Oral Health America Webinar Series
Iowa: An Example of an Integrated Teaching/Service & Research Geriatric Program
March 1, 2018
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Ronald Ettinger, BDS, MDS, DDSc, DDSc (hc), DABSCD Professor Emeritus, Department of Prosthodontics
Howard Cowen, DDS, MS, DABSCD
Clinical Professor, Department of Preventative & Community Dentistry
“Iowa: An Example of an Integrated Teaching/Service & Research Geriatric Program” Ronald L. Ettinger, BDS, MDS, DDSc, DDSc (hc), DABSCD Professor Emeritus, Department of Prosthodontics
Howard Cowen, DDS, MS, DABSCD Clinical Professor, Department of Preventive & Community Dentistry
Integrated Geriatric Dental Education This presentation will review the history of the development of Geriatric Dentistry programs in the USA; It will describe the IOWA program as an example of a Geriatric Dentistry comprehensive care program which combines teaching with service to the community by predoctoral and postgraduate students/fellows and also generates research;
USA: Life Expectancy at Birth in Years Men
Women
Both
1900
43.6
48.3
47.2
1950
65.6
71.1
68.2
1960
66.6
79.1
69.7
1970
67.1
74.8
70.9
1980
70.0
77.4
73.7
1990
72.1
79.0
75.6
2000
73.5
80.4
77.0
2020
74.9
81.8
78.3
5 0
Decline in Edentulousness
4 0
1960-62 NHES 1971-74 NHANRS 1985-86 NIDR 1988-91 NHANRS III
3 0 2 0 1 0 0
3544
4554
5564
6574
Iowa Survey Identified New Elderly Consumer Ettinger RL & Beck JD Spec Care Dent1982;2:62-9.
Will represent a larger proportion of the population; Better educated; More politically aware; More accepting of social services; Greater economic security; More positive attitudes with regard to dental services: May be healthier but will have some chronic disease;
MAJORITY have
some teeth;
The Growth of Geriatric Education In the 1970’s in anticipation of the “Baby Boomers” – babies born after World War II –there was recognition of a need for dentists trained as “Geriatric Dentists”; Geriatric education had only a token presence in the dental schools; A series of surveys of dental schools over time have showed a steady increase in didactic and clinical teaching of Geriatric Dentistry;
Didactic Teaching of Geriatric Dentistry in the USA, 1974-2017 1974 Taught at all
1979 1985
1998
2003
(N = 59) (N = 58) (N = 56) (N = 52) (N = 54) 57.6% 100.0% 100.0% 100.0% 100%
2017 (N=56) 100.0%
As a required course
0.0%
77.5%
66.6%
88.0%
98%
92.8%
As a specific course
0.0%
12.2%
58.0%
83.0%
50%
62.5%
44.1%
22%
25.0%
*
38.5%
18%
8.9%
0.0%
13.5%
8%
3.6%
As lectures in a course 44.1% 69.0% Integrated in a curriculum * Other
*
29.3% 5.2%
85.0%
*Not reported
MODIFIED from: Ettinger RL et al Journal of Dental Education 2017
Sites of Clinical Teaching of Geriatric Dentistry in the USA, 1974-2017 1974
1979
1985
1998
2003
2017
(N = 59) (N = 58) (N = 56) Percent of schools with 59.3% 67.2% 78.0% clinical component Mandatory clinical 54.2% 41.3% 42.0%
(N = 52) (N = 54) 75.0% 67%
(N=56) 67.9%
73.0%
54%
57.1%
Extramural sites
43.0% 78.0%
64.0%
55.0%
10%
67.9%
Nursing home
39.0% 43.1%
27.0%
55.0%
*
37.5%
Community clinic
20.3%
31.0%
19.0%
18.0%
*
60.7%
Geriatric hospital
15.3%
17.2%
40.0%
20.0%
*
Geriatric day care
*
15.5%
*
13.0%
*
14.3%
8.0%
*
12.5%
12.0%
*
*
Mobile unit Sheltered high rise
10.2%
10.3%
8.5%
6.9%
1.8% *
*
*Not reported
MODIFIED from: Ettinger RL et al Journal of Dental Education 2017
Summary of the Status of Geriatric Dental Education in US Dental Schools Didactic material has been incorporated into all dental schools; Clinical experiences and funding have not kept up with the increased didactic education; Competencies have been identified by the Commission on Accreditation of Dental Schools, however not much will change in the near future;
THE DEVELOPMENT of GERIATRIC DENTISTRY PROGRAMS at the UNIVERSITY of IOWA
1973 – 1975 In 1973 I was asked to develop an Elective\Selective course for junior dental students which I taught twice a year as part of an Oral Biology course; Not more than 10 students per session; Each session was two hours a week for 5 weeks; Each course was taught twice/year;
In 1975 I invited others to team teach with me and we added oral examinations in nursing homes to the program;
We observed a very
negative response
to elderly in nursing homes by our students and in 1977 Dr. James Beck designed a series of attitudinal studies;
