A Survey of Hamilton-Wentworth Dentists' Perceptions
Of Their Education Needs
Sandra Bennett, BDS DDPH MSc
James Morreale, DDS

Ontario Dentist, March 1996, 44 - 54

The Canadian population, like other Western populations, is aging, and average life expectancy is rising. Consequently, the care of the elderly is assuming an increasingly important role in the planning for, and delivery of, health care services.¹ Dentistry should, therefore, address the needs of the Canadian population of the future and develop strategies to ensure that both current and future dentists are equipped to care for the aging population that they will encounter.

The elderly population has been defined as the cohort of individuals 65 years of age or older.² This chronological criterion is inappropriate because significant variation in physical, medical, and mental condition exists among older individuals. Irrespective of age, if a person remains relatively healthy, he or she may be treated (dentally) in much the same way a younger individual. Seventy per cent of the aging population are functionally independent.

The report of the Ontario University Coalition for Education in Health Care of the Elderly (1993)³ defined "geriatric dentistry" as a branch of dentistry "which focuses on the diagnosis, prevention and treatment of oral diseases in adults who, because of their medical condition or old age, are handicapped or institutionalized and require special management during their dental treatment."

The field of geriatric dentistry is rapidly changing. More elderly are retaining their natural dentition and, thus, they require more complex restorative procedures and more preventive strategies than previous cohorts of elderly. Because of this trend, there is a need for continual training of dentists in order to meet not only their needs for high level expertise but also the changing needs of their elderly patients. 4

As the population ages and the number of frail and/or medically-compromised individuals increases, demand for care outside the traditional dental practice will likely ensue. 5 Currently, approximately one Canadian in 10 is over 65 years of age. This represents a tripling in the proportion of elderly in Canada (from 4.1 percent to 11.6 per cent) between 1881 and 1991. By the year 2036, the elderly will represent over 23 per cent of the population. 6

This survey identifies the knowledge needs Of Hamilton-Wentworth dentists with respect to treating elderly patients. The data collected allow conclusions to be made regarding the issues/fields appropriate for inclusion in future continuing education programs for the group of dentists surveyed. Extrapolating conclusions to the general dental population should be made with caution because patient and dentist needs may vary from province to province.

Treatment of the Elderly Dental Patient

Prejudices exist in the way dentists make decisions regarding treatment planning for older patients. 7 The uncertainty and complexity related to treatment planning for frail and medically compromised elderly might contribute to some of the variation observed in treatment planning.

Maintenance of the dentition in this population is important, not only for quality of life but also for the maintenance of general health. Oral changes (e.g., changes in the ability to chew food and drug-induced xerostomia) may contribute to nutritional problems in the elderly. 8 These factors are often overlooked by the health care field in general, and thus, knowledge deficiencies on oral health are not confined to dental health care workers. 9 The knowledge base required to manage the oral health requirements of elderly individuals does not require mastery of new technical skills but a thorough understanding of the following:

Results
Response rate: 185 completed surveys (78 percent) were received prior to the selected cut-off date.
Characteristics of study subjects: Study subjects ranged in year of graduation (DDS or equivalent) from 1951 through to 1994 (Table 1).

It is clear from the results in Table 13 that dentists in the Hamilton-Wentworth area do not wish to have continuing education (on geriatric dentistry) that lasts for greater than two days. The majority of respondent dentists would prefer to have a one-day continuing education forum on either a weekend (37 percent) or a weekday (28 percent).

Discussion

Results show that 38 percent of respondent dentists spend greater than 10 percent of their clinical time treating elderly patients. Given demographic trends for Canada, this figure will likely rise over the coming decades as the "baby-boomers" move into their retirementment years.

The results indicate a trend toward greater wheelchair access with more recent graduation. This may be a reflection of emphasis on accessibility to health care services during training, an increase in awareness among younger graduates to the needs of the physically impaired or, it may reflect the time at which the dentist's practice was established. Newer practices are more likely to be designed to accommodate wheelchairs due to the greater awareness of this barrier to accessing dental care throughout society. Older graduates may be equally sensitive to the needs of the physically impaired but may be unable to alter their existing practices to accommodate wheelchairs. Where alteration is possible, consideration should be given to conducting alteration given the demographic trend.

