he health of these patients' mouths was not exceptional. When people get sick, they neglect their teeth. This is only natural. However, It should be equally natural for family members, caregivers, nurses, and doctors to look in the mouths of geriatric patients to assess their unhealthy situation and seek appropriate treatment.
As dentists, we have a responsibility to educate other healthcare professionals and the general public about the oral health of geriatric patients" as well as how to assess and take care of the persistent infections that occur in the mouths of these individuals. We also have a responsibility to educate the allied medical professions about dental neglect, and its impact on the general health of their geriatric patients.
The Metropolitan Toronto Public Health Office puts out reams of statistics each year, but no one seems to be paying much attention. There is a tremendous need for organized dentistry and government to address the problems that exist in treating the Alzheimer patient, the elderly patient who has some form of dementia, the stroke patient who experiences some disabilities, and the cancer patient in palliative care.
We have healthy 70-year-old patients who have had all or most of their teeth restored or enhanced with fixed bridges, veneers, crowns, cosmetic restorative procedures, endodontic procedures, periodontal procedures (gingival grafts etc.), prosthetic appliances, and even orthodontics.
These patients have spent time and money to maintain and improve their oral health. But if they have a stroke, or other disabling disease, their access to quality dental care will likely be severely curtailed. They will probably be placed in a nursing home, where no one has the time or motivation to help them care for their teeth, or even to assess their oral health at admission. They eat each day, but no one is available to encourage them to follow good oral hygiene, or to take a brush to their teeth and gingiva.
We dentists, who have been well paid to restore and maintain the teeth of these patients in the past, forget or lose track of them once they are no longer able to visit our offices. Yet unless we meet our responsibility to educate the care-givers, family, and other health care professionals about the daily preventive dental care of these patients, their teeth will eventually rot in their mouths. By the time we get to see them, we wiII have a dilemma on our hands. It is difficult to provide restorative or corrective treatment, because these patients are very old, are often taking many medications for different ailments, and may have allergies.
Even patients who practice good oral hygiene to control calculus and plaque need to have their teeth professionally cleaned and scaled regularly. Unless you have seen it for yourself, it is hard to imagine what happens to the oral health of patients who either cannot care for their own teeth, or have no one to do it for them. Their mouths are full of plaque, calculus, inflammation, candidiasis, denture sore spots, hypertrophied tissue, loose dentures, xerostomia and even cancer.
In British Columbia, hygienists have taken on the responsibility of caring for these people. Dentists are not in the front line or anywhere near it. The situation is somewhat better in Manitoba. Under the leadership of Dr. Arthur Schwartz and Dr. Douglas Galan, the University of Manitoba has established a Home Dental Care Program that relies on a mobile dental clinic to provide service to nursing homes and some homebound patients. Care is provided by practitioners who are specifically trained in geriatric dentistry, assisted by dental students.
I recently surveyed the 10 Canadian dental faculties on their course guidelines. Of the seven faculties that responded, only one, the University of Alberta, has a specific 'geriatric dentistry' course. This course is offered in third and fourth years, and involves 27 hours of lectures and clinics over the two years.
The calendars and course outlines of the other six survey respondents included geriatric dentistry in their elective programs or as a part of the community care program, with no mention of any structured program of lectures or clinics.
In Quebec, McGill University offers a six-weekend, certificate granting program in geriatric dentistry. The University of Laval also has a program. It sent a dentist to be trained in the United States for two years. When he returns, he will head a program in geriatric dentistry. Quebec also seems to have an organized system to deliver dental services to the geriatric population.
In Ontario, where the majority of elderly Canadians live, some limited services are provided through public health offices. This occurs in regions where there is an interest, and sufficient finances, to provide examinations and some hygiene care. But the province's two dental faculties have provided no formal leadership in how to develop nursing home dental care programs in communities.
Dental clinical programs have been established in Toronto at BayCrest, Queen Elizabeth's Hospital, Sunnybrook Health Science Centre, and the Metro Toronto Community Health Services. Mobile dental services are only offered privately and by the Metro Toronto Community Health Services, however, and very little treatment is performed in mobile dental clinics.
