General dentists’ attitudes and perceived barriers in providing domiciliary dental care to older adults in long‐term care facilities or their homes in Northern Ireland: A descriptive qualitative study

: Objective: Many older patients, housebound or living in long-term care facilities (LTCFs) have limited access to dental care. This descriptive qualitative study aimed to understand general dental practitioners (GDPs) attitudes and perceived barriers to undertaking Domiciliary Dental Care (DDC) for those patients in Northern Ireland (NI). Methods: Semi-structured telephone interviews were conducted with a purposive sample of 12 GDPs in Northern Ireland. Interviews were digitally recorded and transcribed verbatim. An iterative coding process using theme-analytic methods was used. Results: The data were characterised into four major themes-risk of professional litigation, remuneration for those undertaking DDC, complexity of treatment, and the overall framework of the dental care system in NI. Two minor themes identified were practice culture and reasons for undertaking DDC. The GDPs in the study identified a number of barriers to undertaking DDC including a legal requirement to transport oxygen, lack of organisation and limited oral hygiene care provision in LTCFs, and confusion around their responsibilities for provision of DDC. Those GDPs who were providing DDC indicated that they did so out of kindness and a sense of loyalty to their long-standing patients. Conclusion: The GDPs in this study identified a number of significant barriers to provision of DDC at organisational, structural and clinical levels. The GDPs indicated that they required clarification of their responsibilities around DDC with clear guidelines necessary given the increase in demand for this service. Abstract Objective: Many older patients, housebound or living in long- term care facilities (LTCFs) have limited access to dental care. This descriptive qualitative study aimed to understand general dental practitioners (GDPs) attitudes and perceived barriers to undertaking Domiciliary Dental Care (DDC) for those patients in Northern Ireland (NI). Methods: Semi- structured telephone interviews were conducted with a purposive sample of 12 GDPs in Northern Ireland. Interviews were digitally recorded and transcribed verbatim. An iterative coding process using theme- analytic methods was used. Results: The data were characterised into four major themes— risk of professional litigation, remuneration for those undertaking DDC, complexity of treatment, and the overall framework of the dental care system in NI. Two minor themes identified were practice culture and reasons for undertaking DDC. The


Abstract
Objective: Many older patients, housebound or living in long-term care facilities (LTCFs) have limited access to dental care. This descriptive qualitative study aimed to understand general dental practitioners (GDPs) attitudes and perceived barriers to undertaking Domiciliary Dental Care (DDC) for those patients in Northern Ireland (NI).
Methods: Semi-structured telephone interviews were conducted with a purposive sample of 12 GDPs in Northern Ireland. Interviews were digitally recorded and transcribed verbatim. An iterative coding process using theme-analytic methods was used.

Results:
The data were characterised into four major themes-risk of professional litigation, remuneration for those undertaking DDC, complexity of treatment, and the overall framework of the dental care system in NI. Two minor themes identified were practice culture and reasons for undertaking DDC. The GDPs in the study identified a number of barriers to undertaking DDC including a legal requirement to transport oxygen, lack of organisation and limited oral hygiene care provision in LTCFs, and confusion around their responsibilities for provision of DDC. Those GDPs who were providing DDC indicated that they did so out of kindness and a sense of loyalty to their long-standing patients.

Conclusion:
The GDPs in this study identified a number of significant barriers to provision of DDC at organisational, structural and clinical levels. The GDPs indicated that they required clarification of their responsibilities around DDC with clear guidelines necessary given the increase in demand for this service. KEYWORDS barriers, dental health, domiciliary care, elderly, qualitative research

