Open Arms Children’s Health

Evaluation Report

May 2014

Prepared for Home of the Innocents

by REACH Evaluation

Dental Service
Open Arms Children’s Health Dental Service

EVALUATION REPORT—May 2014

A Service of Home of the Innocents

Prepared for Home of the Innocents by:

REACH Evaluation

501 Park Avenue

Louisville, KY 40208

502.585.1911

www.reachevaluation.com

Funded by the Social Innovation Fund through the Foundation for a Healthy Kentucky

Photo Credits:

Courtesy of Home of the Innocents, Louisville, KY. Used by permission.
Contents

A Satisfied Patient and Her Parents .................................................................. 2

I. Report Highlights ................................................................................. 4

II. Program Background and Problem Definition....................................... 6

III. Documentation of the Need .................................................................. 9

IV. Logic Model for Evaluation of the Open Arms Dental Service............. 12

V. Evaluation Questions, Methods, and Level of Evidence ....................... 13

VI. Challenges to the Data ........................................................................ 17

VII. Findings ............................................................................................ 18

 Characteristics of Patients Served...............................................................18

 Number and Demographics of Children Served .................................18

 Priority Population.............................................................................19

 Distribution of Payer Resources.........................................................19

 Description of Clinical Encounters ...........................................................20

 Appointment Kept and Missed...........................................................20

 Preventive and Restorative Encounters...............................................20

 Behavioral Aids used during Treatment..............................................20

 Difference in Patient Records and Implications 

 for Continuity of Care ....................................................................21

 Impact of Clinical Service.........................................................................22

 Treatment Acceptance ........................................................................22

 Status of Oral Health and Hygience...................................................25

 Oral Health Quality of Life: Overall Concerns and Impact

 on Child and Parent........................................................................27

 Results of the Parental Caregiver Perceptions Survey ..........................28

 Themes from the Focus Groups....................................................................29

 Perspective of Staff and Youth in Residental Treatment Services.............29

 Perspective of Staff at KCPCC...............................................................31

 Impact of Rotation on Dental Students at Open Arms ..............................34

 Fourth-Year Dental Students: Pre/Post Measures.................................34

 Comparison of U of L Students and Other Dental Schools................35

 Pediatric Residents: Focus Group Summary.......................................37

VIII. Early Lessons Learned, Enhancements Underway,

and Success Stories.............................................................................. 39

IX. References ........................................................................................... 43

X. Appendices .......................................................................................... 44

 Appendix A: Statistical Analysis.................................................................44

 Appendix B: Fourth-Year Dental Students: Pre/Post Measures....................48

Open Arms Children’s 

Health is a service of Home 

of the Innocents and provides 

compassionate, expert 

care for children who are 

medically fragile, children 

with autism, children in 

foster care and children 

with other exceptional needs. 

The Dental Service is a 

component of Open Arms 

Children’s Health.

OpenArmsChildrensHealth.org
While there are many, 

many stories of satisfied 

patients, Rebecca’s 

experience provides some 

insight into the special 

nature of this service.

A Satisfied Patient and Her Parents

An interview with a dad and his daughter provided a stunning case study of 

the uniqueness of the Open Arms Dental Service. Tim and his wife and their 

daughter Rebecca were “early adopters” of the Open Arms Dental Service 

and very satisfied customers. Rebecca has been diagnosed with Down syndrome and 

autism.* She comprehends verbal communication but uses signs to communicate 

with others. Rebecca had a history of being extremely anxious about going to the 

dentist, and she was particularly anxious about sitting in the dental chair and having 

to be reclined.

The family’s gratitude for the sensitivity and patience of the staff was evident in 

Tim’s review of their early visits to Open Arms and the change that has occurred 

since that time. In his words, “I expected them to be patient, I just didn’t realize 

they would be THAT patient.” “THAT” degree of patience turned out to be three 

visits to Open Arms, scheduled for time with the dentist, during which Rebecca 

was able to become increasingly more comfortable with the atmosphere, the dentist, 

and especially the chair. On the third visit, she agreed to sit in the dental chair and 

allowed Dr. B to recline it. 

Open Arms staff took time to get to know Rebecca and to discover a routine that 

would work for her. The established “routine” begins the moment Rebecca arrives. 

Rebecca’s favorite color is red, and staff make sure that she can sit in the red chair for 

her appointment. Dr. B. gave Rebecca her own nitrous oxide mask to take home and 

handle, so that she could get used to the idea and comfortable with the feeling of a 

mask on her face. She brings it to every appointment. 

At Open Arms, the dentist views Rebecca’s dental care as a collaborative process. 

He informs her parents where she needs to target particular attention, and he has 

prepared them for the kinds of new issues for which they will need to plan in the 

future. Tim noted that “you can see he has an agenda in his head. He has good notes 

and he knows exactly what has been done so far. I’m very satisfied that we’ve never 

detected a sense of indecision.” And perhaps the best endorsement comes from 

Rebecca. She has become very comfortable with him, and trusts that he will stop 

what he is doing as soon as she objects. Dental appointments are no longer terrifying 

for Rebecca, or disturbing for her parents. 

*Seventy-five (75) children with autism were served during the evaluation period, and these 

children are included in the other priority populations served by the Open Arms Dental Service 

(details are on page 19).

2 | Open Arms Children’s Health Dental Service 
“I expected them to be patient, I just 

didn’t realize they would be THAT 

patient.” 

“As long as [you} have that patience at 

the beginning and set up that routine, 

all the stress is gone and she knows 

nothing bad is going to happen.” 

Tim, Rebecca’s dad

Evaluation Report May 2014 | 3
4 | Open Arms Children’s Health Dental Service 

Open Arms Dental Service, Courtesy of 

Home of the Innocents, Louisville, KY

“The Open Arms Dental 

Service uses a variety 

of behavioral aids and 

techniques to make the 

experience as positive 

for children and their 

caregivers as possible.”

Report Highlights

This report summarizes the evaluation activities and the findings associated 

with those activities. Although the Open Arms Dental Service opened in 

March 2011, data collection had to be postponed until IRB approval was 

received (June 18, 2012). This report, therefore, includes data on children served 

between July 1, 2012 and the end of the grant period, March 31, 2014. 

Highlights of Preliminary Findings

n Home of the Innocents (HOTI) exceeded its annual goal of serving 880 children 

within a year. During the first 12 months of the evaluation period (July 1, 2102 – 

June 30, 2013), they served 920; in the final 12 months (April 1, 2013 – March 

31, 2014), they served 1,411. This report analyzes data from seven quarters and 

includes 1,488 patients (unduplicated count).

n HOTI met its annual goal of serving 80 dental students and 6 pediatric residents.

n The Open Arms Dental Service is a resource for children throughout the 

Commonwealth, with children from 78 Kentucky counties represented, along 

with one county in Indiana.

n The Open Arms Dental Service is fulfilling its objective of serving special needs 

children. Participation by priority population during the 21-month period was as 

follows:

•	 Medically Fragile: 134

•	 Intellectually/behaviorally disabled: 28

•	 Foster care or residential care: 682

•	 Other Medicaid eligible children at-risk for poor dental health outcomes: 631

(+13 missing data)

n The Dental Service has been a welcome resource for refugees (136 during the 21 

month period), many of whom have experienced years of impoverishment in wartorn countries and refugee camps. They are included among the “other Medicaid 

eligible children” above.

n The Open Arms Dental Service uses a variety of behavioral aids and techniques 

to make the experience as positive as possible for children and their caregivers 

(see page 20). The tools are directed not only at lessening a child’s anxiety, but also 

of positioning the child in a manner that is both comfortable and conducive to 

a thorough examination. One unique example includes transitional visits to the 

Open Arms Dental Service where children can meet with a therapist to reduce 

anxiety and promote a positive experience prior to receiving treatment.

n There has been a dramatic improvement in the completeness and quality of the 

dental staff notes, allowing for a more thorough note and better continuity of 

care.

n Most children are accepting of treatment. When parental expectations of their 

child’s acceptance of treatment were compared to the dentist’s assessment of the 

child’s acceptance of treatment, there was agreement in 39.8% of the cases. In 
Evaluation Report May 2014 | 5

50.5% of the cases, however, the dentist’s assessment was more positive. (The 

parent provided a pre-visit expectation and the dentist provided an end-of-visit 

assessment; suggesting that the reality may be more positive than the parental 

expectation.)

n When the mean scores of treatment acceptance were compared (mean scores at 

Time 1 compared to mean scores at all subsequent visits), there was a significant 

difference in a favorable direction (at the .05 level). When the scores of the 279 

children who had four measures of treatment acceptance (Time 1, 2, 3, and 4) 

were compared; there was slight movement in a positive direction. The high 

scores, even at Time 1, reflect the attention given to the child and the willingness 

of staff to move at the child’s pace. This also explains the relatively modest 

change in treatment acceptance among these children, in that it is difficult to 

improve on scores that already are positive.

n Medically fragile children, refugees, and children in out-of-home care with other 

agencies, had poorer scores on three oral health measures (plaque, calculus, oral 

hygiene) than other children served by the Open Arms Dental Service. These 

results point to the severity of the need within these populations.

n In analyzing change in oral health scores over time, there was very little difference 

in the assessments between Time 1 and Time 2. Greater differences are found 

between Time 2 and Time 3, among children who have had more exposure to the 

Open Arms Dental Service.

n In interviews and focus groups with staff of the Kosair Charities Pediatric 

Convalescent Center (KCPCC) and staff and youth in HOTI’s residential 

treatment program, they commented on the changes brought about by the 

opening of the Open Arms Dental Service. Themes from the staff at KCPCC 

involved improvements in the quality of the services, enhanced oral health quality 

of life, enhanced treatment acceptance, increased convenience for the client, and 

more efficient use of staff time. Themes from staff 

and youth in the residential treatment program dealt 

with the attitude and responsiveness of staff, the 

accessibility of the service, and the attractiveness of the 

facility and the quality of its supporting equipment. 

Overwhelming, the comments addressed the quality of 

the interactions between staff and patients.

In conclusion, the Open Arms Dental Service has 

emerged as a significant resource for special needs children 

throughout the Commonwealth and as an excellent 

teaching venue for the dental profession. Throughout 

the implementation period, Jean O’Brien, vice president 

of Open Arms Children’s Health, has worked closely 

with the dentists and dental staff to make ongoing 

improvements. The result is a welcoming environment 

with highly skilled professionals who believe in the 

mission and who enjoy serving a previously underserved 

population. 

“You have a first rate 

facility and a dedicated 

staff who believe in what 

they do. I have been 

telling many people 

about the good work of 

the Home of Innocents 

and hopefully it will not 

only generate goodwill 

and patient care but also 

collaborations with likeminded individuals and 

organizations.” 

Dr. Mofidi

Dr. Mofidi with Open Arms patient.

Dr. Mofidi is a Dental Officer and Branch Chief within the federal 

Health Resources and Services Administration (HRSA). He heard 

about the opening of the Open Arms Dental Service and came to 

Louisville to take a tour and to learn more about the model.
6 | Open Arms Children’s Health Dental Service 

Program Background and Problem Definition

The Home of the Innocents (HOTI) partnered with the University of 

Louisville School of Dentistry’s (ULSD) Pediatric Dental Program to deliver 

state-of-the-art dental services within its newly constructed Hockensmith 

Pediatric Assessment Center (HPAC). This partnership, between one of Kentucky’s 

most comprehensive child-caring agencies and a prominent 

research university, focuses on better oral health outcomes 

for children with special needs through enhanced access to 

quality oral health services. One component of enhanced 

access to quality care is provided through an on-site dental 

service within HOTI’s Open Arms Children’s Health 

program. A second component provides for expanded 

access in other locations as a result of the additional 

knowledge, skills, and comfort level of the students and 

residents who participate in this specialized component of 

their training and who continue to serve this population 

upon entering practice. 

The result of this partnership has been the development 

of an outpatient dental service and teaching environment 

that provides compassionate, coordinated, high quality 

preventive and restorative dental care that is further enhanced by adaptive 

technologies and supportive techniques. Projected benefits of care in this setting 

were projected to include:

•	 Children with special health care needs would experience increased treatment

acceptance, which would lead to decreased oral symptoms and limitations, and 

therefore decreased missed appointments.

•	 Patients would, over time, experience improved oral health, with a long-term goal

of improved oral health quality of life being achieved for children with special 

health care needs and their families. 

•	 Parental/family stress would be decreased, in a concurrent fashion, as short and

intermediate goals are achieved.

Significant support for the project was provided by the Foundation for a Healthy 

Kentucky (http://healthy-ky.org/) through their Kentucky Healthy Futures Initiative 

(KHFI), which is funded through the federal Social Innovation Fund (SIF), enacted 

under the Edward M. Kennedy Serve America Act.

Populations of Focus

The Open Arms Dental Service provides opportunities for specialized treatment 

of some of the most underserved children from across the region and state. The 

overarching mission of the dental service is to improve the oral health of any child 

who comes to their attention who has an unmet need (and, through insurance, 

Medicaid or other payer source, an ability to pay). 

More specifically, the Open Arms Dental Service at HOTI provides oral health 

services for children from the following groups: 

•	 Children who are medically fragile, children with complex medical needs, and

children with severe physical anomalies that make the delivery of oral health 

treatment more difficult;

Open Arms Dental Service, Courtesy of 

Home of the Innocents, Louisville, KY

The result of this 

partnership has been 

the development of 

an outpatient dental 

service and teaching 

environment that 

provides compassionate, 

coordinated, and high 

quality preventive and 

restorative dental care.
Evaluation Report May 2014 | 7

•	 Children with intellectual, behavioral, or emotional disabilities, including children

with autism spectrum disorders;

•	 Children in foster care;

•	 Children of refugees; and,

•	 Other, low income children, whose only resource may be Medicaid.

Most children in foster care are victims of abuse and neglect and have experienced 

the trauma of being separated from their parents. These traumatic events can lead 

to behavioral and emotional problems that complicate their ability to establish 

relationships and receive consistent care. Neglect takes an additional toll on children’s 

health, growth and development as a result of poor nutrition, unsafe housing, 

inadequate supervision and the absence or delay of preventive medical and dental 

care.

