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Factors that influence dentists' decisions to treat patients in long-term care Chowdhry, Nita 2010

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Factors that Influence Dentists’ Decisions to TreatPatients in Long-term CarebyNita ChowdhryBSc., University of British Columbia 2006A THESIS SUBMITTED IN PARTIAL FULFILMENTOF THE REQUIREMENTS FOR THE DEGREE OFMASTER OF SCIENCEinThe Faculty of Graduate Studies(Craniofacial Science)THE UNIVERSITY OF BRITISHCOLUMBIA(Vancouver)January 2010© Nita Chowdhry, 2010ABSTRACTThe purpose of this study was to evaluate what factors influence dentists in their decisionto provide services in long-term care facilities within British Columbia. The secondarypurpose was to determine if dentists practicing in rural areas of British Columbia aremore willing to provide services in LTC compared to dentists in urban areas. Also, toassess if there were any changes in opinions of dentists (practicing in Metro-Vancouver)in providing services to patients in long-term care compared to a similar study from 1985.A questionnaire was developed to determine views and opinions of general dentistspracticing in British Columbia with respect to the provision of services in long-term care.Eight hundred dentists from urban and rural areas of British Columbia were randomlyselected to participate in this study. The British Columbia Dental Association mailed apackage containing 3 questionnaires. The participants were to fill out one of thequestionnaires based on whether they treated, never treated or stopped treating patients inlong-term care. These questionnaires were faxed back to the British Columbia DentalAssociation. A reminder was sent out to the dentists 3 weeks after the initial mail-out.About thirty percent of those dentists surveyed responded with completed questionnairesfor analysis. Dentists who treated patients in long-term care reported that it was a part oftheir professional responsibility to provide services. The lack of a dental operatory andlack of experience/training in geriatric dentistry were primary concerns of dentists whonever provided services. Compared to 1985, dentists in 2008 showed increasedawareness for a need for dental services by patients in long-term care facilities. Dentistsin rural areas were more likely to be providing services to patients in long-term carefacilities, compared to dentists in urban areas. Dentists who never provided services inlong-term care facilities expressed interest in providing dental services.11TABLE OF CONTENTSAbstract.iiTable of ContentsiiiList of TablesvList of FiguresviiAcknowledgementsviiiDedicationixCHAPTER 1 Introduction11.1 The Aging Population1 .2 Oral Healthcare in Long-termCare Facilities21.3 Daily Mouth care in Long-termCare Facilities41.4 Dentists’ Attitudes and Willingness to ProvideServices in Long-term CareFacilities51.5 Urban and Rural Dentists7CHAPTER 2 Objectives of the Study9CHAPTER 3 Materials and Methods103.1 Development of the Questionnaire103.2 Pre-testing the Questionnaire113.3 Sampling123.4 Administration of the Questionnaire123.5 Statistical Analysis133.6 Non-Response Analysis133.7 Reliability Testing14CHAPTER 4 Results154.1 Non-Response Analysis154.2 Reliability Testing164.3 Comparison between Dentistswho Currently Treat, Never Treated, and StoppedTreating Patients in Long-term Care Facilities214.4 Comparison of 1985 study and 2008study394.5 Urban and Rural Differencesin the 2008 study45CHAPTER 5 Discussion465.1 Discussion of Findings465.2 Limitations of the Study505.3 Conclusion525.4 Suggestions for Future Research53References54111Appendices .62Appendix A Instruction Sheet for Questionnaire Package 63Appendix B Letter of Initial Contact and Consent 64Appendix C Questionnairesi. Dentists who Currently Treat Patients in Long-term Care Facilities 67ii. Dentists who Never Treated Patients in Long-term Care Facilities 70iii. Dentists who Stopped Treating Patients in Long-term Care Facilities 72Appendix E Modifications from 1986 Questionnaire 74ivLIST OF TABLESTable 1: Responders & Non-Responders.15Table 2: Comparison of demographic characteristics of dentists who currently treat,nevertreated and stopped treating patients in LTC22Table 3: Personal characteristics of dentists who currently treating, dentists who stoppedtreating and dentists who never treated patients in LTC24Table 4: Perceptions treating the elders-a comparison among dentists currently treating,dentists who stopped treating and dentists who never treated patients inLTC 26Table 5: Preferred methods of payment for treating patients in LTC facilities - acomparison among dentists who currently treat, never treated, and stopped treatingpatients in long-term care28Table 6: Comparison of common services provided by dentists that never treated, andstopped treating patients in LTC29Table 7: Important considerations of dentists who currently treat patients in LTC 30Table 8: Methods of payment and fee guide used when providing services to patients inLTC31Table 9: Reasons for providing treatment in LTC answered by dentistswho currentlytreat patients in LTC33Table 10: Perceptions of dentists who treat patients in LTC34Table 11: Factors influenóing decisions of not treating patients in LTC36Table 12: Reasons for stopping treatment in LTC facilities37Table 13: Importance of factors for stopping treatments in LTCfacilities 38Table 14: Comparison of personal characteristics of dentists surveyed in 1985and 2008 40Table 1 5a: Perceptions and important considerations for treating patientsin LTCcomparison between dentists surveyed in 1985 and 200842Table 1 5b: Important considerations for treating patients in LTC42vTable 16: Reasons for not providing services and stopping services in LTC compared inthe 1985 and 2008 studies 44Table 17: Location of dentists who currently treat, never treat, and stop treating patientsin LTC (2008 study) 46viLIST OF FIGURESFigure la: Box-and-Whisker Plot for reliability testing of how often oral hygieneinstruction was provided by dentists who currently treat patients in LTC17Figure ib: Box-and-Whisker Plot for reliability testing of how often bridges orcrownswere provided by dentists who currently treat patients in LTC 19Figure ic: Box-and-Whisker Plot for reliability testing of how often endodontic treatmentwas provided by dentists who currently treat patients in LTC20viiACKNOWLEDGEMENTSI offer my enduring gratitude to all of the thesis committee members: Dr. Chris Wyatt,Dr. Jolanta Aleksejuniene, Dr. Michael MacEntee, & Dr. Ross Bryant for providing mewith guidance throughout the entire process.The UBC Faculty of Dentistry and the British Columbia Dental Association haveprovided support in kind for this thesis and I extend my appreciation. I am indebted to allthe dentists who participated in this study.I would like to express my deepest gratitude to my supervisor, Dr. Chris Wyatt, for hisexcellent guidance and patience and for providing me with encouragement and supportthrough each step of the way in completing my Master of Science.I am so thankful to Dr. Jolanta Aleksejuniene for her guidance and ideas, and teachingme how to be a successful researcher.I would like to express gratitude to my family for their encouragement and support formy education.Finally, I would like to thank my husband, Kevin, for always supporting me and standingby me throughout the entire process.viiiDEDICATIONTo my FamilyixI INTRODUCTIONLi The Aging PopulationThe Canadian population is aging due to a combination of increased life expectancy anddecreased birthrate (Canada’s Aging Population, 2002).The life expectancy is 78.0 years for males and 82.7 years for females in BritishColumbia (Statistics Canada, 2002), some argue that individuals who are over 65 yearsshould no longer be considered seniors (Posner, 1995) and that a numerical value of 65should not be a standard to define old age. Nevertheless, age in years continue to definethe elderly population and within the general definition of seniors, subcategories havebeen constructed; there is now the young-old (65-74), the old-old (75-84) and the oldestold (85+). Amongst these three groups, the standards of care and health conditions ofindividuals may vary significantly.In the 1920s and 1930s, only 5% of the Canadian population consisted of seniors,whereas in the 1950s and 1960s, the senior population reached nearly 8% (A Portrait ofSeniors in Canada, 2006). Over this time, the percentage growth of the total populationwas greater than for those over the age of 65 years. Today, the situation is far different:low fertility rates, longer life expectancy and the large baby boom generation are amongthe most prominent factors contributing to the aging population, resulting in a greatergrowth rate of seniors compared to the remaining population (A Portrait of Seniors inCanada, 2006). In fact, the proportion of seniors in the Canadian population is expectedto double by the year 2025 (A Portrait of Seniors in Canada, 2006).Amongst seniors, the number of individuals who are 85+ has rapidly increased over thelast two decades. From 1981 to 2005 the number of seniors in this group grew from196,000 to 492,000 and by 2021, the total number of seniors 85+ is estimated to increaseto 800,000 (A Portrait of Seniors in Canada, 2006). The rapid growth in this cohort ofthe population has caused a shift in the patient population at long-term care (LTC)facilities. Currently, seniors that reside in LTC facilities are significantly frailer1(McGrath & Jackson, 1996) and at a later stage of dementia than seniors who resided inLTC 23 years ago.1.2 Oral Healthcare in Long-term Care FacilitiesIn Canada, the utilization of health care services drastically increases beyond the age of75 years and is correlated with a consistent decline in health status (Rosenberg, 1997).Individuals aged 75+ are more likely than other adults to suffer from a decline in theirhealth status; 40% of women and 30% of men that are 85+ reside in long-term carefacilities and this rapidly increased with age (Rosenberg, 1997). Despite this, themajority of elderly patients in LTC lack access to basic dental care (Lamy, 1999).Challenges regarding health care for seniors in Canada include health-care providerpreparedness, educational background, experiences and attitudes (Rosenberg, 1997). TheCollege of Dental Surgeons of British Columbia, the British Columbia DentalAssociation (BCDA Report on Seniors’ Oral Health, 2008), the Canadian DentalAssociation (CDA Report on Seniors’ Oral Health, 2008), and the Ministry of Health aredeveloping strategies to improve oral health for elderly individuals and in particular thoseresidents of LTC facilities.With the mean age of residents in a typical LTC facility in Vancouver being 85 years old(Wyatt, 2006), significant challenges exist in providing these patients with adequatedental care. Due to these challenges, many of the seniors who reside in LTC facilitiessuffer from poor oral health and have limited access to dental care (Wyatt, 2002). Thedental care provided within LTC facilities is often worse than dental services that frailelders received in the community (Longhurst, 1999). The perceived need for dental careis greater for seniors than for the general public, but their use of dental services is lessthan that for the general public (Marvin, 2001).Routine oral care and screening for oral diseases has increased the demand for dentalservices (Marcus et al., 1997). Patients who are admitted into LTC facilities are older,frailer (Robichaud, 2006), and are in great need of oral health care than previous2generations (McNally, 1998). In the past, elders in the United States composeda smallproportion of the population, the majority being edentate, and only seeking dental carewhen there is pain or an oral problems (Ekiund, 1999). In Ottawa, Canada, the rateofedentulism has decreased as well (Locker et al, 1991). Cross-sectional studies in Ottawaindicate a steady decline in rates of edentulism from 45% to 20% in seniors(Leäke et al.,1988). Presently, a high proportion of elders retain