A 30-year review of a geriatric dentistry teaching programme
Ronald L. Ettinger BDS, MDS, DDSc, DABSCD, Professor, Department of Prosthodontics and Dows Institute for Dental Research, University of Iowa, Iowa City, IA 52242, USA.
Tel.: (319) 335 7378
Fax: (319) 335 8895
A 30-year review of a geriatric dentistry teaching programme
Objective: To review the development of the Geriatric Dental and Special Needs Education programme at the University of Iowa over the last 30 years.
Background: The programme at Iowa evolved from a didactic elective programme taught by a single faculty person to a required didactic and clinical programme, which includes a Special Care Clinic in the dental school and a mobile unit with portable dental equipment which serves ten area nursing homes with comprehensive care.
Materials and methods: Changes have been made in the programme over time based on formal and informal feedback from students and graduates, and we have also looked at the impact of the programme on dental services to our target population.
Results: The factors influencing the curriculum development are identified and discussed.
Conclusion: As no dental schools are the same, some general applications are suggested from the Iowa experience.
In the last 100 years, through advances in public health and innovations in the treatment of disease, the industrialised world has added 30 years to a person’s longevity at birth1–4. There have been similar advances in dental care, which has evolved from exodontia and vulcanised complete dentures associated with the focal infection theory proposed in 19115–8, to today’s advanced restorative techniques with computer assisted design/computer assisted manufacturing, implants and lasers, and an understanding of preventive care9–11. These changes in oral status have had a direct and dramatic effect on the oral health needs of the ageing population12–15.
In the past, the majority of elderly people were edentulous, and they sought dental care only when previously unmet needs could no longer be ignored7,16. However, in the last 30 years, the majority of the US population aged 65 and older have retained some of their natural teeth13,17 These dentate older adults have become a much larger portion of the population and they are better educated, more politically aware, and more easily accept social services. They tend to be more economically secure, and there is evidence to show that they may be healthier, with higher health expectations18. They may not have benefited from preventive dental care as children, but many have become active preventive dental patients as adults. Dentate older adults are 6.5 times more likely to seek dental care than their edentulous counterparts12. However, these dentate persons do have a higher risk of new coronal and root caries as well as recurrent caries. This is because they have age-related recession with changes in the microenvironment of their mouth, and so they have changes in the biofilm on the teeth, and these changes may result in problems removing plaque19,20. Another complication is that many medications used to manage their chronic diseases have anticholinergic properties, which can cause xerostomia or may cause salivary gland hypofunction, which affects about 30% of this older adult population21,22. This reduction in the quality and quantity of saliva can create potential difficulties with mastication, gustation and swallowing, as well as the ability to wear dentures comfortably. As many of these persons wear some kind of prosthesis, they also have a higher risk of denture-related oral mucosal problems. Ill-fitting or worn dentures may contribute to inappropriate nutritional selection23.
However, these older dentate adults utilise dental services similar to younger dentate adults, provided they remain functionally independent24. Thus, their use of dental services is related more to the presence of a natural dentition rather than to age25. These older patients may have a wide range of complex restorative needs. They also may have bone loss owing to periodontal disease, as well as caries, and unresolved periapical pathology. Unlike previous cohorts, these dentate older adults will not accept extraction of their remaining natural dentition and their replacement with complete dentures as the treatment of choice26–28.
Having more older adults with more teeth creates not only more needs but also more complex needs29. The scope of geriatric dentistry now extends well beyond denture care to include more complex aesthetic and restorative procedures as well as orthodontics, veneers and dental implants. Even denture care, which may be considered a comparatively simple treatment intervention, has become much more complex for the older geriatric patients30. While the number of elders with complete dentures is decreasing (in 2004, 20.2% of persons 65 and older were edentulous31), many of these older adults have been edentulous for over 25 years and may have severely resorbed ridges or compromised ridge forms, which may make wearing mandibular dentures particularly difficult32. Additionally, many in this group will have chronic debilitating diseases that may limit their tolerance of dental procedures or lower their neuromuscular ability to adjust to new dentures, which may make wearing dentures difficult33. Maintaining good oral function and comfort for even the ‘simple’ denture patient requires skilful management of all of these factors and can challenge even the most experienced dentist.