The severity of the needs of Kentucky children in out-of-home care are assessed to 

determine their “Level of Care” and the amount of funding that is proportional to 

the child’s level of need. These levels are described below:

Level 5 = severe impairment, disability or need: severe risk of causing harm to self 

or others.

Level 4 = moderate problems: moderate risk of causing harm to self or others.

Level 3 = occasional problems requiring flexible levels of intervention from low to 

moderate

Level 2 = minor but frequent problems 

Level 1 = adequate functioning

Open Arms Children’s Health Dental Service accepts children at all levels of need, 

including those in residential settings and youth in inpatient psychiatric treatment.

Many of the children served in the dental service are current or former recipients of 

other HOTI services; including crisis and residential services; pediatric convalescent 

center services; foster care services; and community-based, in-home services for 

children with autism and other behavioral health needs. However, eligibility is not 

limited to current or previous recipients of HOTI services; rather, the Open Arms 

Dental Service is a resource to children with unmet needs throughout the region and 

state.

Dental Student Training

In addition to offering much-needed dental health care, HOTI’s dental service is 

a specialty teaching site for dental professionals-in-training at the University of 

Louisville School of Dentistry (ULSD) and their Pediatric Dental Program. With 

the opening of the Open Arms Dental Service in 2011, fourth-year dental students 

and post-doctoral residents have had access to a training environment that specializes 

in serving some of the state’s most physically, behaviorally, emotionally, and socially 

challenged children.

Fourth-Year Dental Students—Fourth-year dental students from the ULSD have 

the opportunity to receive a total of 20-32 training hours during a four-day rotation 

Open Arms Dental Service, Courtesy of 

Home of the Innocents, Louisville, KY

In addition to offering 

much-needed dental 

health care, Home of the 

Innocent’s dental service 

is a specialty teaching site 

for dental professionalsin-training at the 

University of Louisville 

School of Dentistry and 

their Pediatric Dental 

Program.
8 | Open Arms Children’s Health Dental Service 

at the Home of the Innocents’ Dental Service. The students complete two rotations 

– one each during the fall and spring semesters. During the fall semester, between 

2.5 – 3 hours are spent in orientation. The orientation includes information sessions 

with the Home’s clinical staff to talk about the populations of children served, and 

an information session with the on-site pediatric pharmacist to discuss the effects of 

some medications on the children’s teeth. 

During the orientation, the students also are asked to complete a pre-test to assess 

their awareness, confidence and willingness to treat children with special health care 

needs. The students learn about the basics of dental care, including room set-up, 

instrument sterilization, work ethic, and appropriate bedside manner. They observe 

and sometimes assist with the examination and treatment of children from the 

targeted populations. The students are taught alternative techniques for addressing 

children with behavioral issues (e.g. desensitization pre-visit to reduce fear, weighted 

blanket, use of TV above child’s head) and adaptive technologies for treating children 

with physical restrictions (e.g. use of motorized lift for children in wheelchairs so 

treatment can occur in a dental chair instead of bedside only).

Pediatric Dental Residents—Six (6) pediatric dental residents serve with the Open 

Arms Dental Service for two years. The rotation consists of approximately 20 days 

per year per resident.

The actual dental procedures that are being performed on the patients are not 

different than procedures that they would receive at any other setting—the dentists 

are doing cleanings, treating dental caries, and completing extractions and scalings. 

Unique to this service is the implementation of these procedures on behalf of the 

most medically fragile population of children in the state, who are housed in the 

convalescent center located on the property. The dental staff provide this care in 

a specialized setting and in a manner that is most appropriate and safe for a given 

child, by using different instruments, therapeutic aides, and adaptive technologies. 

Examples of the therapeutic aides are described in more detail on page 20, but they 

include the use of bean bags for positioning, special holds to comfort and stabilize, 

weighted blankets to reduce anxiety, lifts to transfer from wheel chair to dental chair, 

and “pre-visits” to desensitize and familiarize the child with the setting and the staff.
Evaluation Report May 2014 | 9

Documentation of the Need

The Home of the Innocents’ application for funding documented, through 

a review of the literature and available data, the high need for oral health 

services among particular populations of children and the implications of 

poor oral health for their overall health and well-being. Key elements of that review 

are provided below:

•	 Research has increasingly linked poor oral health to illness,

chronic disease and early mortality. Poor oral health has 

been linked to preterm births, pancreatic cancer, coronary 

heart disease and stroke. It can also make it difficult to eat 

a balanced diet, impacts self-confidence, and affects adults’ 

ability to find employment (Childress & Smith-Mello, 

2007).

•	 Research into the health of foster children has documented

a broad range of health needs. In the first national 

overview of the well-being of children involved with the 

child welfare system researchers found that children in the 

child welfare system are more likely to have health problems 

than those living with one or both parents (Kortenkamp and Ehrle, 2002). In the 

area of dental care, an earlier study of children entering foster care found that for 

children >3 years of age, more than half needed urgent or nonurgent referrals 

for dental services (Chernoff et. al, 1994). The national overview provided a 

comparison of children in out-of-home foster care and children living with their 

parents. This national study found that 37% of children in out-of-home care 

through Child Welfare had not seen a dentist in the past year as compared to 

28% of all children in parent care. The same study found that 28% of children 

involved in the child welfare system had a “limiting physical, learning, or mental 

health condition” as compared to 8% of children in the care of their parent(s) 

(Kortenkamp and Ehrle, 2002). These conditions, some of which are caused by 

or exacerbated by the abuse and neglect they have experienced, can make the 

delivery of care more difficult and more time-consuming. This is particularly 

true in the area of dental care, when the oral cavity has been the (a) site of abuse. 

The primary conclusion drawn from the national study was that addressing the 

broad range of health needs of children in foster care necessitates the design an 

implementation of better models of health care delivery (Kortenkamp and Ehrle, 

2002). 

•	 Kentucky has the highest percentage of edentate persons (those who have lost

all their natural teeth due to tooth decay or gum disease) ages 18 to 64, and 

the second highest percentage among individuals 65 and older. Additionally, 

Kentucky ranks eighth in adults who have lost at least one permanent tooth due 

to tooth decay or gum disease and fourteenth in adults who have lost six or more 

teeth (Childress & Smith-Mello, 2007). 

•	 A 2001 state survey suggested that a high percentage of even very young

Kentucky children may be in pain daily, affecting their overall health as well as 

their capacity to learn. The survey found disturbingly high levels of cavities in 

two- to four-year-olds (47%) and visible, untreated tooth decay in 29% of third 

and sixth graders (Childress & Smith-Mello, 2007). Only one-third of Kentucky’s 

low-income Medicaid or Kentucky Children’s Health Insurance Program 

(KCHIP) enrolled children received dental care in 2002. Jefferson County fared 

only slightly better with a rate of 41% (McNary, 2005). 

Open Arms Dental Service, Courtesy of 

Home of the Innocents, Louisville, KY

The primary conclusion 

drawn from the 

national study was that 

addressing the broad 

range of health needs of 

children in foster care 

necessitates the design 

and implementation of 

better models of health 

care delivery (Kortenkamp 

and Ehrle, 2002). The 

Home of the Innocents’ 

Open Arms Children’s 

Health is one such model 

responding to this need.
10 | Open Arms Children’s Health Dental Service 

•	 The Pew Center on the States graded Kentucky a “C” in terms of providing

disadvantaged children with dental health and access to care they need. One 

measure of how children are faring in terms of dental health is the percentage with 

untreated cavities. The national goal is to have no more than 21% of third graders 

with untreated tooth decay; Kentucky achieved a substandard 34.6% (Pew, 2010). 

•	 Kentucky trails the nation in Children with Special Health Care Needs (CSHCN)

who have received routine preventative dental care in the past year by 3.7% 

(74.8% in Kentucky versus 78.5% nationally) (CDC, 2007). Individuals with 

SHCN have a heightened risk for oral diseases, which further jeopardizes their 

health. Those who have mental, developmental or physical disabilities, who lack 

the ability to understand, assume responsibility for or cooperate with preventative 

oral health practices are especially vulnerable (AAPD, 2008). The root of this 

problem has three components: mental and physical impairments frequently keep 

individuals from properly caring for their mouths; disabilities and sensitivities can 

make dental visit experiences unpleasant; and families struggle to find dentists 

who can meet patients’ special needs (Pew, 2010).

•	 Dr. C. Lewis’ 2009 study, Dental Care and Children with Special Health Care

Needs: A Population-Based Perspective, provides a comprehensive current look 

at the need for dental care among CSHCN nationally. This study found that 

81% of CSHCN were reported as needing preventative dental care and 24% 

as needing other dental care in the past 12 months. The frequency of need for 

preventative dental care was second only to prescription medications. Overall, 

8.9% of CSHCN who needed dental care were unable to get it, making it the 

most common unmet need for CSHCN.

•	 Specific condition, severity of condition, insurance status and poverty all played a

role among CSHCN who had disproportionate levels of unmet dental care needs. 

Children with Down’s syndrome had the highest instance at 17.4%, followed by 

other forms of intellectual disabilities, cerebral palsy, autism, and ADHD. Publicly 

insured and uninsured CSHCN had unmet dental care needs at rates of 14.3% 

and 36.3%. CSHCN living below poverty level and up to 299% of poverty level 

had a disproportionate unmet need for dental care, ranging from 17.6% to 9.3% 

respectively. Poor and low-income children with the most severe special health 

care conditions have more than 13 times the adjusted odds for unmet dental care 

needs compared with high-income unaffected children (Lewis, 2009). 

•	 The American Dental Association (ADA) adopted a resolution supporting

access to oral health care for persons with special needs in 2002. Through this 

resolution, the ADA supports appropriate initiatives and legislation aimed at 

improving the oral health of persons with special needs. The resolution also 

challenges dental programs to educate students about oral health needs and issues 

among people with special needs (Fenton, Hood, Holder, May, & Moradian, 

2003).

Similarly, HOTI’s application also detailed the need for training for dental 

professionals in working with special needs populations and the benefits of the 

medical home model of service delivery for this population. 

•	 Several surveys have documented the lack of an adequate curriculum for

predoctoral dental students, and the average number of lecture hours devoted to 

the subject actually decreased from 12.9 hours to 5 hours from 1993 to 1999. 

This educational environment makes it difficult for future dentists to develop 

necessary skills for working with this population (Fenton et al., 2003). 

The American Dental 

Association (ADA) 

adopted a resolution 

supporting access 

to oral health care 

for persons with 

special needs in 

2002. Through this 

resolution, the ADA 

supports appropriate 

initiatives and 

legislation aimed at 

improving the oral 

health of persons with 

special needs.
Evaluation Report May 2014 | 11

•	 Pediatric dentists receive special training in treating children ages birth through

teen years, and are particularly skilled at making sure a child has a comfortable 

and positive visit. Most dental schools, however, only require five hours or less of 

classroom instruction and less than five hours of clinical time devoted to children 

and adolescents (McNary, 2005).

•	 A study regarding dental education and acceptance of patients with special needs

was conducted by T. H. Brickhouse, DDS, PHD, of the Virginia Commonwealth 

University School of Dentistry. Dr. Brickhouse found that members of the 

Virginia Dental Association who had post-graduate or continuing education 

were more likely to routinely treat adult and pediatric patients with special needs. 

Additionally, providers who felt it was part of their mission to treat patients 

with special needs were more likely to routinely treat patients with special needs 

(2007). 

•	 Lack of specialized training is not the only issue impacting availability of dental

care in Kentucky. The state also saw 77% of its dental school graduates leave the 

state in 2006 (only 30 out of 130 stayed in Kentucky), and less than one-fourth 

of Kentucky dentists participate in the Medicaid program (Childress & SmithMello, 2007). 

•	 The American Academy of Pediatric Dentistry’s guidelines for evidence-based

best practices state that “health care for individuals with special needs requires 

specialized knowledge, increased awareness and attention, adaptation, and 

accommodative measures beyond what are considered routine” (AAPD, 2008). 

•	 A medical home model which includes dental care is one recommended approach

to decreasing disparities in dental care among CSHCN (Lewis, 2009).

•	 Finally, a recent study conducted by REACH Evaluation under the auspices of the

Louisville Metro Primary Care Association (LPCA), found that only one-third 

(33.5%) of Louisville Metro dentists were willing to accept Medicaid or KCHIP 

(the Federally supported children’s health program).

Pediatric dentists receive 

special training in 

treating children ages 

birth through teen years, 

and are particularly 

skilled at making sure a 

child has a comfortable 

and positive visit.

Open Arms Dental Service, Courtesy of Home of the Innocents, Louisville, KY
12 | Open Arms Children’s Health Dental Service 
Evaluation Report May 2014 | 13

Evaluation Questions, Methods, and Level of Evidence

REACH evaluators consulted with Open Arms Dental Service staff and 

evaluators from the Center for Community Health and Evaluation to design 

an evaluation that was as rigorous as possible within the parameters of the 

project and the amount of available funding. The evaluation design sought to yield 

information in two major domains: child patient care and dental professional training.

Evaluation Questions

The following evaluation questions were designed to provide a focus for the 

evaluation, meet the expectations of funders, and provide Open Arms Dental Service 

staff and key stakeholders with relevant information about the project: 

Child Patient Care

n How many children are being served by the Open Arms Dental Service? What are 

their demographic, oral health, and special health condition characteristics? Is the 

Open Arms Dental Service serving the intended populations of focus? 

n What is the rate of missed appointments among children being served by the 

Open Arms Dental Service? How many children complete treatment? [measured 

by “completed” Treatment Plans created for patients in electronic medical records 

system] 

n Do children that complete treatment at the Open Arms Dental Service 

demonstrate:

•	 increased acceptance of dental treatment, compared to baseline?

•	 improved oral health quality of life, compared to baseline?

•	 reduced oral symptoms, compared to baseline?

•	 reduced functional limitations, compared to baseline?

•	 improved emotional well-being, compared to baseline?

n Do parents/caregivers of children that complete treatment at the Open Arms 

Dental Service report decreased parental distress/negative impact on family 

functioning, compared to baseline?

n What barriers to adequate dental care exist among CSHCN served at the Open 

Arms Dental Service? How has the Open Arms Dental Service reduced these 

barriers?

