Dental_JJ Care_NN1 and_CC Children_NN2 with_IW Special_JJ Health_NN1 Care_NN1 Needs_VVZ :_: A_ZZ1 Population-Based_JJ Perspective_NN1 This_DD1 paper_NN1 grew_VVD out_II21 of_II22 an_AT1 American_JJ Academy_NN1 of_IO Pediatrics_NN1 project_NN1 reviewing_VVG progress_NN1 in_II the_AT area_NN1 of_IO children_NN2 's_GE oral_JJ health_NN1 after_II the_AT publication_NN1 of_IO Oral_JJ Health_NN1 in_II America_NP1 :_: A_AT1 Report_NN1 of_IO the_AT Surgeon_NN1 General_NN1 in_II 2000_MC ._. 
It_PPH1 includes_VVZ a_AT1 summary_NN1 of_IO key_JJ advances_NN2 in_II national_JJ dental_JJ care_NN1 and_CC oral_JJ health_NN1 surveillance_NN1 of_IO Children_NN2 with_IW Special_JJ Health_NN1 Care_NN1 Needs_NN2 (_( CSHCN_NP1 )_) ,_, and_CC presents_VVZ more_RGR recent_JJ national_JJ data_NN on_II dental_JJ care_NN1 need_NN1 among_II CSHCN_NP1 ._. 
Prior_II21 to_II22 2000_MC ,_, there_EX existed_VVD no_AT population-based_JJ studies_NN2 describing_VVG the_AT dental_JJ care_NN1 utilization_NN1 or_CC needs_VVZ among_II CSHCN_NP1 residing_VVG in_II the_AT United_NP1 States_NP1 ._. 
When_CS Oral_JJ Health_NN1 in_II America_NP1 :_: a_AT1 Report_NN1 of_IO the_AT Surgeon_NN1 General_NN1 was_VBDZ published_VVN that_DD1 year_NNT1 ,_, it_PPH1 addressed_VVD oral_JJ health_NN1 of_IO disabled_JJ populations_NN2 only_RR briefly_RR ,_, in_II large_JJ part_NN1 ,_, according_II21 to_II22 the_AT authors_NN2 ,_, because_CS there_EX were_VBDR such_DA limited_JJ data_NN available_JJ ._. 
In_II April_NPM1 2000_MC ,_, Newacheck_NP1 and_CC colleagues_NN2 published_VVD a_AT1 sentinel_NN1 paper_NN1 entitled_VVN ,_, "_" Access_NN1 to_II Health_NN1 Care_NN1 for_IF Children_NN2 with_IW Special_JJ Health_NN1 Care_NN1 Needs_NN2 ,_, "_" relying_VVG on_II data_NN from_II the_AT 1994-1995_MCMC National_JJ Health_NN1 Interview_NN1 Survey_NN1 on_II Disability_NN1 and_CC representing_VVG the_AT first_MD time_NNT1 that_CST dental_JJ care_NN1 was_VBDZ described_VVN as_II the_AT leading_JJ unmet_JJ health_NN1 care_NN1 need_NN1 among_II US_NP1 CSHCN_NP1 ._. 
Since_CS the_AT article_NN1 by_II Newacheck_NP1 and_CC colleagues_NN2 ,_, other_JJ population-based_JJ studies_NN2 have_VH0 been_VBN published_VVN ,_, furthering_VVG understanding_NN1 of_IO dental_JJ care_NN1 needs_NN2 and_CC access_NN1 of_IO CSHCN_NP1 ._. 