When treating dentate patients who require more invasive procedures, the challenges grow exponentially. Treatment of older patients demands excellence in clinical techniques because tissues, neural control and functional reserves may be compromised. Therefore, dentists who treat geriatric patients should be clinicians who have good assessment skills as well as technical expertise. These skills should include the ability to comprehensively assess how the patient functions in his/her environment and understand how oral health fits into their overall well-being. It is imperative that the dentist learns to work with the patient and their significant others to develop a treatment plan that is compatible with the patient’s needs and lifestyle; this is the key to success in geriatric dentistry. Therefore, the goal of geriatric dental education should be to prepare dentists to meet the complex needs of these new older adult patients34.
The history of geriatric education in the USA
Because of the changing health care needs of the ageing baby boomers, there was a recognised need to focus on the ageing/geriatric population in the 1970s among health care professionals. Some dentists became aware that elderly persons had some significant and unique oral health issues. The term ‘geriatric dentistry’ was coined as part of the effort to formalise training in geriatric education in dentistry. At that time, education in geriatric dentistry consisted of references to ageing in lectures in some curriculum courses depending upon the knowledge or interest of the lecturer. Over the years, a series of surveys of dental schools in the USA have documented the steady increase in didactic teaching (Table 1) and clinical teaching (Table 2), as well as a change in funding support for the programmes (Table 3)35–39. The growth that occurred from 1974 through 2003 gained support from the epidemiological studies reporting the emergence of dentate older adults who had restorative needs, and also there was a decline in caries among children and young adults who were the mainstay of many private practices7,8,16,40,41. An evaluation of these data showed an age shift in patients needing restorative services, which helped promote the need for geriatric training, to prepare dentists to care for the oral needs of their ageing patients. Since 1979, national funding sources have been available in the USA for the development of curricula and for clinical training of dentists in geriatric dentistry (Table 4). These educational initiatives have included federally funded training programmes through the National Institute on Aging (NIA), the Veterans Administration (VA), and the Health Services Research Administration (HSRA)42. In 1982, the American Association of Dental Schools (AADS) – now known as the American Dental Education Program (ADEA) – developed curriculum guidelines in geriatric dentistry43. Additionally, in 1988, the AADS, with funding from the Administration on Aging, sponsored the development of a curriculum resources book in geriatric dentistry44. The curriculum guidelines developed in 198243 were revised in 198945.
Table 1. Method of didactic teaching in the USA
|Teaching geriatric dent (%)||57.6||100.0||100.0||100.0||100|
|As required course (%)||0.0||77.5||66.6||88.0||98|
|As specific course (%)||0.0||12.1||58.0||83.0||50|
|Lecture as part of a course (%)||44.1||69.0||85.0||44.1||22|
|Integrated in curriculum (%)|| a ||29.3|| a ||38.5||18|
|Other (%)|| a ||5.2||0.0||13.5||8|
Table 2. Site of clinical teaching in the USA
|Percentage of schools with clinical component (%)||59.3||67.2||78||75||67|
|Mandatory clinical training (%)||54.2||41.3||42.0||73||54|
|Extramural sites (%)||43.0||78||64||55||10|
|Nursing home (%)||39.0||43.1||27.0||55|| a |
|Community clinic (%)||20.3||31.0||19.0||18.0|| a |
|Geriatric hospital (%)||15.3||17.2||40.0||20.0|| a |
|Geriatric day care (%)|| a ||15.5|| a ||13.0|| a |
|Mobile unit (%)||10.2||10.3||1.8||8.0|| a |
|Sheltered high rise (%)||8.5||6.9|| a ||12.0|| a |
Table 3. Funding of geriatric programmes
|Line item in school budget (%)||0.0|| a ||58.1||40|
|Federal government (%)||9.8||10.7||9.7||1|
|Local/state government (%)||26.4||53.5||8.1||7|
|Corporate/private grants (%)||5.5|| a ||9.7||0|
|Patient care (%)||44.4||79.0||38.7||52|
|Other (%)||13.9|| a ||17.7|| a |
Table 4. Geriatric education
|In the 1980’s, national funding sources became available to develop curricula and clinical training programmes for residents/graduate students|
| HRA – Health Research Administration – curriculum development from 1979 to 1982 (6 given)|
| NIA – National Institute on Aging – Geriatric Academic Awards from 1981 to 1898 (8 given)|
| VA – Veterans Administration – Dentist Geriatric Fellowships; 1982–1994 (52 trained)|
