orthodontics, dental hygiene and dental assistant programs. The American Dental Association likewise updated its Code of Professional Conduct to read, “dentists shall not refuse to accept patients into their practice or deny dental service to patients because of the patient’s… disability.”
“Dentists will no longer be able to refer these patients out without first attempting to treat them,” Farrell said.
The reason
Martin Nutt is already a regular in Farrell’s dental chair, with a plan for a full dental restoration — from fillings to extractions to a lower partial denture. During his visits, he enjoys watching NASCAR races as the dental team does its work.
“I love it here,” he said. “It’s like Cheers. You walk in, and it’s like, ‘Hey, Norm!’ Everyone knows your name,” he said, referencing the 1980s sitcom by the same name.
Nutt has a complex medical history that includes a brain tumor at the tender age of nine, a malignant jaw mass at age 14 and a stroke at 40. In speaking with him, one might wonder why he would need care at a special patient clinic. Besides some irregularity in the shape of his jawline and a slight speech impediment, Nutt doesn’t seem like a patient who would have trouble being seen at any dental office.
For Farrell, this is exactly why dental students need exposure to the special patient population.
“Honestly, there are many patients who have disabilities who can be seen in the regular dental office. Unfortunately, many clinicians make assumptions about these individuals based on the way that they present rather than attempting care to see if they can tolerate it,” she said.
“To the defense of referring clinicians, I can understand their trepidation, as very few, including myself, were trained to provide care to these folks while in dental school,” Farrell added.
The solution
Third-year dental student Gabby Ward has begun the
clinical portion of her dental curriculum in earnest. As an aspiring pediatric dentist, Ward values the opportunity she has to interact with patients like Martin Nutt.
“Pediatric and special needs dentistry work hand in hand,” she said. “More often than not, kids with special needs are sent to a specialist because their general dentist is just not equipped to treat them.”
In addition to a didactic course introducing them to special care dentistry, Ward and her classmates will each be assigned a one-week rotation through the special needs clinic. Each day starts and ends with a clinic huddle to discuss the patients, their conditions and treatment.
“We talk about what they may encounter or things they should think of in terms of developing a treatment plan for a particular person,” Farrell said. “We also anticipate challenges we might have during an appointment and discuss how we would navigate those.”
The students are then ready to interact with their patients. Working in groups of three or four, Farrell has her students alternate tasks such as charting and assisting with or conducting the dental treatment.
“I’m facing the exact same challenge that my patients face. It’s not just with dental care but all health care.”
— Jennifer Farrell, DDS, DABSCD
Ward will officially rotate through the clinic later this term and again in her fourth year, but she has been volunteering in the clinic in her free time since it opened. She shadows Farrell, charts, helps with X-rays or with more important tasks for patients, such as blowing up balloons, hitting the skip button on YouTube video ads or bringing them popsicles.
Since spending time in the clinic, Ward said she came to an important conclusion about special patient dentistry.
“It runs just like any dental visit would,” she said. “It may run a bit slower. You need a little patience to explain everything and make the patient comfortable, but Dr. Farrell treats it just like any other dental visit.” One particular visit made quite an impression on Ward.
“We had one patient who was so scared when he arrived. His mom said that he hadn’t sat for a cleaning in 10 or 15 years,” Ward said. “The mom was ready to give up on finding a dentist, but she knew her son had cavities and other things wrong. By the end of it, we got X-rays, he sat for a cleaning and we’ve even done extractions on him! His mom was crying because she was so happy.”
The trick, according to Ward, is finding a way to make dentistry approachable by taking the time to explain every step along the way. “Everyone deserves access to care,” she said. “I’m glad I get exposure to these patients now, so when I graduate, I feel confident with any patient.”
The future
Farrell is passionate about sharing her expertise with her students but is just as eager to share it with dental professionals who need strategies for treating special care patients.
“We are developing continuing education courses aimed at educating practicing providers because we’re a collaborative team, we should all be working together,” she said.
She is also looking forward to working more collaboratively with local community partners, like The Arc, a national community-based organization that advocates for people with intellectual and developmental disabilities, which held a desensitization event at the clinic in September 2024 to help take some of the mystery out of the dental office.
“Potential patients and their families were invited to come see, touch and feel the dental equipment. They could sit and try out the dental chair and talk with me and some of our students,” Farrell said.
The School of Dentistry will, in the future, explore areas of research or scholarship within the special care clinic, such as treatment models that are seen as being most effective. Before that type of work begins, Farrell is solely focused on building relationships and trust with her patients and their families.
‘A huge bite’
“I like to tell my students that if every dentist in the U.S. saw even one patient with a disability, we could take a huge bite out of the access to care issue for that population,” Farrell said.
Accommodating patients with autism
By understanding the way in which an individual with autism experiences the world, dental providers can easily adapt their approach to care
Autism spectrum disorder is a complex neurodevelopmental condition that presents unique challenges, particularly in settings like dental offices, where a patient’s normal routines are disrupted and sensory inputs are heightened. For dental professionals, understanding the needs of autistic patients is crucial for providing effective care and a positive experience.
What is autism?
Autism is characterized by persistent challenges with social communication, restricted interests and repetitive behaviors. The disorder is a spectrum, meaning the degree of impairment varies greatly between individuals. According to the U.S. Centers for Disease Control and Prevention’s Autism and Developmental Disabilities Monitoring Network, approximately 1 in 36 children have been identified with autism, and adults with the disorder often struggle to access dental care due to a lack of training among providers and their general uneasiness in treating this population.
Tips for treatment
1. Emphasize routine. Patients with autism thrive on routine. Changes to their daily schedule, such as dental appointments, can cause significant distress. Be aware that their discomfort may stem from the disruption of their routine rather than fear of dental procedures.
2. Use visual aids. Visual aids like pictograms can help autistic patients understand what to expect during their visit. These tools make communication clearer and more consistent, which can reduce anxiety and improve cooperation.
3. Create a comfortable environment. Sensory overload is a common issue for autistic patients. Dimming the lights, providing noise-canceling headphones and minimizing sudden changes in the environment can help make the experience less overwhelming.
4. Incorporate breaks. Frequent, fun breaks can alleviate stress for both the patient and the provider. Consider activities like dancing or playing with a foam ball to lighten the mood and provide a welcome distraction.
5. Offer positive reinforcement. Reward positive behavior during the visit, but only when it’s genuinely earned. Consistent and meaningful rewards encourage good behavior in future visits.
6. Communicate simply and gently. When a patient is distressed, verbalize what you believe they might be feeling in simple terms. This acknowledgment can make them feel understood and help de-escalate intense emotions. Offer to let them rip up a piece of paper if it will help them express their emotions.
7. Be flexible. Some autistic patients may be more comfortable being treated outside the traditional dental chair. If they prefer a different location in the office, accommodate them to the best of your ability.
8. Understand behavior as communication. Many autistic individuals may lack the verbal skills to express discomfort, so their behavior often serves as their primary mode of communication. Recognize that what might appear as resistance is often a form of expressing an unmet need.
By adopting these strategies, dental professionals can create a more welcoming and effective environment for those with neurodevelopmental conditions, ultimately improving their access to quality dental care and their overall experience at the dentist’s office.
This information was presented during the Dental Education Network for Texas ECHO session on March 21, 2024, by Jennifer Farrell, DDS, DABSCD. Watch the entire lecture and a case study by visiting the network’s website.
