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,…