DESIGN OF STUDY Beck JD et al Gerontologist 1979;19:580-5. Pretest Freshman Dental Students were asked to evaluate a person aged 32 and a person aged 65 using a semantic differential; Posttest 6 weeks later they were randomly divided into 3 groups: Group 1 – saw slides of 4 elderly with poor oral hygiene; Group 2 – saw slides of same 4 elderly with mouth cleaned up; Group 3 – control only– no slides All asked to redo Semantic Differential for persons aged 65 only;
One of the
Pre & post treatment pictures of a male aged 68;
Negative response to Poor Oral Status:
Summary Exposure to elderly persons with poor oral health resulted in significantly more negative attitudes towards the elderly; Implications are that programs designed to give students experience with improving the oral health of nursing home patients may be generating negative attitudes; Therefore dental students should be properly prepared for what they will encounter before doing screenings and oral hygiene programs in nursing homes;
Iowa Survey of Oral Health 1979- 1980 Statewide household survey of oral health; Non-institutionalized population; Randomized cluster sample of households stratified by size of community and by age; Telephone interview for demographic information and attitudes and utilization of dental services of 1,228 households; Clinical examination of 436 persons in their homes
We identified an aging population with significant oral & dental problems;
Introduction to Geriatric Dentistry IOWA 1979 As a result of our state wide epidemiological studies we were able to convince our curriculum committee to add a required, semester long multidisciplinary course, in Geriatric Dentistry to the junior year; We received Funding from the Health Resources Administration, (HRA - Federal Government) and the Heritage Agency on Aging,(County Government) to develop an elective clinical rotation in Geriatric Dentistry on a Geriatric Mobile Unit which was added to the existing senior extramural program in Preventive & Community Dentistry;
The 1979 Geriatric Mobile Unit [GMU] Funded by HRA & Heritage Agency on Aging
Equipment built from dental school parts by Dr. Robert Glenn
1981-1986 My National Institute on Aging Award paid the salary of faculty (dentist, assistant & hygienist) of the GMU program;
GMU PROGRAM Students Interact with: 1.Physicians on the phone; 2. Nursing staff daily; 3. Care staff daily; 4. Social workers as needed;
5. Patient advocates as needed; 6. Pharmacists on the phone; 7. Hygienist on the 6-month recall program;
Evaluation of the Program Cunningham MA, Beck JD & Ettinger RL Spec Care Dent 1984;4:113-8. Cunningham MA, Beck JD & Ettinger RL Geront & Geriat Edu 1985;6:17-23
“ We used Pre and Post-rotation QUESTIONNAIRES on
confidence and attitudes in caring for nursing home residents found that for our students:
Initial program for 2 weeks – NO change in confidence; At 4 weeks – they felt MORE confident at post-test;
Feelings of competency were NOT associated with attitudes towards the elderly “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 elderly.”
Beck 1985
SUMMARY OF OTHER ATTITUDE STUDIES 1. The dental students had similar negative attitudes towards the elderly as medical students; 2. These negative attitudes were present at the beginning of training; 3. Poor oral health status in elderly persons stimulated more negative attitudes towards the elderly; Beck JD et al Gerontologist 1979;19:580-5. Holtzman J, Beck JD, Ettinger RL, Educ Geront 1981;6:195-207 Recent educational interventions used for nursing , medical, dental, allied health students had little effect on improving attitudes to older adults. Cummings SM, et al 2006; Williams B, et al 2007; Christmas C,et al 2008, Nochajski TH, et al 2009;
Special Care Clinic was added in 1984 with 8 Chairs
Special Care Students interact with: 1. Physicians on the telephone; Clinic was integrated with 2. Pharmacist at chairside; 3. Family and Carers; GMU Program 4. Social workers in 1985
Special Care Clinic
Clinical Pharmacist, Dr. Cindy Marek consulting with a patient with Scleroderma at chairside;
Geriatric Mobile Unit 1980s-1990s Hygiene 6-month Recall Program Hygienist providing recalls 6monthly; Annual dental in-service; Prophylaxes – bedside and chairside;
Cleaning and naming of dentures; Mobile equipment built by Dr. Robert Glenn in 1980;
How Does One Define a Dental Geriatric Patient?