Clearly, there is some understanding by dentists that there is a need for the provision of dental services within long-term care facilities. Seventeen percent of Hamilton-Wentworth dentists responded that they provide visits to long-term care facilities which is similar to the results obtained by MacEntee et al 16 (19 percent). A few participants indicated that they would like to provide services within such facilities but did not know how to initiate such an endeavour. Facilitation is required to match these dentists with facilities that desire the provision of dental services. The Hamilton Academy of Dentistry Geriatric Care Committee may be able to provide assistance in this area.

Results indicate that a need for further skills training is required to assist the 25 percent of respondents who indicated that they felt comfortable in treating medically-compromised or frail elderly either "some of the time" or "never" to raise their comfort level. This may indicate that dentists feel more comfortable dealing with the patient's dental condition and caregiver than with their medical management.

Only 16 per cent of dentists responded that they felt their current knowledge base and experience enabled them to feel comfortable dealing with an elderly patient's caregiver only "some of the time" or "never". It is possible that some dentists prefer to deal directly with their patient than with a third person such as a caregiver. If this is true, some re-education and experience may help ameliorate this feeling.

Geriatric dentistry was rated as being either "very important" or "somewhat important" to dentistry as a whole by 97 percent of dentists, demonstrating the high awareness of the responsibility of the profession to the continual treatment of the frail and medically-compromised elderly. However, geriatric dentistry was rated as being "very important" or "somewhat important" to the dentist personally by 94 percent of dentists. This may be a reflection of the fact that seven respondents (four percent) were either pedodontists or orthodontists who do not regularly deal with elderly patients, and/or that 58 percent of respondents spend 10 percent or less of their clinical practice time treating elderly patients.

It is a concern that 38 percent of respondent dentists reported having difficulty accessing the information on geriatric patients that was required for the provision of dental treatment. Collaboration between health care professionals when dealing with elderly patients may ensure a timely flow of critical information.

Dental journals appear to be well read with one-third of respondents citing journals as the information source from which they gained most of their information on dealing with elderly patients. This may be one forum for appropriate dissemination of geriatric dental continuing education. There were also a large number of respondents selecting more than one option for the question "where have you gained most of your information on dealing with the elderly patient?" For these dentists, journal articles were one of the information sources frequently cited. It is possible that dentists graduating prior to 1990 are accessing readily available theoretical sources to gain information compared to recent graduates (1990 or later) who utilize their dental school and/or hospital residency programs as a source of information.

It is conceivable that older graduates wish to update their didactic knowledge to complement their practical experience whereas recent graduates wish to gain practical experience to augment their up-to-date didactic knowledge base. This would be supported by the 12 dentists graduating from 1990 to 1994 who correctly checked the "other" category, citing either dental school or a hospital residency program as their main source of information on treating their elderly patients.

The disadvantage of dental journals as a mode of education is that clarification of an article or direct feedback is difficult. On the positive side, however, the infrastructure for such an educational tool is already in place and easy to access; therefore, it may be a useful adjunct to other forms of continuing geriatric dental education.

When asked about their preferred format for continuing geriatric dental education, 37 percent of dentists responded lecture / seminar and 24 percent sponded lecture plus clinical participation (where appropriate). Given that these two formats are similar, the clinical participation component may be offered additionally to the lecture / seminar for interested participants.

The majority of dentists rated themselves as requiring some more knowledge in most of the topic categories listed and when asked to rate their level of knowledge on a variety of topics related to the practice of geriatric dentistry, data reveal that for six of the topics listed many respondent dentists felt that they required more knowledge. They were:

1. Setting up a dental program in a long-term care facility (over one-third of respondent dentists felt that they "need much more knowledge in...")
2. Communication techniques for the sensory impaired elderly patient;
3. Management of a medical emergency during the treatment of an elderly patient;
4. Potential drug interactions between dental medications commonly consumed by the elderly;
5. Elder abuse and the dentist's role in diagnosis; and
6. The clinical assessment of the elderly patient for sensory and functional impairment.