Key_NN1 to_II expansion_NN1 of_IO research_NN1 on_II this_DD1 topic_NN1 was_VBDZ the_AT formal_JJ definition_NN1 of_IO CSHCN_NP1 by_II the_AT Maternal_JJ and_CC Child_NN1 Health_NN1 Bureau_NN1 as_II31 well_II32 as_II33 the_AT development_NN1 of_IO a_AT1 screening_NN1 instrument_NN1 that_CST operationalized_VVD this_DD1 definition_NN1 :_: "_" Children_NN2 who_PNQS have_VH0 special_JJ health_NN1 care_NN1 needs_NN2 are_VBR those_DD2 who_PNQS have_VH0 (_( or_CC who_PNQS are_VBR at_II risk_NN1 for_IF )_) a_AT1 chronic_JJ physical_JJ ,_, developmental_JJ ,_, behavioral_JJ or_CC emotional_JJ condition_NN1 and_CC who_PNQS also_RR require_VV0 health_NN1 and_CC related_JJ services_NN2 of_IO a_AT1 type_NN1 or_CC amount_NN1 beyond_II that_DD1 required_VVN by_II children_NN2 generally_RR ._. "_" 
This_DD1 validated_JJ tool_NN1 ,_, called_VVN the_AT Children_NN2 with_IW Special_JJ Health_NN1 Care_NN1 Needs_VVZ screener_NN1 ,_, is_VBZ intended_VVN to_TO be_VBI broadly_RR inclusive_JJ and_CC non-condition_JJ specific_JJ ,_, and_CC dichotomously_RR classifies_VVZ children_NN2 as_CSA having_VHG a_AT1 Special_JJ Health_NN1 Care_NN1 Need_NN1 or_CC not_XX ._. 
The_AT CSHCN_NP1 screener_NN1 is_VBZ now_RT a_AT1 component_NN1 of_IO several_DA2 national_JJ surveys_NN2 ,_, including_II the_AT Medical_JJ Expenditure_NN1 Panel_NN1 Survey_NN1 administered_VVN by_II the_AT US_NP1 ._. 
Agency_NN1 for_IF Health_NN1 Care_NN1 Quality_NN1 and_CC Research_NN1 ,_, the_AT National_JJ Survey_NN1 of_IO Children_NN2 with_IW Special_JJ Health_NN1 Care_NN1 Needs_NN2 (_( NS-CSHCN_NP1 )_) ,_, and_CC the_AT National_JJ Survey_NN1 of_IO Children_NN2 's_GE Health_NN1 ._. 
The_AT latter_DA two_MC are_VBR Maternal_JJ and_CC Child_NN1 Health_NN1 Bureau-funded_NN1 surveys_NN2 conducted_VVN by_II the_AT National_JJ Center_NN1 for_IF Health_NN1 Statistics_NN of_IO the_AT Centers_NN2 for_IF Disease_NN1 Control_NN1 and_CC Prevention_NN1 ._. 
The_AT capability_NN1 to_TO uniformly_RR define_VVI CSHCN_NP1 and_CC relate_VV0 this_DD1 to_II the_AT dental_JJ care_NN1 and_CC oral_JJ health_NN1 variables_NN2 within_II these_DD2 3_MC nationally_RR representative_JJ surveys_NN2 has_VHZ produced_VVN a_AT1 respectable_JJ expansion_NN1 in_II oral_JJ health_NN1 research_NN1 focused_VVN on_II US_NP1 CSHCN_NP1 in_II the_AT last_MD decade_NNT1 ._. 
Published_VVN dental-related_JJ findings_NN2 from_II these_DD2 surveys_NN2 are_VBR summarized_VVN in_II Table_NN1 1_MC1 ._. 
The_AT second_MD iteration_NN1 of_IO the_AT NS-CSHCN_NP1 (_( 2006_MC )_) is_VBZ the_AT focus_NN1 of_IO this_DD1 research_NN1 ._. 
Some_DD revisions_NN2 since_CS the_AT 2001_MC NS-CSHCN_NP1 were_VBDR relevant_JJ to_II better_JJR understanding_NN1 dental_JJ care_NN1 needs_NN2 of_IO CSHCN_NP1 ._. 
