Introduction

The World Health Organization (WHO) and the United Nations highlight the profound challenges faced by individuals with disabilities, constituting approximately 15% of the global population, during the COVID-19 pandemic. People with disabilities were identified as being at an elevated risk of and from COVID-19 due to various specific issues, including reliance on close contact for personal care, difficulties in basic hand hygiene, communication challenges, limited access to appropriately formatted information, co-morbid health conditions, underlying socio-economic disparities associated with disability, risk in residential settings, and the heightened potential for stigma and isolation1,2.

The pandemic exacerbated concerns about reduced access to essential support and healthcare services, compounding existing inequalities. Additionally, fears were expressed that the intensified efforts to isolate and protect people with disabilities might negatively impact their access to healthcare, a concern that has unfortunately manifested, particularly affecting those with physical and neuro-developmental impairments3. These children often require complex and specialized care, and their oral health needs are no exception. Ensuring that they receive appropriate dental care has always been a priority, but the pandemic has posed unique challenges in achieving this goal. In light of this, it is advisable that the care of the patients strictly follow national guidelines. It is also important to understand and follow the most recent evidence in the literature regarding the management of cross-infection both in public structures and in private clinics4,5.

Global oral health policies and recommendations have long played a pivotal role in guiding the provision of dental care to children with SHCN, aiming to provide them with equitable access to quality oral healthcare. However, the emergence of COVID-19 has raised critical questions about the applicability and effectiveness of these existing policies and recommendations in the face of a rapidly evolving healthcare landscape.

The pandemic did result in changes in health care delivery but care has now returned to pre-pandemic delivery, necessitating significant adjustments for future pandemics. By conducting a comprehensive and critical evaluation of the available literature, this review seeks to provide insights into how global oral health policies and recommendations have been adapted, modified, or augmented to address the unique challenges posed by the pandemic. It also aims to assess the extent to which these policies and recommendations have succeeded in safeguarding the oral health of children with SHCN during these trying times6.

In doing so, we aspire to contribute to a deeper understanding of the evolving oral healthcare system in the COVID-19 era and provide valuable information to policymakers, healthcare providers, and advocates. Our ultimate objective is to support evidence-based decision-making and promote effective strategies so that children with special healthcare needs continue to receive the dental care they require, even in the midst of a global health crisis.

Materials and methods

This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Eligibility criteria and exclusion criteria

Eligibility criteria were established by using the Population-Interventions-Control-Outcomes (PICO) strategy as follows:

Participants/population- Children and adolescents with Special healthcare needs.

Intervention(s)- Oral Healthcare.

Comparator(s)/control- The individual Guidelines, Policies and Recommendations of each association will be compared with the other available Guidelines.

Outcome(s) –

  • Comprehensive assessment of the applicability and effectiveness of global oral health policies and recommendations for CSHCN and during COVID-19.

  • The understanding of various guidelines and recommendations across the globe and identify the differences if any, which can further be used for the improvement of the oral healthcare delivery to the special healthcare needs population and for future research.

Exclusion criteria

  • Policies/Recommendations/Guidelines not addressing oral health care.

  • Studies focusing on populations other than special healthcare needs.

Information sources and search strategy

Various online search engines such as PubMed, LILACS, Web of Science, EMBASE, Scopus and the Cochrane Library were searched. A search of the grey literature was performed in Google Scholar and hand search of references. The search strategy included the use of text words and MeSH terms for the time period of 2008–2023.Search was performed individually by three researchers as per the inclusion and exclusion criteria. Any conflict/disagreement was resolved by the fourth author. Various search terms included- oral health policy, clinical practice guidelines, oral health recommendations, special child dentistry, children with special health care needs, individuals with special health care needs, special health care needs, Covid-19. Data set for the search strategy can be made available on request.

Quality assessment of the studies

The guidelines, policies and recommendations were appraised using the Appraisal of Guidelines for Research and Evaluation Instrument (Table 1, AGREE II). AGREE II evaluates the overall methodological quality, with a focus on the development process.