Geriatric Medicine The institute of Medicine defined Geriatrics as that:
”Branch of general medicine concerned with the clinical, preventative, remedial and social aspects of illness in the elderly” Institute of Medicine, “Aging and Medical education”, September, 1978.
GERIATRIC DENTISTRY A group of us at a conference defined geriatric dentistry as that portion of dentistry which deals with the special knowledge, attitudes and technical skills required in the provision of oral health care for older adults. Curriculum Guidelines J. Dent Edu. 1989.
Classification of Older Adults Functionally Independent older adults (70% over age 65); Frail older adults (20% over age 65);
Functionally Dependent older adults (5% in LTC, 5% homebound); Ettinger RL & Beck JD Spec Care Dent 4:207,1984.
Basis of our course is: “How does the patient function in his/her environment and how does dentistry fit into their life style�?
Geriatric Mobile Unit 1980-1985 Summary Screened 853 residents in 14 nursing homes; After screening 571 (66%) were believed to be able to benefit from dental treatment; 274 (48.0%) accepted treatment; Only 215 (37.7%) completed all their treatment;
Geriatric Mobile Unit (Summary) Group who received treatment were: Slightly younger; More alert; More ambulatory; More likely to be dentate; More likely to be receiving public funds;
Group for whom NO treatment was recommended 92.1% were edentulous; Ettinger RL, et al. Spec Care Dent 1988;8:178-83
Longitudinal Evaluation 1980-1985 Ettinger RL & Jakobsen J, J Dent Res,1989;68(Spec Issue):934
Visit 1 Visit 2 Visit 3 Visit 4 New Patients 257 55 107 96 Recall 1 195 29 44 Recall 2 102 18 Recall 3 50 Study of 853 residents in 14 nursing homes; Only in 3 homes with 257 residents did we have 3 follow up visits and only 50 were alive;
Summary Over 5 Years Survivors were more likely to be younger; Females were more likely to survive; Physical and mental status of the residents declined; Medication use increased; At the initial appointment prosthodontics (38%) was the most treatment need followed by restorative (30%) & Perio (20%); After 5 years it was prophylaxis (36%) prosthodontics (22%) &Oral Surgery (18%); Survivors need maintenance care;
Geriatric Mobile Unit 1990s – 2000s
New Mobile Equipment
Geriatric Mobile Unit 1990s – 2000s ď Ž
New RV to transport portable equipment and for developing x-rays and sterilizing instruments
New Van to transport staff, faculty, and students
New DNTL Units
http://www.medicine.uiowa.edu/igec Dr. Paul Mulhausen
2005-2008 Funded 3 Dental Fellows
Summary of the Current Iowa Geriatric Dental Program (2018) Introduction to Geriatric Dentistry - Didactic course (D3) Multidisciplinary seminar series in spring semester of the junior year; (medicine, nursing, social work, pharmacy); It is an introduction to the study of aging with an emphasis on
clinical decision making and the management of the medically, physically and intellectually disabled adult
Geriatric & Special Needs Program Clinical & didactic course (D4) 5 week clinical rotation on the GMU and the Geriatric & Special Needs Clinic
Geriatric & Special Needs Certificate Program Graduate level, 1 year interdisciplinary program
GERIATRIC & SPECIAL NEEDS PREDOCTOCTORAL PROGRAM 5 week senior extramural program; ~70% of students participate; 8-10 full days clinical experience in NF; 12-14 days clinical experience in G&SNC; 4 ½-day seminars with case study analysis and case presentation;
Populations Served by Geriatric & Special Needs Clinic
Geriatric
- medically, intellectually and functionally compromised elderly (frail and functionally dependent)
Special Needs - Medically, physically & intellectually disabled adult - Including a large cohort of intellectually disabled patients from residential facilities in Eastern Iowa
Homeless Anxious or dental phobic
Funding Sources
Private Pay – 60% Medicaid – 30% Private Insurance – 5% United Way of Johnson County / other Charitable organizations – 5%
Delta Dental of Iowa Foundation Geriatric & Special Needs Clinic 2012
12 Chair Clinic
2 Private Operatories
Wheelchair Lift
Laboratory
The Geriatric Mobile Dental Unit: A Model of Service & Education 1998 ADA Geriatric Oral Health Care Award
The University of Iowa College of Dentistry
Populations Served by Geriatric Mobile Dental Unit
• 11 nursing homes
surrounding Iowa City; • Hospice; • Homebound;
