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INTRODUCTION
The elderly population today
is less likely to utilize dental services than any other
population group in developed countries, such as the
United States. Similarly, the 1978-79 Canadian Health
Survey showed that 67% of the elderly had not visited
a dentist within the previous 5 years. A comparison
of the attendance of elderly Canadians with their U.S.
and U.K. counterparts over a one year period indicates
the level of attendance in Canada (23%) is half that
of the other countries. Some studies indicate that attitudes,
with respect to dentistry, may be changing. Several
authors have stated, that as people age, a brighter
picture may emerge, as the elderly will:
· Be better educated
than the previous generations of older adults,
· Have higher expectations about maintaining
and preserving their natural dentition, and
· Have the financial resources to fulfill their
expectations.
As a result a question arises
as to the impact of changing attitudes on the provision
of oral health care services for those most in need
- the institutionalized, medically or physically compromised
elderly .
The provision of dental services
to elderly populations is a complicated area. Dental
consultation and treatment of older adults can be more
difficult depending on physical and mental changes,
as well as the problems of access to care for the more
medically compromised clients and the experience of
dental professionals providing the care. When the client
is cognitively impaired, a new set of variables are
introduced in the form of designated family members,
caregivers or administrators, who are responsible for
the oral health care of the client and the treatment
the client will receive. The problems can be grouped
as follows:
· Access to care
· Perceptions of the importance and need for
oral health care services
· The delivery of dental services
· The benefit of providing dental services
Kiyak suggests that the reasons
for low utilization patterns in the elderly are related
to perceived need for care and perceived importance
of oral health, as well as the number of natural remaining
teeth and knowledge of the available dental resources
in the community. The more traditionally cited barriers
of - cost, fear and physical access are thought to be
less important. This may be the case in some parts of
the elderly population, who can decide for themselves
the type of healthcare they wish to receive. Differences
in attitudes and perceptions of stakeholders, with respect
to oral health, may lead to better or worse access for
institutionalized clients, because of the positive or
negative effects on the provision of services for the
populations. The stakeholders affecting access to oral
health care for this population are many and include:
· Clients
· Caregivers
· Family members
· Nursing staff
· Physicians
· Administrative staff
· Dental professionals
· Faculties of dentistry
· District Health Units
· Local government-health advisers
· Federal government-health advisers
· Professional dental organizations
· Professional dental licensing authorities
Negative influences may be governed
by the perceptions or beliefs held by stakeholder groups.
These perceptions may result from lack of education
in the importance of oral health care to perceived lack
of benefit from oral health services in the elderly.
In order that the key areas of access and barriers to
care can be fully understood and action taken, which
is appropriate to the population, perceptions and attitudes
of all stakeholders have to be investigated.
The
goals of the investigation are:
-
Better understanding of the barriers to care faced
by nursing home administrators.
- Better information on where
and how to target educational and service resources,
in order to reduce barriers.
The specific objective is to:
Investigate the desires of nursing home administrators
in the provision of oral health care to elderly populations.
METHODS
A
survey questionnaire was developed to ascertain the
commitment of the nursing homes to provide on-site oral
health services to their residents. Questions were asked
of nursing home administrators in the following areas:
- Interest in a dental program
- Willingness to support a
dental program
- The level of support for
a dental program
- Estimated level of resident
participation in a dental program
- Likely acceptable cost for
the program
- Types of services, which
would be desirable (screening, referral, cleaning
of natural and artificial teeth, and denture labeling)
A separate section was also
included in the questionnaire for input on other dental
services, which would be desirable or of interest to
the residents in the home, and how, in the opinion of
the nursing home administrator, could the health unit
assist in maintaining the oral health of the residents.
The names and addresses of all
24 nursing homes in Simcoe County, Ontario, were collated
from District Public Health Unit records. The survey
questionnaire and explanatory letter was sent by mail
to the 24 identified nursing homes in Simcoe County,
Ontario, Canada. The nursing homes were subsequently
contacted by telephone within one week of the questionnaire
being sent to provide additional information on the
nature and aim of the study. An introduction to the
questionnaire was also provided, and any questions regarding
the survey were answered.
RESULTS
Twenty-four nursing homes were
sent a questionnaire and 22 completed and returned the
questionnaire (92%). The two non-responders did not
reply because one was due to close imminently and the
other was a residential home, where the residents attended
their own dentist outside of the home. The majority
of nursing homes that responded were from major towns
in Simcoe County, Barrie and Orillia (five from each).
The number of residents in the nursing homes that responded
ranged from 20 to 155, with a mean number of 78 residents.
Of the 22 nursing homes that responded some did not
fully complete the questionnaire, and this is reflected
in the numbers and percentages quoted below.
The support for a dental program
in nursing homes was strong (Figure 1). More than 90%
(19) of the nursing homes surveyed were interested in
having a dental program provided by the District Public
Health Unit. In addition, 90% (17) of the nursing homes
said that they would be willing to provide support to
the District Public Health Unit for the program. The
actual level of support was more variable: 94% (17)
said they would be prepared to request a consent signature
for program participation on admission to the nursing
home, 80% (16) would designate a staff or volunteer
to assist with onsite visits, and only 64% (14) would
be willing to collect an annual fee on behalf of the
District Public Health Unit.
