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The ‘Dental Desert’ Hiding in Plain Sight

About 300,000 North Texans with special needs have trouble finding dental treatment. Dr. Dan Burch wants to fix that.
Marc Montoya

Dan Burch thought he would become an engineer. He grew up on an Army base in Germany, where his father was stationed. On his first day at the elementary school there, which offered some Montessori-style education options, teachers saw him playing with Legos and put him in a track that added basic technical skills to the core curriculum.

That path for Burch ran in a straight line all the way to his senior year in high school. Then, in 2001, while watching TV with a family friend, he saw a report about the large number of engineers getting laid off. The friend laughed and said, “Man, you’ll never see a dentist getting laid off.”

That facetious remark was all it took to chart a new course for Burch. A few years later, he found himself working as a dental hygienist on a large base in Germany, cleaning soldiers’ teeth before they shipped off to Iraq and Afghanistan. He loved the job, especially because it gave him an opportunity to make new friends from all over the United States.

The story of how he came to establish a groundbreaking program for young dentists in Dallas, however, requires a few more stops. First, in Nashville, Tennessee, where he studied biology at Fisk University; then a master’s degree from a joint Fisk-Vanderbilt program; then dental school at the University of Tennessee Health Science Center; then to Washington, D.C., for a residency in pediatric dentistry at Howard University. It was there that he entered a program that integrates traditional pediatric dentistry with adults with disabilities and met a 67-year-old man with special needs who opened his eyes to a new challenge.

Once patients with special needs age out of their pediatric dentists’ offices, few general practice dentists will see them. Patients with special needs sometimes require sedation for a routine exam or cleaning. Parents might have to physically restrain their adult children, sitting on their feet or holding their hands, just so a hygienist can work.

The scarcity of dentists trained to treat patients with special needs is a national problem, but it’s especially acute in North Texas. About 300,000 patients with disabilities lack adequate dental care in Dallas because no one will take them. In May, while giving a national presentation to the American Dental Education Association, Burch noted, “There are dozens and dozens of pediatric dentists that are willing to see special needs kids. But as they transition into adulthood, it went from dozens and dozens of clinics to roughly six clinics that were willing to treat special needs adults and teenagers.”

He first encountered the issue in Dallas after he’d taken a faculty position as a clinical assistant professor at the Texas A&M College of Dentistry (formerly Baylor), whose campus lies on the edge of downtown. One mother in particular drove the point home. Her daughter had cerebral palsy, and Scottish Rite saw to her dental care until she turned 18. Ten years passed as the mother hopelessly searched for a new dentist. When Burch told the woman he’d see her daughter, the mother was so overjoyed that she burst into tears in his office.

“I’m used to kids crying on a day-to-day basis,” he says with a laugh. “But having a mom crying hysterically, it really hit home for me. That was the one event that pushed me to say, ‘I have to do something. Let’s find a way.’  ”

The A&M dental school is affiliated with Scottish Rite for Children and Children’s Medical Center, so Burch was able to analyze local patient populations through three years of their chart reviews. He found that 40 percent of patients at both Scottish Rite and Children’s needed medical immobilization, and 38 percent of the patients needed full mouth dental rehabilitation in an operating room—procedures that most general dentists cannot perform.

As Burch and his residents began seeing teens and adults with special needs, word spread around Dallas, surrounding areas, and even into Oklahoma. “We started seeing more and more of these tweens and teenagers that need adult dentistry, general dentistry,” he says. “And it kind of got to the point where the residents were like, ‘We really have to find another way to assist these patients. Because, you know, our specialty focus is just a kid.’  ” He knew that training more dentists was key.

While Burch’s pediatric residency at Howard required him to treat adults with disabilities, many dental programs across the nation fail to incorporate the same hybrid training. “It’s strongly suggested by [the Commission on Dental Accreditation] that students have the ability to manage special needs patients,” Burch says. “The issue is that it’s open for interpretation. So you can have classes on special needs, diseases, syndromes, or interactions with patients, but it really doesn’t hit home until you work on that patient base.” Thus, many graduates cannot comfortably care for adults with physical, intellectual, or developmental disabilities because their school may have satisfied the requirement via patients with high blood pressure rather than severe special needs.

Burch’s strategy is twofold, approaching the lack of training through “upstream and downstream” tactics. Upstream, Burch changed A&M’s curriculum for third- and fourth-year dental students, increasing the mandatory special needs courses. Fourth years in particular are required to practice giving treatment plans in clinical scenarios with adults with disabilities to learn what a specialist would do. Burch focused not only on the third and fourth years but also the postdoctoral students, increasing special-needs-centered lectures and full mouth dental rehabilitation cases for teenagers.

