What is Being Taught to Canadian Undergraduate Dental Students About the Oral Health of Long-Term Care Residents?

Introduction

On average, Canadians are living longer and, more often than not, retaining their teeth.^1,2 The geriatric population, particularly those in long-term care (LTC) facilities, is more susceptible to oral conditions, such as xerostomia, periodontal disease and caries. This is because of deterioration of general health, changes in diet, an increased intake of medications and increasing frailty.^2-4 Residents of LTC facilities may have or develop dexterity issues, making it difficult for them to care for their own teeth. Furthermore, mobility challenges, along with physical or mental compromise, such as dementia, can affect their ability to carry out daily mouth care.³ More important, poor oral health can have effects on systemic conditions, including but not limited to cardiovascular and respiratory health.^5,6 Poor oral health is a risk factor for diabetes and affects quality of life, including nutrition, speaking and socializing with others.^5,7 Oral health is part of general health, and a resident’s overall health can be impacted by it.

People living in LTC are a vulnerable population and may depend on staff for their mouth care, especially those with physical and cognitive impairment.³ Oral health care standards for LTC residents are not always enforced, and their oral care does not often meet best practice standards.⁸ This shortcoming can be a result of such factors as limited education of staff regarding oral health care, resistant behaviour by residents, lack of adequate supplies and time constraints; staff may also be unprepared or unqualified to provide mouth care. In addition, each LTC resident has specific needs and requires individualized mouth care.⁹ Residents not receiving individualized daily preventative oral care may, consequently, require professional dental and/or dental hygiene treatment.

There is a need for comprehensive understanding of the oral health of LTC residents and the barriers and facilitators involved in providing oral care to them; such information can aid in developing and implementing effective strategies to optimize the oral health of the aging population. In addition, to instill a professional attitude toward the elderly, undergraduate dental education should facilitate the acquisition of the specialized knowledge and skills needed to treat geriatric patients.¹⁰

The purpose of this study was to determine to what extent accredited dental and dental hygiene programs in Canada prepare students in the areas of geriatric oral health and oral health of LTC residents.

Methods

We surveyed all 10 accredited dentistry and 4 university-based dental hygiene programs in Canada represented by their associate deans, programs directors, chairs of geriatric dentistry or curriculum directors. The Commission on Dental Accreditation of Canada (CDAC) provided the names of all eligible accredited programs. This study was approved by the University of Manitoba’s Health Research Ethics Board.

In May 2016, a questionnaire was sent via Fluid Survey (Survey Monkey, USA) to an identified contact (i.e., an associate dean, programs director, chair of geriatric dentistry or curriculum director) at each institution (n = 14). Completing the online questionnaire constituted informed consent. A reminder was sent to all non-responders, along with the questionnaire link; a final reminder was sent in November 2016.

The project team developed the questionnaire to determine what type and how much clinical experience and education undergraduate dental and dental hygiene students receive on geriatric oral health and the oral health of LTC residents. A previously developed tool used to survey dental programs about teaching in the area of infant oral health informed this current work.¹¹ Specific questions explored methods and materials used to educate students and the number of hours dedicated to each method.

Information collected via the survey was exported to an Excel spreadsheet (Microsoft, Redmond, Wash., USA) and analyzed using Number Cruncher Statistical Software (version 13, Kaysville, Utah). Statistics included frequencies, means and standard deviations (SD). Bivariate analysis was conducted using χ2 and t tests. A p value ≤ 0.05 was considered significant.

Results

Description of Participants

Representatives of 9 of the 10 accredited dental and all 4 university-based dental hygiene programs responded to the survey for an overall 93% response rate. For all dental hygiene schools (100%) and 7 dental schools (77.8%), respondents stated that the geriatric oral health of people living in LTC facilities is an explicit component of their curriculum (Table 1). Although most (84.6%) indicated that geriatric oral health is a vital part of their dental program, the remaining respondents (15.4%) indicated that their program is considering adding it to the curriculum.

Only 6 respondents (46.2%) were aware of the Canadian Dental Association’s (CDA) position statement on the oral health care of LTC residents (Table 1), 2 dental programs (22.2%) and 4 dental hygiene programs (100%). Furthermore, only 2 dental programs (22.2%) and 2 dental hygiene schools (50%) reported using this statement as a teaching tool. Most respondents (84.6%) indicated that their program educates about medically, physically and cognitively compromised geriatric patients.

Most respondents (76.9%) stated that their program provides didactic learning opportunities on the oral health of LTC residents (Table 1). However, the time devoted to this topic varied, with dentistry programs allotting an average of 12.5 ± 6.3 h (mean ± SD; range 5–22 h) and dental hygiene programs allotting an average of 15.5 ± 5.7 h (range 12–24 h).

