Indian Journal of Dental Research

: 2020  |  Volume : 31  |  Issue : 3  |  Page : 486--493

Barriers to utilisation of dental care services among children with special needs: A systematic review

Lakshmi Krishnan, Kiran Iyer, PD Madan Kumar 
 Department of Public Health Dentistry, Ragas Dental College and Hospital, Chennai, Tamil Nadu, India

Correspondence Address:
Dr. Lakshmi Krishnan
Department of Public Health Dentistry, Ragas Dental College and Hospital, East Coast Road, Uthandi, Chennai, Tamil Nadu


Background: Disabled population accounts for 2.86 Crore of total Indian population. Among these 27.4% of population consists of children within age group of age 0 to 19 years. Studies have shown oral health status of children with special needs is lower than children without special needs. Though there are various attributing factors, access to dental care delivery and difficulties faced during dental treatment delivery are of major concern. Therefore the aim of this systematic review was set to assess the barriers faced by children with special needs during utilization of dental services; through caregiver's perception. Materials and Methods: For this review MEDLINE, EBSCO, COCHRANE, EMBASE and Google Scholar were the electronic data bases searched based on the PICO. PRISMA guidelines were followed for final inclusion of articles. Results: The search generated a total of 259 articles from five different electronic bases: PUBMED, EMBASE, EBSCO, COCHRANE and GOOGLE SCHOLAR. Based on inclusion criteria, 7 articles made it to final analysis. All the 7 studies reported that dentist were unwilling to treat children with special needs as a major barrier followed by fear towards dentist by the children with special needs. Conclusion: The cross sectional studies of this review were assessed for quality using a modified Newcastle Ottawa Scale, proposed by Egger et al. in 2003. Even though the available literature forms a lower standard of evidence, further evaluation of barriers are recommended using better designed studies to substantiate the in equal access to healthcare facilities by these marginalized population.

How to cite this article:
Krishnan L, Iyer K, Madan Kumar P D. Barriers to utilisation of dental care services among children with special needs: A systematic review.Indian J Dent Res 2020;31:486-493

How to cite this URL:
Krishnan L, Iyer K, Madan Kumar P D. Barriers to utilisation of dental care services among children with special needs: A systematic review. Indian J Dent Res [serial online] 2020 [cited 2023 Oct 4 ];31:486-493
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Full Text


Disability in India accounts to 2.1% of total population and among those 26.4% are children within the age group of 3 to 19 years. These children with disabilities are as those with a chronic physical, developmental, behavioral or emotional condition and a require health care services beyond what is required by children in general.[1] Several literature evidences have shown that their oral health status is also poor than the children in normal population.[2],[3],[4],[5],[6] One way of maintaining oral health status is by making regular dental visits to health care centers to reinforce preventive oral health habits, and to ensure prompt diagnosis and management of dental anomalies. Patients with regular dental visits are more likely to have oral diseases detected in the earlier stages and obtain restorative care as needed. Non receipt of regular dental services or a delay in accessing such services can result in delayed diagnosis leading to untreated oral diseases and conditions which in turn can jeopardize the general health status of a person compromising on their quality of life.

Past reviews have shown that utilization rate of dental services among children with special needs is less when compared to children of normal population.[3],[4] The reason for such a scenario can be attributed to the various obstacles faced by these children during the utilization of dental care services. The barriers to seeking dental services have been classified by the Federation Dentaire Internationale as related to: (a) individuals themselves (such as lack of perceived need, anxiety or fear, financial considerations and lack of access), (b) the dental profession (inappropriate manpower resources, uneven geographical distribution, training in-appropriate to changing needs and demands and insufficient sensitivity to patient's attitudes and needs), and (c) society (insufficient public support of attitudes conducive to health, inadequate oral health care facilities, inadequate oral health manpower planning and insufficient support for research).[5]

Previous studies have documented the factors which affect the utilization of dental care services among children with special health care needs. These factors have been identified to have direct and indirect impact on the utilization of oral health services. They include age, sex, ethnicity, education, language, perception of need, anxiety states, and feeling of vulnerability. Others may include cost of treatment, transportation, health status of the individual, residence and attitude of dental workforce.[6]

Although many of these barriers may not be amendable to intervention, access to health resources has been taken into consideration as an indicator of public health. To increase accessibility it would be necessary to remove the barriers. Also numerous studies have repeatedly confirmed that the population of persons with disability still meets considerable difficulties and obstacles in access to medical and dental care despite the attempts at legal regulation.[3],[4],[6] There seems to be no satisfactory solution for dental treatment among these chronically ill patients who cannot leave their homes.

