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Credit: WHYY Special Smiles Founder Mark S. Goldstein, DDS, in one of the operating rooms.
Mark S. Goldstein, DDS founded Special Smiles Ltd. in 2003. From the vantage point of 2023, he looks back on 20 years of progress — but acknowledges not nearly enough progress — in providing access to comprehensive oral health care for severely compromised special needs patients. Below are excerpts from a recent conversation.
It’s impossible to sum up 20 years in a few words but tell me the biggest change over the last two decades.
Special Smiles inception was what I believe to be the first attempt to focus a dental practice exclusively on treating the most severely compromised portion of the special needs population, the 1-2% who require general anesthesia in order to receive their oral healthcare in a safe, controlled environment.
In general, most of these patients are non-communicative, consequently when they develop pain and/or infection, the parent/caretaker would notice swelling or observe their adult child was not sleeping well, ceasing to eat, or holding their face in pain. Historically, the typical treatment was to refer them to an oral surgeon, who would then sedate the patient and finally extract the infected tooth. This cycle would be repeated as each dental emergency occurred. There was no true comprehensive care similar to care the general population typically receives every six months or so.
Fortunately, the situation is not nearly as bad now. There are a few excellent practitioners in our area who are equipped to do full mouth rehabilitation under general anesthesia, and are treating these patients, virtually all on a limited part-time basis. As far as I know, Special Smiles is the only facility of its kind in Pennsylvania, and one of the few in the country, that is exclusively designed and totally dedicated full-time, five days a week, to treating only this segment of the population. Consequently, lack of access to care still persists for this small but severely compromised segment of the special needs population. The Special Smiles practice has increased its capacity from 700 patients the first year to about 2,000 last year. Due to the ever-increasing demand for our services, we are now expanding our facility again.
Let’s step back for a minute and fill in a little background on you, what led you first into pediatric dentistry and then special needs dentistry.
When I decided to pursue a career in dentistry, pediatrics was a natural fit. I have worked with children all my life. My parents were schoolteachers and owned a summer camp. I was a camp counselor every summer, so I became very comfortable with kids.
After graduating from Temple University School of Dentistry, I did my Pediatric Dental Residency at St. Christopher’s Hospital for Children. Treating children with special needs was part of the job and I found I always enjoyed the interactions with those children and their parents. I loved working with them, the challenges they presented, and making their experience a positive one.
Special Smiles was not the first dental practice you founded. Talk a little bit about Pediatric Dental Associates.
I co-founded PDA with my partners in 1975 at Episcopal Hospital. We treated children from infants to teens, many of whom had special needs. Mostly, these children just need more care, time and attention. In general, there has never been a serious lack of access to care for special needs children due to them mostly being treated in the pediatric dental offices. The real challenge occurs as they get older and then typically present with more complicated oral health care and management issues.
Twenty years later, in 1995, PDA partnered with Episcopal Hospital to create the Episcopal Hospital Pediatric Dental Residency Program. My partners and I were the instructors for this program in which we educated general dentists to become pediatric dental specialists. Through the years we were very fortunate to hire some of our graduated dental residents into our practice and ultimately, they became our partners. Later Episcopal Hospital was acquired by Temple University Health System.
A portion of the training naturally focuses on treating children and teens with special needs. Part of their education involves operating room dentistry where they can participate in full mouth rehabilitation, that being the complete dental treatment of the entire mouth in one visit. Naturally as children age and become young adults, we would continue to treat them in the operating room. We were performing approximately 100 full mouth rehabilitations on teenager/adult special needs patients per year.
Is that how you caught the attention of the Pennsylvania Department of Human Services?
Yes. DHS, which manages the state’s managed care system for people on Medicaid, reviewed the level of access to dental care provided by the various Managed Care Organizations (MCOs) for adults with special needs who required general anesthesia to have dentistry safely accomplished. The results were not surprising: poor access, at best. DHS made an unusual request by suggesting the MCOs come together and find one solution instead of each company creating its own.