The topics included in didactic learning opportunities are shown in Table 2. Some respondents reported that they face barriers when providing opportunities regarding LTC residents’ oral health (Table 3). The main barrier to didactic teaching on this topic appeared to be time constraints within the curriculum.

In terms of clinical education opportunities with LTC residents, 8 programs (61.5%) provide students with clinical experiences, including 3 dental hygiene schools (75%) and 5 dental schools (55.5%). Of these opportunities, most (75%, 6/8) are requirements of the program, while the remaining 25% (2/8) are elective. Clinical opportunities and experiences for dental and dental hygiene students most commonly take place through the use of mobile dental and dental hygiene equipment at LTC facilities; at dental public health/community clinics, dental clinics within LTC facilities; and at hospitals and rehabilitation centres (Table 4).

There was considerable variation in the number of hours of exposure of students to such clinical opportunities: dentistry programs: 15.4 ± 15.8 h, dental hygiene programs: 24.0 ± 13.0 h. Oral health assessments and daily mouth care of LTC residents were important components of these clinical opportunities. Most respondents (7 or 53.8%) stated that their program also taught students about proper positioning techniques when providing dental and dental hygiene care as part of the didactic and clinical educational opportunities.

Some programs reported barriers to providing clinical educational opportunities to students working with LTC residents (Table 5). These included lack of academic staff, lack of access to LTC residents, lack of funding for residents for dental services, time constraints in the curriculum, minimization of the importance of daily oral care, lack of resources and educational tools, insufficient funding and not listed as an accreditation requirement. In addition, less than a third of dental programs reported that all students receive clinical experiences with LTC residents. In contrast, respondents from 3 of the 4 dental hygiene schools (75%) reported that all students have clinical experience in LTC.

More than half of the respondents (53.8%) indicated that their program has a mobile dentistry/dental hygiene program for residents working in LTC facilities (Table 1). This included 4 dental schools (44.4%) and 3 dental hygiene schools (75%). In addition, all dental hygiene schools and 44.4% of dental schools reported providing mouth care training for caregivers and staff working with LTC residents.

Discussions

This is the first Canadian study in recent decades to examine university-based dental and dental hygiene curricula pertaining to geriatric dentistry and the oral health of LTC residents. It was initiated at the request of the Manitoba Dental Association (MDA) to determine what proportion and to what depth and breadth dental and dental hygiene programs offer geriatric didactic and clinical opportunities for their students. The findings will help inform MDA advocacy activities in the area of geriatric oral health and residents of LTC facilities. They also provide an insight into the types of barriers preventing dental and dental hygiene schools from offering didactic and clinical education on geriatric oral health in LTC facilities.

Despite efforts to teach students about this important topic through clinical and didactic opportunities, our study revealed considerable variation in curricula and time devoted to the topic. For instance, the mean number of hours devoted to clinical training opportunities is greater than number of hours spent in didactic learning opportunities (18.6 ± 14.5 h vs. 13.7 ± 6.0 h). Dental institutions should further evaluate how well they are preparing dental professionals to provide care in LTC facilities. However, it is encouraging to note that 77.8% of dental schools and all of the dental hygiene schools considered the oral health of LTC residents an important component of their curriculum.

According to survey respondents, only 1 dental school provides postgraduate training in geriatric dentistry, and no dental hygiene school offers such educational opportunities to students. In the United States, 1 study stated that if a specific geriatric dentistry program exists, a broader range of interdisciplinary topics is likely to be taught to dental students provided they are combined with extracurricular and intracurricular clinical experiences.¹² Postdoctoral and fellowship programs in geriatric dentistry would be beneficial, as they would increase the number of postdoctoral academic training opportunities for dental faculty. In addition, they would expand the numbers and types of alternative pathways to geriatric education for dental and dental hygiene professionals and encourage lifelong learning.¹³ Regardless, representatives of all dental hygiene schools and 7 dental schools reported educating their students about medically, physically and cognitively compromised geriatric patients.