Specifically_RR ,_, in_II the_AT 2006_MC version_NN1 ,_, it_PPH1 is_VBZ now_RT easier_JJR to_TO identify_VVI specific_JJ subgroups_NN2 with_IW more_RGR unmet_JJ dental_JJ care_NN1 need_NN1 ,_, to_TO separate_VVI out_RP preventive_JJ versus_II "_" other_JJ dental_JJ care_NN1 "_" (_( eg_REX ,_, fillings_NN2 and_CC other_JJ restorative_JJ dental_JJ care_NN1 )_) ,_, and_CC to_TO make_VVI comparisons_NN2 between_II children_NN2 with_IW and_CC without_IW special_JJ health_NN1 care_NN1 needs_NN2 ._. 
Without_IW a_AT1 nonspecial_JJ needs_VVZ comparison_NN1 group_NN1 ,_, it_PPH1 had_VHD previously_RR been_VBN difficult_JJ to_TO know_VVI whether_CSW disparities_NN2 in_II dental_JJ care_NN1 access_NN1 were_VBDR associated_VVN with_IW a_AT1 child_NN1 's_GE special_JJ need_NN1 or_CC with_IW other_JJ factors_NN2 that_CST may_VM disproportionately_RR affect_VVI CSHCN_NP1 ._. 
This_DD1 project_NN1 had_VHD the_AT following_JJ objectives_NN2 :_: 1_MC1 )_) to_TO determine_VVI ,_, from_II a_AT1 population_NN1 perspective_NN1 ,_, a_AT1 more_RGR current_JJ prevalence_NN1 of_IO unmet_JJ dental_JJ care_NN1 needs_NN2 ,_, including_II preventive_JJ and_CC other_JJ dental_JJ care_NN1 ,_, among_II CSHCN_NP1 and_CC compare_VV0 this_DD1 with_IW children_NN2 without_IW special_JJ health_NN1 care_NN1 needs_NN2 ;_; 2_MC )_) within_II the_AT constraints_NN2 of_IO cross-sectional_JJ data_NN ,_, to_TO compare_VVI 2001_MC CSHCN_NP1 findings_NN2 to_II those_DD2 of_IO 5_MC years_NNT2 later_RRR ;_; and_CC 3_MC )_) to_TO identify_VVI factors_NN2 associated_VVN with_IW a_AT1 greater_JJR odds_NN2 of_IO unmet_JJ dental_JJ care_NN1 needs_VVZ in_II CSHCN_NP1 ._. 
The_AT impact_NN1 of_IO condition_NN1 severity_NN1 was_VBDZ of_IO particular_JJ interest_NN1 ,_, as_II31 well_II32 as_II33 whether_CSW poverty_NN1 ,_, which_DDQ is_VBZ known_VVN from_II previous_JJ work_NN1 to_TO be_VBI an_AT1 independent_JJ risk_NN1 factor_NN1 for_IF unmet_JJ dental_JJ care_NN1 ,_, mediated_VVD the_AT effect_NN1 of_IO condition_NN1 severity_NN1 on_II unmet_JJ dental_JJ care_NN1 need_NN1 ._. 
Discussion_NN1 In_II this_DD1 study_NN1 of_IO the_AT 2005_MC NS-CSHCN_NP1 ,_, about_RG 9%_NNU of_IO CSHCN_NP1 who_PNQS needed_VVD dental_JJ care_NN1 were_VBDR unable_JK to_TO obtain_VVI it_PPH1 compared_VVN with_IW 5%_NNU of_IO children_NN2 without_IW special_JJ needs_NN2 ._. 
Although_CS dental_JJ care_NN1 remains_VVZ the_AT leading_JJ unmet_JJ health_NN1 care_NN1 need_NN1 for_IF CSHCN_NP1 ,_, 23%_NNU fewer_DAR CSHCN_NP1 had_VHD unmet_JJ dental_JJ care_NN1 needs_NN2 compared_VVN with_IW the_AT 2001_MC survey_NN1 (_( 755_MC 581_MC in_II 2001_MC vs_II 579_MC 477_MC in_II 2005_MC )_) ,_, even_CS21 though_CS22 more_RRR CSHCN_NP1 were_VBDR said_VVN to_TO have_VHI needed_VVN preventive_JJ dental_JJ care_NN1 in_II 2005-2006_MCMC (_( 78%_NNU in_II 2001_MC vs_II 81%_NNU in_II 2005-2006_MCMC )_) ._. 