their teeth, which increase thedemand for treatment of oral conditions than in the past (Ettinger, 2007). Previously, themajority of seniors admitted to LTC facilities were younger and wearing dentures.However, with improved community dental services, fluoridation of drinking water andfluoride toothpaste, and better access to dental services, the rate of edentulismhasdecreased (Beltran-Aguilar et al., 2005). A growing number of seniors have retainedtheir natural teeth, but the prevalence of dental diseases remains extremelyhigh amongstthis population; they now have an increased risk of suffering from chronic oral conditions(dental caries & periodontal disease) which increases their need for dental care (Alian,2006). In America, although the dental health status has improved over the past decade,alack of services available to this group remains to be a concern (Hurtado, et al., 2001,Nelson, 2003). Over 70% of institutionalized English seniors had not seen a dentist inover five years (Frenkel, 2000).Oral health should be given the same priority as other health care services provided inLTC facilities (Pino et al., 2003). The World Health Organization has defined healthas“a state of complete physical, mental and social well-being and not merely the absenceofdisease and infirmity.” This definition reflected a view of western medicine, which hasexpanded well beyond the scope of physical health, and into social, psychological andphysical functioning (Reisine, 1985). Oral health is fundamental for quality of life,psychological well-being, and life satisfaction (Thorne et al., 2001& Pino et al., 2003).Poor oral health in elders includes oral pain, difficulty with eating andcommunication(Reisine, 1988, Tickle et al., 1997). Seniors suffer from untreated dentalcaries,periodontal complications and loose dentures (Kiyak et al., 1993); as a result, seniorstendto eat less and lose weight, which causes deterioration in overall health(Andrews, et al.,1990).3Poor oral health adversely affects nutrition, dietary habits, and leads to diminished socialinteraction (Pino et al., 2003). Residents of LTC facilities are prone to gingivitis, dentalcaries, halitosis and improperly fitting dentures (MacEntee, 2006). Tooth decay, missingteeth, periodontal disease, and gingivitis should not be considered a part of healthy aging.1.3 Daily Month Care in Long-term Care FacilitiesAccess to dental services, healthy diets, and the use of fluoride toothpaste along with thefluoridation of the water supply has reduced tooth loss due to dental caries in Westernpopulations. However, while many more seniors retain more teeth, daily mouth carewithin LTC facilities seems to be at the bottom of the priority list for nursing staff (Pinoet a!., 2003).Oral hygiene (daily mouth care) is significantly neglected in LTC settings (Pino et al.,2003). The lack of daily mouth care in LTC facilities has been a significant concernsince it was first documented in the 196Os. For example in Brooklyn, Massachusetts,more than half of denture wearers in LTC had not removed their dentures for nightlycleaning for at least four months (Maloof, 1964). In a survey from a UK hospital, 80% ofpatients with complete dentures and 69% of patients that had natural teeth did not receiveany daily mouth care (tooth & denture cleaning) (Longhurst, 1999). Eighty percentofcomplete denture users had not had their dentures cleaned and 69% of dentate patientsdid not have their teeth cleaned daily (Preston et al., 2006). In Edinburgh Scotland, 65%of LTC residents had dentures with visible soft debris, calculus and stains (Munroe,1990). To date, denture cleaning and elimination of plaque remain to be neglected inlong-term care facilities in Canada (Gornitsky et al., 2002).41.4 Dentists’ Attitudes and Willingness to Providing Services in Long-term CareFacilitiesDentists’ attitudes and their willingness to provide services to LTC residents wereanalyzed over 20 years ago within Metro-Vancouver (MacEntee, et al., 1992). In thisstudy, a multiple choice and open ended questionnaire was sent to 603 general dentists inthe Metro-Vancouver area of British Columbia to determine dentists’ views on workingwith LTC residents. Socio-cultural, professional, and an economic models wereinvestigated to identifr the key factors that would determine whether a dentist wouldprovide treatment to patients in LTC facilities. Findings suggested that both professionaland economic factors influenced treatment decisions. Professional models, such aslimited treatment options and lack of training in dental school influenced the desire totreat this group. Economic factors, such as loss of leisure time, age, unrewardingfinances, type of practice, years of practice and loss of private practice time wereamongst the most common barriers to providing treatment to long-term care residents.MajOr barriers to providing dental care within LTC include lack of support for theservice, time constraints, limited financial support, difficulty providing care to residents,lack of training of health care workers, and a poor comprehension of the necessity of care(Weeks, 1994). Patient compliance with dental treatment plans was also reported to be amajor factor that encouraged or discouraged provision of dental services (Preston et al.,2006). Perhaps some dentists felt they were not adequately trained to work with frailseniors (MacEntee et al., 1992).In 1994, a qualitative study was performed in Metro-Vancouver to identify ethicalproblems that may influence decision making for dentists who provide services in LTCfacilities (Bryant, 1995). This study investigated the views and experiences of dentistsworking with institutionalized elders as well as the ethical difficulties of treating seniorsin LTC. Ten dentists who treated institutionalized patients in Vancouver wereinterviewed to identify their ethical viewpoints to treating elderly patients. Attention waspaid to the varying view points of the dentists on their bioethical principles (non5maleficence, beneficence, patient’s autonomy and justice) and decision making fortreatment. Both ethical and practical problems influenced decision making for dentistswho attempted to provide oral care to elders in long-term care facilities. Findings fromthis study also indicated that dentists faced practical problems such as the lack of supportfor services and the inefficiency with the delivery of services associated with providingdental care in LTC facilities (Bryant, 1994). Consequently, the environment of thefacility and the lack of training and experience with providing services to the elderly weresignificant factors that impacted decisions to treat (Bryant, 1994). Such factors may havedeterred dentists to consider providing treatment within the LTC setting. To date, therehas been no follow-up study in Metro-Vancouver to evaluate any changes in dentists’decisions in treating the institutionalized elderly and reasons behind their opinions.Coordination between the dental profession and health authorities is needed to addressoral health care needs of elders to educate the public concerning the relationship betweenoral and systemic health as oral infections are now recognized as a risk factor forsystemic diseases (Lamster, 2004). In the United States, there are an increasing numberof seniors requiring dental service, but not enough dentists that are willing to providedental services to geriatric patients (Hurtado et al., 2001). Similarly in Canada, there areonly a few dentists who serve frail elders residing in long-term care (Bryant et a!., 1995).It is important to identify if the increased need for dental services in ETC facilities hasinfluenced and changed dental professionals’ decisions on providing services to thisvulnerable age group. A qualitative interview was conducted to understand how dentistsview the concept of social responsibility and its relationship with access to oral health inNorth America (Dharamsi et al., 2007). Findings from this study suggested thateconomic, professional, personal choice and politics were the main factors thatinfluenced social responsibility in dentistry. A balance between social and fiscalresponsibilities were identified as well, along with a reminder that dentists makereasonable efforts to provide their services to all people, regardless of social status(Dharamsi et al., 2007).61.5 Urban and Rural DentistsMedical professional’s job satisfaction and job-related pressure differed significantlybetween those working in urban and rural areas (Luman et al., 2007). Family physiciansin rural California tended to have a greater sense of professional satisfaction andcommunity satisfaction compared to urban counterparts (Luman et al., 2007 & Bible,1970). Background information such as the physician’s hometown had a significantinfluence on the size of the community where the physician would chose to practice(Bible, 1970). Medical students from a rural background were approximately 2.5 timesmore likely to practice in a rural environment compared to urban raised students(Woloschuk & Tarrant, 2004). It was difficult to recruit physicians who were raised in ametropolitan environment to work in a rural setting (Luman et al., 2007). Exposure torural medicine through electives and rotations had a significant influence on choosing arural practice over an urban practice (Chan et al., 2005). Gender differences have alsobeen identified in rural and urban practice location in mid-level health care providers inNew York State and Pennsylvania (Lindsay, 2007). Although women comprise themajority of medical professionals, they were less likely to work in a rural environmentcompared to men (Lindsay, 2007). Some identified advantages of practicing in a rurallocation were greater autonomy, respect, professional satisfaction, expansion of skills,less commute time, and a more personable nature and relation with patients (Lindsay,2007). In a similar Australian study, benefits of practising rural medicine were a sense ofbelonging attained from working in a close-knit community and the greater amount ofrespect given to the medical professional (Rashid, 2007). However, general practitionersalso admitted that working in an intimate network in which they knew their patients on apersonal level also made it difficult to draw the line between professional and personallife (Rashid, 2007). Medical professionals also indicated some disadvantages of workingin a rural environment; such factors were professional isolation and longer practice hours(Lindsay, 2007). In contrast, both males and females enjoyed practicing in the urbanlocations as they preferred a fast paced, team oriented approach, with greater technologyand wider breadth of medical practice (Lindsay, 2007).7In Canada, the majority of physicians serving rural populations expressed greater overalljob satisfaction than their urban counterparts and indicated that a wider range ofprocedures was linked to higher overall job satisfaction (Rivet & Ryan, 2007). InCanada, the majority of physicians serving rural populations expressed greater overall jobsatisfaction than their urban counterparts (Rivet & Ryan, 2007). However, the reasonsfor job satisfaction varied in different countries: in Australia, rural physicians had higherjob satisfaction scores for autonomy (Ulmer & Harris, 2002), whereas in New Zealand,rural general practitioners expressed a greater concern for their independence than urbanmedical professionals (Walton et al., 1990). Evidently, rural and urban health careprofessionals present a variety of pros and cons of working in rural and urban settings.Research was conducted in nine small town communities across Canada to identify howthe concept of community operates with respect to the provision for community careservices for seniors (Skinner et al., 2008). From a medical perspective, the growing needfor geriatric care and long-term care was recognized in small town communities. Astrong belief existed amongst service providers in which rural communities were able toprovide for their seniors despite limitations associated with services in