This study reports on important challenges to providing didactic learning opportunities regarding the oral health of LTC residents. In addition to the barriers revealed in this study, Chowdhry et al.¹⁴ reported that dentists themselves feel it is time consuming to treat elderly patients. They also noted the lack of administrative and financial support for dental services as additional barriers to providing dental care in LTC facilities. Similarly, time constrains in terms of having a busy private practice, were the main barrier preventing dentists in Manitoba from providing oral care in LTC facilities.¹⁵

Factors that impede the expansion of geriatric teaching in dental schools include already full dental curricula, the perception that predoctoral dental students cannot treat medically compromised patients, the assumption that the care taught in dental schools is not compatible with the kind of care elderly patients need and the impression that faculty members do not feel comfortable supervising students who are caring for elderly patients.¹⁶

Residents of LTC facilities face financial barriers to oral health care services. Some in society are now advocating for publicly insured dental benefits for this demographic.¹⁷ Finances may hinder dental and dental hygiene institutions from reforming their curricula. Limited financial resources have already been identified as a barrier to the development of gerodontology curricula in Austria, Switzerland and Germany.¹⁸ One suggested way to overcome this is by intensifying communication, cooperation and collaboration among university dental schools.¹⁸ The guidelines of the Association for Dental Education in Europe suggest that this can be done by encouraging the exchange of faculty members and students.¹⁹

According to our study, 75% of dental hygiene programs and 55.6% of dental schools provide their students with clinical experiences with LTC residents. A study by Ettinger and colleagues¹⁶ stated that schools with special care or extracurricular clinics in LTC facilities provide positive and adequate experiences that allow trainees to gain confidence in caring for functionally dependent people.

Didactic teaching, with the opportunity to provide clinical treatment to patients, is well accepted by students compared with simply carrying out diagnostic procedures and treatment planning, which frustrates students as they are not able to provide actual treatment.¹⁸ Clinical experiences with older adults through extracurricular clinical rotations are associated with positive student attitudes toward this group and their being more likely to want to treat medically compromised patents after dental school.²⁰ Without such positive clinical experiences, most graduates are unlikely to care for these patients in a private practice.^15,21

If providing clinical experiences is the academic goal of an educational institution, it is important to consider why most dental schools continue to prefer a lecture-based format for teaching geriatric dental care. Levy N and colleagues²⁰ found 4 major barriers to providing geriatric clinical experiences to students: not enough time, lack of adequately trained academic faculty, lack of student exposure to truly medically compromised patients and a discordance between competency assessment and treatment of patients with special needs.

The lack of adequately trained academic faculty members could be addressed by providing advanced education to all faculty members with the benefit of expanding the number of trained dentists capable of treating medically compromised older adults.²⁰ The British Columbia Dental Association’s report on Oral Health Care Delivery in Residential Care Facilities stated that many dental professionals are not familiar with the complexities of working with the geriatric population.³ Further training on caring for seniors with dementia, cognitive frailties and multiple chronic health conditions would help increase confidence in treating this expanding population.³

As most of older patients seen in program-based dental clinics are moderately healthy, students are not seeing patients who require the highest levels of care, such as those in nursing homes and LTC facilities.^20,22 Exposing students to special care clinics would help them gain more experience in this area and, hence, allow treatment of a wider range of medically compromised patients.²⁰

Providing oral health care to LTC residents is quite demanding for staff, as many residents have limited mobility, impaired visual acuity, cognitive impairment and decreased manual dextrity.¹ All of these factors contribute to residents relying on LTC staff, who may be overloaded with other daily work duties, experience frequent interruptions and have little training in oral health management.^8,23,24 Two recent studies reported that nursing staff perceive time constraints, being overworked and uncooperative behaviour of residents, such as screaming and resisting care, as the top barriers to oral care delivery in LTC facilities.^25,26 Designing condensed oral health educational programs aimed at nursing home or LTC staff may be instrumental in addressing the aforementioned oral care barriers. In addition, the family of LTC residents may be pivotal in alleviating some of the staff’s workload burden by providing some oral care.²⁵

As LTC residents have mobility issues, it is important to ensure that dental and dental hygiene students have the knowledge and physical ability to deal with these accessibility barriers. In our study, 75% of the dental hygiene schools had a mobile dental program for LTC residents, which can aid in alleviating accessibility issues. According to Tang et al.,¹⁵ having proper portable equipment motivates dentists to care for residents living in LTC facilities.¹⁵ Mobile clinics can provide a wide range of services, such as fillings, extractions and dental hygiene and can reach across geographic and socioeconomic boundaries, potentially increasing access and improving clinical oral health status and outcomes.²⁷

Daily mouth care should be a priority for LTC staff, as a healthy mouth contributes to the overall health and well-being of residents.¹⁵ Inadequate mouth care results in poor oral hygiene, which is associated with caries (tooth decay), mucosal inflammation and periodontal diseases.^9,28 Patients with periodontal diseases harbour a large number of subgingival, Gram-negative bacteria, which have been associated with lower respiratory tract infections, such as aspiration pneumonia.²⁹ Complications from aspiration pneumonia, including hypotension and bacteremia, can be fatal.³⁰

This study is not without limitations. Although the response rate was high (92.9%), it would have been better if all 10 dental schools had participated. In addition, we surveyed only the 4 university-based dental hygiene programs rather than all accredited hygiene programs in Canada. Recall and response biases are possible, as respondents were asked to estimate the amount of time devoted to geriatric oral health in their curriculum. There is a possibility that some may have responded in a particular manner to position their program in a better way.