Nevertheless_RR ,_, there_EX remains_VVZ considerable_JJ disparity_NN1 in_II ability_NN1 to_TO obtain_VVI needed_JJ dental_JJ care_NN1 by_II degree_NN1 of_IO poverty_NN1 and_CC condition_NN1 severity_NN1 ._. 
With_IW 13.4_MC times_NNT2 the_AT adjusted_JJ odds_NN2 of_IO unmet_JJ dental_JJ care_NN1 need_NN1 for_IF severely_RR affected_VVN ,_, poor/low-income_JJ CSHCN_NP1 (_( relative_II21 to_II22 unaffected_JJ high-income_JJ children_NN2 )_) ,_, we_PPIS2 are_VBR far_RR from_II the_AT goal_NN1 of_IO ensuring_VVG that_CST all_DB children_NN2 are_VBR able_JK to_TO obtain_VVI the_AT dental_JJ care_NN1 that_CST they_PPHS2 need_VV0 ._. 
These_DD2 results_NN2 emphasize_VV0 the_AT importance_NN1 of_IO attending_VVG to_II the_AT dental_JJ care_NN1 needs_NN2 of_IO our_APPGE nation_NN1 's_GE most_RGT vulnerable_JJ children_NN2 ._. 
Similar_JJ to_II studies_NN2 in_II all_DB US_NP1 children_NN2 ,_, having_VHG public_JJ insurance_NN1 such_II21 as_II22 Medicaid_NP1 or_CC State_VV0 Children_NN2 's_GE Health_NN1 Insurance_NN1 Program_NN1 and_CC one_PN1 's_GE race/ethnicity_NN1 were_VBDR not_XX ,_, in_RR21 general_RR22 ,_, significantly_RR associated_VVN with_IW unmet_JJ dental_JJ care_NN1 needs_VVZ in_II CSHCN_NP1 after_II adjusting_VVG for_IF family_NN1 income_NN1 relative_II21 to_II22 FPL_NP1 ._. 
Separate_JJ questions_NN2 about_II preventive_JJ and_CC other_JJ dental_JJ care_NN1 made_VVD it_PPH1 possible_JJ to_TO characterize_VVI unmet_JJ need_NN1 for_IF specific_JJ category_NN1 of_IO dental_JJ care_NN1 ,_, something_PN1 not_XX previously_RR reported_VVN ._. 
There_EX was_VBDZ more_RGR unmet_JJ need_NN1 for_IF other_JJ dental_JJ care_NN1 than_CSN for_IF preventive_JJ dental_JJ care_NN1 among_II CSHCN_NP1 ._. 
Delivering_VVG preventive_JJ dental_JJ care_NN1 to_II a_AT1 CSHCN_NP1 is_VBZ very_RG important_JJ ;_; however_RR ,_, it_PPH1 is_VBZ more_RGR straightforward_JJ than_CSN restorative_JJ care_NN1 ,_, which_DDQ can_VM be_VBI time-consuming_JJ and_CC labor-intensive_JJ for_IF dental_JJ professionals_NN2 ,_, particularly_RR if_CS the_AT child_NN1 is_VBZ more_RGR severely_RR affected_VVN ._. 
Restorative_JJ dental_JJ care_NN1 is_VBZ also_RR more_RGR expensive_JJ ,_, and_CC more_DAR of_IO the_AT cost_NN1 burden_NN1 for_IF such_DA care_NN1 is_VBZ borne_VVN by_II families_NN2 ._. 
This_DD1 may_VM help_VVI to_TO explain_VVI why_RRQ other_JJ dental_JJ care_NN1 needs_NN2 were_VBDR less_RGR often_RR met_VVN ._. 