While setting up a dental program in a long-term care facility was the top-ranked topic for lack of knowledge, it was one of the least popular topics selected for continuing education. Dentists may prefer to treat patients in their dental offices where they feel they can provide a larger range of services or feel that they do not have training which would allow them to feel at ease with the provision of services in long-term care facilities. There is likely a need for more dialogue between long-term care facility representatives and the Geriatric Care Committee at the Hamilton Academy of Dentistry to match facility and dentist's needs.

The areas in which dentists most often felt they had sufficient knowledge were:

1. The impact of oral disease on quality of life;
2. The demographics of aging;
3. The biological, physiological and psychological changes that occur with age; and
4. The awareness of, and sensitivity to, the emotional aspects of dealing with the dying patient.

These are perhaps not surprising given the high level of awareness among the dental profession about population trends. In addition, dentists see and hear first-hand the impact on quality of life of dental conditions on a daily basis and have all studied (to some extent) the biological, physiological and psychological aspects of aging during their training.

Kress (1991) 17 recommended that continuing education in geriatric dentistry be targeted to specific clinical areas in order to improve course attendance which many academics feel falls short of dental practitioners' needs. Respondent dentists selected the following choices for continuing education: (1st) Clinical decision making for the frail and/or medically compromised elderly patient; (2nd) Preventive strategies for the elderly patient; (3rd) Managing a medical emergency when treating an elderly patient; and (4th equal) The biological, physiological and psychological aspects of aging and their effect on oral health. and assessment of the frail and/or medically-compromised elderly patient.

Preventive strategies are becoming more important as more elderly are keeping their natural dentition and it would appear that dentists would like some direction with this important area of clinical practice. Decisions around preventive strategies are also part of clinical decision making. The latter forms a very important part of both the general dental practitioner's and many specialist dental practitioner's clinical practice for without the correct clinical assessment and decisions, one cannot formulate the correct treatment or preventive strategy. An up-to-date basic understanding of the biological, physiological and psychological aspects of aging would provide a sound base on which to build a clinical assessment and, therefore, the most popular topic choices for continuing dental education are complementary. While it is hoped that a medical emergency will not arise if the above listed topics are dealt with adequately, one must commend dentists on wishing to be informed and prepared for the unexpected. Such preparation may make the difference between an acceptable and an unfortunate outcome should an emergency arise.

The topics selected all have a multidisciplinary focus, indicating that there is a need for collaboration between health care disciplines in order to adequately provide for the continuing education needs of Hamilton-Wentworth dentists.

ConclusionsThe Hamilton-Wentworth dentists participating in this survey indicated that they would benefit from geriatric continuing education on a variety of topics.

Data revealed that the topics respondent dentists felt that they required the most knowledge on were:

1. Setting up a dental program in a long-term care facility;
2. Communication techniques for the sensory-impaired elderly patient;
3. Management of a medical emergency during the treatment of an elderly patient;
4. Potential drug interactions between dental medications and medications commonly consumed by the elderly;
5. Elderly abuse and the dentist's role in diagnosis; and
6. The clinical assessment of the elderly patient for senory and functional impairment.

Respondent dentists indicated that their top choices future continuing education were:

1. Clinical decision making for the frail and/or medcally-compromised elderly patient;
2. Preventive strategies for the elderly patient;
3. Managing a medical emergency when treating an elderly patient; and
4. The biological, physiological and psychological aspects of aging and their effect on oral health and,assessment of the frail and/or medically-compromised elderly patient. These topics should be considered by those persons responsible for conducting continuing education courses for health care professionals in Ontario.

These topics also indicate that there is likely a need for collaboration between health care disciplines in order to adequately provide for the continuing education needs of Hamilton-Wentworth dentists because the topics selected all have a multidisciplinary focus. Organizers of continuing dental education for the Hamilton-Wentworth region should take note that lectures/seminars with an optional practical component (where applicable) were the preferred forum indicated for such continuing education with one day (either on the weekend or during the week respectively) being the preferred length of the course.