small towncommunities (Skinner, et al., 2008).Although many studies suggest differences in attitudes between medical professionalspracticing in a rural or urban environment, a study of dental professionals has not beenperformed. This thesis will explore whether dental professionals in rural and urbanBritish Columbia differ in their reasons behind treating elders in long-term care facilities.82 OBJECTIVES OF THE STUDYa) To examine factors behind why dentists decide to treat, not to treat, or why theystopped treating patients in Long-term Care (LTC) facilities.b) To determine if dentists practicing in rural areas of British Columbia are morewilling to provide services in LTC compared to dentists in urban areas.c) To identify if there has been any changes in attitudes and willingness of dentists(practicing in Metro-Vancouver) to treat patients in long-term care from 1985.93 MATERIALS & METHODS3.1 Development of the QuestionnaireA questionnaire to investigate attitudes of dentists working with LTC patients wasdeveloped previously and used as the basis for this study (Weiss, 1986). The objective ofthis study was to examine attitudes of dentists working with elderly patients and to alsosee if attitudes had changed from 23 years ago. Many of the original questions wereincluded in the new survey questionnaire (Appendix A); however, the questionnaire wasupdated to include new questions relevant today, and to eliminate questions which werenot of interest, and to reduce repetition. Wording and language were modified to enhancereadability and understanding of the new questionnaire.Instead of creating one long questionnaire as was done for the 1985 survey, three separatequestionnaires were created to target the different groups of dentists: those who treatpatients in LTC, those who do not, and those who have stopped treating patient’s in LTC.Breaking the questionnaire into 3 parts was intended to reduce the amount of time thatparticipants would need to fill out applicable questions, and therefore, to achieve a higherresponse rate. Each questionnaire was clear and concise, and took an average of 10minutes to complete.Each questionnaire was divided into two sections; the first section related to personalinformation including gender, years of practice, and post graduate training; and thesecond section had questions that targeted professional, personal, and economic factors toexplore opinions on treating patients in LTC.Three colour-coded questionnaires were created which were specific to dentists whoa) currently treat, b) never treated, and c) stopped treating patients in LTC. Thequestionnaires were mailed out in a semi-anonymous fashion: each package had a uniquenumerical code which was used to identify information pertaining to which questionnaire10was returned or not returned. In addition, the code was used to determine demographicdata from the non-respondents.Responses from all three groups were analyzed to determine key differences in opinionstowards providing services in LTC. Additional questions were incorporated to shed lighton why dentists decide to treat, stop treat or never treat patients in LTC. Also, questionswere used to determine if there were any differences in decisions to treat in LTC based onlocation of practice.Questions that were common between the questionnaires administered in 1985 and 2008were compared to explore professional, personal and economic factors with respect todentists decisions to treat in LTC facilities. Certain questions may have fallen into morethan one of the three categories (APPENDIX F).3.2 Pre-testing the QuestionnaireThe survey was provided to eight dentists of various ages, genders, and experienceworking with LTC patients. The sample group included dentists who treated, nevertreated, and stopped treating patients in LTC. In addition, the sample group includeddentists from both rural and urban parts of British Columbia. Each dentist filled out thequestionnaire depending on his or her private practice situation. After completing thequestionnaire, each participant was interviewed for feedback on the wording andappropriateness of the questions. In addition, the questionnaire was also given to threeUBC Dentistry faculty members for their feedback. All comments and/or suggestionsrelated to wording or structure of the questionnaire were used to refine the finalquestionnaires.113.3 SamplingA sample of size of 300 dentists (10%) was determined to be representative of the over3,000 dentists in British Columbia. Past survey experience by the British ColumbiaDental Association has found that 50% of dentists will likely respond. Therefore arandomly selected sample of 600 dentists was considered. Since the survey was to be sentout in the summer, when dentists often are on holidays, an additional 200 surveys weresent out for a total of 800.In 1985, only Vancouver, Buniaby, North and West Vancouver were included in thesurvey of dentists, however, this study used Metro-Vancouver, which also includesAnmore, Belcarra, Bowen Island, Bumaby, Coquitlam, Delta, Langley, Lions Bay, MapleRidge, New Westminster, North Vancouver, Pitt Meadows, Port Coquitlam, Port Moody,Richmond, Surrey, Vancouver, West Vancouver, and White Rock.3.4 Administration of the QuestionnaireThe British Columbia Dental Association (BCDA) assisted in this study by randomlyselecting 800 general dentists from their database. The questionnaires were packagedand mailed out to the dentists from the BCDA office.An introductory letter was included in the package which provided instructions on whichquestionnaire was to be filled out, along with an incentive to participate (Appendix E);the dentists were asked to fax back the completed questionnaire to the BCDA.Although the majority of questionnaires were faxed back to the BCDA, somequestionnaires were mailed or faxed back to the Faculty of Dentistry at UBC. Threeweeks after the initial mail-out, a fax reminder was sent to encourage the non-respondersto fill out the questionnaire. A second reminder was sent out five weeks after the initialmail out as a broadcast email by the BCDA12Each survey package included a letter of initial contact with a consent form and aquestionnaire. The letter of initial contact and consent explained the purpose, benefits,description and confidentiality agreement for this study (Appendix B).The study was approved by the Ethics Committee of the University of British Columbia,Canada. The Ethical Approval Number for this study is H08-00222.3.5 Statistical AnalysisFor all the statistical analyses, the SPSS programme, Version 16.0 was used (SPSS Inc.,Chicago, IL). Data were analyzed based on general responses that were commonamongst the three questionnaires and later analyzed separately for groups of dentist whocurrently treated, never treated, or stopped treating the elderly in LTC.Firstly, the three groups of dentists (currently treating, never treated, and stopped treatingelderly residents of LTC facilities) were compared by means of Chi Squared test andANOVA with a post hoc Bonféronni adjustment. Descriptive statistics were employed togenerate frequency distributions. Bivariate statistics were conducted for non-responseanalysis, reliability testing, and comparisons between the three groups of dentists namelythe ones who currently treat, never treated and stopped treating patients in long-term care.3.6 Non-Response AnalysisA non-response analysis was performed in order to determine if there were anysystematic differences among the responders and non-responders. Differences indemographic information (gender, year of graduation, and location of practice) werecompared between the responders and non-responders. Information on year ofgraduation, gender and location of practice was provided by the BCDA. The year ofgraduation was used as a proxy measure of an estimate of how many years the dentistshad been in clinical practice. In addition, the location of practice (urban/rural & MetroVancouver/outside of Metro-Vancouver) were compared between responders and non13responders. Proportional distributions regarding aforementioned factors between theresponders and non-responders were compared by a Chi-Square Test.3.7 Reliability TestingReliability testing was conducted in the questionnaire for dentists who currently treatpatients in long-term care. In the first half of the questionnaire, dentists were asked howoften they provide a list of services to patients in LTC. In the second half of thequestionnaire, the same questions were slightly reworded, but asked the same question inthe same order. For example, the first question asked ‘In an average work week, howoften do you (or your staff) provide the following services to patients in long-term care?’The second question asked ‘What are the most common dental services that you provideto patients in long-term care?’ Box-and-Whisker plots were created to illustrate anydifferences in responses. A paired sample t-test was used to test the reliability of selfreports on the p-values that were generated.144 RESULTS4.1 Non-Response AnalysisA total of 234 questionnaires were returned of the 800 that were sent out; creating a29.3% response rate. There were no statistically significant proportional differencesbetween responders and non-responders with respect to gender, years of practice,urbanization and or location of practise (Table 1).Twenty-seven out of 44 rural dentists that were given a survey responded (61.36%). Twohundred and seven urban dentists out of a total of 756 urban dentists responded to thesurvey (27.3 8%).Table 1. Comparison between Responders & Non-RespondersFACTORS NON-RESPONDERS RESPONDERSURBANIZATIONNumber of Dentists (% of total)Urban 549(97.0) 207(88.5)Rural 17(3.0) 27(11.5)Chi square test, P=0.2l3LOCATIONMetro-Vancouver 340(60.1) 114(54.8)Outside of Metro- 226(39.9) 93(45.2)VancouverChi square test, P=0.349GENDER Males 438(77.4) 191(81.6)Females 128(22.6) 43(18.4)Chi square test, P=0. 183YEARS OFMean±SD Mean±SDPRACTICE22.0±10.9 22.4±10.1Chi square test, P=0.089*total number of responders=23415Reliability TestingReliability testing was performed for the group of dentists that currently treat patients inLTC. Similar questions based on the services that are provided in LTC facilities wereasked twice and the mean differences between similar questions were compared using apaired sample t-test. Box-and-Whisker plots were used to illustrate the results of thistesting (Figures 1 a-c). The mean differences for similar questions were compared usinga paired sample t-test and p-values were generated. There were no statistically significantdifferences between responses for the similar questions.16Figure la. Box-and-Whisker Plot for reliability testing of how often oral hygieneinstruction was provided by dentists who currently treat patients in LTC (pairedsample t-test comparisons)I’_Meandifference*0.488IIti,sttne.post*lvery often, 2often, 3sometimes, 4seldom, 5=neverDentists differed slightly in their responses during the first and second part of thequestionnaire (Figure la). In the first question that asked how often they provided oralhygiene instruction to patients in LTC, responses fell between the two intervals for‘sometimes’ to ‘seldom.’ Therefore, 50% of the responses from dentists that currentlytreat patients in LTC (n35) indicated that they provided oral hygiene instructionsometimes to seldom. The highest and lowest observations ranged from ‘never’ to‘often.’ Twenty-five percent of the dentists said they provided oral hygiene instructionoften to sometimes; another 25% of responses from the dentists fell between seldom tonever. Out of the total sample group, only one dentist stated that they provide oralhygiene instruction to patients in LTC facilities very often. The second time around theentire range of responses fell between very often to never. Fifty percent of the responsesranged between ‘often’ and ‘seldom’ and the median response was that oral hygieneinstruction was provided only sometimes. Twenty-five percent of responses fromdentists stated that they provide this service often to very often, while another 25% ofsncondline17dentists said they provide oral hygiene instruction seldom to never. A p-value of 0.107was attained which indicated that there was no statistically significant difference betweenthe two repeated questions.18Figure lb. Box-and-Whisker Plot representation for reliability testing of how oftenbridges or crowns were provided by dentists who currently treat patients in LTC(paired sample t-test comparisons)4.5.ll•11’:i.Meandifference*0.018P=0.9242firattime secondpre.post*1=very often, 2=often, 3=sometimes, 4=seldom, 5=neverDentists were consistent in their responses during the first and second part of thequestionnaire. In the first question that asked how often they provided bridges or crownsto patients in LTC, responses fell between ‘seldom’ to ‘never.’ For the second question,all responses were the same, except there were no outliers as seen in the first question.Box-and-Whisker plots for both questions indicated that the same upper bounds andlower bounds were attained. A p-value of 0.924 was attained which indicated that therewas no statistically significant difference between the two repeated questions.19Figure ic. Box-and-Whisker Plot for reliability testing of how often endodontictreatment was provided by dentists who currently treat patients in LTC (pairedsample t-test comparisons)4.5.4aCo03Meandifference*0.083C25P=0.697Co2819 65C 2firSt tirre second time*l=veryoften, 2=often, 3sometimes, 4=seldom, 5=neverDentists were consistent in their responses to repeated questions in the first and secondpart of the questionnaire. In the first question that asked how often their providedendodontic treatment to patients in LTC, 75% of the responses fell between the twointervals for ‘seldom’ to ‘never.’ Box-and-Whisker plots for both had a lower boundwhich ranged between ‘seldom’ to ‘sometimes.’ For both questions, a total of 3 dentistswere outliers and they indicated that they ‘often’ provided endodontic treatment topatients in LTC. A p-value of 0.697 was attained which indicated that there was nostatistically significant difference between the two repeated questions.204.3 Comparison between Dentists who Currently Treat, Never Treated andStopped Treating Patients in Long-term Care FacilitiesDemographic characteristics among the dentists currently treating the institutionalizedelderly, who stopped treating institutionalized elderly and, who never treatedinstitutionalized elderly are presented in Table 2. There were statistically significantdifferences among the groups of dentists regarding age, gender and location of practice.In general, dentists currently treating institutionalized elderly tended to be males, andwere slightly older than dentists who do not treat the elderly.21Table 2. Comparison of demographic characteristics of dentists who currently treat,never treated and stopped treating patients in LTCTREATING ELDERS IN LONG-TERM CARE FACILITIESYES NEVER STOPPEDDEMOGRAPHIC (n=3 5) (n 152) (n=47)FACTORSNumber of Dentists (% of total)GENDERMales 33(94.3) 116(76.4) 41(87.2)Females 2(5.7) 36(23.6) 6(12.8)Chi Squared Test or Fishers Exact Test P0.024URBANIZATIONUrbanRural25(83.3) 138(90.8)I38(82.6)5(16.7)I14(9.2)I8(17.4)Chi Squared Test P=0.18663(41.4)88(57.8)10(21.3)37(78.7)Metro-VancouverOutside Metro-Vancouver9(26.0)26(74.0)Chi Squared Test P0.012AGE mean±SD Mean±SDmean±SD53.8±8.0 47.0±9.0 51.0±9.0ANOVA with Bonferonni Post Hoc adjustmentCurrently vs. Never: P=0.001; Currently vs. Stopped: P=0.568;Never vs._Stopped P=0.03422In general dentists in all three groups had many years of clinical experience (currentlytreating: mean26.3 years, never treated: mean=20.3 years, & stopped treating:mean24.5 years) (Table 3). Dentists who currently treat patients in ETC or whostopped treating them had significantly more years of dental practice compared to thedentists who never treated the elderly in LTC.A very small percentage of dentists in all three groups had training in geriatric dentistry,whether it was clinical training or lectures. Overall, within all three groups, about 20% ofthe dentist’s patient pool consisted of patients that were 65 years or older.23Table 3. Personal characteristics of dentists currently treating, dentists whostopped treating and dentists who never treated patients in LTCCHARACTERISTICSTREATING ELDERS IN LONG-TERM CARE FACILITIESNumber of Dentists (% of total)YES NEVER STOPPED(n=35) (n152) (n=47)YEARS OFmean±SD mean±SD mean±SDPRACTICE26.3 ±10.9 20.3±9.9 24.5±9.7ANOVA with Bonferonni Post Hoc adjustment P0.002HOURS PERWEEKADVANCEDTRAININGNoYesmean±SD35. 1±8.0ANOVA with Bonfeimean±SD33.4±5.7onni Post Hoc adjustnmean±SD33 .6±5 .2Lent P0.403Number of Dentists (% of total)30(85.7)5(14.3)Chi Squared Test P0.376148(91.4)14(8.6)42(89.4)5(10.6)PERCENTAGE OFmean±SD mean±SD mean±SDPATIENTS 6521.4±10.1 18.4±10.7 20.8±12.9YEARS OR OLDERANOVA with Bonferonni Post Hoc adjustment P0.22024All 3 groups of dentists (currently treating, never treated, and stopped treating patients inLTC) ‘slightly agreed’ that treating patients is a pleasant experience (Table 4).Responses from all groups of dentists tended to be neutral when asked if elders rarelyfollow-up with recommended treatment. All three groups of dentists agreed that it is hardto improve oral health of elders. Age of a patient was not perceived as influencingdecisions to the provision of care. Overall, dentists who currently treat elders or whostopped treating them agreed that it is hard to improve health of elders, while dentistswho never treated elders had a more neutral perception. Dentists from all three groupsagreed that treating elders is time-consuming. The most profound difference inperception among three groups related to the statement ‘elders present difficulties due tomedical problems/dementia.’ Dentists who stopped treating patients in long-term careagreed to this statement (mean2. 1) and dentists who currently treat patients in LTC werealso in agreement with this statement (mean =2.5). Self-reports from dentists who nevertreated patients in long-term care, indicated that they ‘slightly agreed’ to this statement(mean = 3.7).25Table 4. Perceptions treating the elderly - a comparison among dentists currentlytreating, dentists who stopped treating and dentists who never treated patients inLTCPERCEPTIONS OF TREATING ELDERS IN LONG-TERM CARETREATING ELDERS FACILITIESYES NEVER STOPPED(n=35) (n=152) (n=47)Treating elders is a mean±SD* mean±SD* mean±SD*pleasant experience2.8±1.3 2.8±1.3 3.0±1.5P=O.6432.5±1.6 2.7±1.63.7 ±1.3P=O.2354. 1±1 .5 4.1±1.52.8±1.1 3.2±1.7Patients age does notinfluence my decision toprovide servicesElders rarely follow upwith recommendedtreatmentIt is hard to improve oralhealth of eldersTreating elders is time-consuming2. 1±1.2P=0.0o12.3±1.0 2.9±1.3 2.5±1.5P=0.013Treating elders is3.2±1.6 3.8±1.3 3.2±1.5financially unrewardingP=0.01 7*the means are derived from the following Likert scale:1 =strongly agree, 2=agree, 3=slightly agree, 4=neutral, 5slightly disagree,6=disagree,7strongly disagree*Multiple comparisons by ANOVA with Bonferonni Post Hoc adjustmentElders presentdifficulties due tomedicalproblems/dementia2.5±1.8P=O.7772.5±1.5P=0.0003.7±1.6 2. 1±1.126The largest difference in preferred method of payment was between dentists whocurrently treat patients in ETC versus the other two groups (dentists who never treated &stopped patients in LTC). Dentists who currently treated institutionalized elderlypreferred to be paid by fee-for-service (73.5 %) as opposed to being paid by fee-for-time(27.3%) (Table 5). Dentists who never treated and stopped treating in LTC were neutralon whether they preferred to be paid by fee-for-time, or by fee-for-service. Only a fewdentists preferred a session fee or a retainer fee when providing services in long-term carefacilities.27(DC(DCCCl)Cl)FCCICDC-)—H‘—.—.—.—.IIIC/)Cl)Lj3C/2.0HCyccCDCDCCDUiCDrCDCDIC,)IC,)IIII-t©CC00Ui .00Co—_I.-’,VCDCV—C)VVo——.C-)-Cl) HUit’JUi,‘,‘,‘,—‘—‘,—‘C-Ui.UiVVUicc—‘cc‘—i‘—,‘—,‘—,Cl)L’J 00Dentists who never provided LTC services provided more periodontal treatment in theirown practices than those who stopped providing services in LTC. Both groups ofdentists occasionally provided biopsies and extractions. The most common servicesprovided by both groups were restorations, oral hygiene instruction, bridges/crowns,periodontal treatment and endodontic treatment.Table 6. Comparison of common services provided by dentists that never treated,and stopped treating patients in LTCNEVER STOPPEDTREATED IN TREATING INSERVICES LTC LTC(n152) (n=47)Mean ±SD*Mean ±SD*P ValueExtractions2.3±1.1 2.3±0.9 0.850Biopsies4.1±0.8 3.9±0.8 0.056Oral hygiene1.3±0.6 1.4±0.7 0.445instructionRestorations1.1±0.4 1.12±0.4 0.708Bridges/crowns 1.6±0.81.6±0.6 0.643Denture Fabrication 3.3±1.03.3±1.0 0.930Denture3.0±0.9 3.1±0.9 0.562AdjustmentsDenture Relines3.3±1.0 3.3±1.0 0.990Periodontal1.6±0.9 1.2±0.4 0.000TreatmentEndodontic1.7±0.8 1.7±0.7 0.978Treatment*the means are derived from the following Likert scale: lvery often, 2=often,3=sometimes, 4seldom, 5=never29Dentists who currently treated the institutionalized elderly indicated that ‘moderatelyimportant’ factors that influenced their decisions to treat were availability of a dentaloperatory and equipment at the facility (mean 2.1), the amount of private practice time(mean 2.5), and personal satisfaction in working with elderly patients (mean 2.2) (Table7). Dentists who currently treat patients in LTC tended to be neutral (mean 2.9) whenasked if remuneration was an important consideration for providing services in long-termcare facilities. A substantial proportion of dentists were fairly neutral whenasked ifexperience and training was an important factor. One-third of the dentists felt that thedistance to the facility was an important consideration, whereas 1/3 of the dentistsfeltthat this was not of great importance in their decision to provide services.Table 7. Important considerations of dentists who currently treat patients in LTCVery Moderately Neutral Minimally NotCONSIDERATIONS Important Important Important Important(1) (2) (3) (4) (5)Number of Dentists (% of total)n=35Amount of Private 12(32.4) 8(2 1.6) 5(13.5) 2(5.4)6(16.2)Practice TimeMean ± SD:2.5±1.58*(2 missing answers)Mean± SD:2.7±1.3*(1 missim answer)Distance to FacilityI4(10.8)I8(21.6)I6(16.2)I6(16.2) 10(27.0)Mean ± SD:3.3±1.4*RemunerationI3(8.1)I12(32.4) 7(18.9)I 7(18.9) I 4(10.8)Mean ± SD:2.9±1.2*Availability of dentaloperatory andequipment19(5 1.4)Personal satisfactions inworking with the elderlyMean ± SD: 2.]±1.2*11(29.7) 13(35.1) 1(2.7) 0(0.0)4(10.8) 4(10.8) 4(10.8) 3(8.1)Amount of PersonalTime7(18.9) 11(29.7) 7(18.9) 5(13.5) 4(10.8)8(2 1.6)Mean ± SD:2.2±0.9*(1 missing answer)Experience/Training in 2(5.4) 7(18.9) 15(40.5)6(16.2) 3(8.1)treating elderlyMean ± SD:3.0±1.0*(1 missing answer)*the means are derived from a Likert scale ranging from 1-5.30The majority of dentists that currently treated patients in LTC facilities were paid by fee-for-time, and only a small number of dentists were paid by fee-for-service, retainer fee,and sessional fee (Table 8). Out of the total number of dentists (n35) who currentlyprovided service in LTC, 45.9% used the British Columbia Dental Association (BCDA)General Fee Guide, and only 24.3% of the responding dentists used the BCDA Fee Guidefor LTC. However, 16.2% of the dentists did not use any fee guide when treating in LTCfacilities.Table 8. Methods of Payment and Fee Guide used when providing services topatients in LTCMETHOD OF PAYMENTNumber of Dentists(% of Total)n=3 I*FEE GUIDE USED IN LTCNumber of Dentists(% of Total)n=32**BCDA General Fee Guide 17(45.9)BCDA Fee Guide for Dental Treatment Services in LTC 9(24.3)FacilitiesNo Fee Guide 6(16.2)Fee-for-timeFee-for-ServiceRetainer Fee (on call)Sessional Fee28(75.7)1(2.7)1(2.7)1(2.7)*4 missing answers,* *= 3 missing answers31The most common reason for providing services in LTC facilities was the perception ofdentists that it was a part of their professional responsibility (mean2. 