Dental Professional Training

n How many post-doctoral residents and dental students participated in 

professional training at the Open Arms Dental Service? Were annual targets 

reached in terms of numbers trained? 

n Do dental students that participate in professional training at the Open Arms 

Dental Service demonstrate: 

•	 increased understanding of CSHCN?

•	 increased confidence in treating CSHCN?

•	 increased willingness to treat CSHCN in future dental practice?

•	 increased skill in treating CSHCN?

Open Arms Dental Service, Courtesy of 

Home of the Innocents, Louisville, KY

The evaluation 

design seeks to yield 

information in two 

major domains: child 

patient care and 

dental professional 

training.
14 | Open Arms Children’s Health Dental Service 

Methods

Child Patient Care

Evaluators gathered data about the program’s participants, services received, and 

results. Several indicators and outcomes related to oral health, oral health quality of 

life, treatment acceptance, and family well-being were measured. The evaluation also 

sought to identify the existence of any factors (emerging techniques) involved in the 

delivery of the oral health service that could be studied in more controlled situations.

Dental Professional Training

The evaluation of the dental training component rested primarily on assessing 

of the degree to which the dental students (N=80 per year) exhibited increased 

confidence in their ability to effectively treat a child with special health care needs; 

and, their anticipated willingness to serve this population in the future. These factors 

were measured at the beginning of the rotations and again just prior to graduation 

via a survey (modified from Cushing & Brickhouse, 2007, for the purpose of this 

evaluation). The confidence and skill of dental post-doctoral residents (N= 6 per 

year) to effectively treat CSHCN was assessed through annual focus groups, which 

served to document their unique perceptions about the (a) “key ingredients” of the 

innovative model of dental health care provided by the Open Arms Dental Service 

for CSHCN, (b) the elements of the model that might be suitable for replication, 

(c) specific barriers to adequate dental care that exist for CSHCN served at the Open 

Arms Dental Service, and (d) ways in which the Open Arms Dental Service reduced 

these barriers.

The data that has been generated is consistent with “preliminary” levels of evidence, 

as outlined in the guidance provided on behalf of the Corporation for National and 

Community Service’s Social Innovation Fund, by their evaluators, JBS International.

Level of Evidence

Preliminary Level of Evidence—Child Patient Care

The primary design for measuring the effectiveness of child patient care involved 

pre- and post-comparisons of outcomes before and after services were delivered. 

Outcomes that relate to global ratings of oral health, decreased oral symptoms, 

decreased functional limitations, increased emotional well-being, increased family 

well-being, and parental perceptions of treatment acceptance were measured with the 

Parental-Caregiver Perceptions Questionnaire (P-CPQ). The P-CPQ was originally 

developed by Jokovic et al (2003) as one part of a larger Oral Health Related 

Quality of Life measure (OHRQoL), and was later adapted by Nelson (2007) to 

include fewer items and incorporate the Family Impact Scale also contained in the 

original OHRQoL measure. 

The psychometric performance of both the P-CPQ and Family Impact Scale 

were previously tested (Locker, Jokovic, & Thompson, 2005; Jokovic, Locker, 

Thompson & Guyatt, 2004). Regarding the P-CPQ, Cronbach’s alpha for internal 

consistency was reported as 0.94, and the intraclass correlation coefficient for testretest reliability was 0.85 (Jokovic et al, 2003). The Cronbach’s alpha and intraclass 

correlation coefficients for the Family Impact Scale were 0.83 and 0.80, respectively 

(Locker et al, 2002). For this evaluation, two items assessing parental perceptions of 

treatment acceptance (see below for explanation) were added to the questionnaire.

Open Arms Dental Service, Courtesy of 

Home of the Innocents, Louisville, KY

The primary design 

for measuring 

the effectiveness of 

child patient care 

involved pre- and 

post-comparisons of 

outcomes before and 

after services were 

delivered. 
Evaluation Report May 2014 | 15

Parents/Caregivers complete the P-CPQ at the first appointment in the dental clinic 

and every 6 months thereafter. Dental clinic staff are responsible for collecting the 

P-CPQ, entering the data into an electronic database, and flagging 6-month followups. 

Other child patient care data is collected from Dentrix, the electronic medical records 

system used by the dental services. Quarterly data mining produces data that allows 

for an assessment of program implementation (e.g. number of children served, 

characteristics of children served) as well as outcomes relating to rates of missed 

appointments, treatment completion, treatment acceptance, and measures of oral 

health. Treatment acceptance is measured through a 4-point, behaviorally anchored 

rating scale developed by Frankl, Shiere, & Frozels (1962) that has been widely used. 

The scale classifies children’s behavior into four groups according to their attitude 

and cooperation during dental procedures. The scale is reported to have good 

reliability (Baier, Milgrom, Russell, Mancl, & Yoshida, 2004), including an interrater reliability index of 0.96 (Machen & Johnson, 1974). The treatment acceptance 

score is noted by the treating dentist at every visit using a procedure code in Dentrix 

developed specifically for this purpose. 

In addition to the procedure code for treatment acceptance, two other custom 

procedure codes were developed that are used by the treating dentist at every visit. 

One procedure code documents any special aids (designed to facilitate success) that 

were used during dental treatment, from a list of 18 options (e.g. use of motorized 

lift, weighted blanket, desensitization pre-visit, pedi-wrap, holding hands, use of TV 

above child’s head, etc.). The second procedure code documents the setting in which 

the child’s last dental care experience took place, and includes the following: (a) child 

has had no prior dental care experience, (b) emergency care, (c) care in hospital, or 

(d) care in dental office.

Data data collection officially began on July 1, 2012, following the receipt of 

approval from the Institutional Review Board at the University of Louisville. 

The pre-post design is limited in terms of validity, and this has been factored into 

summary statements related to the preliminary findings described in this report. The 

largest threat to internal validity exists because of the lack of a comparison group; 

other threats to validity also exist (e.g. history) but are attenuated somewhat by 

the use of instrumentation that has been previously tested and been found to have 

acceptable reliability. 

Preliminary Level of Evidence - Professional Dental Training

In addition to elements of the evaluation of dental training described earlier (e.g. 

focus groups with post-doctoral residents, completion of specific training objectives), 

the evaluation design included a comparison of outcomes related to increased 

awareness, confidence and willingness to treat CSHCN within dental students from 

U of L that complete rotations at the Open Arms Dental Service. A pre-post survey 

design was used. Also anticipated was a between groups post-test only comparison 

of U of L dental students with a group of newly licensed dentists (recent graduates) 

in Kentucky from (a) other dental schools within the state or outside the state 

(grads who move to Kentucky to practice), and (b) who did not have exposure to 

the unique training experience at the Open Arms Dental Service. The names and 

practice addresses of newly licensed dentists were obtained from the Kentucky Board 

of Dentistry and a survey was mailed to them. 
16 | Open Arms Children’s Health Dental Service 

Evaluators modified an unpublished survey used in a thesis project by Cushing and 

Brickhouse (2007) that assessed the relationship between dental education and future 

acceptance and treatment of special needs patients among dentists in Virginia. The 

pre-survey was administered in August (2012 and 2013) and coincided with the 

beginning of the rotation at the dental clinic. The post-survey was administered after 

the completion of the rotation, just prior to graduation.

Similar to child patient care, the proposed designs for professional dental training 

were limited in terms of validity, and these limitations are factored into statements 

about the effect of the dental clinic in this report.

Open Arms Dental Service, Courtesy of Home of the Innocents, Louisville, KY
Evaluation Report May 2014 | 17

Challenges to the Data

Although the Open Arms Dental Service opened in March 2011, approval 

was not received from the Institutional Review Board (IRB) until June 

2012. Data collection for the evaluation could not begin until approval was 

obtained. 

The 15-month period between the start of the program and approval to collect data 

was consumed by efforts to get the evaluation plan approved by the two different 

evaluation teams under contract with the Corporation for National and Community 

Services. Upon approval of the evaluation plan, in January 2012, and upon learning 

that approval from an Institutional Review Board was required, documents were 

submitted to the University of Louisville’s Human Subjects Protection Program 

Office. Notice of approval was received from the Biomedical Review Board on June 

18, 2012. 

In addition to the late start of the data collection process, there were several 

challenges to obtaining a robust data set for each of the planned measures. These are 

listed below:

n The majority of the children served by Open Arms Dental Service do not reside 

with their parents; instead, they are in a residential, out-of-home placement. 

Because the Parental-Caregiver Perception Questionnaire demands intimate/

extensive knowledge of the child’s oral health, data from the P-CPQ is only 

available on a limited number of the children served (216 of 1,488 during the 

21-month time period).

n The Home of the Innocents has an electronic medical record and an electronic 

dental record (Dentrix). Information on the child’s oral health and dental 

treatment is contained in Dentrix. Other information is included in the EMR. 

While the two systems are linked, the linkages do not always yield accurate data. 

Additionally, the Dentrix system was created (over 10 years ago) for use in a 

dental office to track health status and procedures that support the treatment 

planning and billing processes. It was NOT developed to support a research 

process; and, retrieving aggregate data for research purposes has been extremely 

difficult. 

n The evaluation design called for surveying newly licensed dentists (Kentucky 

license) from schools other than the University of Louisville. Surveys were sent 

to 39 dentists who had a recent license date (licensed after May 2012) and who 

graduated from a school other than the U of L. The response rate was 38%.

In summary, while the evaluation is final, the results provide only a preliminary level 

of evidence.

NUMBERS

1,114 NEW Patients between

7/1/12 and 3/31/14

(time period)

1,488 Unduplicated count of

children served in time

period; includes

children who began

services before 7/1/12

2,670 Appointments scheduled

in time period

2,219 Appointments kept in

time period
18 | Open Arms Children’s Health Dental Service 

Findings: Characteristics of Patients Served

Open Arms Dental Service, Courtesy of 

Home of the Innocents, Louisville, KY

THE ANNUAL GOAL of serving 880 children was surpassed. During 

any four consecutive quarters of the project period covered by this evaluation, 

the Open Arms Dental Service served more than 880 children. During the first 

12-month period the goal was exceeded by 80 children. During the last 12-month 

period, the goal was exceeded by more than 180 children. Throughout the 21 

months of the evaluation period, 1,488 children were served (unduplicated count).

The following charts provide detailed information on the characteristics of the 

children served during the twenty-one (21) months for which data are available 

(July 2012 through March 2014). 

Children of all ages are being served, including a substantial portion of children of 

preschool age. The mixture of patients by gender and race are portrayed below. The 

racial and ethnic diversity of the patients exceeds the diversity of Kentucky’s citizens. 

This may be a factor of the overrepresentation of African American children in outof-home care (a population of focus for Open Arms), and a factor of Open Arms 

Health Services’ openness to underserved populations, including refugees.

While not portrayed in the charts on these pages, a brief listing of some of the 

diagnoses of children served by the Dental Service reveals the complexity of the 

children’s physical, mental and emotional needs. Prominent among them are: 

anxiety disorder, sleep apnea, scoliosis, bipolar disorder, Cushing’s syndrome, 

gastroesophageal reflux disease (GERD), blood disease, heart disease, respiratory 

problems, hepatitis, Down’s syndrome, and abuse (physical, mental, sexual).

Characteristics

of Children Served

THE ANNUAL GOAL OF SERVING 

880 CHILDREN WAS SURPASSED. 

The charts on pages 18 and 19 reflect only those 

whose first visit to the Open Arms Dental Service 

was July 1, 2012 or after (N=1,114). 

On subsequent pages, all children who received 

services during the period (even those who began

the service prior to July 1, 2012) are included. 

(N=1,488).

____ _

Age

TOTAL: *1,114

800

700 811

600

500

400

300

200 296

100 7

0

< 5 YEARS 5-18 YEARS 19-39 YEARS

*Does not include children who began services 

prior to July 1, 2012.

Gender

TOTAL: *1,114

600

605

400 509

200

0

FEMALE MALE

*Does not include children who began services 

prior to July 1, 2012.

Race or Ethnicity

TOTAL: *1,114

600

400 511

200 277 237

0

AFRICAN CAUCASIAN OTHER

AMERICAN

*Does not include children who began services 

prior to July 1, 2012; and missing data on 89 children.
Evaluation Report May 2014 | 19

Priority populations share one common feature: their history of being an 

underserved population or their difficulty in accessing dental services. Beyond this 

common characteristic, the populations vary greatly. Some are grouped by the type 

of out-of-home setting in which they live; others are grouped by a physical disability, 

others by an emotional/behavioral/intellectual disability; and others by their status as 

new arrivals in this county.

Consistent with the original intent of the service, the majority of the children served 

by Open Arms have some form of Medicaid as their payer. These numbers are 

evidence of the value of the resource, in that Open Arms is a place where children 

with challenging needs are accepted and treated. Because of the low reimbursement 

rates for dental care and the time-intensive needs of these patients, many dentists are 

unwilling to serve them. 

The Medicaid reimbursement structure allows the scheduling of 

medically fragile children on a three-month cycle through Early 

and Pediatric Screening, Diagnostic, and Treatment (EPSDT). 

Other insurance plans do not recognize the need for some 

children to be on a similar three-month cycle. Therefore, the 

financial responsibility of the oral health and hygiene falls solely 

on the caregivers who are many times already overwhelmed 

with the daily challenges of caring for these children.

Open Arms has provided needed dental care to children from 

many other parts of the state who are in residental care at the 

Home of the Innocents or other similar programs in the area. 

The map below represents the various counties and the number 

of children served from each county.

Reimbursement of Preventive and Restorative Treatment

DISTRIBUTION OF

PAYER RESOURCES Private 

Sources of funding Insurance

13% for clinical services

(preventive and

restorative). 

As envisioned, the Open

Arms Dental Service is Medicaid

serving a low income 87%

population, with 92% of 

the children qualifying

for Medicaid. 