References

1. Ontario University Coalition For Education In Health Care Of The Elderly. Education Development and Curriculum Content in Aging and Health: Guidelines for Health Professionals In Ontario.Education Centre for Aging and Health, Hamilton (1993).
2. Ettinger, R.L. and Berkey, D.B. Treatment Planning for the Older Adult In Papas, A., Niessen, L.C., and Chauncey, H.H. (Eds.). Geriatric Dentistry, Aging and Oral Health(pp.126-128). Mosby Year Book Inc.Toronto (1991).
3. Ontario University Coalition For Education In Health Care Of The Elderly. Education Development and Curiculum Content in Aging and Health: Guidelines for Health Professionals In Ontario. Education Centre for Aging and Health, Hamilton (1993).
4. Gutman, G.M., and Wister, A.V. Health Promotion For Older Canadians: Knowledge Gaps and Research Needs(p.50). Simon Fraser University, Burnaby, B.C. (1994).
5. MacEntee, M.I., Weiss, R.T., Waxler-Morrison, N.E., and Morrison, B.J. Opinions of Dentists on the Treatment of Elderly Patients in Long-Term Care Facilities. Public Health Dent 52(4):239-244 (1992).
6. Statistics Canada. Population Aging and the Elderly, Current Demographic Analysis (p.11). Statistics Canada, Ottawa (Catalogue #91-533E) (1993).
7. Ettinger, R.L. and Berkey, D.B. Treatment Planning for the Older Adult In Papas, A., Niessen. L.C., and Chauncey, H.H. (Eds.). Geriatric Dentistry, Aging and Oral Health (pp. 126-128). Mosby Year Book Inc. Toronto (1991).
8. Palmer, C.A. Nutrition and Oral Health of the Elderly. In Papas, A-, Niessen, I-C., and Chauncey, H.H. (Eds.). Geriatric Dentistry, Aging and Oral Health (p. 265). Mosby Year @ Inc. Toronto (1991).
9. Palmer, C.A. Nutrition and Oral Health of the Elderly In Papas, A-, Niessen, L.C., and Chauncey, H.H. (Eds.).Dentistry, Aging and Oral Health (p. 265). Mosby Year Book Inc. Toronto (1991).
10. Ettinger, R.L. and Berkey, D.B. Treatment Planning for the Older Adult. In Papas, A., Niewn, L.C., and Chauncey, H.H. (Eds.). Geriatric Dentistry, Aging and Oral Health (pp.126-128). Mosby Year Book Inc. Toronto (1991).
11. Ettinger, P-L. and Berkey, D.B. Treating Planning for the Older Adult. In Papas, A., Niessen, L.C., and Chauncey, H.H. (Eds.). Geriatric Dentistry, Aging and Oral Health (pp. 126-128). Mosby Year Book Inc. Toronto (1991).
12. Kiyak, H.A., and Brudvik,J. Dental Students' Self-Assessed Competence in Geriatric Dentistry. Dental Educ 56(11):728-734 (1992).
13. Kress, G. An Analysis of the Supply and Demand for Continuing Education in Geriatric Dentistry. Special Care in Dentistry 11 (4):151-154 (1991).
14. MacEntee, M.I., Weiss, R.T, Waxler-Morrison, N.E., and Morrison, B.J. Opinions of Dentists on the Treatment of Elderly Patients in Long-Term Care Facilities. Public Health Dent 52 (4).,239-244 (1992).
15. Dillman, D.A. Mail and Telephone Surveys - The Total Design Method. Whiley-Interscience, New York (1978).
16. MacEntee, M.I., Weiss, R.T, Waxler-Morrison, N.L, and Morrison, B.J. Opinions of Dentists on the Treatment of Elderly Patients in Long-Term Care Facilities. Public Health Dent 52 (4);239-244 (1992).
17. Kress, G. An Analysis of the Supply and Demand for Continuing Education in Geriatric Dentistry. Special Care in Dentistry 11(4):151-154 (1991).

Acknowledgements

Drs. Bennett and Morreale wish to acknowledge the Educational Centre for Aging and Health (ECAH) and its Director, Dr. A.S. Macpherson, for their support of this project. ECAH was established in the Faculty Of Health Sciences at McMaster University in 1987 with funding from the Ontario government through the Ministry of Colleges and Universities.
At the time this study was conducted, Dr. Bennett was a Dental Consultant for the Educational Centre for Aging and Health and part-time Director of Dental Services at Perth District Health Unit.