When they were seeking someone with the knowledge and experience to advise them, as mentioned, I had been treating about 100 cases a year. Consequently I received a call, “Mark, we have this problem, would you mind meeting with us?” We sat down, brainstormed, and it became clear that there was no place in the state exclusively committed to these particular patients, the severely compromised special needs adults who required general anesthesia for their dental care.
They asked, “Can you come up with a plan to expand your treatment of 100 patients a year to about 500 to 1,000 adults per year?” My response was, “Give me a few weeks to do some homework and I’ll let you know.” About six months later Special Smiles opened.
So that was the genesis of Special Smiles. What makes the practice unique and successful?
We didn’t invent a new type of dentistry, but rather developed protocols addressing the multitude of dental, medical, and logistical issues that must be accomplished to treat these patients safely and efficiently. We are acutely aware of the unique challenges our patients and their parents/caretakers face. We have made every effort to address each in a genuine caring manner.
Working in partnership with the state and the MCOs greatly smoothed the way to Special Smiles’ development. We initially took over two operating rooms that Episcopal Hospital had closed. We hired general dentists along with clinical and administrative staff to support them. We started receiving referrals from the various MCOs in the area, and so it began. Approximately 20 years later, when I retired from Pediatric Dental Associates, I committed myself full time to Special Smiles.
Special Smiles later expanded and you’re about to expand again. Tell us about that.
Demand for our services has never been a problem, but one of the main limiting factors is we can only handle a certain number of patients per operating room. In 2018, when we moved from Episcopal Hospital to our current location, we were able to add a third sedation room. That enabled us to treat about 2,000 patients annually. Most we see once a year. With our clinical model, we complete all their dental treatment during that single visit about 98% of the time.
Not in a million years did I think we would be expanding again, just five years later. As a consequence of COVID-19 and a variety of other factors, we now require additional clinical space. We are currently building a new Special Smiles with four sedation suites, just one floor below in the same building. We anticipate that with this new facility we will ultimately be able to treat close to 2,800 patients per year.
During the design process we sought advice from several of our higher functioning patients, along with parents/caretakers. Every aspect of its design takes into consideration our unique patient population. It will have little resemblance to any dental/medical office our patients have experienced. Our goal is when they enter this facility, it will foster a sense of calm and wellbeing.
There is a general theme throughout the office of natural surroundings, with the walls, ceiling, and floor textures and colors supporting this. Although we have no windows, we have placed virtual skylights just about everywhere, showing bright sunny skies with green trees. We have nine individual private waiting rooms, each with rocking chairs, virtual fish tanks, and more. One is specifically designed for our patients with autism. There is much more. As you can probably tell, I can talk about this for hours. It might sound a bit dramatic, but it is something you really need to experience.
When we started this conversation, you lamented that lack of access to care is a continuing problem. What is being done to improve access?
It all starts with education. Everybody, especially people caring for the severely compromised segment of the special needs population, needs to be educated about how important the health of the oral cavity is to our overall health. Think about how difficult it is to maintain a healthy oral cavity in the general population. That difficulty is magnified many times over with people who are unable to manage their own daily oral hygiene and are unable to receive routine dental care in a traditional environment.
Next, we need dental schools to increase the level of education and exposure of their students to treating special needs patients. I am happy to say that Dr. Mark Wolff, Dean of Penn Dental School, has always been a strong advocate for the special needs population. He recently opened a Care Center for Persons with Disabilities. This new facility is now giving their dental students invaluable direct real-world experience treating these patients.
Ultimately, we need more facilities like Penn Dental’s new Care Center and Special Smiles that are focused on the education of health professionals, patients and caretakers, along with treatment for the special needs population.
To close on a few positive notes, when you walk into the facility at Penn or the new Special Smiles, you are going to experience what I believe are state-of-the-art special needs dental offices. We truly have come a long way in understanding and embracing the many ways we can make dental facilities welcoming and comfortable for people of all abilities.
Finally, as mentioned and perhaps most important, is for young dental practitioners to be comfortable, confident, and competent treating in their office the 99% of special needs patients who do not require general anesthesia. This is without question the key to greatly increasing access to care for special needs patients.