Private 

Insurance

8%

Medicaid

92%

Priority Population

Population

Medically Fra

Other Agencie

CKC (Child Ki

Impact Plus

CKC - Autism

Outpatient (n

Refugee

Unknown

Total

*Many medicall

prior to July 1, 2

the numbers on

**Seventy-five 

served during t

are counted in 

Number of participants 

Indiana

Kentucky 

Knox

Vigo Clay

Rush

Parke

Greene

Pike

Ripley

Gibson

Perry

Clark

Posey

Henry

Owen

Boone

Jackson

Putnam

Dubois

Shelby

Marion

Harrison

Sullivan

Wayne

Daviess

Orange

Monroe

Madison

Morgan

Martin

Warrick

Franklin

Brown

Spencer

Randolph

Decatur

Lawrence

Clinton

Fountain

Hamilton

Washington

Jennings

Delaware

Montgomery

Hendricks

Jefferson

Johnson

Tipton

Scott

Hancock

Crawford

Jay

Dearborn

Bartholomew

Fayette Union

Floyd

Warren Tippecanoe

Switzerland

Vermillion

Vanderburgh

Ohio

Howard Grant Blackford

Ohio Pike

Clay

Hardin

Pulaski

Hart

Trigg Logan

Bell

Lewis

Christian

Graves

Adair

Warren Barren

Todd Knox

Butler

Harlan

Laurel

Wayne

Floyd

Hopkins Casey

Leslie

Allen

Carter

Knott Perry

Grayson

Whitley

Nelson

Union Daviess

Breathitt

Owen

Bath

Shelby

Scott

Madison

Bullitt

Lee

Estill

Lyon

Morgan

Marion

Breckinridge

Henry

Lincoln

Meade Clark

Calloway McCreary

Green

Letcher

Taylor

Grant

Larue

Fleming

Lawrence

Jefferson

Henderson

Monroe

Jackson

Muhlenberg

Caldwell

Elliott

Greenup

Webster

Rowan

Marshall

Ballard

Boone

Russell

Fayette

Wolfe

Harrison

Crittenden

Magoffin

Martin

Mason

Mercer

Bourbon

Metcalfe

McLean

Fulton

Johnson

Boyle

Boyd

Rockcastle

Edmonson

Hickman Clinton

Pendleton

Simpson

Owsley

Powell

Franklin

Washington

Carlisle

Menifee

Bracken

Oldham

McCracken

Spencer

Livingston

Garrard

Cumberland

Nicholas

Hancock

Kenton

Anderson

Trimble Carroll

Woodford

Campbell

Jessamine

Montgomery

Gallatin

Robertson

Fulton

0

1

2 - 5

6 - 22

23 - 633

Count

gile 52*

s 347

nd Center) 199

13

6**

on-medically fragile) 357

128

12

1,114

y fragile children began services

012, and are not included in

 pages 18 and 19.

(75) children with autism were 

he project period, however, they 

one of the other priority populations.
20 | Open Arms Children’s Health Dental Service 

Findings: Description of Clinical Encounters

The three charts below portray information from July 1, 2012 through 

March 31, 2014.

Of the 2,670 appointments scheduled, 16.9% were missed. The rate of missed 

appointments remained fairly consistent across the time period, and is lower 

(better) than the rates experienced by other dental clinics that serve people who 

have Medicaid or are medically indigent. For example, data were obtained from the 

Family Health Centers* regarding their missed appointment rates for dental services 

among patients age 18 and under. Within a recent 5 month period (12-1-2013 to 

4-29-2014), their missed appointment rate was 38.5%. (Note: More than 25% of 

the Open Arms patients live, at least temporarily, on the HOTI campus and have staff 

assistance in keeping their appointments). 

The chart in the lower left corner differentiates between preventative and restorative 

encounters. One-quarter of the office visits involved a restorative service. Restorative 

dentistry is concerned with the restoration of existing teeth that are defective because 

of disease, trauma, or abnormal development to normal function, health, and 

appearance; it includes fillings, crowns and bridgework. The majority of the visits 

(74%) are devoted to preventive work, including cleanings, exams and x-rays.

The dentists and staff of Open Arms Dental Service work closely with each child to 

make the experience in the dental office as positive and supportive as possible. To 

accomplish this, they use a variety of behavioral aids. The frequency of use varies: 

from the television, positioned above the child’s head, which is used for most 

patients to the desensitization pre-visit which is used for children with autism or 

other children with high levels of anxiety about the dental experience. Also available 

at Open Arms is a lift for children who are unable to move to the dental chair 

without assistance.

Open Arms Dental Service, Courtesy of 

Home of the Innocents, Louisville, KY

* Family Health Centers, Inc. is a not-for-profit community 

health center that provides a variety of health care services 

regardless of a person’s health insurance status or ability to 

pay for services. Family Health Centers serve more than 

42,000 patients annually through seven sites throughout 

Louisville Metro. The payer mix among the dental patients 

in the 5-month period was: 47% Medicaid, 41% indigent, 

and 11% commercial insurance. 

Appointments Kept and Appointments Missed

Appointments Kept Appointments Missed

July 1, 2012-March 31, 2014

(2,219) (451)

451

2219

0 500 1000 1500 2000

Preventive and Restorative Encounters

July 1, 2012-March 31, 2014

Restorative, 26%

Preventive, 74%

0% 25% 50% 75% 100%

Behavioral Aids Used

During Treatment

(Type by Number of Children)

Aids Count

Use of TV above Child's Head 1470

Bean Bag 180

Holding Hands 164

Holding Hands and Legs 134

Mouth Prop 138

Holding Head 82

Caregiver on Chair with Patient 61

Lap to Lap 50

Weighted Blanket 21

Desensitization Pre-Visit 17

Lift 5

Visual Aids 2
Evaluation Report May 2014 | 21

Difference in Patient Records and Implications for Continuity 

of Care 

(sample of staff notes before and after the opening of Open Arms Dental Service)

The photocopied pages presented here provide a compelling picture of the 

differences in the dental services before and after the opening of the Open Arms 

Dental Service. Both documents contain the medical notes of the treating dentist. 

Both documents reflect services to the same child. However, the level of detail and 

specificity of the content are dramatically different. The hand-written notes typically 

entailed one to two lines of data in handwritten form per visit. These visits occurred 

at the child’s bedside, with no ability to provide proper positioning, lighting, or 

medical equipment for a thorough examination. 

These brief notations present a stark contrast to the current documentation. 

Since its opening, the Open Arms Dental Service has used an electronic 

medical record. This format captures detailed information about medications, 

allergies, dental spacing, existence of crossbite or overbite, type of treatment, 

status of oral hygiene, and measures used to address behaviors or emotional 

needs. Rather than the one or two lines of information, the Open Arms 

progress notes for this child average a full page of detailed, easy-to-read 

information. Easy access to detailed information about the child’s recent 

history is particularly important for children with complex needs and for 

practitioners who are working in a teaching environment. 
22 | Open Arms Children’s Health Dental Service 

1,488 

patients who were served during this period 

Findings: Impact of Clinical Service

Treatment Acceptance

One of the indicators used to measure success is “treatment acceptance.” The 

evaluation of the Open Arms Dental Service includes data on treatment acceptance 

from the perspective of both the treating professional and the parent. The treating 

dentist makes a notation about the child’s acceptance of treatment at the end 

of every dental office visit and parents report their expectations for their child’s 

acceptance of treatment at the beginning of the appointment 

Both the dentist and the parent use the following “Treatment Acceptance Scale” (a 

validated scale taken from the literature). The scale allows for one of four scores, 

chosen on the basis of one of the following descriptions: 

1. Good Rapport with dentist, interest in dental procedures (++)

2. Cautious but willing to accept treatment (+)

3. Reluctant to accept treatment, uncooperative (-)

4. Refusal of treatment, fearful (--)

Treatment acceptance is 

measured through a 4-point, 

behaviorally anchored rating 

scale developed by Frankl, 

Shiere, & Frozels (1962) that 

has been widely used. The 

scale classifies children’s 

behavior into four groups 

according to their attitude 

and cooperation during 

dental procedures. The scale 

is reported to have good 

reliability (Baier, Milgrom, 

Russell, Mancl, & Yoshida, 

2004), including an interrater reliability index of 0.96 

(Machen & Johnson, 1974). 

Treatment Acceptance as Rated by Dentist

The analysis of treatment acceptance as perceived by the treating dentist involved 

extracting data from the Dentrix database on all patients who received a dental 

service between July 1, 2012 and March 31, 2014. There were a total of 

and who had at least one notation of 

treatment acceptance by the attending dentist. Evaluators looked at the overall level 

of treatment acceptance as determined by the treating professional at the end of the 

visit and at the change in mean scores over time. Of the 1,488 patients with a “Time 

1”* score, there were 860 patients with a “Time 2” score, 486 patients with a “Time 

3” score, and 279 patients with a “Time 4” score. The limited period of the analysis 

(nine months) and the ongoing acceptance of new patients are reasons for the much 

higher number of patients with only one visit during the time frame. 

The chart below depicts the mean scores of patients, as recorded by the dentist, at 

the initial and subsequent visits. There was a significant difference in a favorable 

direction (at the .05 level) for patients between Time 1 and all subsequent time 

periods. See Appendix A, pages 44-48, for additional analysis.

1.3 (1,488 patients)

1.24 (860 patients)

1.2 (486 patients)

1.22 (279 patients)

1 2 3 4

T1

T2

T3

T4

Mean Treatment Acceptance Score 

As scored by the dentist on a

4 point scale with 1 being the

best (good rapport and interested

in dental procedure) and 4 being

the worst (refusal of treatment, 

fearful).

Good Rapport Cautious, but willing

to accept treatment

Reluctant to accept

treatment, uncooperative

Refusal/Fearful

* Time 1 is the first time the child was in the Open Arms Children’s Health Center for dental care 

after July 1, 2012, the date on which data collection began.
Evaluation Report May 2014 | 23

The chart below portrays the dentist’s perceptions of the child’s acceptance of 

treatment within the four categories. Regardless of whether this was the first office 

visit in the time period or the fourth, at least 90% of the children were deemed to 

be cooperative and willing to accept treatment. For the children with at least four 

dental visits at Open Arms, the scores were even higher, with 96% of the patients 

demonstrating an acceptance of treatment.

A second analysis looked at the 

difference in the acceptance scores 

among the various priority populations. 

The following chart depicts the mean 

Treatment Acceptance scores for “Time 

1”. The first two priority populations 

(CKC and Other Agencies) relate 

primarily to children and youth who are 

dependent, abused or neglected and in 

out-of home care (crisis and longer term). 

The second group of priority populations 

(Medically Fragile, Outpatient, Impact 

Plus and CKC Autism) are predominantly 

patients who seek care at Open Arms 

because of a special health care need 

(behavioral or medical). The third group 

includes patients who are relatively 

new to the United States, most of these 

patients entered the United States as 

refugees from war-torn countries where 

dental care was limited or not available. 

There was a greater reluctance to accept 

treatment and more fear of treatment 

among children with extraordinary 

medical, behavioral, social or emotional 

needs. While the number of patients is 

low (10), the highest (worse) treatment 

acceptance scores were noted for children 

with autism who were in crisis or outof-home care. The most favorable scores 

were noted for children and youth 

who were in the care of the Home of 

the Innocents or other child-caring 

agency for reasons of abuse, neglect or 

abandonment/dependence.

Treatment Acceptance: Percent of Patients

by Category of Acceptance

1. Good rapport with dentist, interested in dental procedures

2. Cautious, but willing to accept treatment

3. Reluctant to accept treatment, uncooperative

4. Refusal of treatment, fearful

79% 82% 87% 82%

13% 12% 8%

14%

7% 5% 4% 3%

0% 1% 1% 1% 1%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

T1

(N=1,488)

T2

(N=860)

T3

(N=486)

T4

(N=279)

See Appendix A, pp. 44-48 for statistical tests on these data.

Population Count Mean Score

Childkind Center 249 1.12

Other Agencies 433 1.14

Medically Fragile 134 1.60

Impact Plus 18 1.39

CKC - Autism 10 2.10

Outpatient 495 1.41

Refugee 136 1.32

Unknown 13 1.62

Total 1488 .

Priority Population

1.30

There was a statistically significant difference between Autism and all other populations. 

See Appendix A, pp. 44-48 for details.

Two Groups: CKC and 

‘Other Agencies’ have 

lower (better) scores.
24 | Open Arms Children’s Health Dental Service 

Expectations of Treatment Acceptance as Rated by Parent

The treatment acceptance measure is a component of the Parental-Caregiver 

Perceptions Questionnaire (P-CPQ). The P-CPQ was originally developed by 

Jokovic et al (2003) as one part of a larger Oral Health Related Quality of Life 

measure (OHRQoL), and was later adapted by Nelson (2007) to include fewer 

items and incorporate the Family Impact Scale also contained in the original 

OHRQoL measure. 

The specific wording, as found in the questionnaire, is as follows: 

•	 My expectations for my child’s acceptance of treatment during this visit can

best be described as: (select only one option)

•	 Good rapport with the dentist; interested in the dental procedures, laughing

and enjoying the situation.

•	 Acceptance of treatment; at times cautious, willingness to comply with

the dentist, at times with reservation, but follows the dentist’s directions 

cooperatively.

•	 Reluctant to accept treatment, uncooperative, some evidence of negative

attitude but not pronounced, i.e./sullen, withdrawn.

•	 Refusal of treatment, crying forcefully, fearful or any other overt evidence of

extreme negativism.

Parents/Caregivers complete the P-CPQ at the 

first appointment in the dental clinic and every 

6 months thereafter. Within the time frame of 

this report, 216 parent scores could be matched 

with dentist scores (same child/same visit).1 The 

chart to the left contains parental expectations of 

their child’s emotional/behavioral response to the 

dental office visit. 

In comparing the scores of the parents with 

the scores of the dentists, parents anticipated 

more resistance than dentists experienced 

in dental visits associated with 109 children 

(50.5%); dentists experienced less acceptance 

than anticipated by the parents in 21 instances 

(9.7%); and the expectations of the parents and 

the experience of the dentist was the same in the 

dental visits associated with 86 children (39.8%). 

Among dentists and parents, the majority of 

the scores reflected an adequate to good level of 

acceptance.

1 Because of the detail and the intimacy of the knowledge 

required in responding to the questions in the P-CPQ, it 

is typically completed by a custodial parent. Therefore, for 

the large number of children in out-of-home care who are 

served by Open Arms, a Parent-CPQ is not completed.

Parental Expectations of Child's Treatment Acceptance

Parental Perceptions on their initial completion of the PCPQ 

1.) Good rapport with

dentist, interested in

dental procedures.

2.) Cautious, but

willing to accept

treatment.