| HRSA – Health Services Research Administration – faculty training grants in geriatric medicine and dentistry; (2001-present) (There were 23, currently 10, 2-year programmes)|
| University of Minnesota – 2-year fellowship since 1983 (55 trained)|
The results of several dental school surveys35–39 provide evidence that there has been great improvement in the didactic teaching of geriatric dentistry in dental schools: 100% of the schools report teaching some didactic curricular content. There is, however, a great variation in the amount and content of these curricula. Schools reporting the presence of a geriatric programme typically offer an elective didactic course, which is taught by a faculty member with an interest in ageing (Table 1). The training of the faculty teaching these courses varies considerably. Many of these courses are not integrated into the regular curriculum and may only include a fraction of the dental student body. Even greater variation exists in the organisation and structure of a geriatric clinical education component. As illustrated in Table 2, mandatory clinical experience increased from 59% in 1974 to 67% in 2003. Regardless of repeated epidemiological evidence of the increasing dental need and demand of older patients, over 30% of schools still report no geriatric clinical component39. Additionally, years after the Omnibus Reconciliation Act46 passed by Congress in 1987, which mandated a dentist of record in each nursing home facility, the majority of dental schools do not offer students any opportunity to experience working in a nursing home environment39. Dental schools that report a clinical component usually combine a lecture or seminar series with a visit to a nursing home. During this visit, students typically provide oral cancer screenings, cursory examinations or denture adjustments for residents within the facility. Clinical experience providing comprehensive oral care for nursing home residents is uncommon.
Today, the philosophical commitment to geriatric dentistry exists to some extent in all of the dental schools; however, a line item of mainstream funding as a commitment to geriatric programmes is reported by only 40% of the schools39 (Table 3).
The Iowa Geriatric Program
At the University of Iowa, the first elective course in geriatric dentistry for dental students was introduced by the author in 1973. It was a 5-week, 2-h elective seminar with not more than 10 students in each course. The course was offered twice a year to interested students and was open to third- (junior) and fourth-year (senior) students as part of their oral biology electives. The focus of the course was to increase knowledge and comprehension of ageing concepts. The overall goal of this geriatric programme was to prepare dental students to provide appropriate and comprehensive oral health care for older adults in their general practices after graduation.
In the late 1970s, a field trip to a nursing home was added to the course so dental students could carry out oral screenings and denture cleaning. The programme was now team-taught because Dr James Beck had joined the faculty. During these field trips, faculty observed that some students had a ‘recoil reaction’ when examining elderly patients with poor oral hygiene. As a result of observing these reactions, a series of attitudinal studies were instituted to identify methods for influencing/changing negative reactions or behaviours of our dental students. Using a variety of students, Dr Beck designed a series of studies to measure changes in student attitudes in response to the visualisation of poor oral hygiene in older adults by using the Rosencranz and McNevin Aging Semantic Differential. We compared changes in attitudes among student groups with and without didactic knowledge and clinical experience47–49. Our results indicated that dental students held negative attitudes towards elderly people and that brief exposure to poor oral health status in older adults increased negative attitudes towards the elderly47. An evaluation of the results of our studies also suggested that students should have adequate knowledge about variations of biological ageing and be able to differentiate between normal ageing and the pathological effects of disease before the students treated frail older adults. We believe that an adequate knowledge base helps the students deal with their fears, their misconceptions, their stereotypes and their negative attitudes about elderly persons. Since publishing our studies, there have been some educational interventions tried for nursing, medical, dental and allied health students and these have had little impact on improving the negative attitudes of these diverse students to older adults50–53.