To overcome these barriers an in depth understanding of the obstacles to dental care is required, which can be achieved by systematically analyzing the available literatures. Thus, this systematic review was done with the aim of assessing the barriers faced children with special needs in utilizing dental care services; through parental perspectives as these findings would provide evidence for making policies for improving access to dental care services for differently abled children.

 Materials and Methods


A systematic review was undertaken using objective and transparent methods as per the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, to identify, evaluate and summarize all relevant research findings. The protocol for this review is not yet submitted to any registry.

Eligibilty criteria

On applying the PICO analysis to the articles searched the criteria were set as shown below:

PICO analysis

o POPULATION – Caregivers of children with special health care needs

o INTERVENTION/INTEREST- Barriers to dental care services

o COMPARISON- Not applicable

o OUTCOME- Dental care services Utilisation rate and barriers encountered while accessing dental care services.

Inclusion criteria

Studies which reported parental perception on barriers to dental care utilization among children with special needs as their primary objectiveStudies which had defined dental care utilization as proportion of population who access dental services over a specified period of timeThe search included only studies published in EnglishStudies which had a population in the age range of 20 years and belowStudies published in the last 10 years were includedCross sectional, cohort studies.

Exclusion criteria

Studies reporting dentist perception on barriers to dental care utilization among children with special needsAlso studies that reported parental perception on barriers to dental care utilization among children without special needsQualitative studies, reviews, expert opinion, systematic reviews, meta analysis and case studies/seriesPublications with no abstract and those which were widely out of scope of the study were eliminatedStudies that required translation to English language.

The remaining studies were sorted on basis of their title and abstract. Finally, those studies in which the abstract fulfilled all inclusion criteria were selected for full-text reading. In those cases in which a study met the eligibility criteria but the information in the abstract was insufficient, full texts of the articles were also obtained. Further literature search was performed based on the bibliography of the selected articles.

Search stratergy

Relevant studies were included from the period of January 2007 to December 2017 via MEDLINE (PUBMED), EBSCO, COCHRANE, EMBASE and GOOGLE SCHOLAR. A detailed search strategy was developed for MEDLINE through the use of MeSH terms and was revised for Google Scholar, EMBASE, EBSCO and Cochranealso. The first set of terms include 'barrier to dental service', 'oral health care' separated by Boolean operator OR. The second set included the term 'access', 'utilization'separated by Boolean operator “OR” 'and the third set included the term 'children with special needs', 'disabled children', 'handicapped children' separated by Boolean operator “OR” [Table 1]. Data searches were done at September 2017 and again at March 2018. Hand searches of reference lists of included studies were conducted to ensure additional relevant references were identified. Although systematic reviews, qualitative studies were excluded, reference lists were checked to ensure all primary research was located for inclusion. Only full papers written in English were included. Where multiple publications reporting on the same study existed in different databases, data from the study were extracted and reviewed only once. Duplication of article was identified using software.{Table 1}

Study selection

Study selection was conducted by two authors who independently screened titles and abstracts against the inclusion/exclusion criteria and identified relevant papers. Then the same two authors independently reviewed the full text studiesunable to be excluded by title and abstract alone. Comparison of papers was completed between the two authors with no disagreements regarding inclusion.

Data extraction

The data extraction from final 7 articles was done using a data extraction form. It includes the first author name, year of publication of the article, study population, disability seen, objectives of the study, study design, method of obtaining relevant information (Assessment Tool), results and primary outcome and author's conclusion.

Quality assessment of the included studies

The final analysis included 7 cross sectional studies and the methodological quality of the selected articles were assessed using the modified Newcastle Ottawa Scale. For cross sectional studies, quality score was based on five items of the following categories: group selection, outcome and exposure. A maximum score of 5 points for group selection and exposure, 2 points for comparison group and maximum of 3 points for outcome represents the highest methodological quality. The higher the score, better the quality of study. The results of the assessment were tabulated in [Table 2] as shown.{Table 2}


Search results

The search generated a total of 259 articles from five different electronic bases: PUBMED, EMBASE, EBSCO, COCHRANE and GOOGLE SCHOLAR. Pubmed produced 58 articles, EMBASE produced 60 articles, EBSCO produced 101 articles, COCHRANE produced 27 articles and Google Scholar produced 13 articles. PRISMA 2009 guidelines regarding the paper selection are shown as flowchart in [Figure 1].{Figure 1}