This_DD1 research_NN1 identified_VVN that_CST CSHCN_NP1 with_IW certain_JJ diagnoses_NN2 ,_, including_VVG Down_RP syndrome_NN1 ,_, other_JJ forms_NN2 of_IO mental_JJ retardation_NN1 ,_, cerebral_JJ palsy_NN1 ,_, and_CC autism_NN1 ,_, encounter_VV0 greater_JJR difficulty_NN1 obtaining_VVG needed_JJ dental_JJ care_NN1 ,_, although_CS what_DDQ it_PPH1 is_VBZ specifically_RR about_II these_DD2 diagnoses_NN2 that_CST interfere_VV0 with_IW dental_JJ care_NN1 receipt_NN1 remains_VVZ unclear_JJ ._. 
It_PPH1 may_VM be_VBI that_CST these_DD2 diagnoses_NN2 merely_RR represent_VV0 more_RGR severely_RR affected_VVN children_NN2 ._. 
There_EX were_VBDR also_RR significant_JJ differences_NN2 in_II the_AT proportion_NN1 of_IO CSHCN_NP1 with_IW unmet_JJ dental_JJ care_NN1 need_NN1 as_CSA condition_NN1 severity_NN1 worsened_VVD ._. 
Moreover_RR ,_, the_AT association_NN1 between_II condition_NN1 severity_NN1 and_CC unmet_JJ dental_JJ care_NN1 needs_NN2 was_VBDZ mediated_VVN by_II income_NN1 ._. 
This_DD1 is_VBZ the_AT first_MD time_NNT1 that_CST a_AT1 child_NN1 's_GE condition_NN1 severity_NN1 ,_, whether_CSW considered_VVN alone_RR or_CC as_II a_AT1 function_NN1 of_IO their_APPGE income_NN1 ,_, has_VHZ been_VBN independently_RR related_VVN to_II unmet_JJ dental_JJ care_NN1 need_NN1 ._. 
Even_RR having_VHG a_AT1 family_NN1 income_NN1 at/above_II 400%_NNU FPL_NP1 was_VBDZ not_XX fully_RR protective_JJ against_II unmet_JJ dental_JJ care_NN1 needs_VVZ for_IF those_DD2 most_RGT severely_RR affected_VVN ._. 
Virtually_RR no_AT parent_NN1 cited_VVD lack_NN1 of_IO availability_NN1 of_IO dentists_NN2 specifically_RR trained_VVN in_II the_AT care_NN1 of_IO CSHCN_NP1 as_II an_AT1 obstacle_NN1 to_II their_APPGE child_NN1 's_GE receipt_NN1 of_IO dental_JJ care_NN1 ._. 
It_PPH1 may_VM be_VBI availability_NN1 of_IO hospital-based_JJ dental_JJ services_NN2 ,_, which_DDQ are_VBR more_RGR likely_JJ to_TO be_VBI required_VVN for_IF severely_RR affected_VVN children_NN2 ,_, as_II31 opposed_II32 to_II33 specifically_RR trained_VVN dentists_NN2 ,_, that_DD1 poses_VVZ the_AT greatest_JJT barrier_NN1 to_II obtaining_VVG needed_JJ dental_JJ care_NN1 in_II these_DD2 parents_NN2 '_GE eyes_NN2 ._. 
Additional_JJ research_NN1 is_VBZ needed_VVN to_TO clarify_VVI the_AT exact_JJ nature_NN1 of_IO barriers_NN2 for_IF severely_RR affected_VVN CSHCN_NP1 ._. 
There_EX are_VBR certain_JJ limitations_NN2 to_II this_DD1 research_NN1 ._. 
Responses_NN2 to_TO survey_VVI questions_NN2 are_VBR based_VVN on_II a_AT1 parental_JJ report_NN1 and_CC are_VBR thus_RR subject_II21 to_II22 bias_NN1 ._. 
Additionally_RR ,_, of_IO the_AT many_DA2 topics_NN2 and_CC questions_NN2 considered_VVN for_IF inclusion_NN1 in_II national_JJ surveys_NN2 ,_, only_RR a_AT1 limited_JJ number_NN1 are_VBR possible_JJ ,_, and_CC most_DAT are_VBR broadly_RR focused_VVN ,_, leaving_VVG remaining_JJ unanswered_JJ questions_NN2 ._. 
