• David Matear, BDS, BM.Sc., DDPH, M.Sc.•

Strategies for Success

A mix of strategies can be used to effectively reach this population. First and foremost, dentists and the dental team should provide a professional service that is sensitive and caring. The dental team should be cognizant of the life circumstances of these patients and tailor treatment plans accordingly

Education

By participating in educational initiatives and subscribing to related journals, the dental team will greatly enhance its ability to effectively treat and manage the elderly. It is of utmost importance for dental professionals to be well-trained, understanding and compassionate, and to be aware of the special needs of the mature population.

The dental profession should seek interdisciplinary team training to better address these needs. Perhaps a geriatric resource centre or database on geriatric topics, available to all dental practitioners, should be created in Canada similar to the South Texas Geriatric Education Center, which serves as the National Repository for Geriatric Dentistry Educational Resources.¹⁰

Education in elderly care, however, must be supplemented with practical experience in the treatment of seniors, in various locations and using appropriate dental equipment. This fundamental change will require a number of initiatives, including changing the undergraduate curriculum in Canada, changing specialist training curricula, and providing adequate coverage of geriatric dentistry in continuing education cours

Office buildings should be accessible to the physically and mentally challenged, and private dental offices or dental departments should be designed for easy access. Some important factors to consider are:¹¹

• carefully selecting and placing signs to support the communicative independence of the elderly patient;

• using firm, standard-height chairs with arms for support;

• providing adequate lighting in each room, to minimize any visual disorientation or mental confusion; and

• setting up office furniture to promote and facilitate good communication and access.

In addition, the operatory should accommodate wheelchair patients or those who use walkers. In some cases, dentists might consider an operatory equipped to treat the patient in a wheelchair.

Educational newsletters and material should be circulated. A number of business and appointment cards and brochures could be printed in extra-large type. Large-print leisure and educational material should be available in the reception room. Articles on geriatric dentistry could be placed in seniors’ magazines and newspapers, and informative talks given to community groups to demonstrate a willingness and ability to treat medically compromised clients.

To improve access for senior adults, projects similar to the one undertaken by the Ottawa-Carleton Health Department, which has developed a senior-friendly dentists’ booklet listing dentists and organizations willing to treat geriatric patients, could be initiated in large urban communities.¹²

Portable dental equipment can be used to service the functionally dependent elderly at home or in nursing homes. This equipment varies from a domiciliary valise to a portable dental office, either housed in a van or set up in an available room in a nursing home. Investment will be governed by the amount of work available and the location of the service provided. For dentists wanting to supplement their practice by providing a domiciliary service, only a modest investment is necessary, but if a strategic move into geriatric treatment in nursing homes is envisaged, more complex and comprehensive equipment is necessary. Training and experience in the use of new portable equipment is clearly essential before embarking on such a service commitment.

Barriers to dental care have been investigated in adult populations for several years.¹³ Recently, it was found that the importance of barriers varies according to various population segments. Penchansky and Thomas¹⁴ define these barriers as availability, accessibility, accommodation, affordability and acceptability.

Barriers to dental care occur for both the functionally independent individual and the functionally dependent person residing at home or in an institution. The main barrier is the perceived need for oral health care. Even though there is now a higher utilization of dental care,¹ those aged 65 and older are still least likely to use dental services (except for children under six).¹⁵ The majority of dentate and edentulous elderly believe they have no need for dental care until they develop pain or eating difficulties, or suffer from social embarrassment.^16,17

Institutionalized elderly have a higher normative need and a lower perceived need than less dependent groups^.18

Additional barriers include the functional and medical status of the individual, transportation and accessibility difficulties, financial considerations, previous patterns of dental utilization, lack of education, and fear.^19,20

It is important, therefore, that education in geriatric dentistry include not only the practical, clinical aspects of treating the elderly, but the social, environmental, psychological, behavioural and financial aspects as well.

Dentists’ attitudes toward the treatment of older patients can also create barriers. We must be aware that the time is fast approaching when the demand for geriatric care will far exceed the number of dentists currently willing and able to provide such care.

Why is there a comparatively low utilization rate for dental care of the elderly despite the normative and perceived needs? Why has this market not been targeted? Why aren’t graduating dental students more willing to fill this void?

Possible answers to these questions include:

• lack of experience and fear when treating geriatric problems;

• lack of financial incentives;

• transportation and access problems to the dental office;

• special problems that exist in providing dentistry to homebound and institutionalized patients;

• negative attitudes toward the elderly’s need for dental care and their low perception and motivation for oral health care;

• the poor oral health status of the elderly, resulting in an edentulous state or teeth compromised by periodontal disease;

• difficulties dealing with debilitating and life-threatening illnesses;

• the problem of informed consent and of family members or residential facility staff members with negative attitudes.²¹

Dealing with the elderly requires an understanding of and a sensitivity to the medical, psychological and financial states of these patients. Our education system will have to change to address these emerging issues. The traditional educational and practice structures currently in place are based on serving the needs of a healthy and affluent population.²² An infrastructure that will allow these issues to be addressed will have to be created. Unlike the United States, where a number of programs are already in place, Canada has not yet responded to this lacuna in the education of both undergraduate and graduate students. It is important that we learn from these experiences to ensure the success of future strategic moves in dental education.

Outlining the issues in geriatric dentistry is not enough. As we prepare for the next millennium, we must find solutions to the problems that exist today not just from a dental practice point of view, but also from an educational and political standpoint. As the population ages and an increasing proportion becomes institutionalized or homebound, there will likely be an increase in undertreatment of caries, periodontal disease, and partial and complete edentulousness. The threat exists for teeth that were carefully maintained throughout childhood and adulthood to be compromised due to diverse medical, behavioural and financial factors.

The burden of providing much of the dental care for the aging population rests with the private dental practitioner and those few practitioners who provide institutionalized care. An integrated approach is critical for the maintenance of an acceptable level of health for the institutionalized elderly. Coordinated medical support is vital, as is support from the various dental specialties. Communication with family and other health care professionals such as pharmacists, physiotherapists and caregivers is essential. An adequate number of trained and competent hygienists, dental assistants and administrators is also of paramount importance.

Lack of government funding means fewer dollars are available to provide dental care and training programs in geriatric care. Ideally, more extensive government policies should be implemented to allow reimbursement and delivery of oral health services to a functionally dependent elderly population unable to access oral health care services in the traditional manner. Universities must go beyond perfunctory references to geriatric concerns within both the undergraduate and graduate curricula and give this growing area of dental education and service the recognition it deserves by fully integrating geriatric dentistry into their programs.

Perhaps long-term care facilities affiliated with a university should become academic and resource centres promoting research and education in geriatrics.23

The dental departments of these facilities may have to initiate their integration into the academic system, reach out to the community of older people to increase their level of perceived oral health care needs, and organize training and education programs for the dental team, dental students and caregivers working in institutions. Exposing students to such facilities would lend tremendous credibility to dental schools and enhance training programs as a result of the additional available resources.

Finally, these facilities could initiate the development of research programs in dental care for the elderly. Investigations are needed to determine various delivery options, specific treatment modalities and appropriate guidelines for care. Clinical trials of old and new dental materials are also needed to understand and demonstrate their effectiveness and to help understand the effects of aging on oral health. Perhaps the above strategies, together with improved advocacy for seniors, may help formulate policies that will lend financial support to this growing part of the population and allow the necessary delivery of oral health care services for the elderly.

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