The full texts of 16 articles were obtained for further review. On basis of inclusion and exclusion criteria 7 articles were included in this systematic review. Among those 9 articles excluded 5 articles had reported the general dental practioners perceptions on barriers in utilising dental services. Two articles have reported findings on parental perception on oral health of their disabled children. One article had a study population of adults with disabilities reporting on barriers encountered by them in utilising dental services. One article had reported both parental and dentist perceptions on barriers faced by children with special needs but had not clearly stated the care giver's perspectives. Bibliographical search of the selected articles yielded no eligible study for inclusion. Study population, study design, objectives, assessment tool, outcome and summary of these included studies are tabulated in [Table 3].{Table 3}

Main findings

All the included studies reported barriers faced by children with special needs in utilizing dental health services; through caregiver's perception, additionally; these studies assessed the proportion of disabled children.

Assesment tool

All the 7 studies have utilized structured questionnaire to assess the barriers faced by children with special needs in utilizing dental care services; through caregiver's perspective. These structured questionnaires had questions related to access to dental services, problems faced during dental treatment delivery, financial aspects of dental treatment were reported in the included studies and two studies Bhaskar et al.[7] and Sharifa[8] had added questions on oral hygiene measures used by children with special needs. All these studies made a descriptive analysis of the questionnaire which was validated in a similar population before being used as a tool to assess the barriers to dental service utilization among children with special needs.


Studies done by Sharifa[8] (2014), Bhaskar et al.[7] and Nelson et al.[9] had a mixed group of disabled children (autism, learning disabilities, Down's syndrome, cerebral palsy, mental retardation), in which children with learning disabilities formed the majority of the subjects and Gerreth et al.[10] (2015) in her study had a population of children with intellectual disability alone. Brickhouse et al.,[11] Barry et al.[12](2013) and Lai et al.[13] had a homogenous population of Autistic children in their studies respectively.

Oral health status

Among the studies which were analyzed, Bhaskar et al.[7]in 2016 reveals the oral health status of children with special needs. This study she reported that children with special needs have higher unmet dental needs than normal population 13, she reported that the mean DMFT of children with special needs was 2.52 ± 2.61 when compared to children without special needs which was 0.61 ± 1.12.

Dental care service utilisation rate

Brickhouse et al.[11] in his study reported that 30% of the disabled children had never visited a dentist. Lai et al.[13] states that 11% of the children with special needs utilize the services only in emergency Sherifa[8] (2014) in her study points out that 84% patients with special needs visit dentist only on emergency basis. In another study done by Bhaskar et al.[7] 33.1% of caregivers are unaware of their children's dental visit status. Nelson et al.[9] reported 94% of children with special needs visit the dentist once a year. Gerreth et al.[10](2015) stated 90.1% of special needs children have utilized the dental services once since their birth.

Out of the 7 studies analyzed, studies done by Gerreth et al.[10] in 2015 and Sherifa[8] in 2014 reported percentage of population having difficulty in accessing dental care services which reveals 46.2% and 69.2% respectively encountered difficulty in accessing dental care services.

Barriers to dental care services – through caregiver's perception

Brickhouse et al.,[11] 2009 had reported majority of the caregivers (75%) has stated reluctant dentist as barrier in utilizing dental services, Lai et al.,[13] 2012 reported financial constraint (38.3%) as major barrier in utilizing dental services. Sharifa,[8] 2014 in her findings suggested that 48.7% of them felt cost or financial difficulty to be the predominant barrier followed by 28.2% of the caregivers felt that their children experienced difficulty in sitting on dental chair as the major barrier. Apart from these two the author had reported that 16.8% of parents felt the dentist were reluctant in treating the children with special needs, 26.9% of them reported the dental clinic was far way and there were transportation difficulties faced by them as barriers during dental care utilization.

Gerreth et al.[10] (2015) mentioned 36.7% and 18.6% of them reported waiting time and reluctant dentist as the main barriers followed by 17.4% reported high cost and 3% of them described architectural limitations of the dental clinic.

Bhaskar et al.[7]in her article highlights 68.6% and 26.9% of caregivers felt expensive dental treatment and fear of dentist respectively as major obstacle for them in utilizing dental services for their children with special health care needs and 30.5% reported uncooperative behavior by their child, 5.4% described unwillingness of dentist to treat and 19% reported transport difficulties as minor barriers.

Nelson et al.[9] in her study reports 39% of the caregivers perceive fear of dentist and uncooperative child as major barrier while 21%, 12%, 9% of caregivers respectively reported cost of dental treatment, reluctant dentist, inaccessible clinic and transport difficulties as less predominant barriers.