Table 1 Agree II quality assessment by domain (% Clinical Practice Guideline).
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Results

Selection

A total of 1479 records were retrieved from the database searches. The full search list has been included in Supplementary File 1. Three authors conducted the search individually, duplicate removal and final selection was done by the three individuals and any discrepancy was resolved by the other two individuals. After the removal of duplicates and updates (n = 107) and of documents deemed ineligible at title/abstract screening stage (n = 1348), 24 records underwent full-text assessment. Eight records were excluded following full-text screening. Sixteen records were included in the synthesis (Fig. 1).

Fig. 1: PRISMA flow diagram.
figure 1

The flowchart illustrates the progression of information throughout the various stages of the systematic review. It mentions the quantity of records identified, included, and excluded, as well as the rationales behind exclusions.

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Characteristics of the included results

Data extraction was done by three authors individually and then reviewed by the other two individuals, any discrepancies were resolved by the sixth individual.The results were tabulated using MS Excel. The guidelines/policies/recommendations originated from international organizations (AAPD, IAPD, NHS England, British society of disability and oral health, MCHB, US Dept. Of Health Services) (n = 6). A total of 16 documents were selected all of which were written in English. Majority of the documents focused on preventive (n = 7) and comprehensive care (n = 11). Other areas of focus included ethical consideration (n = 4), importance of necessary referral (n = 7) clinical setup and training of the dentist and staff (n = 5). Results are further explained in the Table 2.

Table 2 Results of included guidelines/policies/recommendations.
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Discussion

The Special Care in Dentistry Association (SCDA) categorizes patients with special needs as those experiencing physical, medical, developmental, or cognitive conditions hindering routine dental care7. The onset of the COVID-19 pandemic on March 11, 2020, marked a global public health emergency declared by the World Health Organization, highlighting challenges that necessitated adaptive healthcare policies. The SARS-CoV-2 virus, characterized by a single RNA strand and specific structural proteins, primarily targets ACE2 receptors, resulting in inflammation and tissue damage. A high transmission rate was observed in COVID-19 typically in immune compromised individuals and children with special health care needs8.

The start of the pandemic led to widespread disruptions, including business closures, population quarantines, and strained healthcare systems, causing shortages in critical resources such as personal and healthcare equipment. Beyond physical health implications, repercussion resulted in disruptions in health insurance, including dental benefits, posing additional challenges for families with vulnerable children9.

During the early pandemic, The Centre or Disease Control (CDC) recommended suspending elective medical procedures, including routine dental care, to conserve resources and prioritized emergency services which significantly impacted the routine oral healthcare services. Dental offices limited services to emergencies, due to concerns about potential aerosol transmission10.

The suspension of elective dental care11, 12 led to delayed routine treatments, contributing to increased dental and oral health issues. Lockdowns resulted in dietary changes and reduced self-care, impacting oral hygiene, especially for children with special needs relying on caregiver assistance.

Concerns have emerged regarding the delivery of oral healthcare services to special needs patients amidst the COVID-19 pandemic and these continue to persist. Dentists were tasked with modifying their practices to address the cross-infection risks associated with the highly contagious SARS-CoV-2. Few of these concerns and adaptations included identifying potentially infected patients and adhering to referral procedures13.

The application of the latest guidelines from regulatory bodies played a crucial role during the pandemic. In countries overwhelmed by COVID-19 infections, the consideration of tele-dentistry became particularly significant. Amidst these considerations, the heightened vulnerability and barriers faced by children with special healthcare needs raised questions about the applicability of existing guidelines tailored to their condition.

In this systematic review, our primary objective was to evaluate the adaptation of global oral health policies for CSHCN amid the challenges posed by the COVID-19 pandemic. The focus of our review centered on assessing the effectiveness of the global policies and recommendations in ensuring equitable access to quality dental care for this vulnerable group amidst COVID-19. Our review encompassed a comprehensive analysis of 16 guidelines, policy documents, and clinical practice recommendations derived from six authoritative sources worldwide, all of which met our predefined inclusion criteria.

