Barriers to dental attendance in older patients
1D Shanahan 2D. O’Neill
1Department of Age-related Healthcare, Tallaght Hospital, Dublin 24,
2Centre for Ageing, Neuroscience and the Humanities, Trinity College Dublin, Dublin, Ireland
Health professionals in Ireland are increasingly concerned about the quality of oral health in older patients. The aim of this study is to identify the obstacles that face this age-group when accessing dental care, so that we are in a better position to address them. A questionnaire was completed by 105 patients attending a geriatric outpatient clinic. Over 50 percent of respondents had not attended a dentist in over 36 months, for the reasons that 'I have no problem or need for treatment’ (62%) and ‘I have no teeth, and therefore I have no need to go’ (54%). While it is common to assume that no teeth means no need to see a dentist, research shows that regular dental visits are vital for ensuring the early screening of oral cancer and other mucosal pathologies, and the optimisation of existing rosthesis/restorations. The chief recommendation of this paper is thus to provide better education and access to older people on the importance of visiting the dentist.
Good oral health is essential for overall well-being, leading to better nutrition, enjoyment of a greater variety of foods, improved aesthetics, and self-confidence,. It is also linked to a reduction in the risk of heart disease, stroke, pneumonia and other respiratory diseases. In Ireland, the oral health of older patients is poor: 41 percent have no natural teeth, while those who are still dentate possess an average of just 8 natural teeth. Older people are more prone to caries, periodontal disease, tooth wear, xerostomia, and oral cancer. Furthermore, the capacity for this age-group to maintain oral hygiene is more challenging, due to the potential decline in dexterity, and impairment of cognition. Such problems will only become more pressing as the population continues to age, with people retaining their teeth for longer. The aim of this study is to identify some of the obstacles to good oral health in older people, so that we are in a better position to overcome them. Involving just over 100 patients from the Dublin region, the investigation will make fruitful comparisons with wider, national trends, as described in the National Survey of Adult Oral Health (NSAOH), conducted by the Oral Health Services Research Centre (OHSRC) in 2000-20026.
The data for this study was derived from oral health questionnaires, completed by 105 patients aged over 65, who were attending the geriatric medical outpatient clinic at Tallaght Hospital (Dublin) in March, April, and May 2016. The patients had been referred to the clinic by their general practitioners for a variety of medical, social, and functional problems. To facilitate comparisons between local and national trends, the questionnaire was based on the one used in the NSAOH in 2000-2002. Patients, together with their relatives or carers, were asked to fill out the questionnaire while waiting to be seen in the clinic. They were asked about their education, denture status, the time that they last visited the dentist, and the reasons if they did not attend regularly. Patients’ clinical letters/notes were also accessed to identify individuals with cognitive impairment. This data was then collected, analysed, and compared with the findings of the NSAOH survey6.
Of the 105 questionnaire respondents, 58 were women, and 47, men. The mean age was 79.6 years. Over 40 percent of patients completed the questionnaire independently (43%), almost 30 percent did so with the assistance of a relative or carer (28%), and just under a third were filled out by the relative/carer alone (29%). Over half the patients had received only a primary school education (51%), with more women having left school at this level (62%) than men. In terms of dental status, 77 percent of respondents had either a partial or full denture, of which nearly 80 percent were female (79%), and had attained a primary school education only (53%).
Half the patients had not attended a dentist in over 36 months, with those who did not attend regularly citing the following two reasons: ‘I have no problem or need for treatment’ (61%), and ‘I have no teeth, and therefore I have no need to go’ (54%). The idea that ‘dental treatment is too expensive’ (6%) and ‘no access to downstairs surgeries’ (2%), were cited less frequently than had been expected. Cognitive impairment had been diagnosed in 56. Nineteen percent of patients, ranging in severity from a mild cognitive impairment (15%), to vascular dementia (6%), mixed dementia (11%), and Alzheimer’s dementia (28%). Those with a cognitive impairment were more likely to be women (58%), wearing a denture (78%), and unseen by a dentist in over 36 months (56%). Of those patients diagnosed with ‘vascular dementia’, 80 percent had not attended a dentist in over 36 months (83%). By contrast, patients with no documented diagnosis of a cognitive impairment tended to visit the dentist more regularly, with only 43 percent having not been in over 36 months.