3.) Reluctant to

accept treatment,

uncooperative.

4.) Refusal of

treatment fearful.

Chart only includes parent scores that could be matched to dentist score.

103

74

17 22

0

20

40

60

80

100

TOTAL CHILDREN: 216

21 Children

109 Children

86 Children 

DENTIST EXPERIENCE WORSE

PARENT EXPECTATION WORSE

PARENT & DENTAL SCORE SAME

Comparison of Treatment Acceptance Scores

39.8%

50.5%

9.7%

TOTAL CHILDREN: 216
Evaluation Report May 2014 | 25

Status of Oral Health and Hygiene (Plaque, Calculus, Oral Hygiene)

Oral Health Measures

Embedded in the notes of the Dentrix records is the dentist’s assessment of three 

oral health measures: the presence of plaque, the presence of calculus, and the overall 

state of the patient’s oral hygiene. These measures, transferred to an Excel data base 

by staff at Open Arms Health Service, provided the basis of the following analyses.

Measures for one point in time were available for 711 children; two measures 

(Time 1 and Time 2) were available for 110 children; and, three measures (Time 2 

and Time 3) were available for 35 children. The analysis considered changes over 

time for all children with two or more measures; and included an analysis of any 

differences between priority populations. The priority populations were: children 

in out-of-home care through HOTI’s Childkind Center (CKC), children in out-ofhome care through Other Agencies, Medically Fragile children though outpatient 

referrals and HOTI’s KCPCC, children in the IMPACT Plus program, children in 

HOTI’s CKC with Autism, Outpatient referrals of non-medically fragile children 

from the community, and Refugees.

Measurement was calculated on a scale of 0 to 3 (0 = no problem, 1 = light/

excellent, 2 = average, 3 heavy/poor).

Upon analyzing the data by priority population, evaluators found that dental 

problems were more common in four (4) of the eight groups of children than in the 

other four groups. The four groups with more problems were children classified as: 

Medically Fragile, Refugee, Other Agency, and ChildKind Center (crisis residential). 

There were no significant differences between the scores of the other four groups 

(Impact Plus, CKC-Autism, Outpatient/Non-Medically Fragile, and Unknown). 

These four groups are depicted on the bar labeled “All Other”.

•	 On the scale of zero to three, the means of the

four groups with more dental problems are: 1.35 

for Medically Fragile, 1.32 for Refugees, 1.26 for 

Other Agencies, and 1.24 for ChildKind Center. 

•	 The other four groups (All Others) have

substantially lower scores, so the graph shows 

them collectively, with a mean score of 1.04. 

•	 A t-test between the two groups of four (the

four shown individually and the four shown 

collectively) indicates that the difference is one 

of nearly nine standard deviations (sig. .000, 

t=8.794).

See Appendix A, pages 44-48, for statistical analysis.

1.04

1.24

1.26

1.32

1.35

0 0.5 1 1.5

Oral Health Measures by Priority Population

Medically Fragile

Refugee

Other Agencies

Child Kind

All Other

Impact Plus, CKC-Autism,

Outpatient (non-medically

fragile), Unknown
26 | Open Arms Children’s Health Dental Service 

In analyzing change over time, there was very little difference in the assessments 

between Time 1 and Time 2. Greater differences are found between Time 2 and 

Time 3; among children who have had more exposure to the Open Arms Dental 

Service. The chart below depicts the degree of change among children, between 

Time 2 and Time 3, on the three measures for Plaque, Calculus, and Oral Hygiene. 

The only group for which the change was significant at the .05 level was Refugees. 

The chart below portrays the degree of change among Refugees and All Other 

Groups.

Measurement was calculated on a scale of 0 to 3 (0 = no problem, 1 = light/

excellent, 2 = average, 3 heavy/poor).

Oral Health Values

T2 T3 Change t p-value d

Refugee (n=52) 1.35 1.08 -.269 -2.707 .009 .375

1.19 1.18 -.008 -.321 .749 .013

Note: Cohen’s d calculation: t-value / (√n). A d value between 0 to 0.3 is a small effect size, 0.3 to 0.6 is a 

moderate effect size, and greater than 0.6 is a large effect size. 

All Other Groups (n=630)

T-Test

See Appendix A, pages 44-48, for additional analysis.
Evaluation Report May 2014 | 27

Oral Health Quality of Life: Overall Concerns and Impact on Child 

and Parent

Findings from the P-CPQ

The evaluation design included a semi-annual assessment by the parent of their 

child’s oral health and their perceptions of the impact of their child’s oral health 

on the child’s and the family’s well-being. The Parental-Caregiver Perceptions 

Questionnaire (P-CPQ) was used for this purpose. The P-CPQ was originally 

developed by Jokovic et al (2003) as one part of a larger Oral Health Related 

Quality of Life measure (OHRQoL), and was later adapted by Nelson (2007) to 

include fewer items and incorporate the Family Impact Scale also contained in the 

original OHRQoL measure. The questionnaire contains questions in the following 

domains: 1. Oral Symptoms; 2. Functional Limitations; 3. Emotional Difficulties; 

and 4. Family Impact.2 (See page 12 for psychometric performance of instruments). 

Because the Parental-Caregiver Perception Questionnaire demands intimate/extensive 

knowledge of the child’s oral health, and because the majority of the children served 

by Open Arms Dental Service do not reside with their parents, data from the P-CPQ 

is only available on a limited number of the children served (305 of 1,488 during 

the 21-month time period). The chart on the next page contains the results of the first 

P-CPQ, on or after July 1, 2012 (when data collection related to the study began). 

The value of the findings is further limited 

by the absence of more than one measure 

on most children. The study period 

encompassed by this report is twenty-one 

(21) months; and six-month follow up 

questionnaires were available for only 37 

children. There was very little change in the 

Time 1 and Time 2 scores, with no more 

than a 1 point change on any item (on a 5 

point scale: 0 = never and 4 = everyday). 

Items with a slight change for the better 

are noted in green on the chart to the right; 

items with a slight change for the worse are 

noted in a gradient from orange to red. The 

degree of the change is also noted.

The P-CPQ included two global measures: 

1.) How would you rate the health of your child’s teeth, lips, jaws and mouth? 

2.) How much is your child’s overall wellbeing affected by the condition of his/her 

teeth, lips, jaws or mouth?

For the thirty-seven (37) children on whom Time 1 and Time 2 measures are 

available, parents noted an improvement in the impact of their child’s oral health on 

his/her well-being. Other areas of significant change in a favorable direction were 

related to how often their child had experienced tooth pain, and how often their 

child had been irritable or frustrated as a result of problems with their teeth/mouth/

lips.

2

A fifth domain related to the parent’s expectations for their child’s acceptance of treatment was added to 

the P-CPQ for this study. This element is discussed on page 23.

QUESTION: During the last 3 months... PRE POST DIFF

OVERALL WELLBEING AFFECTED 2.52 1.88 -0.6

how often has your child had pain in the teeth, lips, jaws or 

mouth? 1.57 1.27 -0.3

because of his/her teeth, lips, mouth, or jaws, how often 

has your child been irritable or frustrated? 1.57 1.27 -0.3

because of his/her teeth, lips, mouth, or jaws, how often 

have you or another family member felt guilty? 1 1.26 0.3

because of his/her teeth, lips, mouth, or jaws, how often 

has your child had trouble sleeping? 1.39 1.67 0.3

because of his/her teeth, lips, mouth, or jaws, how often 

has your child taken longer than others to eat a meal? 1.11 1.56 0.4
28 | Open Arms Children’s Health Dental Service 

Results of the Parental Caregiver Perceptions Survey

Symptoms, limitations and difficulties in the last three months...

July 1, 2012-March 31, 2014

N=305

D����� I: Oral Symptoms

Pain in teeth, lips, jaws, or mouth?

Bleeding gums?

Sores in mouth?

Bad breath?

Food stuck in the roof of the mouth?

Food caught in or between the teeth?

Difficulty biting or chewing food?

D����� II: Functional Limitations

Breathed through the mouth?

Had trouble sleeping

Had difficulty saying any words?

Taken longer than others to eat a meal?

Had difficulty drinking/eating hot/cold foods?

Had difficulty eating foods he/she likes to eat?

Had diet restricted to certain types of food?

D����� III: Emotional Difficulties

Upset?

Irritable and frustrated?

Anxious of fearful?

D����� IV: Family Impact

Been upset?

Had sleep disrupted?

Felt guilty?

Taken time off work?

Had less time for yourself or the family?

Worried that your child will have fewer life opportunities?

Felt uncomfortable in public places with your child?

1 2 3 4 5

Never Once Sometimes Often Everyday

or Twice

 

1.79

2.1

1.43

1.37

2.06

1.67

2.1

1.74

2.45

1.76

1.97

1.71

1.58

1.46

1.25

1.74

1.7

1.8

1.71

1.38

1.47

1.47

1.39

1.28

1.32

1.44

1.3

1.78
Evaluation Report May 2014 | 29

Themes from the Focus Groups

To understand the impact of the Open Arms Dental Service beyond the 

quantitative data, evaluators conducted a series of interviews and focus 

groups. Through these efforts, findings from the surveys and the medical 

records were augmented with (1) the perspectives of several youth in residential 

treatment and the staff of that program and (2) the perspectives of staff at the Kosair 

Charities Pediatric Convalescent Center. Following the section entitled “Perspective 

of Staff and Youth in Residential Treatment Services” and the section entitled, 

“Perspective of Staff at KCPCC” is a brief sampling of the stories of the experiences 

of children and families 

Perspective of Staff and Youth in Residential Treatment Services

The Home of the Innocents is the state’s largest emergency placement center. It is 

staffed 24 hours a day and offers a safe place for children who have been removed 

from their homes because of abuse, abandonment or neglect. HOTI serves children 

and youth from infancy to age 18, through a variety of residential settings (on 

campus residential homes, therapeutic foster care homes, and relatives’ homes 

through kinship care). In these settings, children benefit from individual treatment 

plans that include the use of the latest one-on-one therapies. 

To better understand the impact of the Open Arms Dental Service on children 

and youth who have come to HOTI for reasons of abuse and neglect, evaluators 

conducted a focus group of residential services staff and youth. Two staff and three 

residents participated in the focus group discussion, held on March 28, 2014.

Themes from the focus group dealt with the attitude and responsiveness of staff, the 

accessibility of the service, and the attractiveness of the facility and the quality of its 

supporting equipment. Overwhelming, the comments addressed the quality of the 

interactions between staff and patients.

Attitude and Responsiveness of Open Arms Staff

The Open Arms Dental Service is in a beautiful new building and it has state-ofthe-art equipment. While those things are important, what focus group participants 

wanted to talk about most was Dr. Brent and the Open Arms staff. Below is a 

summary of their comments: 

•	 One	resident	had	experienced	quite	a	bit	of	dental	work	due	to	his	need	to	have	

teeth fixed after damage from fights. He repeatedly described the office, the 

experience, the dentist and the staff as “chill” and “very relaxed.” He felt that 

his prior dental experiences were not as “chill”, and his previous dentist was not 

as accommodating as Dr. Brent. Dr. Brent always “explains in detail” what he 

is about to do. Dr. Brent provided this resident with special toothpaste that has 

greatly helped with his issues, and told him to “stop fighting and stop drinking 

Monsters (energy drinks).”

•	 Discussing	Dr.	Brent,	another	resident	(youth)	stated	that	after	their	first	

meeting, he felt as though “he had known him for months.” Residents agreed 

that Dr. Brent includes his patients in their own care, and truly works to make the 

experience a collaboration. He “has a conversation with you”, one resident noted. 

He is “just so nice about everything.” 

Open Arms Dental Service, Courtesy of 

Home of the Innocents, Louisville, KY

“My old dentist was rough. 

Dr. B is gentle and makes 

sure you’re okay. He does 

everything in his power to 

make sure you’re comfortable. 

He never tries to trick you. 

He’s for real on his word.” 

—Adolescent in HOTI 

Residential Treatment 

Services
30 | Open Arms Children’s Health Dental Service 

•	 It was also noted that the staff are “not judgmental”, that they “treat everyone

with respect,” and that they “know how to work with kids.” 

•	 All participants in the focus group wanted to be sure that the Open Arms dentists

and staff “keep the personal going.” Participants acknowledged that current 

staff are great at knowing the personalities and preferences of each client. One 

participant commented, “Building a relationship [with Dr. Brent and the staff] 

makes you want to go back.” Another described their mutual respect, and said 

that Dr. Brent is “everything a dentist should be.” 

Accessibility of Service

•	 Staff described the Open Arms Dental Service and the setup as “very accessible,”

and noted that residents no longer miss appointments because access is so 

convenient. Staff felt that they can very easily communicate any questions or 

concerns they have about a resident’s dental health. One staff member described 

the dental office as “super comfortable.” 

•	 Staff noted that prior to the Open Arms Dental Service, a dentist came to HOTI

for assessments, but only once or twice a week. Often, issues were not addressed 

for a week. In severe cases, residents had to be sent out to be seen. In the words 

of one staff member, the current setup is “just very convenient.” 

Attractiveness of Facility/Quality of Equipment

•	 All three residents felt that watching movies while in the chair receiving care

helps them to relax. (Though one requested a better variety.) They did emphasize, 

however, that their extremely positive feelings about the dental service were 

based upon their experience with Dr. Brent and the staff, rather than the physical 

setting. One noted that “The dental clinic would be just another dentist without 

these people.”

•	 Residents also agreed with the comment that “other dentists’ offices look scary

and depressing, but the HOTI clinic is happy.” They noted the bright blue and 

orange, and felt that the colors “lighten up the mood.”

All participants stated that they would absolutely recommend the Open Arms Dental 

Service to family or friends. 
Evaluation Report May 2014 | 31

Perspective of Staff at Kosair Charities Pediatric 

Convalescent Center

Interviews with Staff of Kosair Charities Pediatric Convalescent Center 

(KCPCC)

The Kosair Charities Pediatric Convalescent Center (KCPCC) is a home away from 

home for medically fragile children, age birth to 21. KCPCC provides short-term, 

long-term and respite care for up to 76 children with severe developmental and/or 

physical disabilities, as well as ventilator dependency. 