The extensive findings of our review shed light on the various barriers faced by children with special healthcare needs, further compounded by the heightened risk of infection during the COVID-19 pandemic. The impact extends beyond general health concerns, significantly affecting oral healthcare for this population. Among the 16 included reports, a predominant focus emerged on the provision of preventive care, ethical considerations, proper training of the dentist and the dental team and the importance of reimbursements or Medicaid in access to dental services for CSHCN.

Each policy and guideline exhibited a consistent emphasis on the importance of adhering to proper referral, emergency response, and consent protocols for treatment. Notably, two policies specifically targeted certain medical conditions, namely cancer and learning disabilities. However, the majority of the guidelines adopted a general approach, applying a uniform protocol for all CSHCN, irrespective of the varying degrees or specific challenges faced by this diverse population14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29.

While the global policies collectively strive to ensure optimal oral healthcare for CSHCN, it is imperative to acknowledge variations in methodological quality and potential sources of bias within these documents. To assess the quality of the included guidelines, we employed the AGREE II Tool, revealing predominantly fair to good quality. However, some guidelines exhibited shortcomings, particularly in terms of stakeholder involvement.

The results extracted from these policies, guidelines, and recommendations can be categorized into several key domains as mentioned in Fig. 2. Each of these domains offers valuable insights that will be put forward in the subsequent sections of this discussion, contributing to a nuanced understanding of the current landscape of oral healthcare for CSHCN during the COVID-19 pandemic.

Fig. 2: Key domains.
figure 2

These illustrate the essential domains within recommendations, guidelines, and policies concerning oral healthcare for individuals with special healthcare needs.

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Key domains

  1. I.

    Patient-centric care & ethical considerations12,21,22,24:

  • Patient-centric care and ethical considerations are crucial for comprehensive and equitable oral healthcare for Children with Special Healthcare Needs (CSHCN).

  • Endorsed by organizations like AAPD, IAPD, and the British Society for Disability and Oral Health, policies stress the importance of emergency oral care for CSHCN.

  • Clear instructions to parents enhance accessibility, promote long-term oral health, and emphasize follow-up to the dental home after emergency treatment.

  • Holistic care extends to vulnerable populations, including LGBTQ youth and military-connected families, reflecting a global dedication to culturally-sensitive care.

  • Ethical responsibilities and professional clinical judgment discussions advocate for legislation to safeguard dentists’ autonomy globally.

  • Best practices for managing patients with special healthcare needs highlight a patient-centered approach, individualized care, informed consent, and effective transitions to adult dentistry.

  • Global convergence in policies signifies a shared commitment to a unified approach in oral healthcare for CSHCN, promoting collaboration, knowledge sharing, and pursuit of best practices.

  • The amalgamation of patient-centric care and ethical considerations in oral healthcare policies aligns with a broader global agenda to standardize practices, enhance inclusivity, and deliver more patient-centric care worldwide.

  1. I.

    Preventive measures and holistic integration: Across policies and guidelines, a consistent theme emerges in advocating for preventive measures and holistic integration of oral health into general healthcare. The focus on early childhood caries prevention, integration with oncology teams, and tailored prevention strategies for CSHCN highlights a important shift towards a preventive approach to oral health. Importance on establishment of dental home, home care, nutrition, fluoride applications have been emphasized14,19,23.

  2. II.

    Comprehensive care: Guidelines addressing oral healthcare during cancer therapy, as discussed by the British society for disability and oral health, exemplify a multidisciplinary and systematic approach. The emphasis on pre-treatment assessment, preventive measures during therapy, and post-therapy care reflects an awareness of the interconnectedness of oral health with overall health in cancer patients. General anesthesia for children with special healthcare needs has also been advocated for providing comprehensive care along with providing proper assessment and treatment protocol for treatment under general anesthesia. Similar specifications attributed to various classifications of special health care needs can guide in better management of that particular condition16,17,19,20,21,22,23.