1); 86.4% of thedentists that currently treat patients in LTC facilities tended to agree with this statement(Table 9). Out of the total number of dentists currently treating patients in LTC, 75.6%tended to agree that they decided to provide services because they wanted to perform apublic service in their community, 51.3% of the dentists reported that they decided toprovide services because a past patient or family member was in a LTC facility. Otherreasons were as follows: 62% of the dentists decided to treat in LTC because they wereasked to provide services and 43.2 % of the dentists wanted to provide services becausethey felt that social contacts with elders were rewarding. The least popular reasons forproviding treatment in LTC facilities were: to increase the size of their practice, becauseit was a part time practice opportunity, or because it was a part of a semi-retirementpractice.32Table 9. Reasons for Providing Treatment in ETC answered by dentistswhocurrently treat patients in LTC (n=35)Strongly Agree Slightly Neutral Slightly Disagree StronglyAgree Agree Disagree DisagreeREASONS (1)(2) (3) (4) (5) (6) (7)Number of Dentists (% of Total)To increase size of 0(0.0) 6(16.2) 1(2.7) 4(10.8) 2(5.4)10(27.0) 12(32.4)PracticeMean ± SD:5.3±1.9*Social contacts with 0(0.0) 5(13.5) 11(29.7) 16(43.2) 0(0.0) 1(2.7) 1(2.7)elders are rewardingMean ± SD:3.5±1.1*Public service 5(13.5)I14(37.8)I9(24.3)I5(13.5)I0(0.0)I0(0.0)I1(2.7)Mean ± SD:2.6±1.2*Part of professional 9(24.3) 16(43.2) 7(18.9) 2(5.4) 0(0.0) 0(0.0)0(0.0)responsibilityMean ± SD:2.1±0.9*Part time practice 0(0.0) 3(8.1) 1(2.7) 8(21.6) 2(5.4)6(16.2) 12(35.1)opportunitiesMean ± SD:5.4±1.7*Part of semi-retirement 0(0.0) 0(0.0) 0(0.0) 3(8.1) 7(18.9) 0(0.0) 22(59.5)practiceMean ± SD:6.5±0.9*Broadens scope of 1(2.7) 2(8.1) 12(32.4) 6(16.2)0(0.0) 5(13.5) 7(18.9)PracticeMean ± SD:4.3±1.9*Iwas asked 8(21.6)I11(29.7) 4(10.8)I2(5.4)I1(2.7) 0(0.0)I7(18.9)Mean ± SD:3.2±2.3*Pastpatientorfamily 8(21.6) 8(21.6) 3(8.1) 4(10.8)0(0.0) 4(10.8) 6(16.2)member was in LTCfacilityMean± SD:3.5±2.3**the means are derived from a Likert scale ranging from 1-7.33The majority of dentists considered that certified dental assistants were importantmembers of the clinical team in LTC facilities (Table 10). Dentists who currently treatedthe elderly in LTC reported continuing geriatric education beyond dental school to behelpful tool in treating patients in LTC facilities.Table 10. Perceptions of dentists who treat patients in LTC (n=35)Certified DentalAssistants areimportantmembers of theclinical team inLTCContinuingeducationbeyond dentalschool would behelpful to treatpatients in LTC15(40.5)17(45.9)14(37.8)Mean ± SD:1.7±0.7*11(29.7)Mean±SD:1.8±1.0*5(13.5)3(8.1)0(0.0)2(5.4)*the means are derived from a Likert scale ranging from 1-7.0(0.0)1(2.7)PERCEPTION Strongly Agree Slightly Neutral Slightly Disagree StronglyAgree Agree Disagree Disagree(1) (2) (3) (4) (5) (6) (7)Number of Dentists (% of total)Dental25(67.6) 8(21.6) 1(2.7) 0(0.0) 0(0.0) 0(0.0) 0(0.0)hygienists areimportantmembers of theclinical team inLTCMean±SD:1.3±0.5*0(0.0)Additional8(21.6) 7(18.9) 7(18.9) 5(13.5) 2(5.4) 4(10.8) 1(2.7)paperwork suchas consent is fortreatment is aconcernMean± SD:3.1±1.8*0(0.0)0(0.0) 0(0.0)34Questions asked to dentists who never treated patients in LTCThe majority of dentists (87.3%) indicated that the lack of a dental operatory and dentalequipment in facilities were the most important reasons for not providing services topatients in LTC. The second most common reason why dentists were not providingservices in LTC facilities was that they felt that they were too busy in private practice(84.9%), and thus may have not been able to take time to provide services in LTCfacilities (Table 11). Many dentists also indicated that the amount of their personal timewas another common reason for not providing services in LTC facilities (81.3%).Dentists had varying opinions about the level of training and experience as a reason fornot providing services in LTC (49.0%). Approximately 37% of the dentists stated thatdistance to the facility was an important consideration for not providing service in LTCfacilities.35Table 11. Factors influencing decisions of not treating patients in LTC answered bydentists who never treated patients in LTC (n452)FACTORS Very Moderately Neutral Minimally NotImportant Important Important Important(1) (2) (3) (4) (5)Number of Dentists (% of Total)Amount of Private 86(56.6) 43(28.3) 10(6.6) 5(3.6) 5(3.6)Practice TimeMean ± SD:1.7±1.0*(3 missing answers)Amount of Personal 79(51.8) 45(29.5) 16(10.2) 5(3.0) 6(4.2)TimeMean ± SD:1.8±1.0*(1 missing answer)Distance to Facility 18(10.8)I43(25.9)I52(31.3)I20(12.0)I21(18.7)Mean and SD:3.0±1.3*Remuneration 21(13.9) 67(44.0) 46(30.1) 6(4.2) 7(4.8)Mean ± SD:2.4±1.0*Availability of 87(57.2) 46(30.1) 16(10.2) 0(0.0) 1(0.6)dental operatory andequipmentMean± SD:1.5±0.7*Personal 23(15.1) 63(41.0) 44(28.9) 10(6.6) 10(6.6)satisfaction inworking with theelderlyMean± SD:2.5±1.1*Experience/Training 27(17.5) 49(31.9) 45(29.5) 15(9.6)9(7.8)in treating elderlyMean± SD:2.6±1.1**the means are derived from a Likert scale ranging from 1-5.36Questions asked to dentists who stopped treating patients in LTCThe most common reason for discontinuing services was uncomfortable workenvironment in the facility (Table 12). Of all, 93.8% of the dentists who stopped treatingpatients in long-term care did not report ‘it is not my responsibility’ as a reason forstopping treatment. A large proportion of dentists (64.6%) stopped providing servicesbecause they felt that LTC facilities entailed an uncomfortable work environment. Only12.5% of dentists stopped treating elderly due to lack of demand for services. Responsesvaried regarding the administrative difficulties and increased commitment to their ownprivate practice.Table 12. Reasons for stopping treatment in LTC Facilities (n=47)REASONS Number of Dentists (% of total)Yes NoLack of demand for 6(12.5) 40(83.3)servicesAdministrative 24(50.0) 22(45.8)difficulties inpatient managementUncomfortable 31(64.6) 15(31.3)work environmentIt was financially 21(43.8) 25(52.1)unrewardingIt resulted in a loss 14(29.2) 32(66.7)of leisure timeIncreasing 24(50.0) 22(45.8)commitments toprivate officepracticeIt was 10(20.8) 36(75.0)professionallyunsatisfyingIt is not my 0(0.0) 45(93.8)responsibility37The most important reasons for stopping treatment in LTC were: a lack of a dentaloperatory (mean=2.O), the amount of private practice time (mean2.3), and the amount ofpersonal time (mean=2.5) (Table 13). Dentists had varying opinions about remuneration(mean=2.9), personal satisfaction (mean=3. 1), and training and experience with treatingthe elderly (mean3.2).Table 13. Importance of factors for stopping treatments in LTC facilities (n=47)Amount of PersonalTimeDistance to FacilityRemunerationAvailability ofdental operatory andequipmentPersonalsatisfaction inworking with theelderlyMean ± SD:2.5±1.4*Mean ± SD:3.7±1.2*Mean ± SD:2.9±1.1*25(52. 1)Mean ± SD: 2.0:4(8.3)+Mean± SD:3.1±1.2*9(18.8):1.4*11(22.9)2(4.2)12(25.0)*the means are derived from a Likert scale ranging from 1-5.14(29.2) 10(20.8) 7(14.6) 6(12.5) 6(12.5)1(2.1) 6(12.5) 12(25.0) 8(16.7) 15(31.3)FACTORSVery Moderately Neutral Minimally NotImportant Important Important Important(1) (2) (3) (4) (5)Number of Dentists (% of Total)Amount of Private16(33.3) 13(27.1) 5(10.4) 2(4.2) 6(12.5)Practice TimeMean± SD:2.3±1.4*Experience/Training2(4.2) 10(20.8) 15(31.3) 9(18.8)6(12.5)in treating elderlyMean± SD:3.2±1.1*2(4.2) 16(33.3) 15(31.3) 4(8.3) 5(10.4)3(6.3) 5(10.4)8(16.7) 7(14.6)384.4 Comparison of 1985 study and 2008 studyThe 2008 data were compared with the 1985 data to determine if there were any changesin opinions of dentists towards treating patients in LTC within Vancouver (Table 14).When comparing age, in 1985 most responding dentists were under the age of 35; whilethe highest percentage of dentists in the 2008 study were in the age group 36-45 years.Most of the responders in both studies had practiced for 6-15 years, however there wasslightly higher number of dentists who practised 16-25 years in the current study. In1985, the substantial proportion (42.0%) of dentists had 5% of their patients who were 65years or older, while in the 2008 study, there were considerable number of dentists(3 8.0%) whose practice consisted of 11-24% of patients who were 65+. A higherpercentage of current dentists stated that they did not have any advanced training ingeriatric dentistry compared to the 1985 study. In the 2008 study only 11% of dentists inVancouver reported that they had some form of geriatric dental training, whereas 22% ofthe dentists from the 1985 study had geriatric training.390 0 0 0 — 0 CIn 2008, a greater percentage of dentists agreed that treating the elderly is a pleasantexperience, however these dentists also agreed that elderly patients present difficultiesdue to medical problems or dementia. Between 1985 and 2008 there was a slightdifference in agreement about elders rarely following up with recommended dentaltreatment from 1985 to 2008. When asked if the patients’ age had an influenceonproviding service, 73.7% agreed with this statement in 2008, whereas only 37% were inagreement in 1985.In the 1985 study, the most common considerations about providing services in LTCwere: availability of a dental operatory or equipment, personal satisfaction in workingwith the elderly, remuneration and the amount of private practice time. In the 2008study, the most common considerations were: availability of a dental operatoryorequipment, amount of private practice time, amount of personal time, and remuneration.In both studies, the availability of a dental operatory or equipment remainedan importantfactor for treating elderly in LTC facilities. In the 2008 study, these considerationsweremore important for the dentists who never provided services comparedto the dentistswho currently treated, or who stopped treating elderly in LTC. Distanceto the facilitywas a greater concern in 1985 compared to 2008, whereas personal timewas of higherimportance in 2008 compared to 1986.41Table 15a. Perceptions of treating patients in LTC- comparison between dentistssurveyed in 1985 and 2008PERCEPTIONS 1985I2008Number of Dentists (% of total)Treating elders is a pleasant 182(54.0) 64(73.0)experienceElders present difficulties due to 109(33.0) 65(74.0)medical problems/dementiaElders rarely follow up with 102(30.0) 34(39.0)recommended treatmentIt is hard to improve the oral 90(27.0) 50(57.0)health of eldersPatients age does not influence my 125(37.0) 185(73.7)decision to provide serviceTable lSb Important considerations for treating patients in LTCCONSIDERATIONS 1985 2008Number of Dentists (% of total)Amount of private practice time 217(74.0) 190(75.8)Amount of personal time 163(56.0) 177(70.6)Distance to facility 193(67.0) 80(31.9)Remuneration 220(76.0) 129(51.4)Availability of dental operatory/equipment 269(91.0) 188(80.5)Personal satisfaction in working with 243(85.0)127(50.7)elderlyExperience/training in treating elderly 108(51.0)103(41.1)42One of the most common reasons for not providing services was because dentists werenot asked to provide services in LTC in both the 1985 and 2008 studies (Table 16).Sixty-six percent of the dentists from 2008 study stated that they did not provide servicesin LTC because they were too busy in private practice; in 1985 this was only 31%. Sixty-one percent of the dentists from 2008 felt that providing services in LTC was financiallycostly and unrewarding, whereas only 15% of the dentists felt this way in 1985.Although a slightly higher percentage of dentists felt that there was a lack of appropriatetreatment facilities in 2008, the percentages from both studies indicate that there has notbeen a substantial change in opinion on this matter.In 1985, 32.0% of the dentists felt that there was a lack of demand for services in LTC(Table 16) and in 2008, only 12.5% of the dentists felt this way. Dentists from 1985 and2008 agreed that they stopped treating institutionalized elderly due to increasingcommitments in their own private practices. Dentists from 1985 and 2008 stated thatthey stopped providing