All the 7 studies report unwilling dentist to treat children with special needs, uncooperative child as barriers in utilising dental care services.

Gerreth et al.[10](2015) and Nelson et al.[9]have stated 9% of the caregivers reported architectural limitations of dental clinics 3% of them stated inconvenient dental clinic working hours as difficulty faced during dental service utilization.

In addition to these above mentioned barriers Nelson et al.[9] has studied that 34% of the caregivers in her study population reported that the underlying medical condition complicated the dental treatment. Sherifa[8] (2014) reported 28.2% of parents of children with special needs had difficulty in sitting on dental chair.


The intent of this systematic review was to find the barriers faced by children with special needs during dental care delivery, through caregiver's perception. Despite the high number of publications in this field which were initially screened, the relatively small number of studies which were finally included in the review corroborates the idea that there is a lack of quality evidence on barriers faced by special needs children in utilizing dental care services.

In the present review, the search based on PRISMA guidelines narrowed down on a set of 7 descriptive cross sectional studies that suggested an outcome on barriers faced in utilizing dental care services by children with special need; through caregiver's perceptions.

Numerous studies have quoted poor oral hygiene status and decay present among children with special needs. The reason could be due to poor muscle coordination, complicated medical condition and decreased dexterity which make their tooth brushing difficulty.[2] Increased unmet dental needs were among children with special needs when compared to their counterpart children without special needs, this was in parallel lines with the findings published by Purohit and Singh et al.[14] This situation can be changed by proper utilization of dental services in many countries.

All the 7 studies showed a huge variation in utilisation rate among disabled children. Bhaskar et al.[7] showed 8.5% of his population utilized dental services once a year, whereas Nelson et al.[9]reported 90.1% of his study participants utilized dental services once a year. The results were comparable to utilisation rate of children without special needs, as reported by Onyejaka et al.[5] (2016) who stated 94.7% of his study participants utilized dental services. The reason for higher utilisation rate and anticipated reason for non – utilization of dental services could be socioeconomicstatus of the subjects; form of parenthood and the perceptionof the child about dental service are some of the significantpredictive factors of dental service utilization.[2] In accordance to the above statement, two studies showed that socioeconomic status plays a vital role in determining utilization of dental services among children. Nelson et al.[9] and Sherifa[8] (2014) in their studies showed a significant association in income, racial ethnicity and education with unmet needs of dental care. However, socioeconomic differences in the utilization of dental services still exist in many countries.

There are also other barriers in seeking regular dental care, including availability of dental services, dental fear, cost, income, accessibility to dental clinic and inadequate training among dental fraternity to handle these patients. In our systematic review, all the 7 studies reported financial constraint, uncooperative behavior of the child and reluctant dentist as one of the few barriers encountered while accessing dental care services, where Kenney et al.[15] and Onyejaka et al.[5]In his study reported financial constraint and inconvenient clinic timings as the common barriers faced by parents of children without special needs. Patients' feelings, beliefs, and attitude are some of the psycho-social determinants of dental health which modify or change the patient's dental health care seeking behavior, but may prove to be the basis for the barriers in accessing dental health care.[6] Several literature studies prove an association between parent's utilisation and their children's utilisation.[16] Since disabled children depend on their caregivers for their daily routine activities especially for maintain good oral hygiene, all the articles selected for analysis had the caregiver's perceptions to barriers faced in dental care service utilization as their primary outcome. Overall findings of this study suggest utilization of dental services among children with special needs show huge variation and there are both environmental and personal factors which act as barriers in accessing and utilization of dental care services. From the current literature, it is difficult to conclude presence of any profound barriers present in dental service utilization among children with special needs due the variations in population.


Certain limitations can be noticed in search criteria and study design. The search included studies reporting barriers faced by caregivers alone. Because of this, five studies were excluded that may have provided additional evidence. Study design selection included observational studies to determine the barriers faced by children with special needs, but, given the lower level of evidence this limited the evaluation and generalization of effectiveness of the difficulties encountered by disabled children during utilizing dental care services. It was not possible to synthesize the data using statistical analyses given the heterogeneity and lower level of evidence within the included studies.


The lack of high quality evidence about the barriers faced by disabled children will remain a challenge to many dental clinicians as the gap created between unmet dental needs and utilisation of dental services still remain unbridged. Though various barriers are listed, reluctant dentist and fear towards the dental practioners among the disabled children seems to be more common ones faced. Henceforth, for further evaluation of the barriers to utilization of dental care services among children with special needs studies of better standards/designs are recommended.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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