Each child receives individualized care from an experienced team of doctors, nurses 

and therapists. In addition to a highly skilled medical team, KCPCC provides 

around the clock staffing. Children at KCPCC typically have multiple medical and 

developmental conditions that make their care extremely difficult for parents to 

manage. The treating professionals, caregivers, and support staff make it possible to 

respond to the complexity, intensity and diversity of the needs of each child.

While parents have turned to the HOTI for support with the daily care of their 

children, families play a vital role in the continuing development of their children. 

From an open visitation policy to total involvement in the child’s treatment program, 

KCPCC becomes an extended part of each child’s family.

Because of their day-to-day contact with children in the KCPCC, evaluators 

scheduled a series of interviews with KCPCC staff. The purpose of the interviews 

was to gather staff perceptions of the impact of the Open Arms’ Dental Service on 

the well-being of the children in their care. 

Five staff were interviewed: the Director of Clinical Services, the Medical Social 

Services Coordinator, two Licensed Practical Nurses (LPNs) and one Certified Nurse 

Assistant (CNA). Tenure with KCPCC among those interviewed ranged from three 

to twenty years. Comments from KCPCC’s Medical Director were provided through 

the Director of Clinical Services.

Themes from the interviews focused on quality of oral health services, quality of life 

as it relates to oral health, treatment acceptance and patient convenience, efficient use 

of staff time, and expanded reach to previously un-served patients. 

Quality of Services

All staff mentioned the dramatic difference in the dental services provided prior 

to the opening of the Open Arms Dental Service and those that are available now. 

Previously, the service consisted of a resident from the University of Louisville 

School of Dentistry making a bedside visit to children at KCPCC. It was typically 

a brief visit, involving limited cleaning, a fluoride treatment, and an assessment of 

restorative needs. Because there was no dental office, the service was delivered in the 

child’s bedroom and without any special equipment. Staff identified a number of 

difficulties associated with delivering a quality service in this manner:

•	 Without a dental chair or other physical aides for support, it was difficult to

position the child in a way that made a full examination possible.

Open Arms Dental Service, 

Courtesy of Home of the 

Innocents, Louisville, KY
32 | Open Arms Children’s Health Dental Service 

•	 Special lighting and examination equipment were not available for use by the

resident/dentist.

•	 The service was provided by a resident who was at the KCPCC on a rotation

associated with his/her degree. Because of the transience of a two-year student 

and the rotation involved in residency experiences, children rarely saw the same 

dentist twice.

•	 When restorative treatment was needed, a referral was made to the University of

Louisville School of Dentistry. Within this setting and with this medically fragile/

developmentally disabled population; services were often performed with the 

patient under anesthesia.

In contrast, the Open Arms Dental Service provides:

•	 A collaborative partnership between the University of Louisville pediatric resident

program and the HOTI dentists and staff who work along with students and 

residents to bring a higher level of expertise to the care management of these 

children.

•	 A fully equipped office setting with excellent positioning equipment, lighting,

and medical instruments that makes both a thorough examination and restorative 

treatment (without the need for hospitalization or anesthesia) possible.

•	 A full-time dentist, employed by HOTI, and a dental staff who can provide

consistent treatment to patients over time.

Children now receive a full cleaning and preventive exam on a regular basis (at least 

every 6 months). An individualized, dental/oral health plan has been developed for 

each child at KCPCC. Direct care staff are participating in video training to enhance 

their knowledge and skills in implementing the techniques prescribed in the plans.

Oral Health Quality of Life

All staff commented on the improved conditions of the children’s oral health, 

including teeth, gums, and breath. The staff nurses noted that, since the opening 

of Open Arms, it was rare to see children with plaque buildup. The Medical Social 

Services Coordinator and the Director of Clinical Services also emphasized the link 

between good oral health and good overall health; and they readily acknowledged 

how important this new service has been to the medically fragile population within 

the KCPCC. One nurse offered a specific example of a child who was experiencing 

bleeding gums and extensive tooth pain. Since receiving care at the Open Arms 

Dental Service, his situation has greatly improved. The child is much more 

comfortable and much more accepting of staff efforts to provide daily preventive 

care. Paraphrasing the comment of one nurse: when a child isn’t in pain, it’s much 

easier to brush their teeth; and their breath smells better. A second case example 

was mentioned by the Director of Clinical Services. This child had stopped eating 

abruptly. He was given an appointment the next morning and his issues were 

resolved. 

Treatment Acceptance and Client Convenience

Staff commented on several factors that make the experience at the Open Arms 

Dental Service more accommodating and less frightening for the children. These 

included:
Evaluation Report May 2014 | 33

•	 Because of the consistency of staff within the Dental Service, children have

a chance to get comfortable with the dentist, the dental staff, and the service 

environment. This familiarity reduces anxiety.

•	 Because of the proximity of the service to KCPCC and the ease of scheduling,

children no longer have to be transported off the grounds and wait in off-site 

clinics. They can simply be taken in their wheel chair across the parking lot to 

Open Arms. This proximity also encourages visits prior to appointments to 

become more comfortable with the surroundings and the staff.

•	 Prior to Open Arms, children received the dental service from a resident who was

unknown to the child and, likely, had limited experience in working with children 

with such complex medical needs. This set the stage for an anxious child and an 

anxious treatment professional. Adding to the negative experience for the child 

was the fact that the service took place in the child’s bedroom; detracting from 

the child’s confidence that his room is his “safe place”. 

Efficient Use of Staff Time

The convenience of the clinic has contributed to staff efficiency. Examples include:

•	 Transporting a child to the Open Arms Dental Service requires one staff member

who can transport the child in the child’s own wheel chair. In contrast, taking 

a child off campus to a clinic at the University of Louisville or other setting, 

demands both a nurse and a respiratory therapist and the transfer of the child 

and the child’s equipment in and out of a van. 

•	 Scheduling is handled by a staff member who knows the KCPCC children and

their daily routines. She is able to schedule around activities that are important 

to the child; and she is able to schedule, or reschedule, an appointment without 

delay.

•	 With improved oral health, and with fewer infections and less pain resulting

from tooth decay or diseased gums, staff are able to respond to the child’s daily 

needs for personal care in ways that are more comfortable to the child and more 

efficient for the staff. 

Expanded Reach to Other Children with Complex Medical Needs

•	 The KCPCC serves 74 children; many of whom reside at KCPCC for years. In

addition, there is a population of children who reside with their parents, and who 

come to KCPCC for temporary care during a period of respite for their parents. 

Because of the growing reputation of the Open Arms Dental Service, parents 

are beginning to request that their child receive dental care through Open Arms. 

This can be done during the period of respite or once the child returns home.

•	 Word is getting out, through both official marketing and word-of-mouth among

parents groups, about the extraordinary service that is now available through 

Open Arms. Not surprisingly, families of children with complex medical needs 

across Kentucky are beginning to take advantage of this new resource.

The final question asked the staff to evaluate the dental service before the opening of 

Open Arms and the dental service that Open Arms now provides. They were asked 

to rate the “before” and “after” on a scale of 1-5, with 1 being “poor” and 5 being 

“excellent”. Average “before” score was 1.4; average “after” score was 4.9. 

“Oral care is remarkably 

different. Reports now 

state ‘continued good 

oral care’.”

—Director of Clinical 

Services
34 | Open Arms Children’s Health Dental Service 

Findings: Impact of Rotation on Dental Students at Open Arms

Eighty fourth-year dental students received part of their clinical 

training at the Open Arms Dental Service. The goal, as set forth 

in the grant, was achieved.

Fourth-Year Dental Students: Pre/post Measures

Prior to the beginning of their fourth year of dental school, dental students in 

the Class of 2013 and the Class of 2014 took the pre-survey. The surveys were 

distributed during an initial orientation meeting, with a request that all students 

who were willing respond to the questions. The vast majority of the students 

completed the survey (147 of 160). Responses (pre-test) to selected questions 

pertaining to their comfort level and willingness to care for special needs children 

are provided below.

Pre-test Responses (N=147)

Percentage of students who responded “very well” or 

“well” to the question, “How well has your dental school 

education prepared you for serving children with special 

health care needs?”

33%

42%

29%

0% 10% 20% 30% 40% 50%

Percentage of students who responded “strongly agree” or 

“agree” to the statement, “I am willing to treat children with 

special health care needs.”

70%

83%

90%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Children who are medically fragile, children with complex medical needs, and children with severe physical anomalies.

Children with intellectual, behavioral, or emotional disabilities, including children with autism spectrum disorders.

Children in foster care.

Percentage of students who responded “very much so” or “somewhat” 

to the question, “To what extent has your dental education increased 

your awareness that oral healthcare for individuals with special 

needs requires specialized knowledge, increased awareness and 

attention, adaptation and accommodative measures?”

92%

When contacted to serve a child with special health care needs (as noted below), my intentions are to:

Refer out Complete Exam & treat

immediately Initial Exam, as necessary

80 71

58

60

40

16

20

0

then refer out

Children who are medically fragile, 

children with complex medical needs, 

and children with severe physical 

anomalies.

60

50 46 

38 40

30

20

10 2 

0

Refer out Complete Exam & treat

immediately Initial Exam, as necessary

then refer out

Children with intellectual, behavioral,

or emotional disabilities, including 

children with autism spectrum disorders.

Refer out Complete Exam & treat

immediately Initial Exam, as necessary

then refer out

140 127

120

100

80

60

40

17

20 1

0

Children in foster care.
Evaluation Report May 2014 | 35

U of L Dental School Students and New Graduates from 

Other Dental Schools: A Comparison of Results

 

One of the evaluation questions addressed whether or not U of L dental students 

(who participated in professional training through the Open Arms Dental Service) 

expressed a greater willingness to treat children with special health care needs 

than new graduates from other dental schools. The post-test responses from the 

University of Louisville’s fourth-year students were compared with the responses of 

recent dental school graduates from other universities who were licensed to practice 

general dentistry in Kentucky.

In the fall of 2012 and again in the fall of 2013, the Kentucky Board of Medical 

Licensure was contacted with a request to provide an electronic copy of all dentists 

licensed to practice in Kentucky. The lists were sorted to identify those for whom 

the date of graduation was May 1, 2012 or later. Among the licensed dentists on the 

two lists, there were thirty-nine (39) non-U of L graduates who were newly licensed 

to practice general dentistry in Kentucky. Letters explaining the project and surveys 

were mailed to the thirty-nine (39) individuals, along with a five dollar bill ($5) as 

an advanced thank-you for participating. Fifteen (15) surveys were returned, for a 

return rate of 38%.

The fifteen (15) surveys from graduates of other universities were compared with 

the twenty-six (26) post-surveys from U of L dental students. (Only twenty-six (26) 

of the post-tests could be matched with the pre-tests. The majority of the responses 

were in a positive direction.) The U of L sample included students in their final 

semester: spring of 2014.

The charts on the following page depict the results.
36 | Open Arms Children’s Health Dental Service 

Comparison Results (U of L, N=26; Other, N=15)

Percentage of fourth-year U of L students and new graduates 

from other dental schools who responded “very well” or “well” 

to the question, “How well has your dental school education 

prepared you for serving children with special health care needs?”

Other, 33%

U of L, 38%

Other, 33%

U of L, 42%

Other, 47%

U of L, 65%

0% 20% 40% 60%

Percentage of fourth-year U of L students and new graduates from

other schools who responded “strongly agree” or “agree” to the 

statement, “I have confidence in my ability to treat children with

special health care needs.”

Other, 60%

U of L, 50%

Other, 60%

U of L, 62%

Other, 87%

U of L, 88%

0% 20% 40% 60% 80%

When contacted to serve a child with special health care needs, 

my intentions are to exam and treat as necessary:

100%

90% UofL

96% 80% UofLOther Other

85% 87% 87% 70%

60% Other

50% 60% 40% UofL

30% 46%

20%

10%

0%

Children who are medically fragile, children with complex 

medical needs, and children with severe physical anomalies.

Children with intellectual, behavioral, or emotional disabilities, 

including children with autism spectrum disorders.

Children in foster care.

While no conclusions can be drawn from this limited number, it appears that the 4th 

year dental students who have experienced the rotation (2 days in fall and 2 days in 

spring) at HOTI have a greater appreciation for the challenges of serving children 

who are medically fragile. Among these challenges is the time involved in preparing 

these children for the experience and in treating them, as it is time that may not be 

adequately reimbursed within many dental insurance program payment structures. 

While all were willing to complete an initial exam on children with these conditions, 

only 46% of the students expressed their intention to “treat as necessary”.
Evaluation Report May 2014 | 37

Pediatric Residents: Focus Group Summary

Evaluators conducted two focus groups, one at the end of the 2012 academic year 

and a second at the end of the 2013 academic year. The University of Louisville 

Pediatric Dentist Residency program is a two year program and graduates three 

pediatric dentists per year. During the year, each resident spends approximately 

20 days at HOTI’s Open Arms Dental Service. The summary below reflects the 

comments of six pediatric dentists in the classes of 2012 and 2013. As a result of the 

rotation at the Home of the Innocents, all residents indicated that their knowledge 

of behavior management techniques had increased and that their willingness to serve 

special needs populations in the future had increased. All but one resident who was 

“not sure”, indicated that their comfort level in dealing with the needs of patients 

had increased.

n What aspects of the residency experience at HOTI were most helpful?

When asked what aspects of the residency experience at HOTI were most helpful 

to them, there were a variety of responses. The response of one resident in the 

class of 2012 was very clear and succinct, noting that working with Drs. Bond and 

Acord was the most helpful aspect of the experience and that they are “excellent 

instructors”. Others responded to the question from the aspect of what they learned 

from the patients. They noted that their experience with patients who are medically 

fragile was extremely helpful in making them feel more confident in treating this 

population. 

One resident said that the reason he chose the program at the University of 

Louisville was because of the rotation with HOTI involving medically fragile 

children. He was pleased with his choice and said that the experience had given him 

enough exposure to medically fragile children to gain confidence in treating them.

Another resident said that the experience had helped him “stretch” his understanding

of who he could serve in an outpatient setting.

Residents indicated a better understanding of potential reactions of children with 

autism and a better understanding of how earlier trauma might affect how a child 

with a history of abuse might respond to touch and to oral care. 