While oral health is important at all stages of life, it is particularly pertinent to older people. The difficulties experienced by frail patients when masticating foods limits their dietary choices, and leads to poorer nutrition, which in turn affects general health1. Other issues include poorly fitted prosthesis and suboptimal restorations, which cause discomfort and pain, and commonly results in the loss of self-confidence, inability to communicate, and a reduction of quality of life. Similarly, systemic diseases, together with the adverse side-effects of treatments, can result in an increased risk of oral diseases, such as xerostomia, impaired taste, oro-facial pain, gingival overgrowth, alveolar bone resorption and mobility of teeth. The advent of polypharmacy further complicates the situation, since taking multiple drugs produces numerous adverse effects on oral health. In the light of these issues, it is paramount that older patients are able to access dental care services regularly, so that their oral and general health can be optimised.
Our survey showed that half of participating patients had not seen a dentist for over 36 months, a timescale which does not adhere to standard recommendations. The National Institute for Care and Health Excellence (NICE) guidelines, for example, advise that the longest interval between oral health reviews in older adults should be 24 months, provided patients can demonstrate that they are able to maintain their oral health, and are ‘not at risk of or from oral disease’. A number of reasons explain why patients do not visit the dentist more regularly, of which the most significant in this study were attitudes towards oral health and the need to see the dentist. The prevailing opinion amongst these patients is that if they have no teeth, there is no need to attend regular dental check-ups; the only cause for dental care is pain. Such a view probably owes much to earlier care modalities and policies, where extraction of teeth was common practice, treatments were cost prohibitive, and regular dental check-ups were rare. As a result, older people tend to have lower expectations, and less favourable attitudes, to both oral health and dental care. Similar findings were reported in 2000-2002 by the NSAOH, where 88% of those with no teeth, and 53 percent of those with natural teeth, cited ‘no need’ as the primary reason for non-attendance. This suggests that little has changed in patient attitudes over the last fourteen years6.
Other studies cite a host of additional obstacles to regular dental care, including patients’ past experiences of dental treatment, the cost of treatment, awareness of entitlements to treatment, reduced mobility, hearing problems, difficulties of communication, and concern about the physical access to dental surgeries ,,. Our study, as well as the NSAOH, discerned that while these factors did play a role, they were not the primary barriers to care. This discrepancy may stem from the fact that patients were asked to select their two main reasons for not attending the dentist regularly; perhaps if they had been given more choice, additional reasons may have been cited.
A striking finding of this study is that education seems to be linked to oral health and dental attendance: those with a higher level of education claimed to attend the dentist more regularly, and were less likely to wear dentures. This connection has also been reported in the NSAOH and other studies. One possible explanation is that education leads a greater health consciousness, and a perception of the importance of oral health to life quality2,. It may be that these individuals are also more confident at communicating with dentists. Turning to gender, we found there was less difference in dental attendance among males and females, although women were more likely to wear dentures (84.4%) than men (68.9%). This may be due to the well-documented tendency of women to place a higher psychosocial value on oral health than men, particularly relating to appearance and self-confidence2.
Over half of respondents in the survey had been diagnosed with dementia, of which those suffering from the vascular variety were less likely to attend a dentist regularly. The incidence of dementia in the world is rising, with those affected having poorer oral health than others in the community. This is probably due to a variety of factors, including difficulties in the communication of pain/oral discomfort, a decline in dexterity, and trouble remembering to perform daily oral hygiene. In turn, these issues commonly lead to dependence on caregivers for assistance, a situation which can be further complicated by behavioural issues as the disease progresses.
A number of lessons can be learned from this study. Firstly, in order to encourage more regular dental attendance amongst older people, a change in attitudes to oral health and dental care is vital. One way to achieve this may be to provide targeted education at geriatric out-patient clinics – both to patients and relatives/carers – which explains the importance of regular attendance, even in people with no teeth. In this setting, it would also be fruitful to inform patients about oral hygiene, as well as their entitlements to dental access/treatments. Secondly, there is a clear need for better preventative and interventional care in the community, as well as in residential care. In particular, dental services should move away from the ‘one size fits all’ approach, and instead, be tailored to the individual needs of patients. Dentists would also benefit from additional training in the care of an older population, as well as special equipment. The third point is that while the majority of patients can be managed by a general dental practitioner, there is also a role for those with a special interest in gerodontology. This notion has been recognised by the European Union Geriatric Medicine Society (EUGMS), in its ‘seven core principles’: it recommends that the medical care of older people ‘needs to be supported by specialist gerontology services’, including dentistry and gerodontology. By encouraging greater collaboration and contact between dentists, geriatricians, and nurses, the care of the older patient can become more holistic.
Conflict of interest
No conflict of interest to declare
D Shanahan B.Dent.Sc MB MFDRSCI,Department of Age-related Healthcare, Tallaght Hospital, Dublin 24, Ireland, Centre for Ageing, Neuroscience and the Humanities, Trinity College Dublin, Dublin, Ireland
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