Little_DA1 is_VBZ known_VVN about_II the_AT specific_JJ factors_NN2 that_CST interfere_VV0 with_IW severely_RR affected_VVN CSHCN_NP1 obtaining_VVG dental_JJ care_NN1 ._. 
Nevertheless_RR ,_, findings_NN2 from_II these_DD2 surveys_NN2 provide_VV0 the_AT basis_NN1 for_IF research_NN1 questions_NN2 better_RRR answered_VVN in_II smaller_JJR scale_NN1 studies_NN2 ._. 
There_EX are_VBR ,_, however_RR ,_, some_DD omissions_NN2 to_II the_AT NS-CSHCN_NN1 that_CST pose_VV0 particular_JJ obstacles_NN2 to_II studying_VVG dental_JJ care_NN1 need_NN1 among_II CSHCN_NP1 and_CC that_CST deserve_VV0 remedy_NN1 --_NN1 specifically_RR ,_, the_AT lack_NN1 of_IO any_DD items_NN2 related_VVN to_II dental_JJ insurance_NN1 ._. 
In_II this_DD1 research_NN1 ,_, medical_JJ insurance_NN1 was_VBDZ used_VVN as_II a_AT1 proxy_NN1 for_IF dental_JJ coverage_NN1 ._. 
But_CCB since_II 2.5_MC times_NNT2 as_RG many_DA2 children_NN2 are_VBR uninsured_JJ for_IF dental_JJ relative_II21 to_II22 medical_JJ care_NN1 ,_, this_DD1 is_VBZ a_AT1 suboptimal_JJ substitute_NN1 ._. 
Finally_RR ,_, differences_NN2 in_II unmet_JJ dental_JJ care_NN1 need_NN1 by_II condition_NN1 severity_NN1 demonstrate_VV0 the_AT shortcoming_NN1 of_IO considering_VVG all_DB CSHCN_NP1 as_II a_AT1 single_JJ group_NN1 ._. 
Such_DA an_AT1 approach_NN1 does_VDZ not_XX allow_VVI for_IF an_AT1 adequate_JJ picture_NN1 of_IO the_AT dental_JJ needs_NN2 of_IO certain_JJ subgroups_NN2 ._. 
By_II including_VVG children_NN2 with_IW little_JJ or_CC no_AT impairment_NN1 among_II CSHCN_NP1 ,_, we_PPIS2 are_VBR diluting_VVG out_RP the_AT difficulty_NN1 experienced_VVN by_II more_RGR severely_RR affected_VVN children_NN2 when_CS they_PPHS2 try_VV0 to_TO obtain_VVI dental_JJ care_NN1 ._. 
Conclusions_NN2 and_CC Recommendations_NN2 In_II this_DD1 paper_NN1 ,_, we_PPIS2 sought_VVD to_TO describe_VVI what_DDQ has_VHZ been_VBN learned_VVN about_II dental_JJ care_NN1 for_IF US_NP1 CSHCN_NP1 since_CS release_NN1 of_IO the_AT Surgeon_NN1 General_NN1 's_GE Report_NN1 in_II 2000_MC ._. 
Indeed_RR ,_, almost_RR everything_PN1 known_VVN about_II this_DD1 subject_NN1 was_VBDZ gleaned_VVN from_II studies_NN2 of_IO the_AT last_MD decade_NNT1 ._. 
Results_NN2 are_VBR remarkably_RR consistent_JJ between_II studies_NN2 in_II describing_VVG relatively_RR equal_JJ rates_NN2 of_IO preventive_JJ dental_JJ care_NN1 use_NN1 by_II children_NN2 with_IW and_CC without_IW special_JJ health_NN1 care_NN1 needs_NN2 ._. 
However_RR ,_, researchers_NN2 have_VH0 also_RR reported_VVN more_RGR unmet_JJ dental_JJ care_NN1 need_NN1 and_CC worse_JJR oral_JJ health_NN1 among_II CSHCN_NP1 relative_II21 to_II22 their_APPGE non-special_JJ health_NN1 care_NN1 need_VV0 peers_NN2 ._. 