Dental Status of Nursing Home Residents and Dental Procedures Delivered on the Geriatric Mobile Dental Unit, 2006-08 Among N = 586 screened residents: mean age at screening was 83.8 years; ~70% female, 30% male; • Among residents with full tooth count data: Dentate: ~60% (both arches), ~10% (lower only) Edentulous: ~25% 1-16 teeth: ~25% 17-24 teeth: ~30% 25-32 teeth: ~20% Dramatic change in dentate status – resulting in much higher need and demand than 30 years ago
GMU / Model of Care Comprehensive Care Model Examinations & Prevention Prophylaxis, OHI, Fluoride varnish, SDF Restorative, Oral Surgery, Prosthodontics (fixed and removable), Endodontics, Restorative & implant services Emergency Services - Extractions, Sedative restorations, Denture repair/fabrication
GMU Process Screen all residents of NF Send letters to designated POA, guardian, etc - request for exam, prophy and Fl varnish - 72% acceptance Bring Mobile equipment to/in the NF Exams – further consent for treatment Complete all care agreed upon Move to next NF
Geriatric Mobile Dental Unit
Fully Electronic with Digital Imaging 2015
Portable Nomad X-ray unit
Dental Hygienist Six-Month Recall Program - general supervision
2017 – Three Month Fl varnish/SDF Program
Emergency Services
Interprofessional Experiences Pharm D students spend 2 weeks in G&SNClinic BSN students spend 3 days on the GMU
- work with D4 students Social worker employed by College of Dentistry - transportation, finances, interpreter services
NURSE PRACTITIONER CLINIC
Nurse Practitioner Clinic for Primary Care and Dental Care One year project, started January 1, 2017; - funded by Delta Dental of Iowa Foundation Thursdays in the Geriatric & Special Needs Dental Clinic; Interprofessional Practice/Education
The Keys to SUCCESS of the GERIATRIC & SPECIAL NEEDS PROGRAM University of Iowa, College of Dentistry A core of full time faculty and staff; Support from the Administration; Continual change from student & graduate feedback;
STUDENT PROGRAM EVALUATION (N = 108) Would you recommend the GSNP to other dental students? (Yes = 98%); Did the time spent in the GSNP increase your willingness to have medically complex or institutionalized elderly patients at your dental practice? (Yes = 94%); Did your experience in the GSNP increase your understanding of medically complex or institutionalized elderly people? (Yes = 98%);
IOWA DENTISTS’ INVOLVEMENT IN CARE FOR PATIENTS WHO ARE HOMEBOUND Watkins C, Ettinger RL, Cowen H, et al. Special Care Dent 2012;32(6):251-8. SURVEY of all IOWA DENTISTS INVOLVEMENT IN TREATMENT OF ADULT SPECIAL POPULATION PATIENTS
(Response rate 54.6%, n=638) 90% provide care In-Office to Nursing Home Patients (NHP) – – – –
32% see 1-5 NHP/yr 16% see 6-10 NHP/yr 19% see 11-25 NHP/yr 23% see 26+ NHP/yr
38% provide care Out-of-Office to NHP – – – –
20% see 1 NHP/yr 8% see 2 NHP/yr 3% see 3 NHP/yr 7% see 4+ NHP/yr
SIGNIFICANT FACTORS ASSOCIATED WITH OUT-OF-OFFICE CARE
Male (40.5% vs. 23.0%) p=0.0465; Years in practice (15.2 vs. 8.9) p=0.0439; Dental school off-site clinical training (41.0% vs. 31.6%) p=0.0254; General dentistry post-grad training (43.8% vs. 35.7%) p=0.0486; Continuing education didactic training (43.4% vs. 33.8%) p=0.0135; Continuing education off-site clinical training (43.9% vs. 35.6%) p=0.0492; Only 10% did not provide care to NHP in their office; Average estimates suggest these responding dentists care for ~7900(19%) of estimated 41,000 NHP in Iowa; This level of care is higher than previous reports from other states;
CONCLUSIONS Findings Suggest: 1) Although Iowa needs to increase care to residents of NF, more care is being provided than many states – possibly due to the clinical education experienced at the U of I College of Dentistry; 2) To increase dentists care of NHP efforts should be made to: a) Train & educate dentists in NHP care; b) Increase dentists commitment to NHP care; c) Increase collegial support for dentists providing NHP care;
Geriatric & Special Needs Certificate Program Evaluate & manage the general health and oral health problems of adults with special needs and older adults across the spectrum of geriatric health care services and levels of function. Interdisciplinary, team based, clinical education: - College of Medicine - grand rounds, palliative care, gero psych - College of Nursing - Nurse Practitioner program, BSN program - St Luke’s, Children Development Disabilities Clinic (UIHC)
Current Geriatric & Special Needs Post-Graduate Certificate Program Not CODA accredited; University of Iowa accredited; - Certificate given through
the graduate college.