The Ontario government issues a Standard of Care Programs and Services to all nursing homes and long-term care facilities, but it is not mandated and is only paid lip service. The problem is that no one wants to spend money on a quality oral hygiene program or a dental service that would require them to train a team of people in oral health care, and make them responsible for the care and assessment of the patients in a facility.
The Canadian dental profession has a responsibility to solve this dilemma. And it can be done. The Minneapolis-St.Paul metropolitan area has implemented a well-organized program that even includes a research component. Using a state-of-the-art portable dental delivery system, this program is attempting to provide nursing home residents with the same quality of dental care that they previously received from their local dentists. The program is called Apple Tree.
If our provincial governments co-operated by mandating care, and providing a subsidy to the poor through a Medicaid-like program that has minimum coverage, we could follow the Minneapolis-St. Paul example and at least try to care for the teeth we have saved.
At St. Peter's Hospital, a geriatric chronic care facility in Hamilton, Ont., we are in the process of developing a made in Canada model that can be adapted to the needs of individual communities. It will be based on a fee-for-service model, and administered by a foundation that is funded in cooperation with a service club or agencies. This should allow the program to become self-sustaining.
We currently have an active treatment clinic in the hospital, and are contracting with five longterm care facilities to provide a mobile treatment service. In addition, we are piloting a preventative care mobile service that will provide cleaning and scaling, as well as refer patients for necessary treatment. This model also includes research and educational components. The educational component is aimed at all long-term care workers (i.e. nurses, RPN'S, care givers, geriatric residents, physicians and dentists). Hopefully we will be able to publish some of our statistics and the results of our model in the near future.
In 1996, the Educational Centre for Aging and Health funded the publication of two papers written by Dr. Sandra Bennett, a senior dental consultant with Population Health Services, Public Health Branch, Ontario Ministry of Health, North York, Ontario, and myself. Both of these papers dealt directly with the topics presented in this article.
The first paper, Dental Care for Elderly Residents was published in the May 1996 issue of Canadian Nurse. It reported on the results of a survey, which was sent to the directors of provincially regulated long-term care facilities. The survey questionnaire was completed by 21 of 25 directors (84 percent). This survey addressed four concerns: which staff member are primarily responsible for the maintenance of the residents' oral health care needs; what services are they currently providing; what level of expertise do they have to perform these duties; and what continuing dental education would enable these staff to perform their duties more effectively.
Overall, the results of the survey indicate the need for a stronger alliance between the dental community and long-term care facilities. Despite the stated importance of dental health to the surveyed facilities and the recommendations of the Ontario Ministry of Health, only one-third of the facilities offered treament by a dental team, and only a few residents were given an initial dental assessment. The dental community could provide practical support to facilities in both these areas.
From a prevention perspective, it is disappointing that only 11 (52 per cent) of the facilities wanted to provide twice-daily oral hygiene for their residents. One of the most striking findings in this survey was that 18 of the respondents' facilities would like to provide treatment by a dental team.
The second article, Providing Care For Elderly Patients was published in the March 1996 issue of Ontario Dentist. It reported on the results of a survey to identify the knowledge needs of a group of dentists with respect to treating elderly patients. Of the 238 dentists who were sent questionnaires, 185 completed and returned them (78 per cent). Based on the data collected, we can now design our future continuing education programs to address these issues. Table 1 identifies the self-perceived need of participating dentists to increase their knowledge of specific topics related to geriatric dentistry.
The results show that 38 percent of the dentists spend more than 19 percent of their clinical time treating elderly patients. They also indicate that there is a need for further skills training to raise the dentists'comfort level. Twenty-five percent of the respondents indicated that they 'never' or only "some of the time" felt comfortable in treating medically-compromised or frail elderly patients. Only 16 percent responded that they felt their current knowledge base and experience enabled them to feel comfortable dealing with elderly patients and caregivers "some of the time" or "never". It is also a concern that 38 percent reported having difficulty accessing the information on geriatric patients that they required for the provision of dental treatment.
There is definitely a need for further education for both the directors of long-term care facilities and dental professionals. Only when the educational needs of these two groups are met will the elderly residents of long-term care facilities and the homebound be assured of the best dental care possible. This will happen when the discipline of geriatric dentistry is finally recognized. |