| INTRODUCTION
Dental domiciliary care (DDC) describes dental care delivered for a patient in an environment outside clinical dental practice, usually in the patient's place of residence. DDC is most often provided for older dependent adults in either a long-term care facility (LTCF) or in the patient's own home as due to illness, disability or frailty they are physically unable to come to the dental practice. General dental practitioners (GDPs) in Northern Ireland (NI) are responsible for the oral health of all their registered patients whether they are able to attend the surgery or not, and receive additional remuneration for travelling to the patient's residence. Figures show the number of patients treated by GDPs via a domiciliary visit has remained around 3000 per year from 2015 to 2020. 1 This figure is low when compared to the 35 000 registered care home residents, and that is not including the elderly housebound. 2 It suggests around 32 000 care home residents do not receive any dental health care in NI. Less GDP domiciliary visits leave the elderly without dental care and places more pressure on the Community Dental Service (CDS), whose main purpose is special care dentistry, usually on a referral basis, but who often have to provide routine DDC when GDPs are unavailable.
As people retain more of their teeth into older age, they are more likely to suffer from chronic dental diseases including dental caries and periodontal disease. These conditions can impact on a number of systemic diseases including diabetes, respiratory, and cardiovascular disease, as well as negatively impacting on quality of life. 3 Amongst older adults, 40% of the 75-84 age group and 33% of the 85+ age group have dental caries, whilse periodontal disease affects 69% of those over 65 years of age. 4 The oral health of LTCF residents is much worse than their community living peers with 73% of residents experiencing caries. 5 With increasing age, the ability to self-care deteriorates, poly-pharmacy leads to dry mouth, and diets become rich in sugars. All these factors significantly increase their disease burden and the risk of future problems.
A previous postal survey of GDPs carried out in Northern Ireland in 2008, recorded decreasing levels of DDC provision and reported barriers to DDC including a lack of time and equipment, and a view that the patients were too difficult to manage in this environment. 6 These obstacles were mirrored in multiple studies which also cite low remuneration as a barrier to DDC provision. These studies also suggest that a lack of preventative care from LTCF staff is a significant cause of dental decay in residents. 7 -9 No study of this kind has previously been carried out in NI. It aimed to gather qualitative information on GDPs attitudes to undertaking DDC for dependent older adults andperceived barriers to providing this care, to potentially address and reduce oral health inequalities amongst the elderly.

| METHODS
A descriptive qualitative study was conducted. The consolidated criteria for reporting qualitative studies (COREQ) was used as a guide throughout data collection and analysis. 10

| Recruitment of participants
The main participant inclusion criterion was to be a GDP working in NHS and/or private practice in NI. Any GDP not currently working in NI was excluded. An invitation to take part in this study was included in a weekly news bulletin emailed to all (approximately 300) members of the NI branch of the British Dental Association (BDA) at the beginning of June 2020. Ten dentists responded citing their interest in taking part. They were emailed a standardised cover letter with the participant information sheet (PIS) and the consent form. The voluntary and anonymous nature of the study was emphasised in the PIS and six dentists returned the written consent form. Four dentists showed initial interest but did not reply after the PIS was emailed.
This was during a time of extreme professional stress within dentistry as a result of the SARS-CoV-2 pandemic so it was assumed they did not want to/were not able to take part and were not followed up.
As the study continued, purposive-iterative snowball sampling was used to identify six more participants. Via direct email, eight GDPs were approached by another member of the research team To ensure a more representative sample, they were chosen based on their practice location, principal (worked in their own practice) or associate (did not own the practice they worked in) status, and whether participants undertook DDC. These dentists were known to the research team through previous work and research links. Seven dentists responded but one was rejected as he had not practised dentistry in over three years.
At no point were participants offered any type of incentive for taking part in the study.

| Topic guide
A topic guide for the interviews was developed by the research team which included the following subjects: • Background career information.
• DDC provision by the participant and/or their practice and how that has changed over time.
• Views and perceptions of current DDC services for dependent older adults including barriers to DDC.
• How to encourage GDPs to undertake more DDC.
The topic guide was pilot tested with two dentists known to the interviewer (Appendix 2).

| Data collection
Twelve in-depth, semi-structured, open-ended telephone interviews were conducted. The interviewer was a female dentist working in general practice who conducted the research as part of a Masters in Public Health (MPH) postgraduate course.
Allowing 30 minutes for each interview gave adequate time for in-depth responses and follow-up questions, but if participants had more to say they were allowed to continue. Two interviews lasted over 50 minutes. Participants were alone while being interviewed either at home or in their practice. Interviews were audio-recorded and transcribed verbatim. Only one interview per participant was conducted, no field notes were made and transcripts were not returned to participants. After approximately eight interviews, no new categories of data emerged but four more were carried out to ensure data saturation.