Stipend available; International Fee for foreign trained dentists;
Geriatric & Special Needs Certificate Program
Piloted in 2012 as a self sustaining model; University accredited in 2013 with 2 Fellows accepted each year (average 10 applicants/yr);
10 Fellows will have completed the program by this spring (2018); - 3 have spent time as faculty (1 full time) Financially Self Supporting Model !!
Barriers to recruitment for Geriatric Fellows in Dental Education • “There is no established career structure for people graduating from these US fellowship programs in geriatric dentistry, unless they also complete a Masters Degree in Public Health, or Dental Public Health or similar area ” (Ettinger et al., 2004 J Dent Educ) • Currently salaries for Academics and Hospital dentists are not competitive with the private sector; • Reimbursement for treatment of patients who are frail, functionally dependent, cognitively impaired or terminally ill depends on the state in which they live and that funding is poor or nonexistent;
Postgraduate Geriatric Dental Education • The challenge in the USA is to recruit graduates when there is no specialty recognition; • However a Diplomate program has been established through the Special Care Dentistry organization;
We Lose candidates to other specialties
Future Directions Integrate The D4 Geriatric & Special Needs Extramural Program into the D4 curriculum so ALL students will participate New Model of Nursing Home Care - Stand alone dental clinic in a new nursing home Dental Clinic in a Geriatric Medicine Clinic associated with University of Iowa Hospital
39 YEARS OF GERIATRIC EDUCATION AT IOWA MADE POSSIBLE BY: Karen Baker (Pharmacist) Chuck Beadles (VA) James Beck Al Bolden Kitty Buckwalter (Nursing) Jane Chalmers Ann Connors Howard Cowen Marsha Cunningham Peter Damiano Julie Daniels Scott Daniels James Dunne Janice Eldredge (RDH) Kay Eldridge-Fahl (RDH) Ronald Ettinger Howard Field
Robert Glenn Adrienne Pearlman (PhD) Karen Granseth John Reinhardt P. T. Grime Jamie Sharp (RDH) Geri Hall (Nursing) Roger Simpson (Minster) Jed Hand Barbara Smith (RDH) Ron Hunt Max Smith Mark Jensen Brad Stiles Gerald Jogerst (MD) Carol van Aernam (RDH) Peter Kambhu Steve Vincent Steve Levy Jerry Walker Henrietta Logan (PhD) Martin Walton Cindy Marek (Pharmacist) Tom Walz (PhD) Hermine McLeran (RDH) John Warren Julie Miller-Eldridge (RDH) Cathy Watkins Woody Morris (PhD) John Wells Kathy Patterson (RDH) Darrell Yeaney (Minster)
Thank You
Lake MacBride
Question and Answer Session • Questions are welcome! This session may last for 10-15 minutes. • Write your questions in your control panel on the upper right hand of your screen. • Submit questions at any time.
CE Credit Available
Contact Information • Ronald Ettinger • ronald-ettinger@uiowa.edu • Howard Cowen • howard-cowen@uiowa.edu • Eamari Bell • eamari.bell@oralhealthamerica.org