Conclusion

Geriatric oral health care is an important part of the curriculum of most dental and dental hygiene programs in our study. However, not all are providing students with clinical training opportunities with LTC residents. Meeting the oral health needs of this population requires urgent attention and care from dental and dental hygiene professionals. Barriers to providing didactic and clinical opportunities to students include a lack of teaching staff, lack of funding, time constraints and lack of access to geriatric populations. Oral health educational institutions must ensure that they are embedding evidence-based gerodontology in their curricula to reflect the oral and overall health needs of today’s aging population. Dental and dental hygiene schools should supplement their curricula to include geriatrics for all students.

THE AUTHORS

	Dr. Singh is research assistant, department of preventive dental science, Dr. Gerald Niznick College of Dentistry, Rady faculty of health sciences, University of Manitoba, Winnipeg, Manitoba.
	Dr. Schroth is professor and clinician scientist, department of preventive dental science, Dr. Gerald Niznick College of Dentistry and departments of pediatrics and child health and community health sciences, Max Rady College of Medicine, Rady faculty of health sciences, University of Manitoba. He is also research scientist, Children’s Hospital Research Institute of Manitoba, Winnipeg, Manitoba.
	Dr. Tang is a private practice dentist, in Airdrie, Alberta.
	Prof. Bertone is associate professor and director, School of Dental Hygiene, Centre for Community Oral Health, Dr. Gerald Niznick College of Dentistry, Rady faculty of health sciences, University of Manitoba, Winnipeg, Manitoba.
	Ms. Yerex is Assistant Professor, School of Dental Hygiene, Dr. Gerald Niznick College of Dentistry, Rady faculty of health sciences, University of Manitoba, Winnipeg, Manitoba.
	Dr. Hai-Santiago is Provincial Oral Health Consultant, Manitoba Health, Seniors and Active Living, Winnipeg, Manitoba.
	Dr. Finlayson is president at Finlayson and Associates Consulting, Inc.
	Manitoba Dental Association Committee on Dental Care for Residents in Long-Term Care Institutions, Winnipeg, Manitoba.

Correspondence to: Dr. Robert J. Schroth, 507—715 McDermot Ave., Winnipeg MB R3E 3P4. Email: robert.schroth@umanitoba.ca.

This article has been peer reviewed.