Findings_NN2 from_II the_AT 2006_MC NS-CSHCN_NP1 confirm_VV0 the_AT anecdotal_JJ impression_NN1 that_CST there_EX is_VBZ more_RGR unmet_JJ need_NN1 for_IF other_JJ dental_JJ care_NN1 than_CSN for_IF preventive_JJ dental_JJ care_NN1 ,_, and_CC that_DD1 condition_NN1 severity_NN1 is_VBZ significantly_RR associated_VVN with_IW unmet_JJ dental_JJ care_NN1 need_NN1 ._. 
Furthermore_RR ,_, we_PPIS2 found_VVD that_CST poor_JJ and_CC low-income_JJ children_NN2 with_IW more_RGR severe_JJ conditions_NN2 have_VH0 more_DAR than_CSN 13_MC times_NNT2 the_AT adjusted_JJ odds_NN2 for_IF unmet_JJ dental_JJ care_NN1 needs_NN2 compared_VVN with_IW high-income_JJ unaffected_JJ children_NN2 ._. 
Children_NN2 facing_VVG the_AT "_" double_JJ disparity_NN1 "_" of_IO poverty_NN1 and_CC a_AT1 severe_JJ chronic_JJ condition_NN1 deserve_VV0 special_JJ attention_NN1 from_II clinicians_NN2 and_CC policy_NN1 makers_NN2 to_TO alleviate_VVI such_DA marked_JJ difficulty_NN1 obtaining_VVG needed_JJ dental_JJ care_NN1 ._. 
Regardless_RR of_IO income_NN1 ,_, at_RR21 least_RR22 90%_NNU of_IO severely_RR affected_VVN CSHCN_NP1 had_VHD a_AT1 personal_JJ doctor_NN1 or_CC nurse_NN1 ,_, which_DDQ reinforces_VVZ the_AT importance_NN1 of_IO including_VVG dental_JJ care_NN1 as_II part_NN1 of_IO the_AT comprehensive_JJ care_NN1 coordinated_VVN by_II the_AT medical_JJ home_NN1 ._. 
Despite_II advances_NN2 in_II the_AT understanding_NN1 of_IO dental_JJ care_NN1 utilization_NN1 and_CC needs_VVZ among_II CSHCN_NP1 ,_, a_AT1 number_NN1 of_IO unanswered_JJ questions_NN2 remain_VV0 ._. 
Specifically_RR ,_, it_PPH1 remains_VVZ unclear_JJ exactly_RR what_DDQ factors_NN2 interfere_VV0 with_IW certain_JJ CSHCN_NP1 obtaining_VVG needed_JJ dental_JJ care_NN1 ._. 
It_PPH1 is_VBZ possible_JJ that_CST a_AT1 system_NN1 of_IO specialized_JJ referral_NN1 centers_NN2 ,_, that_CST provided_CS preventive_JJ and_CC restorative_JJ dental_JJ care_NN1 to_II severely_RR affected_VVN CSHCN_NP1 within_II a_AT1 region_NN1 may_VM help_VVI to_II better_JJR address_NN1 dental_JJ care_NN1 need_NN1 for_IF these_DD2 children_NN2 ._. 
In_II such_DA a_AT1 model_NN1 ,_, general_JJ and_CC pediatric_JJ dentists_NN2 would_VM continue_VVI to_TO care_VVI for_IF mildly_RR and_CC moderately_RR affected_VVN CSHCN_NP1 in_II or_CC near_II their_APPGE home_NN1 communities_NN2 ._. 
To_II my_APPGE knowledge_NN1 ,_, no_PN121 one_PN122 has_VHZ proposed_VVN such_DA a_AT1 system_NN1 ._. 