Over the past 30 years, the geriatric dental didactic programme at Iowa has progressed from a didactic elective involving a minority of students to an integrated component of the undergraduate dental curriculum. Currently, all junior students are required to take a 2-h spring semester multidisciplinary didactic course.
We believe that there is a body of knowledge on ageing that is best presented in the context of caring for geriatric patients. Thus, our overall goal required a commitment to a clinical geriatric experience for our dental students.
In 1979, with local and federal funding, we developed an elective mobile clinical programme for senior dental students, caring for persons in area nursing homes. The author was appointed director of geriatric dental programmes to chair a committee of persons from various divisions and departments, which developed an integrated multidisciplinary course using liaisons with social work, medicine, nursing, speech and hearing and pharmacy. We were able to convince the curriculum committee that the didactic programme should be required for all junior students.
We became aware through the attitude studies47–49 we had conducted earlier on that we were measuring a response to a stimulus, but these responses did not necessarily influence behaviour. Instead, positive behaviour resulted when students reported a feeling of confidence in managing dental care for older persons. Initially, the senior students were assigned to a 4-week, 5-day/week experience providing comprehensive dental care to residents of nursing and county homes using portable equipment. In the next series of studies54,55, we evaluated not only attitudes but also student confidence in completing procedures for these frail and functionally dependent patients. Specifically, we found the following:
- 1 A 2-week (10 concurrent clinical days) experience on the Geriatric Mobile Unit (GMU) did not significantly change students’ feelings of competency on an instrument we developed and validated54.
- 2 A 4-week experience (20 concurrent clinical days) on the GMU did result in a significant increase in the students’ feelings of competency. However, feelings of competency were not associated with improved attitudes towards the elderly.
- 3 Interestingly, students with a 4-week experience did view the elderly as personally more acceptable (but also more ineffective and more dependent) as compared with students having a 2-week experience or no GMU experience. These comparisons were made using Rosencranz and McNiven’s Aging Semantic Differential54.
Our conclusions were that ‘the measurement of students’ confidence in treating elderly patients may be a better predictor of their willingness to treat them than their attitudes toward the elderly54.
When we began developing the geriatric dental curriculum, the concept of the geriatric patient was a person who was old, frail and sick. However, we did not find this definition or a chronological definition of ageing particularly useful in identifying the ageing dental patient population. It became apparent that a dentist working in the oral cavity needed a variety of instruments to provide appropriate care; therefore, he/she was more like a surgeon who needs an ‘operating room,’ rather than a physician who needs only a stethoscope and a few instruments and a prescription pad to diagnose and treat disease. Therefore, we determined that a key to dental care for an ageing patient was the ability of that patient to physically get to the dentist where necessary equipment was available. Consequently, it seemed more useful to develop a functional definition of the elderly based upon an older individual’s ability to seek services.
Currently, the majority of persons in the USA aged 65 and older (95%) live in the community; of these, approximately 5% are homebound and another 17% have a major limitation in mobility because of some chronic condition56. Using similar data, we determined that the ageing population, based on their ability to attend a dentist, could be functionally categorised into three broad groups57:
- 1 the functionally independent older adult
- 2 the frail older adult and
- 3 the functionally dependent older adult.