services due to administrative difficulties in patient management.Half of the dentists in 2008 admitted that they stopped due to administrative difficultiesin patient management, whereas in 1985, only 12% of dentists felt this way. In 2008,64.6% of dentists stopped providing services because they found it financially costly andunrewarding-this was only the case for 9.0% of the dentists in 1985. Loss of leisure timeand lack of professional satisfaction were more common reasons for stopping treatmentsin LTC in 2008 compared to 1985.43Table 16. Reasons for not providing services and stopping services in LTCcompared in the 1985 and 2008 studiesREASONS FOR NOT 1985 2008PROVIDING SERVICES IN.LTC FACILITIESNumber of Dentists (/o of total)Too busy in private practice 85(31) 58(66)Inadequate training and 64(24) 41(47)experience with medicallycompromised patientsFinancially costly and 42(15) 41(61)unrewardingBureaucratic barriers would 33(12) 34(39)hinder proper treatment ofpatientsLack of appropriate treatment 95(3 5) 44(39)facilitiesI have not been asked by 152(56) 55(63)residents/administrators/familyREASONS FOR STOPPING TREATMENTLack of demand for services 2 1(32) 6(12.5)Administrative difficulties in 8(12) 24(50)patient managementFinancially unrewarding 6(9) 21(64)Loss of leisure time 9(15) 14(43)Increasing commitments to 24(38) 24(29)private office practiceProfessionally unsatisfying 11(18) 10(50)44Urban and Rural Differences in the 2008 studyLocation of practice and decision to treat was compared between urban and ruraldentistsin the sample group (Table 17). Comparing responders to the surveys, 14.5%of urbandentists and 18.5% rural dentists currently treat patients in LTC. In summary,66.7% ofurban dentists and 51.9% of rural dentists never treated patients in LTC while 18.8% ofurban dentists stopped treating in LTC, and 29.6% of rural dentists stopped treatinginLTC.Table 17. Location of dentists who currently treat, never treat, andstop treatingpatients in LTC (2008 study).STATUS OF TREATING LOCATIONNumber of Dentists (% of total)URBAN RURALBRITISH BRITISHCOLUMBIA COLUMBIAn=207 n=27Currently Treating 30(14.5)5(18.5)Never Treated 13 8(66.7)14(51.9)Stopped Treating 39(18.8)8(29.6)455 DISCUSSION5.1 Discussion of FindingsThe non-response bias of mail-out surveys has been identified as a validity problem(Armstrong & Overton, 1977). If results from the non-responders differ significantlyfrom the responders, it is not possible to say how the entire sample would haveresponded. A non-response analysis was performed which showed no systematicallysignificant differences amongst responders and non-responders with respect to age,gender, location and years of practice. Although non-response analysis did not show anysystematically significant difference between responders and responders, it doesn’t implythe same for other parts of the questionnaire where data from non-responders was notcollected.Many of the opinions and attitudes of dentists within Metro-Vancouver regardingtreatment for elders in LTC have changed from 1985 to 2008. In 2008, a greater numberof dentists treated patients who were 65 years or older in their practice comparedtodentists practising 1985. This difference between the two studies mightbe that there wasa greater number of seniors in the population requiring dental treatment comparedto1985. In 1985, the majority of dentists were 35 years or younger; whilein 2008 thehighest proportion of participants were between the ages of 3 6-45 (MacEnteeet al.,1992). This may be a reflection of the aging population of dentistsin British Columbia,or a lack of interest in treating LTC seniors by younger dentists.Dentists who nevertreated patients in LTC had fewer years of practice comparedto dentists who currentlytreated, and dentists who stopped treating patients in LTC. In both studies,professionaland economic factors were important in whether or not dentists decided to provideservices in LTC.In 1985, 24% of the dentists reported that they had inadequate trainingto treat medicallycompromised patients compared to 47% in 2008. A qualitativestudy identified that some46dentists did not feel good about the services that they were capable of offering to patientsin LTC facilities because it seemed to contradict their professional ethics, idealism andautonomy (Bryant, 1994). Asides from this, nursing staff also lacked adequate trainingwhen it came to oral health needs (Dolan & Atchison et al., 2005). Interestingly, fewerdentists admitted to having advanced training in geriatric dentistry in 2008 compared to1985. Dentists today may not be seeking or find available post-graduate or continuingeducation courses in geriatric dentistry.Distance to the facility was a greater concern for dentists in providing services in LTC in1985 compared to 2008. Not only has the general population increased, but also thenumber of dentists in British Columbia, increasing the likelihood of dentists living orpracticing closer to a long term care facility. The availability of a dental operatory andequipment was the most dominant consideration in providing services in LTC both in1985 and in 2008. In the USA, only 3% of LTC facilities have dental operatories (Smithet al., 2007). In 2008, dentists admit that personal time was a significant factor indetermining whether they decided to provide services in LTC facilities in contrast to1985. In 2008, dentists stated that they decided not to treat patients in LTC due tobusyness in their own private practice, and the lower financial gain associated withtreating patients in LTC. These findings agree with previous findings where dentistsreported that practical problems such as a lack of support for the service and inefficiencywith the service were the primary reasons for the lack of interest in providing services toseniors in LTC facilities (Bryant, 1994).In 2008, a greater percentage of dentists felt that treating patients in LTC was financiallyunrewarding, patients had more complex medical conditions, and it was harder toimprove their oral health. Previous studies have also indicated issues encountered inlong-term care facilities such as difficulties with providing treatment on-site at facilities(Gift et al., 1998), time constraints with treatment and a lack of support from hospitalstaff (MacEntee et al., 1999 & Bryant, 1994) in LTC facilities.47In 1985, 32% of dentists stated that they stopped treating in LTC facilities due to a lackof demand for services; while only 12.5% of dentists reported this reason in 2008. Thisdifference between the two studies might be due to an increase in the retention of teethinto old age along with an increased awareness of the importance of oral health. Dentistsreported that they stopped treating the elderly because they were not requested to provideservices in LTC, and because there was poor administrative support from facilities. Fromthe 2008 study, some dentists commented in writing that they felt that it was inefficientfor them to visit the facility to treat a small number of patients.Of the dentists who never provided treatment in LTC facilities from the 2008 study,20.5% indicated an interest in providing services. The most prevalent reasons behindwhy dentists refused to treat patients in ETC in the currently study were: because theywere too busy in their private practice, they were not asked to provide services, andbecause of a lack of appropriate treatment facilities in their area. Approaching potentialdentists who are willing to provide services in LTC facilities and creating a work space(dental operatory) may encourage these dentists to start and continue to provide services.Dentists who currently treated patients in LTC were slightly older and their practiceswere comprised of a greater percentage of seniors than the 1985 cohort. Dentists whocurrently treated patients in LTC firmly agreed that having dental hygienists & certifieddental assistant as well as continuing dental education beyond dental school wereimportant factors facilitating treatment in LTC facilities. Placing a greater emphasis ongeriatric dentistry in the training of dentists, dental hygienists and certified dentalassistants may encourage more dental professionals to provide services to this vulnerablepopulation. Dentists self-reported that the most common reasons for providing dentalservices in a LTC facility were because: it was a part of their professional responsibility,they were asked to provide treatment, it was a public service, and they provided servicesfor a past patient or family member. Compared to 1985, more dentists were aware thatthere is a demand for services in LTC facilities. Dentists who never treated, and dentistswho stopped treating patients in LTC only ‘sometimes’ did denture fabrication, denturerelines, and denture adjustments. Dentists who currently treat patients in LTC provided48these services more often, perhaps because they also offered these services morefrequently in LTC facilities, or may have had extra training and experience.Out of the total sample population (responders and non-responders), 94.5% of the dentistswere from urban areas, and 5.5% were from rural areas. However, a higher proportion(61%) of the rural dentists responded; 27 out of the 44 rural dentists that were given asurvey responded. For urban dentists, 207 out of 756 responded, resulting in a responserate of 27%. A greater percentage of rural dentists were interested or involved withdental treatment in LTC facilities, compared to urban dentists. Similarly, whencomparing urban and rural practise and the decision of not providing services, there was ahigher percentage of dentists who never provided services in LTC in urban areas ofBritish Columbia. Despite the fact that a low percentage of dentists from both rural andurban areas currently treated patients in LTC, rural dentists were more involved thanurban dentists in providing services in ETC facilities; this may reflect a greater sense ofcommunity responsibility and attachment within the rural community.After 22 years, very little has changed with respect to the interest of dentists providingservices within LTC. The widespread neglect for dental care of frail institutionalizedelderly is an increasing concern. The inclusion of a dental operatory within LTCfacilities may encourage more dentists to provide services to the frail elderly. Perhapsthis way, dentists may feel that they have their own space to work with patients in thefacility. To provide proper care for seniors, a multidisciplinary care team is requiredincluding dental professionals, dental auxiliaries and residential staff (Chalmers, 2000).In addition, the provision of more geriatric training in dental school as well as postgraduate training may help the situation. Increasing administrative, nursing, and patient’sfamily support may encourage dentists to provide services in LTC. Many dentistsindicated willingness to provide services if they were asked by family, patients, oradministrators of facilities.495.2 Limitations of the StudyThis study only achieved a response rate of 30% compared to 51% for the 1985 study.Low response rates in questionnaire surveys are a common finding. For example, in2007, a National Physician Survey (NPS) was mailed to Canadian physicians andphysicians in training, and only a 34.1% response rate was achieved (Grava-Gubbins &Scott, 2008). However a low response rate does not necessarily affect the validity of theresults, as long as the results gathered from the non-response analysis are documented,tested and understood (College of Family Physicians of Canada, Canadian MedicalAssociation, Royal College of Physicians and Surgeons of Canada, 2007).However,generalizations of the present findings cannot be done with absolute certainty.A low response rate from mail out surveys may occur as a result of a change of addressand failure to receive (or return) the questionnaire, all of which may effect the nature ofresponse bias (Etter & Pergner, 1997). The low response rate in the present surveymaybe due to the timing of the mail out; the questionnaires were mailed