Figure 1. Level of support
for dental program in nursing homes
Percent of valid respondents
The estimated numbers of residents
who would be willing to participate in a dental program
varied from nursing home to nursing home (Figure 2).
Of the 16 nursing homes that answered this question,
9 (56%) felt that more than 50% of the residents would
participate in a dental program provided by the District
Public Health Unit.
Figure 2. Estimated percentage
od residents that would participate in dental program
Valid number of responses n=16
An estimate of the acceptable
annual cost for a dental program in the nursing homes
was recorded (Table 1). Of the 16 nursing homes that
responded to this question, several gave more than one
acceptable cost (or range of costs) for a dental program.
The majority of responses (60%) identified an acceptable
cost of under $35.
Table 1: Acceptable
Annual Cost of Participation in a Dental Program
| Category |
Count |
% ofresponses |
% ofcases |
| Under $25 |
8 |
30 |
50 |
| $25 to $34 |
8 |
30 |
50 |
| $35 to $49 |
6 |
22 |
38 |
| $50 or above |
5 |
18 |
31 |
Note: Multiple response allowed,
n=16 valid respondents
Figure 3 shows the nursing
homes responses to the desirability of four dental services
cited in the questionnaire. The vast majority of the
nursing homes desired the following services: dental
screening (90%), referral for treatment (86%), cleaning
of natural or artificial teeth (82%), and denture labeling
(73%).
Figure 3. Types of Desired
Dental Services
Count of valid respondents,
n=22
When the nursing home administrators
were asked to comment on other services that they would
be interested in receiving from the District Public
Health Unit or other general comments related to assisting
in them in maintaining the oral health of the residents,
the following themes emerged:
In-service Education for
Staff
Several nursing homes identified
the need for staff education on oral health care of
their residents in the following areas. Specific comments
were:
In-service on techniques to
clean residents own teeth, particular those with dentures.
Health Teaching regarding care
of elderly clients and their own teeth/dentures, especially
of the cognitively impaired.
Keeping our staff up to date
with latest tools in providing and maintaining good
oral health.
Provision of Current Information
Current information on the importance
and benefits of oral health care and best practices
should be provided to staff and residents. Specific
comments were:
Provide current information
on evidenced- based best practices that are feasible
and recognized the limitations that LTC has to provide
services. Identification of Dentists willing to provide
services to the elderly whose office will accommodate
visits.
Cost and Budget Restrictions
Nursing home administrators
identified limits on the cost of a dental program for
residents. Specific comments were:
$50 too prohibitive for most
- If issues of use and access are not addressed first
the rest is just an academic exercise.
Residents cannot/will not pay
more than $25, more than this and few will participate.
DISCUSSION
Perceptions of the importance
and priorities of dental services have not been reported
in the literature. The importance of perceptions lies
in the exploration of the concept of access. Part of
the concept includes the notion of acceptability of
the services to the gatekeeper of care, nursing home
administrators.
The emerging profile of the
desired dental services in nursing homes from this study
is one which provides screening, referrals for interventive
care when appropriate, and basic denture care as necessary.
Staff education was seen as important by administrators.
Complex care was not considered a priority. Services,
which are not identified as important, can also provide
information on the types of services, which perhaps
would not be utilized even if offered.
The inference of the responses
from nursing homes administrators is that a basic program
is desired not one providing a comprehensive list of
services. If this opinion truly reflects the desires
of this population then a modest range of services could
be provided at minimal cost by utilization of the whole
dental team. For example:
- Screening, referral and education
- Dental Hygienist
- Prevention (including denture
cleaning and labeling) - Dental Hygienist
- Diagnosis/restorative care/extractions/denture
alteration or fabrication - Dentist and Dental Nurse
The
willingness of the nursing home administration to participate
and support a dental program in this setting is demonstrated
in this study. The estimates of the numbers of residents
of nursing home prepared to participate are also encouraging.
However, the limiting factors of providing such a service
may be the barrier that has been identified for all
population groups, that of cost of the service.
It would seem that the gatekeeper
stakeholders are willing to participate in service development.
The range of services desired is limited, but prevention
focused. There is also an identified need for in-service
education, which emphasizes the importance placed on
dental knowledge in this environment and has been identified
in the literature. The willingness of the professionals
to commit in a similar manner may depend on the support
for this type of initiative from local government funding
agencies. Administrators identify the importance of
cost barriers. A financial investment from government
for this type of program may be essential to overcome
this problem.
CONCLUSIONS
The residents of the nursing
homes and their family members share similar views in
the types and frequency of dental services that should
be provided in the nursing home setting. They describe
a basic dental service of check-ups and preventive care,
with restorative, denture and surgical intervention
where necessary. Complex care is not a priority. Services
should be available once or twice a year.
There is an explicit wish on
behalf of the nursing home administration to have dental
services, which would be supported by staff in the nursing
home environment. The services desired are preventive
in nature and include in-service education of staff.
However, but barriers exist to the development of such
services and programs. The main barrier is cost. The
estimated ability of the clients' ability to pay may
fall between$20 and $50 per year. It is more than likely
that the basic assessment and preventive services required
would cost more than double this figure. A government
investment for program development in nursing homes
is required to make this a reality.
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