| Data analysis
Theoretical thematic analysis using Braun and Clarke's framework was conducted on the transcripts to code relevant data. 11 Open coding was used to attribute different codes to related script. Coding was completed by hand using hard copies of the transcripts. No computer software was used in coding. One data coder, the interviewer, coded all the data. Recoding was performed 10 days after initial coding to increase dependability of the analysis. The codes were grouped into 15 categories and these were further consolidated to develop four major and two minor themes. Four participants were emailed the themes as a form of member-checking. Three replied, and all agreed the themes were appropriate. Table 1 summarises the main characteristics of the sample of 12 GDPs recruited to the study. All were working as dentists in Northern Ireland, in predominantly National Health Service (NHS) practices. 33% (n = 4/12) of the participants were female, 67% (n = 8/12) worked as associate dentists and 83% (n = 10/12) worked in independent practices (not part of a larger group practice). The number of years qualified ranged from 5 to 36 with a median of five visits per year. There was a wide range of DDC activity reported by each dentist during the previous year, from zero to one hundred DDC visits. The research team endeavoured to interview dentists from all over NI and Figure 1 shows where each participant worked.

| RESULTS
Four participants worked in Belfast city which reflects the area of highest population density. The only other city represented is Derry/ Londonderry while the remaining participants worked in towns that service the surrounding rural areas. Fermanagh and Down are not accounted for. The dental healthcare system is the same throughout NI and no pattern in opinion was linked to the dentist's gender nor to geography, whether the practice was in an urban or rural area.
Four major themes emerged from this study: 1. The risk of professional litigation was perceived to be too high to allow dentists to comfortably undertake DDC.
2. Remuneration for dentists undertaking DDC was considered too low to be economically sustainable.
3. Treatment of dependent older patients in DDC was viewed as complex.
4. The organisation of dental services in Northern Ireland was confusing and actually impeding DDC delivery for dependent older adults.
Two additional minor themes were also identified:

| Theme 1
The risk of professional litigation was perceived to be too high to allow dentists to comfortably undertake DDC.
Most dentists fundamental problem comes from…, the fear of being sued because we have a litigious so-ciety…, they are the major fears and barriers we have  All dentists agreed the biggest risk was if a domiciliary patient had a medical emergency, they would be exposed to litigation if they did not carry the correct emergency equipment. None of the GDPs had more than one emergency kit in their practice which was a significant problem when travelling to a DDC visit. Only one of the seven dentists who regularly offered DDC reported carrying an oxygen cylinder to visits, despite this being a legal requirement. 12 The majority of GDPs said they would prefer to provide DDC in a LTCF rather than the patient's own home as they perceived it to have more support from other staff and less risk. Fear of litigation as a barrier to DDC was summarised by one experienced GDP:-I would be more afraid of doing treatment and something happening than not doing it and somebody asking me why I didn't.

| Theme 2
Remuneration for dentists undertaking DDC was considered too low to be economically sustainable.
All of the dentists interviewed agreed that the fees offered for undertaking DDC were too low given the time required for However, some dentists did recognise the benefit of sharing the service as they felt it was important for the patient to have the option of seeing their own dentist.

| Theme 4
The organisation of dental services in Northern Ireland was confusing and actually impeding DDC delivery for dependent older adults.
All of the GDPs in the study reported that they were actually unsure of how DDC was organised and who was responsible for ad-

| Theme 5
The culture within each dental practice dictates provision of DDC.
GDPs reported that some practices traditionally offered the service while others did not. Those working as associates felt they could only provide DDC with the practice owner's approval:-At best it is a free service at worst it costs me money.
I can do that because I'm the boss but my associate couldn't do it or he would be pulled by me.