Comments included: 

•	 “I	was	much	more	comfortable”	(having	had	this	experience);	

•	 “Before	(the	rotation	at	HOTI),	I	had	seen	them	as	so	fragile	that	I	could	hardly	

touch them.”; “Now I know that they are not going to ‘break’.”

•	 “I’m	feeling	more	comfortable	with	their	reaction.”	Residents	explained	that	they	

now understood that some children were going to express some resistance, but 

that it was okay.

n How (if at all) has the opening of the Open Arms Children’s Health Dental 

Service led to better dental care of the patients/clients of HOTI? (e.g. better 

equipment, more staff, more time with the patient, greater involvement of the 

caregiver, better access to other members of the treatment team). 

“Before (the rotation at 

HOTI), I had seen them 

as so fragile that I could 

hardly	touch	them.”;	

“Now I know that they 

are not going to ‘break’.”

—Graduating Pediatric 

Dentist Resident
38 | Open Arms Children’s Health Dental Service 

Residents noted their use of wheel chair lifts and bean bag supports as tools for 

making the experience more comfortable for the child. They also noted the difference 

the clinic is making in their ability to provide preventive and restorative care. Prior 

to the opening of the clinic, dental residents provided bed-side care. The new clinic, 

with its better positioning equipment and better lighting has made it easier to 

effectively and thoroughly deliver preventive care. 

They also commented on the benefit to children at the pediatric care center of 

having an accessible service. The accessibility of the clinic to children at the pediatric 

convalescent center also enabled them to see the benefit of having a child follow the 

schedule of recall appointments. 

Residents stated that the pace of the scheduled appointments enabled them to 

deliver the necessary services and provide adequate support without feeling rushed. 

Strategic access to other members of the treatment team was acknowledged in a 

discussion of a child with autism who was brought to the clinic by an aide on several 

occasions as a way of orienting the child to the setting and making the child feel 

more comfortable. These visits occurred prior to the actual dental procedure and 

were described as very helpful in gaining the cooperation of the patient. 

n How could the residency experience at HOTI could be improved?

The residents were generally very positive about their rotation at Open Arms. They 

said the experience was “beneficial”, “good”, and “reinforced my confidence and 

knowledge”. Residents expressed a clear preference for working with children with 

special needs (medically fragile, autistic) in the HOTI setting (rather than children 

without disabilities in the foster care system), as this was their best opportunity to 

work with these more challenging to serve populations. This point was stressed 

several times, with one resident explaining that, unless they were seeing a child with 

special needs, then their time was better spent at the University of Louisville clinic. 

Rotation of the residents to the HOTI setting only occurs one to two times per 

week when other commitments at the University of Louisville does not take priority. 

Scheduling is based upon the request of the caregivers to provide better access and 

convenience for their child’s dental care and may not always match the days when 

residents are present.

If logistically possible, an effort should be made to schedule the residents on days 

in which children from KCPCC or other special needs children are to be seen. 

Otherwise, the relative value of the experience to them as students of pediatric 

dentistry will be compromised. 
Evaluation Report May 2014 | 39

Early Lessons Learned, Enhancements Underway, 

and Success Stories

The relationship between the Home of the Innocents and the 

University of Louisville School of Dentistry preceded the grant 

announcement. It consisted of consultation from Dr. Ann 

Greenwell, Program Director of the Pediatric Dentistry Division at the 

U of L and of bedside care provided by postdoctoral students in the 

Pediatric Dentistry Residency program. This prior relationship was 

strategic in defining the vision and mission of the service to be funded 

by the grant. The result was a teaching environment for U of L students 

that included children with a myriad of special needs and a resource 

to children throughout the community who had experienced barriers 

accessing needed services.

Lessons Learned and Enhancements Underway

•	 Fine-tuning of the working relationship is on-going. For exampl

a uniform process for orienting students to the rotation at HOTI 

was developed. Additionally, the relationship with the University 

of Louisville has evolved, with Dental School leadership seeing the 

value of the Open Arms Dental Service to both the oral health of 

patients and to the education of their students. The availability of 

a rotation at the Open Arms Dental Service has been used by the 

University in their recruitment of pediatric residents. 

•	 Several strategies for staffing the Open Arms Dental Service have been tried.

In the first iteration, the Dental Service was staffed by two part-time pediatric 

dentists. These individuals were on the U of L School of Dentistry’s faculty and 

they each maintained a private practice. Currently, the Dental Service is staffed 

by a full-time general dentist (Dr. Brent Hurst) and at least one day each week, 

University of Louisville Pediatric Dentistry faculty and residents. Having a fulltime dentist employed by HOTI along with additional staff from the university 

has meant that the work at the Open Arms Dental Service is the highest priority. 

It also has eliminated the potential for a conflict of interest that is present when 

an individual is both on staff with one service and is offering a similar service in 

a private practice environment. A full-time general dentist also had been a better 

“fit” for the extensive amount of restorative treatment that is needed within the 

foster care, adolescent and residential populations.

•	 While medically fragile children are receiving dramatically different care with the

opening of the Open Arms Dental Service than they did at their bedside, the 

condition of their teeth and oral cavity can deteriorate quickly. This is particularly 

true of children who use feeding tubes. Under the leadership of Dr. Brent Hurst 

and the directors of Open Arms Children’s Health and KCPCC, an enhanced 

regimen of oral hygiene is being supported within KCPCC. Training of direct 

care staff is given and electronic tooth brushes are provided. As a result, the daily 

care of teeth and gums has been made more comfortable for the child and easier 

for staff to perform.

With children who do not reside on the HOTI campus, Dr. Hurst uses part of his 

time with the patient to educate the parents or other caregivers about caring for 

the child’s teeth and gums. 

Open Arms Dental Service, Courtesy of 

Home of the Innocents, Louisville, KY

“This prior relationship 

[between the Home of 

the Innocents and the 

University of Louisville 

School of Dentistry] was 

strategic in defining the 

vision and mission of the 

service to be funded by 

the grant. The result was 

a teaching environment 

for U of L students that 

included children with 

a myriad of special needs 

and a resource to children 

throughout the community 

who had experienced 

barriers accessing needed 

services.”
40 | Open Arms Children’s Health Dental Service 

•	 While the Dental Service was designed to provide access to vulnerable and

underserved populations (medically fragile, behaviorally disordered, intellectually 

disabled, victims of abuse or neglect), the students, and particularly the pediatric 

residents, are most interested in gaining experience with children who are 

medically fragile or who have a mental or behavioral condition that requires 

particular sensitivity. To fulfill student expectations and to address the goal 

of making new dentists more comfortable in treating children with medical, 

intellectual, emotional disabilities, Jean O’Brien continues to work with the 

University on finding a schedule that is compatible with the Dental Service and 

other demands being placed on the students. 

•	 Additional emphasis may be needed on educating the students and pediatric

residents on the special needs of children in foster care and residential care. While 

the majority of these children have no obvious physical anomalies and most do 

not have a behavioral health diagnosis, they, nevertheless, are at risk for poor 

health outcomes and for being re-traumatized. Open Arms staff will make sure 

that the special needs of these youth are addressed in the orientation. Also, to 

the extent possible, elements of the training associated with Trauma-Informed 

Care will be incorporated into the orientation and education process. A related 

article in Pediatrics, the official journal of the American Academy of Pediatrics, 

acknowledges the value of having dentists who are familiar with issues of child 

abuse and neglect, in that physicians may not always pick up on the oral and 

dental aspects of child abuse and neglect.

In an effort to summarize the uniqueness of the Open Arms Dental Service in ways 

that many thousands of lines of data cannot, evaluators asked parents, youth, and 

staff what they considered to be the key ingredient that makes this service special. 

The response can be distilled down to two words: “patience” and “gentleness”. If 

a third word were to be added, it would be “relationship”. From the moment a 

patient walks through the door, into the bright, attractive waiting room, to the time 

they get up from the dental chair, administrative and clinical staff create a patientfriendly and family-friendly experience. Staff understand that every child is unique, 

and that, with patience and understanding, the child’s experience at Open Arms 

can be a positive one. With a scheduling pattern that doesn’t overload the waiting 

room, children and families typically encounter a calm and supportive environment. 

However, when a child is unusually active or expressive, staff take it in stride. They 

work to support the parent or caregiver in dealing with the child’s behavior and 

anxiety and they work to build a relationship with the child. From the receptionist to 

the dentist, staff at Open Arms get to know their patients. They learn what works, 

and what does not work, in providing a particular patient with the care that is 

needed. As a small example, this evaluation report began with Rebecca’s story. Staff 

became aware that Rebecca’s favorite color is red... and that Rebecca is happier if 

she is in the red dental chair. They make sure she gets that chair.

Also at Open Arms, the dentist focuses on one child at a time. While he has support 

staff, the model provides for more intensive time with the dentist and for private 

patient rooms. Unlike large practices where several patients might be in the same 

room, separated by partitions, and where the dentist checks the work of other staff, 

the experience at Open Arms allows for more direct contact between the dentist and 

the patient, and the building of a relationship. In the words of Dr. Hurst as he spoke 

about his patient interactions at Open Arms, “The quality of the relationship is very 

different”, and because of the time I have with the patient, “I’m always able to give 

the best quality care”.
Evaluation Report May 2014 | 41

The challenge to the Open Arms Dental Service in the future, now that the grant 

funds have ended, will be to manage this highly individualized, patient-centered 

service within a managed care, fee-for-service model. Values associated with being 

patient, and moving at the pace of the child, are inconsistent with a business 

model that rewards productivity and a high volume of billable units. This issue is 

particularly prominent in working with children with autism. While the proportion 

of children with autism spectrum disorders (ASD) is relatively small (less than 2% 

of American children and 5% of the Open Arms’ patients), the quality of their care 

depends on an approach that is responsive to their disorder. Possible solutions for 

offsetting the time it takes to address the oral health needs of a child with ASD and 

the difficulty of assuring adequate oral hygiene between dental visits include:

•	 Approval of a differential (higher) rate for children with a confirmed diagnosis of

ASD by the Department of Medicaid Services and the managed care companies 

that serve individuals with Medicaid.

•	 Use of the EPSDT option to cover an enhanced service for this population.

Currently, Kentucky’s Department of Medicaid Services, through EPSDT, 

provides for follow-up visits to the dentist every three (3) months; rather than the 

typical 6-month follow-up period, for children who are medically fragile. Because 

of the difficulty associated with assuring adequate oral hygiene among children 

with ASD, they would benefit from a similar health care benefit. 

Finally, to meet the challenge of sustainability, Open Arms’ staff will continue their 

outreach to the insurance companies, managed care organizations, and agencies that 

serve families. They also will continue their efforts to inform the larger community 

about Open Arms Children’s Health and the many services they deliver. This will 

be done through community-wide health fairs, dental screens at child and family 

friendly events, educational materials and scheduled meetings with advocacy groups. 

The Open Arms Dental Service is a unique and extremely valuable 

component of the service array. Through the support of the Foundation 

for a Healthy Kentucky, and its Kentucky Healthy Futures Initiative 

(KHFI)*, the Home of the Innocents was able to respond to the charge 

of “increasing the scale of a community-based solution that has evidence 

of real impact.” Now, with the community’s support, it is positioned to 

continue its role as a driver of innovative and compassionate care.

“The quality of the 

relationship is very 

different”, and because of 

the time I have with the 

patient, “I’m always able to 

give the best quality care.”

—Dr. Brent Hurst, DMD

*KHFI is funded by the Social Innovation Fund of the Corporation of National and Community Service.
42 | Open Arms Children’s Health Dental Service 

d

Open Arms Dental Service, Courtesy of 

Home of the Innocents, Louisville, KY

“Because of Open Arms, 

“I didn’t have to watch my 

child be wheeled off into 

surgery for a simple cleaning. 

It was a miracle.” 

—Mother of a patient 

served at Open Arms 

Children’s Health

Success Stories

A testimonial:

Agrateful parent described her experience with the Open Arms Dental Service in an email to the evaluator. She learned about the service in 

a training session and brought her two sons in for an appointment. She 

described her older son as “severely medically fragile;” and commented that 

her younger son had had a “horrible first dental visit” in another setting. That 

earlier experience involved her younger son being strapped into the chair and 

screaming, with seemingly little effort to calm him down.

Both her sons now receive their oral health care through Open Arms. In her 

words, “my special needs son is treated with great care and accommodated 

with what he needs to have his teeth care for properly. He cannot hold his 

head up or sit on his own. He requires frequent suctioning. Since attending 

Open Arms, he is more relaxed; and so am I.” 

She also described how different her younger son’s experience has been at 

Open Arms. She warned the staff and the Open Arms dentist of his horrible 

first visit to another dentist. She was relieved with their response, saying “no 

one looked at me like I had three heads, and they didn’t rush with cleaning his 

teeth. That helped my son feel more relaxed at his next visit.” 

As a busy, working mother, she also mentioned how helpful it is to be able to 

take both children to Open Arms. “The fact that I don’t have to take them to 

different pediatric dentists is very exciting for me. It helps my younger son 

understand how important dental care is for his special needs brother; that 

even though they are different, they both have to have good healthcare and 

dental hygiene.” 

When asked what she considered to be the best thing about having the dental 

service at Open Arms, she responded: “When my special son had what I 

thought was an emergency, they got me right in, so I didn’t have to take him 

to a hospital. Finally, when asked what Open Arms could do to make the 

experience even better, she said” I love the HOTI dental clinic! I believe they 

are doing a great job!”

—Parent and Advocate 
Evaluation Report May 2014 | 43

d

d

d

Other stories of success: 

Open Arms Children’s Health served a child with autism who once had an explosive behavior in the waiting room and destroyed some items. After the 

staff worked with the child and parent beforehand, the actual dental visit was very 

successful. The clinic later contacted the parent to be assured the child was doing 

well and to comfort them about any concerns over the items that were destroyed. The 

parent was very happy with the care their child received and was pleased to come back 

for their six-month visit. 

Achild, who was a refugee from Congo, was served by Open Arms Children’s Health. Their family had only been in the country a few weeks at the time of 

their visit. When seen in the medical area, the physician was so concerned that they 

sent the patient down the hallway immediately for evaluation in the dental area. 

The child was scheduled for surgery within a week and their extreme dental issues 

were addressed immediately. The remaining children in the family were also in 

similar need of dental care and were scheduled and treated right away. 