However_RR ,_, the_AT degree_NN1 of_IO disparity_NN1 in_II unmet_JJ dental_JJ care_NN1 needs_VVZ for_IF severely_RR affected_VVN children_NN2 ,_, which_DDQ was_VBDZ identified_VVN in_II this_DD1 study_NN1 ,_, should_VM provide_VVI the_AT basis_NN1 for_IF additional_JJ research_NN1 directed_VVN at_II better_JJR understanding_NN1 modifiable_JJ barriers_NN2 to_II dental_JJ care_NN1 for_IF these_DD2 children_NN2 ._. 
Designing_VVG a_AT1 system_NN1 of_IO care_NN1 specifically_RR for_IF more_RGR severely_RR affected_VVN CSHCN_NP1 also_RR would_VM require_VVI objective_JJ data_NN about_II the_AT actual_JJ dental_JJ health_NN1 of_IO CSHCN_NP1 ,_, such_II21 as_II22 would_VM be_VBI obtained_VVN from_II oral_JJ examination_NN1 ._. 
Although_CS there_EX exists_VVZ a_AT1 mechanism_NN1 ,_, in_II the_AT form_NN1 of_IO the_AT ongoing_JJ National_JJ Health_NN1 and_CC Nutrition_NN1 Examination_NN1 Survey_NN1 (_( NHANES_NP2 )_) ,_, to_TO measure_VVI national_JJ prevalence_NN1 of_IO oral_JJ disease_NN1 ,_, the_AT accompanying_JJ NHANES_NN2 questionnaire_NN1 includes_VVZ only_RR a_AT1 very_RG limited_JJ number_NN1 of_IO items_NN2 that_CST could_VM identify_VVI a_AT1 child_NN1 as_CSA having_VHG a_AT1 special_JJ need_NN1 (_( eg_REX ,_, special_JJ education_NN1 use_NN1 )_) ._. 
We_PPIS2 recommend_VV0 inclusion_NN1 of_IO the_AT CSHCN_NP1 screener_NN1 and_CC condition_NN1 severity_NN1 items_NN2 in_II the_AT NHANES_NP2 questionnaire_NN1 ,_, as_II31 well_II32 as_II33 an_AT1 oversampling_NN1 (_( to_TO improve_VVI precision_NN1 in_II the_AT resulting_JJ nationally_RR representative_JJ estimates_NN2 )_) of_IO severely_RR affected_VVN CSHCN_NP1 who_PNQS receive_VV0 dental_JJ examinations_NN2 ,_, as_CSA a_AT1 part_NN1 of_IO NHANES_NP2 ._. 
The_AT last_MD 10_MC years_NNT2 have_VH0 brought_VVN considerable_JJ gains_NN2 in_II knowledge_NN1 about_II dental_JJ care_NN1 need_NN1 and_CC use_VV0 among_II US_NP1 CSHCN_NP1 ._. 
These_DD2 would_VM not_XX have_VHI been_VBN possible_JJ without_IW efforts_NN2 on_II41 the_II42 part_II43 of_II44 the_AT Maternal_JJ and_CC Child_NN1 Health_NN1 Bureau_NN1 ,_, Agency_NN1 for_IF Health_NN1 Care_NN1 Quality_NN1 and_CC Research_NN1 ,_, Centers_NN2 for_IF Disease_NN1 Control_NN1 and_CC Prevention_NN1 ,_, and_CC National_JJ Center_NN1 for_IF Health_NN1 Statistics_NN to_TO develop_VVI and_CC implement_VVI nationally_RR representative_JJ surveys_NN2 focused_VVD on_RP or_CC specifically_RR inclusive_JJ of_IO CSHCN_NP1 ._. 
A_AT1 number_NN1 of_IO questions_NN2 about_II dental_JJ care_NN1 for_IF CSHCN_NP1 remain_VV0 ,_, but_CCB we_PPIS2 are_VBR now_RT closer_JJR to_II the_AT goal_NN1 of_IO better_JJR understanding_NN1 the_AT dental_JJ care_NN1 needs_NN2 of_IO CSHCN_NP1 and_CC of_IO developing_JJ systems_NN2 of_IO care_NN1 to_TO meet_VVI these_DD2 needs_NN2 ._. 