About 70% of the population over the age of 65, or about 24.3 million persons who are living in the community are able to visit the dentist’s office independently56 and can be designated as functionally independent older adults. As stated earlier, 17% of these older community-dwelling adults can be quite frail and medically compromised but can attend a dental office if somebody brings them. In the early 1980s, clinical statistics from the University of Iowa College of Dentistry revealed that there were a growing number of frail and compromised adult patients coming to the dental school for emergency treatment, but not returning for comprehensive care. While a majority of these patients were older, it was the medical, mental or physical compromise, and not chronological age, that characterised these patients. Believing that dental graduates from the University of Iowa should have adequate knowledge and skills to treat these persons in their dental offices, we opened the ‘Special Care Clinic’ within the dental school in 1985. In contrast to other clinics within the school, the ‘Special Care Clinic’ was based on a medical education model of care. In the ‘Special Care Clinic’, patients are assigned to a faculty member, not to a student dentist. The faculty dentist is responsible for the continuity of patient care. Senior dental students provide the majority of care under the direct supervision of the same faculty member. The faculty dentist provides any complex treatment that is beyond the student’s ability, and the student serves as a primary assistant.
Geriatric and special care programme
In 1986, the Special Care Clinic and the Geriatric Mobile Dental Unit were combined to form the Geriatric and Special Care Programme. Combining the programmes was a natural solution to the problem reported by some students about experiencing a high level of stress or ‘burnout’ while providing care in nursing facilities 5 days/week for 4 weeks. Currently, in the combined Special Care Program, senior students spend five total weeks in direct provision of care in both the dental school-based clinic and the GMU. Each Wednesday morning, there is a 90-min seminar, which is a case-based discussion. The dental school has a pharmacy with two pharmacists who have joint appointments as faculty members in the dental school and in the College of Pharmacy. Doctorate of Pharmacy students are assigned to work under the supervision of our pharmacists as part of their extramurals. One of these Pharmacy students is assigned to the Special Care Clinic to help faculty and students understand the complex drug histories of the patients attending this clinic. At the end of the programme, there is a detailed structured exit interview.
Programme outcome assessment
Since 1991, about 90% of the senior students have rotated through the Geriatric and Special Care Programme. We have continuously made changes to the programme based upon formal and informal feedback from current and past students as well as from faculty teaching within the programme. We continue to evaluate and monitor the programmes using organised exit interviews and questionnaires. This somewhat independent evaluation exercise yields more candid feedback than the traditional questionnaires and is a critical part of our continuing assessment procedures.
If we teach geriatric and special needs dentistry, what outcome measures should we have to assess the effect of our programme? One measure could be improving access to dental care for patients who are elderly and have special needs in the state of Iowa. In other words, are our graduates caring for the frail and functionally dependent adults in their private practices? Another measure would be our ability to attract and recruit dentists who wish to train as fellows in our programme and the ability of the programme to attract trained dentists who wish to teach in the programme. Because nearly 80% of dentists working in Iowa are graduates of the University of Iowa, studies of the dentists in private practice would give us a measure of the programme’s success in reaching its goals.
One of the first studies58 we did was to evaluate the opinions and practices of dentists who had graduated before the geriatric programme was instituted and compare them with those who had participated in the programme 5 years after its inception. Over 70% of our 926 graduates responded with 472 usable questionnaires. An evaluation of the data suggested that the cohort group of dentists who had had a clinical geriatric experience as students (n = 56) was significantly more likely to be carrying out comprehensive dental care in nursing homes than those who graduated with them (n = 211) or before them (n = 205). However, in spite of the data being statistically significant, the actual number carrying out this care was still very small.
In another study59, the comfort levels of 726 senior students who graduated between 1992 and 2004 were measured before and after extramural experiences with special needs populations. It was found that there were some significant differences with how our students perceived these patients. Men and those who had graduated earlier were more comfortable treating patients who had special needs, including frail older adults and patients who were homebound or institutionalised. The authors59 concluded that ‘effective clinical education programmes need to go beyond mere minimum exposure to various populations, intensive clinical experiences, especially in an environment that provides oversight and guidance, which allows students to develop a greater degree of comfort and provides the foundation for mainstreaming those populations into dental offices.’
This was followed by a study60 of 372 dentists working in private practice who had graduated from 1992 to 2002. The authors evaluated their perceived comfort in treating specific Geriatric and Special Needs populations. Dentists from larger communities who were in a group practice were more likely to feel comfortable treating patients with HIV/AIDS, those with complex medical histories, or persons who were homebound than solo dentists working in small towns.
