A Wake-Up Call to CDA and Provincial Regulatory Bodies

Unless you maintain a pediatric practice, you’ve probably noticed an increase in geriatric patients. Elderly patients not only provide diagnostic challenges, but also medical and behavioural challenges. Last year a 90-year-old lady was brought to my office for a root canal. A resident of a long-term care facility, she had gradually stopped eating as a result of unrelenting mouth pain. There was no dentist on staff at the facility; occasionally a hygienist and a denturist treated the patients. A ward clerk who had had a root canal thought that was what the woman needed, and that is why the patient was eventually referred to me.

On presentation of the patient, I plowed through the medication list and medical history. The lady was frail, but then she wasn’t eating. She pointed to her left mandibular area as being the source of her problem. When I retracted her cheek, she recoiled in pain. There was one solitary premolar in the area. There was a lot of plaque and inflamed gingivae. I asked her if she had experienced this kind of pain before and she said yes — and that it had usually been followed by an extraction. I asked her if that had helped the pain and she said no, but someone had once given her some medicine that had helped. Well, it was no great diagnostic feat to ascertain that the patient had a neuralgia. No caries, no periodontal disease — just an untreated facial neuralgia and poor oral hygiene. After a few days of gabapentin, her pain was gone. Her physician was pleased and assumed responsibility for her monitoring. I saw her a few weeks later in the facility. I suspect she added me to her will.

Was this such a difficult diagnosis to make? For a dentist, no. Especially a dentist with some years of experience under his or her belt. Why would dental paraprofessionals even want to take on this aspect of practice without a dentist being involved? Elderly patients represent a segment of the population that is underserved and they are a difficult group to treat effectively. Unfortunately, there is a shortage of dentists providing care in long-term care facilities. The reasons for this are numerous and include a lack of proper equipment, an inadequate understanding of the medical conditions of the elderly and insufficient remuneration (if one follows provincial fee guides).

Dental hygienists and denturists anxious to expand their scope of practice see this population as their ticket to mainstream dentistry. Remember dentures? Remember partial dentures? This is all déjà vu — today the elderly for “assessment” and “treatment,” tomorrow the population at large. Let’s face it, if paraprofessionals can provide diagnostic and treatment services to the most challenging segment of the population, what is to stop them from treating the patients in your practice?

Now, imagine you are retiring and would like to “give something back” by offering your services one day a week in geriatric homes. Then you find out how expensive it is to give back: licence, provincial association dues, CDA dues, malpractice insurance, continuing education. The “bodies” standing in line to collect money can overwhelm a dentist who is just retiring. How unfortunate for the long-term care population. After all, who better to serve these people than dentists with years of practice, who have actually watched their patients’ periodontium age? A dental hygienist (while well-meaning) has neither the knowledge nor the skills to manage all the oral health care needs of patients in long-term care facilities.

The “Brain Drain”

One might think the brain drain applies only to 30-year-old computer whizzes and surgeons. In fact, if one examines the number of dentists getting ready to retire in the next few years, it is clear there will be a serious loss of dental knowledge to golf courses and backyard gardens. Who will see to the dental needs of the elderly in long-term care facilities? It won’t be the new graduates — they have neither the knowledge base, the interest, nor the stamina to handle some of the difficult situations encountered in these homes. How often does one see a new graduate have a long-term care facility “forced upon” him or her, only to rid him or herself of the responsibility at the earliest opportunity?

Several retiring dentists have told me that for $100, a licence can be obtained in the Yukon or the Northwest Territories. Another alternative is the “Third World” approach to dentistry, i.e., go to Thailand or Mexico for a while and take care of the needy there. Sure it helps some people. But have you ever seen the mouth of a resident in a Canadian long-term care home? It is in as dire a need for help as any mouth in the Third World. Unfortunately, to do some good as a dentist in Canada you have to pay a “tax” of about $5,000 a year (i.e., the above-mentioned registration licence fees and other expenses) before you can even volunteer. No wonder dental hygienists and denturists are scrambling to treat this population since their level of “taxation” is much lower.

Removing Barriers

Affordable Licensure

Imagine not having to mortgage your soul to provide dentistry to long-term care residents. In British Columbia, one barrier has been removed. Both the Association and the College of Dental Surgeons have agreed to give a licence and association fee grant to retiring dentists wishing to provide such care. This fund will be administered by the Dentistry Canada Fund. What is CDA doing? Currently, the membership fee for a retired dentist is considerable and it is a barrier to those wishing to treat the elderly in long-term care facilities. Given how understanding B.C. has been to its older dentists, the challenge now is for CDA to show similar support by reducing or eliminating its membership fees for these dentists.

Promoting Dental Plans

It is well known that people with dental plans seek dental treatment more often than those without plans. Recently the federal government announced its intention to have a voluntary dental service plan for public service pensioners. Although a step in the right direction, this plan will only help a small proportion of the aging population.

Pacific Blue Cross was approached by the Association of Dental Surgeons of B.C. to join its geriatric working group and the third-party payer has agreed. In Ontario, the provincial government has recently expressed a willingness to become involved in the “promotion” of oral health for the elderly by considering providing dental coverage for seniors.

There are other barriers to oral health for the elderly that cannot be removed overnight. We can best promote oral health if our own provincial and national associations and licensing bodies become aware of the crisis that is fast approaching. They should look to their policies and see where they can improve access to licensure for older dentists and help to reduce the “brain drain” of these dentists who still can and want to treat people. We are all aging. On a purely selfish level, wouldn’t it be good to know that you’ll have help from a dentist if you end up in a long-term care facility?

Dr. Battrum is chair of the geriatrics committee and president-elect of the Association of Dental Surgeons of British Columbia.

The views expressed are those of the author and do not necessarily reflect the opinion or official policies of the Canadian Dental Association.