[Participant 7, NHS GDP, Belfast]
The only participants who reported that their practices did not undertake DDC at all were those working in practices owned by a dental corporate:- The company has meetings at times and it was never mentioned that there is a code for this item of service (payment for DDC). You were the first one to actually mention this.

| Theme 6
The positive attitudes dentists have towards DDC.
Most participants perceived a high need for oral health care amongst dependent older adults. All of the dentists felt it was im-

| DISCUSSION
The purpose of this study was to explore GDPs attitudes and perceived barriers towards providing DDC to dependent older adults in Northern Ireland. Many of the barriers identified in this study have been reported elsewhere but to our knowledge this is the first to describe the risk of professional litigation as a significant barrier to DDC. 6,9,13 This could reflect the dramatic growth in litigious claims against GDPs in the UK over the past ten years. 14,15 Most of the relevant literature on DDC predates this so it may not have been at the forefront of dentists' minds, as it is now. The participants concerns are fully supported by the quantity and significance of recent literature on dental litigation. 1 4 -1 6 More experienced participants were not as concerned about litigation as their younger colleagues perhaps due to having built good relationships with their patients over many years or as one Dutch study found, a lack of concern as they are nearing the end of their career. 14 Although poor remuneration for DDC was another major barrier there was the prevailing impression amongst approximately half of the participants that no amount of financial reward would encourage them to jeopardise their professional registration. Maybe it is not that dentists do not want to do DDC but that they are afraid to. Therefore, when dentists say DDC is not financially viable, it is not because the fee is low per se but because it is low in relation to the amount of time DDC takes and the money that could be earned instead by treating patients within the dental surgery. This explains why any GDPs who undertake DDC do so during lunchtime or after work, often without a nurse, to minimise out of surgery time.
The difficulty in treating domiciliary patients was described by all participants, but they did elaborate that it is not so much complex treatment but a complex environment in which to provide treatment. Prior studies have not differentiated this clearly. 13,18,19 Nor have they accounted for the high volumes of lost dentures which all participants cited as a major, but easily preventable problem. It is recommended that all new dentures are labelled with patient details as described by the National Institute for Clinical Excellence (NG48) and awareness raised on the risk of wrapping dentures in tissue when not being worn. 20 In agreement with other studies, GDPs suggested a more united front on prevention, especially from LTCF staff, could help to improve the oral health of dependent older adults and may reduce DDC demand for acute dental issues. 21,22 Patients' oral health journey should not start and end with the GDP and LTCFs must be made more accountable for oral care of their residents. 23 9 The government has a statutory obligation to provide the highest level of available dental care equally to all citizens, via the dental care system as a whole, and not just GDPs. As the findings of this study suggest a majority of dependent older adults in NI do not have access to oral health care, it raises concern around deep inequalities between those adults in LTCFs and their community living peers, and supports previous research highlighting their plight. 5 Reframing the problem away from GDPs and setting it within the context of the government's health agenda could provide upstream solutions, reducing need through active prevention strategy and demystifying the service through clear direction.
The researcher, a practising dentist with experience in DDC in Northern Ireland was the main data collector and interpreter. Her personal experience will have introduced bias, but it is also an important strength. With a deep understanding of practical dentistry reduced time was spent finding common ground between interviewer and interviewee so more in-depth responses could be garnered. Response bias was minimised by reinforcing anonymity, reminding the participant there were no right or wrong answers, and passing no judgement. Member-checking with three participants increased the dependability of the data.
Although telephone interviews do not allow for visual cues, participants can feel more relaxed because they feel safer in their own space and often feel able to disclose more sensitive information. 26 Evidence is weak that face-to-face interviews produce better quality data and due to the SARS-CoV-2 pandemic and national restrictions on movement, telephone interviews became the most suitable option.
The majority of participants providing DDC did so in LTCFs so the data collected inadvertently focused on LTCF residents and captured fewer issues specific to dependent older adults in their own homes. This seems to be a shortcoming in all research on DDC and this specific niche would benefit from further investigation.

| CONCLUSION
This qualitative study provides in-depth understanding of GDPs views towards DDC. Avoidance was the predominant attitude, built on the perception of multiple barriers which centre round finance, high risk of litigation, complexit y of treatment, and the system within which DDC lies. Anxiety associated with litigation and professional indemnity for DDC provision has emerged as a new theme in this area. The implications of these findings suggest that for dependent older adults, access to oral health care is often limited.