Alittle girl who was both deaf and blind and only nine years old was served by Open Arms Children’s Health. She suffered from chronic lung disease, 

seizures, and dysautonomia, a disease of the autonomic nervous system. She received 

dental care throughout her young life, but until recently a visit to the dentist for 

this child required a risky sedation procedure and a full day at the hospital. Routine 

dental care was anything but routine, and was one more fearful hospital visit for a 

fragile little girl. 

Fortunately, the child’s family discovered Open Arms Children’s Health, and their 

first experience at Open Arms was one of surprise and delight. They entered the 

dental office and the nine-year old was situated on a big, body-sized tie-dyed pillow 

which was fitted to the dental chair. As the dentist began his initial examination, 

the mother noticed that he began to reach for instruments. Shocked, she asked what 

he was doing, and the dentist calmly told her he was cleaning her teeth. This was 

the first time in nine years that a dentist had ever tried to clean her teeth without 

sedation. The little girl never fought the dentist, and never cried. The mother 

wondered, “Why had no other dentist ever even tried?” She was overwhelmed by the 

experience and told the staff that that day she was able to revel in a simple joy—a joy 

that most moms take for granted. She said, because of Open Arms, “I didn’t have to 

watch my child be wheeled off into surgery for a simple cleaning. It was a miracle.” 

Since that day, the little girl passed away but her mom was very thankful for this 

special moment in her life.
References

American Academy of Pediatric Dentistry (AAPD). (2008). 

Clinical Guidelines. Reference Manual, 31(6), 114-117.

Baens-Ferrer, C., Roseman, M. M., Dumas, H. M., Haley, S.M. 

(2005). Parental perceptions of oral quality of life for children 

with special needs: impact of oral rehabilitation under general 

anesthesia. Pediatric Dentistry, 27(2), 137-142.

Baier, K., Milgrom, P., Russell, S., Mancl, L., & Yoshida, 

T. (2004). Children’s fear and behavior in private pediatric 

dentistry practices. Pediatric Dentistry, 26(4), 316 - 321.

Brickhouse, T. H. (2007). Dentists and Special Needs Patients: 

Dental Education and Patient Acceptance. Presented to Strong 

Roots for Healthy Smiles Oral Health Summit, July 2007. 

Retrieved from: www.medhomeplus.org/Media/docs/Dental_

Summit_DrBrickhouse_SCHCN_Oral_Health_pres.ppt#1.

Childress, M. T. & Smith-Mello, M. (2007). Kentucky’s Oral 

Health Poses Challenges. Foresight, 50. Retrieved from: http://

www.kltprc.net/foresight/Chpt_94.htm

Cushing, B. & Brickhouse, T. (2007). General Dentists 

and Special Needs Patients: Dental Education and Patient 

Acceptance. A.D. Williams Fellowship Program. Virginia 

Commonwealth University, Richmond Virginia.

Fenton, S. J., Hood, H., Holder, M., May, P. B., & Mouradian, 

W. E. (2003). The American Academy of Developmental 

Medicine and Dentistry: Eliminating Health Disparities for 

Individuals with Mental Retardation and other Developmental 

Disabilities. Journal of Dental Education, 67(12), 1337-1344. 

Frankl, S.N., Shiere, F.R., Frozels, H.R. (1962). Should the 

parent remain with the child in the dental operatory? J Dent 

McPherson, M., Arango, P., Fox, H., Lauver, C., McManus, 

M., Newacheck, P., Perrin, J., Shonkoff, J., & Strickland, B. 

(1998). A new definition of children with special health care 

needs. Pediatrics, 102(1), 137-140. 

McNary, L. (2005) Kentucky’s Cavity: Parents Voice Concerns 

about Children’s Dental Care in Their Communities. Retrieved 

from Kentucky Youth Advocates: http://www.kyyouth.org/

Publications/05pub_DentalCareReport.pdf.pdf.

Nelson, K.E. (2007). Children with special health needs oral 

health quality of life survey. Unpublished master’s thesis, 

Virginia Commonwealth University, Richmond, Virginia.

Pew Center on the States (2010, February). The Cost of Delay: 

State Dental Policies Fail One in Five Children. Retrieved from 

the Pew Trusts: www.pewtrusts.org/uploadedFiles/Cost_of_

Delay_web.pdf

United States Department of Health and Human Services, 

Centers for Disease Control. (CDC) (2007, December). 

Summary Tables from the National Survey of Children with 

Special Health Care Needs, 2005-2006. Retrieved from 

National Center for Health Statistics Reports: www.cdc.gov/

nchs/products/browsepubs.htm

Kortenkamp, Katherine and Ehrle, Jennifer. 2002. “The WellBeing of Children Involved with the Child Welfare System: A 

National Overview.” The Urban Institute Series B, No. B-43.

Robin Chernoff, Robin, Combs-Orme, Terri, Risley-Curtiss, 

Christina, Heisler, Alice, 1994. “Assessing the Health Status of 

Children Entering Foster Care.” Pediatrics Vol. 93 No. 4. Pp. 

594-601.

Kellogg, Nancy 2005. “Oral and Dental Aspects of Child 

Abuse and Neglect” Pediatrics, Vol. 116, No. 6 pp 1565-1568

Child, 29, 150-163.

Jokovic, A., Locker, D., Stephens, M., Kenny D., Tompson, B., 

& Guyatt, G. (2003). Measuring parental perceptions of child 

oral health-related quality of life. J Public Health Dent, 63(2): 

67-72.

Jokovic, A., Locker, D., Thompson, B., & Guyatt, G. (2004). 

Questionnaire for measuring oral health-related quality of life 

in eight- to ten-year-old children. Pediatric Dentistry, 26(6): 

512-18.

Lewis, C. W. (2009). Dental care and children with special 

health care needs: a population-based perspective. Academic 

Pediatrics, 9(6), 420-426.

Locker, D., Jokovic, A., & Thompson, B. (2005). Healthrelated quality of life for children aged 11 to 14 years with 

orofacial conditions. The Cleft Palate-Craniofacial Journal, 

42(3): 260-66.

Locker, D., Jokovic, A., Stephens, M., Kenny, D., Tompson, B., 

& Guyatt, G. (2002). Family impact of child oral and oro-facial 

conditions. Community Dentistry and Oral Epidemiology, 30(6), 

438-448.

Machen, J.B., & Johnson, R. (1974). Desensitization, Model 

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44 | Open Arms Children’s Health Dental Service 
Appendix A: Statistical Analysis

Dentist evaluation of Treatment Acceptance

p.22 mean scores (lower is better) 

Last year This year

 T1 1.37 (n=760) 

 T2 1.35 (n=347) 

 T3 1.34 (n=129) 

 T4 1.23 (n= 31) 

 T1 1.30 (n=1488) 

 T2 1.24 (n= 860) 

 T3 1.20 (n= 486) 

 T4 1.22 (n= 279) 

 T5 1.24 (n= 156) 

 T6 1.18 (n= 71) 

 T7 1.27 (n= 26) 

 T8 1.21 (n= 14) 

Dentist evaluation of Treatment Acceptance - crosstab 

p.23 

Last year This year

score count % score count % 

T1 1

2 

3 

4

75

16 

9 

1

1

2 

3 

4

1175

198 

102 

13

79%

13% 

7% 

1%

T2 1

2 

3 

4

72

21 

6 

1

1

2 

3 

4

709

103 

39 

9

82%

12% 

5% 

1%

T3 1

2 

3 

4

77

13 

7 

2

1

2 

3 

4

421

38 

20 

7

87%

8% 

4% 

1%

T4 1

2 

3 

4

84

13 

0 

3

1

2 

3 

4

230

38 

9 

2

82%

14% 

3% 

1%

T5 1

2 

3 

4

126

25 

3 

2

81%

16% 

2% 

1% 

T6 1

2 

3 

4

62

6 

2 

1

87%

 8% 

3% 

1%

T7 1

2 

3 

4

22

2 

1 

1

85%

8% 

4% 

4%

T8 1

2

11

3

79%

21%

 Evaluation Report May 2014| 45
46 | Open Arms Children’s Health Dental Service 

Appendix A: Statistical Analysis (continued)

Dentist evaluation of Treatment Acceptance

p.23 for each of eight populations: count and mean rapport score 

Last year This year

Priority Population count mean count mean

ChildKind Center 173 1.13 249 1.12

Other Agencies 205 1.18 433 1.14

Refugee 36 1.53 136 1.32

Impact Plus 12 1.58 18 1.39

Outpatient 224 1.57 495 1.41

Medically Fragile 99 1.61 134 1.60

Unknown 5 1.60 11 1.73

CKC – Autism 6 2.00 10 2.10

All 8 groups 760 1.37 1486 1.30

Parental Expectations of Child’s Treatment Acceptance and Comparison

p.24 Comparison of Treatment Acceptance Scores at T1

Last year This year

Parent score count mean count mean

1 Good rapport 31 103

2 Cautious 26 74

3 Reluctant 9 17

4 Refusal 8 22

total 74 216

Not every time & usually not collected for children in out-of-home care. 

Comparison of Treatment Acceptance scores

p. 24 parents better (12, 16%), same (33, 45%), worse (29, 39%) 

Last year This year

count mean count mean

Parent & Dental Score Same 29 39.2% 86 39.8%

Parent Expectation Worse 33 44.6% 109 50.5%

Dentist Experience Worse 12 16.2% 21 9.7%

74 100% 216 100%
 Evaluation Report May 2014| 47

Appendix A: Statistical Analysis (continued)
48 | Open Arms Children’s Health Dental Service 

Appendix A: Statistical Analysis (continued)

Parental Caregiver Perceptions 

(pgs. 27-28) 

at T1 & T2 (combine 25pre & 25post) 

 last year N=11/143; this year N=37/305 

 3-month change Last year This year

Problems T1 Pre T2 Post Diff T1 Pre T2 Post Diff

Saying words 1.7 1.3 -0.4

Food stuck 1.2 0.9 -0.3

Pain in mouth 1.2 1.4 0.2

Sores in mouth 1.0 1.2 0.2

Other felt guilty 1.0 1.2 0.2

Worried 1.0 1.2 0.2

Breathed through mouth 1.2 1.5 0.3

Difficulty sleeping 1.0 1.4 0.4

Difficulty eating 0.9 1.5 0.6

Bad breath 1.6 2.3 0.7

 3-month change Last year This year

Problems T1 Pre T2 Post Diff # N T1 Pre T2 Post Diff

Health of child’s teeth, lips, jaws, mouth

Overall wellbeing affected

1

2

37

33

2.27

2.52

2.35

1.88

.08

-.64

Domain I: Oral Symptoms

1 Pain

2 Bleeding gums

3 Sores in mouth 

4 Bad breath

5 Food stuck in roof of mouth

6 Food caught in teeth

7 Difficulty eating or chewing

3 

4 

5 

6 

7 

8 

9

37 

36 

37 

37 

37 

37 

36

1.95 

1.36 

1.24 

2.19 

1.38 

2.03 

1.53

1.59 

1.17 

1.41 

2.00 

1.38 

1.92 

1.67

-.35 

-.19 

 .16 

-.19

 .00 

-.11 

.14

Domain II: Functional Limitations

1 breathed through mouth

2 trouble sleeping

3 difficulty saying words

4 taken longer to eat a meal

5 trouble eating/drinking cold/hot food

6 difficulty eating what he/she wants

7 restricted diet

10 

11 

12 

13 

14 

15 

16

36 

36 

34 

36 

35 

36 

36

1.61 

1.39 

1.42 

1.11 

1.20 

1.00 

1.00

1.50 

1.67 

1.40 

1.56 

1.37 

1.19 

1.11

-.11 

.28 

.03 

.44 

.17 

.19 

.11

Domain III: Emotional Difficulties

1 upset

2 irritable or frustrated

3 anxious or fearful

17 

18 

19

37 

37 

37

1.46 

1.57 

1.32

1.27 

1.27 

1.32

-.19 

-.30 

.00

Domain IV: Family Impact

1 been upset

2 sleep disrupted

3 felt guilty 

4 took time off work

5 had less time for self or family

6 worried about child’s opportunities

7 uncomfortable in public

20 

21 

22 

23 

24 

25 

26

36 

35 

35 

35 

33 

33 

33

1.03 

1.03 

1.00 

1.03 

1.15 

1.18 

1.00

1.11 

1.06 

1.26 

1.03 

1.00 

1.06 

1.00

.08 

.03 

.26 

.00 

-.15 

-.12 

.00
 Evaluation Report May 2014| 49

Appendix A: Statistical Analysis (continued)

Parental Caregiver Perceptions at T1 

(pg. 28) 

 

 N= 143 N=305 

Last year This year

Means means

Domain I: Oral Symptoms

1 Pain 

2 Bleeding 

3 Sores 

4 Bad breath 

5 Food stuck 

6 Food in teeth 

7 Difficulty eating

1.56

1.50 

1.38 

1.13 

2.07 

1.31 

2.04 

1.48

1.79

2.10 

1.43 

1.37 

2.06 

1.67 

2.10 

1.78

Domain II: Functional Limitations

1 breathed through mouth 

2 trouble sleeping 

3 difficulty saying words 

4 taken longer to eat a meal 

5 trouble eating/drinking cold/hot food 

6 difficulty eating what he/she wants 

7 restricted diet

1.50

1.97 

1.59 

1.83 

1.42 

1.35 

1.20 

1.14

1.74

2.45 

1.76 

1.97 

1.71 

1.58 

1.46 

1.25

Domain III: Emotional Difficulties

1 upset 

2 irritable or frustrated 

3 anxious or fearful

1.45

1.40 

1.52 

1.43

1.74

1.70 

1.80 

1.71

Domain IV: Family Impact

1 been upset 

2 sleep disrupted 

3 felt guilty 

4 took time off work 

5 had less time for self or family 

6 worried about child’s opportunities

7 uncomfortable in public

1.28

1.40 

1.36 

1.30 

1.10 

1.21 

1.30 

1.28

1.38

1.47 

1.47 

1.39 

1.28 

1.32 

1.44 

1.30
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facilitate change, and improve the welfare of people. Over the years, REACH has established an exceptional reputation in 

planning and evaluation of integrated health, human service, and community programs. With a multidisciplinary team of 

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