out inJune, whendentists were more likely on holiday or may have been working fewer hours.Perhaps thestaff may have been opening the mail and filtering what mail actually passed on to thedentist; therefore, the dentist may not have even seen the survey. Also,the complexity ofthe survey (3 different types of questionnaires in one package) may have deterred dentistsfrom completing and mailing it back. Another reason for not respondingmight be thelength of the questionnaire. Studies indicate that the length of the survey hasa negativeinfluence on mail survey response rates in which longer surveysare less likely to be filledout, resulting in a lower response rate (Steele, Schwendig & Kilpatrick, 1992).A shortersurvey may have increased the response rate; however it wouldlimit the amount ofinformation that could be analyzed.Previous studies based on response rates from mail-outsurveys indicated that mailsurveys have been criticized for non-responsebias (Armstrong & Overton, 1977). Ifresults from the non-responders differ significantly from the responders,it is not possibleto say how the entire sample would haveresponded. Although maximizing the response50rate is important for surveys, there is not one single threshold for an acceptableresponserate (Charlton, 2000). Mail surveys require a more self initiated cooperation than othersurvey techniques, thus the number of responses may differ as a result of personalcharacteristics as well as interest in the survey topic (Locker, 2000). Research on mailoutsurveys has indicated that responders and non-responders differ significantly based oninterest of the topic (Scott, 1960). The ‘interest hypothesis’ is a widely recommendedbasis for subjective analysis for non-response which states that individualswho areinterested in the topic of the survey are more likely to respond (Donald, 1960).A lowresponse rate for this study may reflect the lack of interest in geriatric dentistryamongdental practitioners.The Leverage-Salience theory states that the probability of response froman individual isa combination of the leverage of the survey attribute and the salienceof the same surveyattribute (Grover, 2000). “Leverage-salience theory does not simplypredict thatpersonsinterested in the survey topic will be overrepresented among respondents(andunderrepresented among non-respondents), relative to those uninterested.It predicts thatthe degree ofoverrepresentation will be afunction ofthesalience of (and attitudetoward) the survey topic among those deciding whether to cooperate, relativeto thesalience of(and attitudes toward) the otherfactors that are partofthe survey request. Ifthere are no other positive features to participation, the effectoftopic should dominatethe decision” (Grover et al., 2004). Somepeople may be interested to participate in thequestionnaire as a result of the topic (Grover, et al., 2004),whereas others may beinterested as a result of the short length or incentiveoffered. A qualitative telephonesurvey targeting non-respondent medical doctorswas conducted to gain a betterunderstanding behind why decided not to respondto a mail out survey showed that theywere more likely to respond to mail-out surveys thathad a high personal interest factor(Kaner et al., 1998). Other reasons why medicaldoctors didn’t reply to postal surveys,reasons were: the questionnaires got lost in paperwork(34%), too busy to do extra work(21%), and they just didn’t fill out surveys (Kaneret al., 1998).51The chance to win an iPod music player may not have been an effective incentivefordentists to participate in this study. Perhaps a larger incentive may have had a positiveimpact on the response rate.Paper based questionnaires may be of limited appeal since some dentists failed to answerall questions. This may have been an indicator for dentists not being in favorof theskipped question or statement. A suggestion for the future studies maybe to create anelectronic survey instead of a paper questionnaire where one is not ableto answer thenext question until the previous questions have been answered. Otherpossibleadvantages of using internet based surveys include the reduction in costof paper andmailing the surveys (Cobanoglu et al., 2001 & McMahonet al., 2003) as well as the timeassociated with returning the surveys (Kaplowitz, 2004). An additional advantagewouldbe that the response times for web-based surveys are several daysfaster compared tomail-out surveys (Kroth et al., 2009). However, the downfall of this wouldbe that thesample group may not entirely consist of people who feel comfortable usinga computer,using the internet or have access to the internet. Since web-basedsurveys have recentlybecome more popular, applying this method may have onlypiqued younger dentists tocomplete the survey. However, in 2009, a study wasconducted which used acombination of web-based and mail-out surveys showed thatthat although a highernumber of results were obtained from the electronic survey,24% of the responderspreferred to use the paper form (Kroth et al., 2009).5.3 ConclusionsOnly a small fraction of dentists continue to provideservices to patients in long-term carefacilities in British Columbia. Despite the increasedawareness of lack of oral care inlong-term care facilities, the majority of dentistschoose not to serve this population.Although the senior population has increased significantlysince 1985 and there is agreater need for dental care, dentists view delivery ofcare less favorably, especially withrespect to economic and personal factors. Dentistsin rural parts of British Columbiashowed greater willingness to provide services topatients in LTC facilities compared to52their urban counterparts. The decision to provide dental services in long-term carefacilities is a complex and includes the health of residents themselves, the behavior andattitudes of caregivers, family, LTC administrators and staff.5.4 Suggestions for Future ResearchBoth qualitative (a more in-depth perspective) and quantitative (a more general view)research might be useful to provide a comprehensive in-depth study of attitudes ofdentists concerning the provision of dental services within ETC. 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Dent Clin NAm 2005; 49:445-461.Smith BJ, Ghezzi EM, Manz MC, Markova CP. Perceptions of Oral HealthAdequacy and Access in Michigan Nursing Facilities. Gerodontology 2008; 25:89-98.Statistics Canada. Statistics Canada Life expectancy at birth, by sex, by province in2002. July 4, 2009. <https://www4O.statcaa.c..calO1Icst0 1 /health26-eng.htm.Steele TJ, Schwendig WL, Kilpatrick JA. Duplicate responses to multiple surveymailings: A problem? Journal ofAdvertising Research 1 992;3 :26-34.Steele JG, Walls AWG, Ayatollahi 5, Murray J. Major clinical findings from a dentalsurvey of elderly people in three different English communities. Br Dent J1996;180:17-23.Taylor G, Loesche W, Lieberman D. Impact of oral disease on systemic health in theelderly: diabetes mellitus and aspiration pneumonia. J Public Health Dent 2000;60:313-20.Tickle M, Craven R, Worthington HV. A comparison of the subjective oral healthstatus of older adults from deprived and affluent communities. Community Dent OralEpidemiol 1997; 25:217-222.60Ulmer B, Harris M. Australian GPs are satisfied with their job: even more so in ruralareas. Fam Pract 2002; 19(3) :300-3.Visschere LM, Vanobbergen IN. Oral Health Care for Frail Elderly People: ActualState and Opinions of Dentists Towards a Well-organized Community Approach.Gerodontology 2006; 23:170-176.Walton VA, Romans-Clarkson SE, Herbison GP. Variety and Views in GeneralPractice. N Z Med J 1990;103(892):287-90.Weeks JC, Fiske J. Oral care for people with disability: a qualitative exploration onthe views of nursing staff. Gerodontology 1994; 11:13-17.Wiseman M. The Treatment of Oral Problems in the Palliative Patient. J Can DenAssoc 2006; 72(5):453-8.Woloschuk W, Tarrant M. Do students from rural backgrounds engage in ruralfamily practice more than their urban-raised peers? Blackwell Publishing Ltd.Medical Education 2004; 38: 259-261.Wyatt CC, Elderly Canadians residing in long-term care hospitals: Part I. Medical anddental status. JCan Dent Assoc 2002; 68(6):353-8.Wyatt CC, Elderly Canadians residing in long-term care hospitals: Part II. Medicaland dental status. JCan Dent Assoc 2002; 68(6):359-63.Wyatt CCL. The development, implementation, utilization and outcomes of acomprehensive dental program for older adults residing in long-term care facilities. JCan Dent Assoc 2006; 72(5):419.Wyatt CCL, MacEntee MI. Caries management for institutionalized elders usingfluoride and chiorohexidine mouthrinses. Community Dent Oral Epidemiol 2004;32:322-8.Yancik R. Cancer burden in the aged. An epidemiologic and demographic overview.Cancer 1997; 80:1273-1283.616 APPENDICES62Appendix A**Win a FREE 4 GB iPod Nano!**HowiI:F out this questio - d bk to1-604-822- Winners wift be-hd phone or email.**irsTHAT ASY”-INSTRUCTIONS:For dentists who:a) currently treat patients in long-term care, please fill out the PINKsurveyb) never treated patients in long-term care, please fill out the BLUEsurveyc) stopped treating patients in long-term care, please fill out the GREENsurvey63Appendix B64Department of Oral Health Sciences2199 Wesbrook MallVancouver, B.C., Canada V6T 1Z3Tel: (604) 822-5064 Fax: (604) 827-4448www.dentistry.ubc.caLetter of Initial Contact and ConsentJune 4, 2008Dear Dental Professional,Re: UBC Faculty of Dentistry Research Project: Factors that Influence Dentists to TreatPatients in Long-term Care.Principal Investigator: Dr. Christopher Wyatt, Department of Oral Health Sciences, Facultyof Dentistry, 604-822-1778.Co-Investigator: Nita Chowdhry, Masters in Science, Department of Oral Health Sciences,Faculty of Dentistry, 604-729-0000.PurposeThe purpose of this study is to identif’ factors that influence dentists on treating the elderly.A similar study was completed in 1986 to determine factors that influence dentists’ decisionson treating the elderly in British Columbia, and we are interested to see if the opinions ofdentists have changed. In addition, this questionnaire will help to determine if dentists fromdifferent parts of British Columbia have different attitudes towards treating elders. Thequestionnaire should take no longer than 10 minutes to complete.BenefitsParticipation in this study may not benefit you personally. However, your participation willhelp to support dental research and help to determine how to encourage dentists in BritishColumbia to treat elderly patients, specifically patients in long-term care facilities that are ingreat need for dental care.Study DescriptionA questionnaire will be administered in a semi-anonymous fashion to800 dentists in BritishColumbia: no name will be used, but the questionnaire will be identified by the fax numberof the dental practice. If you chose to participate in the study, the fax number fromwhere thequestionnaire is returned will be entered into a draw to win an iPod Nano in appreciationofyour contribution to this study. If you do not wish to participate, you can still be enteredinthe draw by returning a blank questionnaire.Who can participate in this studyGeneral dentists who are currently practicing in British Columbia will be eligibletoparticipate in this study.65Potential RiskThere are no potential risks.Right to Leave the StudyYour participation is greatly appreciated; however, you are completely free to decline thestudy. You may withdraw from this study at any time without providing any reason for yourdecision, without prejudice. If you have any concerns about your participation or rights as aresearch participant, you may call the Research Subject Information Line in the UBC Officeof Research Servicesat 604-822-8598.Confidentiality of RecordsBy submitting the questionnaire, you have consented and you are advised to keep a copy ofthe consent form. Your confidentiality will be respected. No information that discloses youridentity will be released or published without your specific consent to the disclosure. Theinformation that you provide will be stored in a locked filing cabinet at the Faculty ofDentistry and placed on a computer that will be protected by a password.If you would like more information about the study or to schedule an interview, pleasecontactDr. Chris Wyatt at 604-822-1778.AuthorizationMy signature below signifies that I understand and agree to the above, and affirms that I havevolunteered to participate of my own free will. I have read and understand the nature,duration and purpose of this study. I understand that I can keep this signed and dated consentand send a fax back to UBC do the B.C Dental Association at 604-736-7588.Subject Signature Witness SignatureDate Date66Appendix C-iQuestionnaire’sFactors that Influence Dentists’ Decisions to Treat the ElderlyFOR DENTISTS WHO CURRENTLY TREAT PATIENTS IN LONG-TERM CAREWhat is your age?What is your gender? 