  3. III.

    Reducing disparities14,16,21,25,26,29:

  • Medicaid-focused studies emphasize strategies to address oral health disparities in Children with Special Healthcare Needs (CSHCN).

  • Proposals advocate for improved Medicaid fee structures and sufficient reimbursement for care coordination to enhance financial accessibility globally.

  • Proposed adjustments to reimbursement models for providers in long-term care facilities aim to incentivize dentists, contributing to improved accessibility to oral healthcare.

  • A significant proposal involves Medicaid coverage for fluoride varnish, emphasizing preventive care, particularly for those in long-term care facilities.

  • Majority of reviewed documents focus on extending Medicaid and incorporating preventive dental measures into policies.

  • Not every region globally advocates for or has facilities for Medicaid or similar medical policies, posing challenges for oral healthcare access.

  • The COVID-19 pandemic has exacerbated challenges, leading to reduced oral healthcare visits for CSHCN due to financial concerns and the lack of reimbursements and Medicaid policies in various parts of the world.

  1. A.

    Quality measurement and continuous improvement14,15,24,26,29:

  • Discussion on quality measurement and evidence reflects a strategic approach to improving oral healthcare for individuals with Special Healthcare Needs (SHCN).

  • Integration of quantitative and qualitative measures, patient-reported outcomes, and evidence-based practices aligns with the global move towards value-based healthcare.

  • Challenges in enhancing oral care for SHCN include a shortage of trained dental providers, deficiencies in dental teams and setups, and issues with third-party payer compensation.

  • Recommendations encompass advocacy, professional development, reimbursement strategies, clinic adaptation for special healthcare needs, program expansion, and health service research.

  • Teledentistry is emphasized as crucial during the COVID-19 pandemic, highlighting the importance of telehealth in oral healthcare.

  • A commitment to professional development is evident through the establishment of a special care patient clinic and training dental students for specialized care, preparing future practitioners for challenges associated with SHCN, including emergencies like the COVID-19 pandemic.

  1. A.

    Systematic referral management and assessing needs: Standards for systematic referral management and assessing needs recognize the necessity for a structured approach. The delineation of care levels, facility requirements, and governance standards ensures a systematic and inclusive strategy. Involving consultants in dental public health in health needs assessment aligns with global efforts to address community-specific oral health needs systematically15,24,27.

The synthesis of global policies emphasizes a dynamic landscape, ranging from emergency care to specialized guidelines for cancer patients. This overarching commitment resonates with a dedication to equitable, patient-centric, and comprehensive oral healthcare. These policies form a robust foundation for a global framework addressing the diverse needs of special populations.

The pandemic emphasized the necessity for adaptable healthcare policies, particularly for those facing increased vulnerability and barriers to oral healthcare. The incorporation of teledentistry, alterations in reimbursement models, and state-level initiatives demonstrated a commitment to addressing the distinctive challenges encountered by special populations. While not all policies explicitly reference COVID-19, likely due to pre-existing formulations or insufficient evidence for modifications, they generally provide recommendations for various special needs without specificity to a particular condition. only one guideline mentioned Covid-19 in the discussion and stated no need of any changes from current recommendation even during covid-19. Homogencity was observed in the recommendations regarding preventive and comprehensive care. Establishment of dental home proper trained staff and team along with proper referrals and emergency management while maintaining indiscrimnable practice was promoted through these documents.

Strengths and limitations

This systematic review has several strengths. We conducted a rigorous and transparent search strategy and our search was not limited to particular area. An internationally accepted gold standard tool was used for quality assessment and appraisal (AGREE II). Limitation still persisted due to lesser available literature in association to COVID-19 and effect on shcn individuals.

Conclusion

In conclusion, the lessons gathered from the COVID-19 pandemic should shape a more resilient and inclusive healthcare framework. By integrating global and local policies and maintaining a commitment to continuous improvement, we can establish a healthcare system that genuinely caters to the needs of all, ensuring no one is left behind even during emergencies or pandemics like COVID-19.