People with developmental disabilities (DD) have a higher risk of poor oral health, which is critical to overall health and wellbeing. Some of the risk is inherent to the disability, which can cause physical, behavioral, or other changes that increase the risk of developing oral health problems. Some of the risk is also due to dental professionals not being able or willing to treat this population.

One reason many dental professionals are not able or willing to treat people with DD is that they haven’t been educated enough about them. During interviews and focus groups, dental professionals and other stakeholders talked about not knowing what each developmental disability is, how to manage behavior, how to be accessible, how to administer sedation and anesthesia, and the ethical importance of serving people with DD. Dental school education has improved in recent years, but there are opportunities for further improvement and a need to reach more dental professionals who have already graduated.

The other reason many dental professionals are not able or willing to treat people with DD is that they aren’t compensated enough for the extra time, other accommodations, and sedation and anesthesia that people with DD often need. Several dental professionals were concerned about the financial sustainability of serving this population. The Medicaid reimbursement rate for interpreters is not enough to even cover discounted prices available to American Dental Association members and state agencies. The Medicaid reimbursement rates for sedation and anesthesia are only about 50 to 65% of what other large commercial dental insurers reimburse, which is well below the Commonwealth’s goal of 82-83%.

Consequently, access to dental care for Virginians with DD substantially lags key benchmarks. Only 56% of Virginians with DD receiving state services had a dental exam in the past year, according to the 2021-22 National Core Indicators. This rate ranked last among 27 states who participated in that data collection effort. This rate was also far below the 86% needed to meet a compliance indicator in Virginia’s settlement agreement with the U.S. Department of Justice.

Despite these access issues, there is limited state oversight of how well the Medicaid dental benefit is meeting the needs of people with DD. The Medicaid dental benefits administrator does not have data on the disability status of its members. The adequacy of the dental provider network is not assessed for people with DD. Feedback is only requested from Medicaid members who have had a dental visit.

Oral hygiene is also a critical component of oral health that should not be overlooked. Several factors limit the ability of people with DD to brush their teeth. Over one-third of people with developmental and other disabilities are not brushing twice a day, according to the 2019 Virginia Department of Health Basic Screening Survey. Educational programs can improve their ability to brush at home but Virginia does not have any that target people with DD and their family members.

The Commonwealth needs to make serious changes to meet its policy goals. Several initiatives are underway to improve oral health for people with DD, which are commendable, but additional support from state policymakers is needed. This report offers 18 recommendations to improve oral health for people with disabilities. The recommendations are action steps to implement six overall strategies. A brief version of each recommendation is listed below, by strategy, and the full recommendations are listed in Appendix A.

Invest in initiatives that increase the exposure of dental students to people with DD

• Virginia General Assembly fund a clinic at the Virginia Commonwealth University School of Dentistry that is dedicated to treating people with special health care needs (Recommendation 1, page 10)

• Virginia General Assembly fund a Fellowship program at the Virginia Commonwealth University School of Dentistry that addresses oral health disparities affecting people with developmental disabilities (Recommendation 2, page 10)

Increase access to and utilization of continuing education on oral health for people with DD

• Virginia Department of Medical Assistance Services (DMAS), Virginia Department of Health (VDH), Virginia Department of Behavioral Health and Developmental Services (DBHDS), and other stakeholders expand continuing education offerings for dental professionals on people with developmental disabilities (Recommendation 3, page 11)

• Virginia General Assembly amend Code of Virginia § 54.1-2709 to allow dental professionals to receive up to two continuing education credit hours for providing uncompensated care to people with disabilities (Recommendation 4, page 12)

• Virginia General Assembly amend Code of Virginia § 54.1-2709 and § 54.1-2722 to require that a portion of the 15 annual continuing education credit hours for licensed dental professionals pertain to underserved populations including but not limited to people with developmental disabilities (Recommendation 5, page 14)

• DBHDS develop a supplemental module on oral health for inclusion in their mandatory direct support professional orientation materials (Recommendation 17, page 38)

• Virginia Department of Education incorporate oral health into guidance regarding Individualized Education Programs (Recommendation 18, page 38)

Invest in the sustainability of the dental service system for people with DD

• DBHDS and VDH establish a pilot program that provides funding for dental professionals to remove physical, communications, or programmatic accessibility barriers that are identified by an on-site accessibility assessment (Recommendation 7, page 20)

• DMAS seek approval from the Virginia General Assembly to increase reimbursement for certified translation or sign language services (Recommendation 8, page 21)

• DMAS seek approval from the Virginia General Assembly to increase reimbursement for sedation and anesthesia provided in the dental office (Recommendation 9, page 26)

• Virginia General Assembly increase funding for the DBHDS Dental Program so they can expand their capacity to meet demand (Recommendation 14, page 33)

Assess how well the Medicaid dental benefit meets the needs of people with DD

• DMAS review the adequacy of individual reimbursement rates that are key to serving people with developmental disabilities, including how the rates compare to the agency’s goal of 82-83% of commercial insurance rates, and report publicly on its findings every three years (Recommendation 6, page 16)

• DMAS collaborate with disability stakeholders to regularly verify self-reported information from dental providers on their physical, communications, and programmatic accessibility using independent site reviews and secret shopper studies (Recommendation 12, page 30)

• DMAS biennially assess network adequacy for people on the Developmental Disabilities waiver (Recommendation 15, page 34)

• DMAS regularly collect feedback from providers and members on disability-specific issues and solicit input from disability stakeholders on Request for Proposals and contracts for the agency’s dental benefits administrator (Recommendation 16, page 35)

Conduct outreach to Medicaid members with DD

• DMAS, VDH, and other relevant stakeholders conduct user testing of their dental provider directories to ensure that they are useful for, understandable to, and accessible to people with developmental disabilities (Recommendation 13, page 31)

• DMAS regularly collect feedback from providers and members on disability-specific issues and solicit input from disability stakeholders on Request for Proposals and contracts for the agency’s dental benefits administrator (Recommendation 16, page 35)

Study additional opportunities for improvement

• Joint Commission on Health Care study innovative ways to address barriers to accessing sedation and anesthesia for dental procedures and innovative ways to reduce the need for sedation and anesthesia (Recommendation 10, page 27)

• DMAS, VDH, DBHDS, and other stakeholders participate in a workgroup on oral health for people with disabilities to continue sharing information and explore opportunities for improvement (Recommendation 11, page 29)