1. Female El 2. Male 0 2How many years have you been practising dentistry? 3yearsOn average, how many hours per week do you practise dentistry’ 4hours per weekWhere is your principal practice? 5City/Town_________________Please list the first three characters of your postal codeDid you have any advanced training in geriatric dentistry outside of dental school? 61.Yes El 2.No [1(Please specify) a) 1] Clinicalb) 0 LecturesApproximately what percent of your patients are 65 years or older?7In an average work week, how often do you (or your staff) provide the following servicesto patients inlong-term care?Very Often Often Sometimes SeldomNever(1) (2) (3) (4)(5)ExtractionsBiopsiesOral Hygiene Instruction 10Restorations 11Bridges/CrownsDenture Fabrication 13Denture Adjustment 14Denture Relines 15Periodontal Treatment (scaling/root planning) 16Endodontic Treatment 17In general, how important are the following factors in your decisionto treat patients in long-term care?Very Moderately Neutral MinimallyNotimportant important importantimportant(1) (2) (3) (4)(5)Amount of private practice time18Amount of personal time19Distance to facility(ies)20Remuneration21Availability of dental operatory & equipment at facility22Personal satisfaction in working with elderly23Experience/training in treating elderly2467Please respond to the following statements:Strongly Agree Slighti Neutral Slightly Disagree StronglyAgree y Disagree Disagree(1) (2) Agree (4) (5) (6) (7)(3)Treating elders is a pleasant experience25Patients age does not influence my decisions to provide26servicesElders rarely follow up with recommended treatment27Elders present difficulties due to medical problems/dementia28It’s hard to improve oral health of elders29Treating elders is time-consuming30Treating elders is financially unrewarding31How many years have you been attending patients in a long-term care facilities? years 32Approximately how many hours per week do you work in the facility? hours 33What are the most common dental services that you provide to patients in long-term care?Very Often Often Sometimes Seldom Never(1) (2) (3) (4) (5)Biopsies 34Extractions 35Oral Hygiene Instruction 36Restorations 37Bridges/Crowns 38Denture Fabrication 39Denture Relines 40Denture Adjustments 41Periodontal Treatment (scaling/root planning) 42Endodontic Treatment 43Other, Specify: 44How are you paid when treating elders in long-term care facilities? 451. Fee-for-Service El2. Fee for Time El3. Retainer fee (on call) El4. Salary El5. Other (specify) ElWhich fee guide do you use when treating patients in long-termcare facilities?461. BCDA General Fee Guide El2. BCDA Fee Guide for Dental Treatment Services in Long-termCare Facilities El3. No fee guide El4. Other, Specify ElDo you charge more than the BCDA General Fee Guidewhen providing treatment in long-term47care facilities?1.Yes El 2. No ElIf you answered yes, please specify by what percentage?MoreHow would you prefer to be reimbursed when treatingpatients in long-term care? 481. Fee per time LI2. Fee per service LI3. Sessional fee El4. Retainer fee (on call) U68Originally, why did you decide to provide dental services in long-term care facilities?Strongly Agree Slightly Neutral Slightly Disagree StronglyAgree Agree Disagree Disagree(1) (2) (3) (4) (5) (6)(7)Opportunity to increase my practiceSocial contacts with elders are$0rewardingI want to perform a public service51Part of professional responsibilities52Part-time practice opportunities53Part of semi-retirement practice54Broadens the scope of my practice55I was asked to work in a long-termcare facilityA past patient or family member wasin a long-term care facilityOther, specifyPlease respond to the following statements.Strongly Agree Slightly Neutral Slightly DisagreeStronglyAgree Agree DisagreeDisagree(1) (2) (3) (4) (5)(6) (7)Dental hygienist’s are important members of theclinical team in long-term care facilities —Certified dental assistant’s are important members60of the clinical team in long-term care facilities —Continuing education beyond dental school would61be helpful to treat patients in long-term care —Additional paper work such as consent for62treatment is a concernTHANK YOU FOR YOUR PARTICIPATION!69Appendix C-ilFactors that Influence Dentists’ Decisions to Treat theElderlyFOR DENTISTS WHO NEVER TREATED PATIENTS IN LONG-TERM CAREWhy have you not provided services in long-term care facilities?In general, how important are the following factors in your decision of not treating elderpatients?Very Moderately Neutral Minimally Notimportant important important important(1) (2) (3) (4) (5)Amount of private practice time10Amount of personal time11Distance to facility(ies)12Remuneration13Availability of dental operatory & equipment at facility14Personal satisfaction in working with elderly15Experience/training in treating elderly16Please respond to the following statements:Strongly Agree Slightly Neutral SlightlyDisagree StronglyAgree Agree DisagreeDisagree(1) (2) (3) (4) (5) (6)(7)Treating elders is a pleasant experience17Patients age does not influence my decisions to provide services18Elders rarely follow up with recommended treatment19Elders present difficulties due to medical problem/dementia20It’s hard to improve oral health of eldersTreating elders is time-consuming22Treating elders is financially unrewardingStrongly Agree Slightly Neutral Slightly Disagree Strongly Not—Agree Agree Disagree Disagree Applicable(1) (2) (3) (4) (5) (6) (7) (8)—Too busy in private practice 1Inadequate training and experience with 2medically compromised patientsFinancially costly and unrewardingElders present difficulties due to medical 4complications/dementia—Bureaucratic barriers would hinder5proper treatment of patients—Lack of appropriate treatment facilities6Have not been asked by7residents/administrators/family—It is not my responsibility8Other, Specify970Please respond to the following statements:What is your age’24What is your gender? 1.Female LI 2. MaleLI 25How many years have you been practising dentistry?26yearsOn average, how many hours per week do you practise dentistry?27hours per weekWhere is your principal practice?28City/TownPlease list the first 3 characters of yourpostal codeDid you have any advanced training in geriatricdentistry outside of dental school’291.Yes LI 2.No LI(Please specify) a) LI Clinicalb) LI LecturesApproximately what percent of yourpatients are 65 years or older?30In an average work week, how oftendo you (or your staft) provide the followingservices?Very Often Often SometimesSeldom Never(1) (2) (3)(4) (5)Extractions31Biopsies32Oral Hygiene Instruction33Restorations34Bridges/CrownsDenture Fabrication36Denture Adjustment37Denture Relines38Periodontal TreatmentEndodontic Treatment40How would you prefer tobe reimbursed if/when treatingpatients in long-term care? 411. Fee per timeLI2. Fee per service LI3. Sessional fee LI4. Retainer fee (on call) LI5. Other (Specify) LIWould you be interested in providingservices in long-term carefacilities? 421.Yes LI 2. NoTHANK YOU FOR YOURPARTICIPATION!71Appendix C-uiFactors that Influence Dentists’Decisions to Treat the ElderlyFOR DENTISTS WHO STOPPEDTREATING PATIENTSIN LONG-TERM CAREWhy did you stop treating patientsin long-term care? (Please mark allthat apply).Lack of demand for services El1Administrative difficultiesin patient management El2Uncomfortable work environmentEl 3Financially unrewarding El4Loss of leisure time El5Increasing commitments to privateoffice practice El6Professionally unsatisfying Li7Not my responsibility El8Other, specify El9In general, how important arethe following factors in your decisionto stop treating patients in long-termcare?Very Moderately NeutralMinimally Notimportant importantimportant important(1) (2)(3) (4)(5)A mount of private practice time10Amount of personal time11Distance to facility(ies)12Remuneration13Availability of dental operatory& equipment at facility14Personal satisfaction in workingwith elderly15Experience/training in treating elderly16Please respond to the following statements.—Strongly Agree Slightly NeutralSlightly Disagree StronglyAgree AgreeDisagree Disagree(1) (2) (3)(4) (5) (6)(7) —Treating elders is a pleasant experience17Patients age does not influence mydecisions to provide servicesiSElders rarely follow up with recommendedtreatment19It’s hard to improve oral health of elders20Elders present difficulties due to medicalproblems/dementia21Treating elders is time-consuming22Treating elders is financially unrewarding2372Please respond to thefollowin2 statements:What is your age?24What is your gender?1. Female LI 2. MaleLI 25How many years have you been practisingdentistry?26yearsOn average, how many hours per week do you practise dentistry?27hours per weekWhere is your principal practice?28City/TownPlease list the first 3 charactersof your postal codeDid you have any advanced training in geriatricdentistry outside of dental school?1.Yes LI 2.No LI(Please specify) a) LI Clinicalb) LI LecturesApproximately what percent of your patientsare 65 years or older?30In an average work week, how oftendo you (or your staft) providethe following services inyour practice?Very Often OftenSometimes Seldom Never(1) (2) (3)(4) (5)Extractions31Biopsies32Oral Hygiene Instruction33Restorations34Bridges/Crowns35Denture FabricationDenture Adjustment37Denture Relines38Periodontal Treatment (scaling/root planning)39Endodontic Treatment40How would you prefer tobe reimbursed if/when treatingpatients in long-term care? 411. Fee per time LI2. Fee per service LI3. Sessional fee LI4. Retainer fee (on call) LI5. Other (Specify) LITHANK YOU FOR YOURPARTICIPATION!73APPENDIX E: Modifications from 1985 questionnaire:a. Section 1: question 3 from the 1985 questionnaire was removed, as it wasnot necessary to ask about specialty practice since all known dentistsworking in LTC are general dentists. The revised questionnaire asked thenumber of years of practice. This questionnaire was mailed only togeneral dentists within British Columbia.b. Section 1: question 6 was removed from the revised questionnaire, as itwas not necessary to ask about the type of practice.c. Section 1: question 8 was removed, as it was not necessary to ask aboutearnings for practice as it makes the questionnaire more personalized,rather, the revised questionnaire asked for satisfaction and preferences ofreimbursements from treatment.d. Section 1: question 19 was removed because dentists would most likelychoose to have funded equipment rather than purchasing their ownportable equipment for LTC facilities.e. Section JIB: Removed as the questions were specific to the actual facilitywhere dentists provided treatment. Only question 3, 4 & 7 were added tothe current questionnaire. For this study, it was not necessary to denotethe name and type of facility, the length of time worked in the facility, orany treatment arrangements.f. Section I: question 4 was modified to specify if dentists practice in a ruralor urban area of British Columbia, with specifications about the cityandtown.g. Questions 19.1-19.4 were added for dentists who currently treat patients inLTC to determine which factors were important in a LTC environment.74


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