A postal survey61 of all 1165 dentists in the state of Iowa netted 646 (55.3%) responses. An assessment of the results found that during the previous year, fewer than 10% of these private practice, general dentists saw no patients who were homebound or in hospice care or living in nursing homes in their dental offices. It was reported that about 50% of the dentists had between 1 and 10% of their total patients from these special needs groups. The most common site for a dentist to provide dental care out of their offices was in a nursing home, and it was most likely to be a denture adjustment or an extraction. Thus, the majority of Iowa dentists reported providing care for homebound patients in their offices, but providing care outside of the office was provided by only a very few dentists who had more years of practice experience.
In Iowa, there is a group of dentists in private practice who are caring for some of our frail and functionally dependent older adults. Has our programme increased access to care? Unfortunately, there are very little data from other states to compare our findings, so we cannot be certain whether we are improving access to care for our geriatric and special needs patients.
Factors influencing curriculum development
A curriculum in geriatric dentistry was developed in Iowa and integrated into the overall dental curriculum at Iowa. The chance hiring of a group of faculty with an interest in ageing provided an impetus, which generated a critical mass with sufficient influence and credibility to affect change. Other significant issues included the political climate at the times: ageing issues were being widely discussed by the media, by politicians, as well as by other university faculty. Also, the university had established a Committee on Aging in which dentistry was represented, a funded Geriatric Education Center in which we were a co-principal investigator, and an Aging Studies Program in which we participated. As a group, we had published the results of our attitudinal studies and had instituted local and statewide epidemiological studies. We were carrying out collaborative research with other faculty within the dental school and the university, and we have continued to do so.
There was also a significant change in the patient population who utilised the dental school in that a higher percentage of these patients were elderly and had problems that required an innovative solution. Fortunately, we had a supportive administration and faculty. When federal grant monies became available, we were organised enough to take advantage of that opportunity to make changes in our curriculum. Thus, because of external funding for curriculum change and support by a core faculty and a supportive administration, as well as the ability to generate interest in ageing research, a clerkship concept of clinical care in geriatric dentistry evolved and has survived.
Every dental school is different, and its internal structure is unique. However, there are some concepts embedded in the Iowa geriatric and special needs programme, which may offer general application for other dental schools:
- 1 Geriatric and Special Needs Dentistry is multidisciplinary and probably should not be identified or completely controlled by a single department.
- 2 Didactic geriatric content needs to be integrated into all relevant clinical departments as part of an ageing continuum.
- 3 To facilitate the integration of dental Geriatric and Special Needs courses at the undergraduate level and to develop graduate-level programmes, the appointment of a senior person as director of ‘Special Patient Care’ programmes is desirable.
- 4 Students should not treat frail and functionally dependent older adults unless they have had adequate educational preparation in the biological, psychosocial and medical aspects of ageing and patient care.
- 5 Only when students have acquired the needed technical dental skills, should they treat persons who are severely biologically compromised, such as patients who reside in nursing homes.
- 6 Students must have sufficient clinical time with these frail and medically compromised patients so that they learn assessment and rational treatment planning and can carry out sufficient treatment to feel confident and comfortable planning and providing treatment.
- 7 Faculty who teach in these clinics need to utilise the opportunities at chairside to reinforce concepts that are taught didactically. Therefore, faculty training should include at least a 1-year clinical fellowship in Geriatric and Special Needs Dentistry.
It seems that the increasing need and demand for oral health care by this older population and ageing special needs population obligates dental schools to prepare general dentists to feel competent to care for the majority of this population who can be seen in their private dental offices.
The need for geriatric dental education continues to grow. However, the development of a fully integrated programme that prepares new dentists to meet the challenges of the geriatric dental patient is difficult. We hope that sharing what we have learned in our 30-year experience will be helpful to those who are now providing, or plan to provide, geriatric dental education in the 21st century.