References

1. Matthews DC, Clovis JB, Brillant MG, Filiaggi MJ, McNally ME, Kotzer RD, et al. Oral health status of long-rerm care residents — a vulnerable oopulation. J Can Dent Assoc. 2012;78:c3.
2. Wyatt CC, Kawato T. Changes in oral health and treatment needs for elderly residents of long-term care facilities over 10 years. J Can Dent Assoc. 2019;85:1-6.
3. Adair L, Brodie A, Bunting N, Demque J, Gee U, Gillan R, et al. Oral health care delivery in residential care facilities: a report of the Seniors’ Oral Health Secretariat. Vancouver: British Columbia Dental Association; 2011.
4. Muscedere J, Andrew MK, Bagshaw SM, Estabrooks C, Hogan D, Holroyd-Leduc J, et al. Screening for frailty in Canada’s health care system: a time for action. Can J Aging. 2016;35(3):281-97.
5. Azarpazhooh A, Leake JL. Systematic review of the association between respiratory diseases and oral health. J Periodontol. 2006;77(9):1465-82.
6. Tavares M, Lindefjeld Calabi KA, San Martin L. Systemic diseases and oral health. Dent Clin North Am. 2014;58(4):797-814.
7. Huang DL, Chan KC, Young BA. Poor oral health and quality of life in older U.S. adults with diabetes mellitus. J Am Geriatr Soc. 2013;61(10):1782-8.
8. Hoben M, Clarke A, Huynh KT, Kobagi N, Kent A, Hu H, et al. Barriers and facilitators in providing oral care to nursing home residents, from the perspective of care aides: a systematic review and meta-analysis. Int J Nurs Stud. 2017;73:34-51.
9. McNally ME, Martin-Misener R, Wyatt CC, McNeil KP, Crowell SJ, Matthews DC, et al. Action planning for daily mouth care in long-term care: the Brushing Up on Mouth Care Project. Nurs Res Pract. 2012;2012:368356.
10. Brondani MA, Chen A, Chiu A, Gooch S, Ko K, Lee K, et al. Undergraduate geriatric education through community service learning. Gerodontology. 2012;29(2):e1222-9.
11. Schroth RJ, Quiñonez RB, Yaffe AB, Bertone MF, Hardwick FK, Harrison RL. What are Canadian dental professional students taught about infant, toddler and prenatal oral health. J Can Dent Assoc. 2015;81:f15.
12. Mohammad AR, Preshaw PM, Ettinger RL. Current status of predoctoral geriatric education in U.S. dental schools. J Dent Educ. 2003;67(5):509-14.
13. Ettinger RL. The development of geriatric dental education programs in Canada: an update. J Can Dent Assoc. 2010;76:a1.
14. Chowdhry N, Aleksejūnienė J, Wyatt C, Bryant R. Dentists’ perceptions of providing care in long-term care facilities. J Can Dent Assoc. 2011;77:b21.
15. Tang S, Finlayson G, Dahl P, Bertone MF, Schroth RJ, Manitoba Dental Association. Dentists’ views on providing care for residents of long-term care facilities. J Can Dent Assoc. 2019;85:j8.
16. Ettinger RL, Goettsche ZS, Qian F. Predoctoral teaching of geriatric dentistry in U.S. dental schools. J Dent Educ. 2017;81(8):921-8.
17. Quiñonez CR, Figueiredo R, Locker D. Canadian dentists’ opinions on publicly financed dental care. J Public Health Dent. 2009;69(2):64-73.
18. Nitschke I, Kunze J, Reiber T, Sobotta BA. Development of undergraduate gerodontology courses in Austria, Switzerland, and Germany from 2004 to 2009. J Dent Educ. 2013;77(5):630-9.
19. Cowpe J, Plasschaert A, Harzer W, Vinkka-Puhakka H, Walmsley AD. Profile and competences for the graduating European dentist — update 2009. Eur J Dent Educ. 2010;14(4):193-202.
20. Levy N, Goldblatt RS, Reisine S. Geriatrics education in U.S. dental schools: where do we stand, and what improvements should be made? J Dent Educ. 2013;77(10):1270-85.
21. McQuistan MR, Kuthy RA, Qian F, Riniker-Pins KJ, Heller KE. Dentists’ treatment of underserved populations following participation in community-based clinical rotations as dental students. J Public Health Dent. 2010;70(4):276-84.
22. Holbrook WP, Brodin P, Balciuniene I, Brukiene V, Bucur MV, Corbet E, et al. Balancing the role of the dental school in teaching, research and patient care; including care for underserved areas. Eur J Dent Educ. 2008;12(Suppl 1):161-6.
23. Dharamsi S, Jivani K, Dean C, Wyatt C. Oral care for frail elders: knowledge, attitudes, and practices of long-term care staff. J Dent Educ. 2009;73(5):581-8.
24. Jablonski RA, Munro CL, Grap MJ, Elswick RK. The role of biobehavioral, environmental, and social forces on oral health disparities in frail and functionally dependent nursing home elders. Biol Res Nurs. 2005;7(1):75-82.
25. Yoon MN, Steele CM. Health care professionals’ perspectives on oral care for long-term care residents: nursing staff, speech-language pathologists and dental hygienists. Gerodontology. 2012;29(2):e525-35.
26. Hoben M, Kent A, Kobagi N, Huynh KT, Clarke A, Yoon MN. Effective strategies to motivate nursing home residents in oral care and to prevent or reduce responsive behaviors to oral care: a systematic review. PLoS One. 2017;12(6):e0178913.
27. Jafari M, Saskatoon Health Region T. Oral health status of Saskatchewan long term care residents: an evaluation following the implementation of the Better Oral Health in Long Term Care program. Saskatoon, Saskatchewan: Saskatoon Health Region, Oral Health Program, Population and Public Health; 2017.
28. Wyatt CC. Elderly Canadians residing in long-term care hospitals: Part II. Dental caries status. J Can Dent Assoc. 2002;68(6):359-63.
29. El-Solh AA. Association between pneumonia and oral care in nursing home residents. Lung. 2011;189(3):173-80.
30. Stein P, Aalboe J, Skelton J, Bright BM. Housley M. Meeting oral health challenges in long-term care facilities. Ann Long-Term Care. 2012;20(9):30-4.