“If 15 or 20 of those students were more than enthused to help this patient base,” Burch says, “that’s a huge jump in the number of dentists in the extended county area that would see these patients.”

As students graduate from the program, Burch hopes that some of them will enter the North Texas market capable and comfortable with teens and adults with special healthcare needs. “To be realistic,” he says, “if 15 or 20 of those students were more than enthused to help this patient base, that’s a huge jump in the number of dentists in the entire Metroplex and extended county area that would see these patients.”

Burch advances the downstream method through the Compromised Care and Hospital Dentistry Fellowship. The Health Resources & Services Administration gave Burch $3.3 million to found the postdoctoral dental program after he went through the laborious process of applying for a federal grant. The fellowship touches on general, pediatric, and public health dentistry, all of which overlap when it comes to patients with special needs. Until he started writing the grant proposal, Burch had no idea how bad things here are. “The two most underserved counties in America for dentistry—the most uninsured counties in America—are No. 1, Harris County, No. 2, Dallas County,” he says. Such a dire statistic made it easier for Burch to secure the federal funds. The fellowship is the first special-needs-focused postdoctoral program in the state of Texas.

Through the grant, two postgrad fellows are trained to work with adults with special needs in a hospital setting. When they aren’t stepping in to assist adults with disabilities, the fellows also work with the pediatric residents. “The first-year residents and the fellows worked synergistically together across that one year of training, and their clinical abilities greatly increased,” Burch says. The fellowship strategically diversifies the patient base for the fellows so that each class exits the program prepared for most cases.

Dr. Nina Ray, also a graduate of Howard’s pediatric program, joined the faculty of the A&M College of Dentistry in August of 2020 as part of Burch’s grant. Ray works directly with the two fellows and saw the first class grow this past year. “So just seeing them go from, say, August 2020 to now, it’s a complete difference,” she says. “It’s like their confidence is built up, their knowledge is built up. They’re asking more detailed questions, things that are making us think together as colleagues.”

But insufficient training is not the only problem. Burch, who last year received his second master’s degree in public health, this one with a focus in public policy, says there is a gap in access to dentistry that is affected by the “social determinants of health.” Parents or caretakers of patients with special needs must overcome many obstacles before they even enter a dentist’s office. Will the dentist see them? If so, will the office take their insurance? Who will watch the rest of the household during the appointment? Burch says, “There are many other segments of the community that have to come together to really uplift not just special needs but the community as a whole.”   

In Texas, that can be harder to do than in other states. Dr. Farah Alam, director of the Special Care Dentistry Fellowship Program at the Rose F. Kennedy Center in New York City, says, “We’re lucky here, for multiple reasons. In New York state, Medicaid is quite generous with services that are covered, especially with dental. Other states are not.” In Texas, the Children with Special Health Care Needs program ends after the age of 20 for all except those with cystic fibrosis.

“In any problem, you have got to look for the money,” says Dr. Jeffery Hicks, a professor of comprehensive dentistry at the UT Health San Antonio School of Dentistry and chair of the Commission on Dental Accreditation. Insurance isn’t the only financial concern. Hicks was a hospital department chairman for 11 years. He says that even if a patient is insured, a hospital might not be inclined to give up the space needed to sedate and treat people with special needs. “When you talk about dental care,” Hicks says, “it’s not very sexy. So our ability to secure operating room time is directly tied to generating revenue. And when you’re competing with a cardiothoracic surgeon who can generate $30,000 operating in three or four hours and the general dentist who can generate $2,000 in three or four hours, there’s no competition there.”

In his May presentation to the American Dental Education Association, Burch said that he looked at 30 North Texas hospitals and found that only one was “open to treating adult special needs patients with restorative services, not just oral surgery services.”

Limited operating room space combined with the few trained dentists in Dallas increases the wait time between dental appointments. Hicks says he has heard of waitlists a year out for operating rooms. As the healthcare industry separates the mouth from the rest of the body, it’s easy to forget that oral health is predictive of overall health. If a patient with special needs is abandoned for years, major conditions such as kidney disease and diabetes may go unnoticed, leading to complications that could have been avoided if a dental office had seen the patient.

Though the public policy and financial issues do impact dental care for patients with special needs, the glaring gap in training is the biggest piece of the puzzle. Burch’s commitment to educating the future dentists of Dallas will hopefully inspire other dental schools across the country to address their curricula and invest in an underserved patient base. Burch wants to extend the program to three or four fellows per year and hopes to draw donor money and foundational grants to build a clinic.

“And hopefully, in the end,” Burch says, “we get the clinic, we increase our curriculum, we increase our fellowship, and we have a really nice patient base that we’re seeing annually for our students, hopefully in perpetuity.”

Write to [email protected]. This story first ran in the August issue of D Magazine with the title “Brush with Greatness.” 

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