The Yad Sarah geriatric dental clinic, a different model
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- Gillian McCormick
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1 Clinical report The Yad Sarah geriatric dental clinic, a different model Jaime Pietrokovski 1,2 and Avi Zini 1 1 Yad Sarah Geriatric Dental Services; 2 Department of Oral Rehabilitation Faculty of Dental Medicine, Hadassah-Hebrew University, Jerusalem, Israel Gerodontology 26; 23; The Yad Sarah geriatric dental clinic, a different model Introduction: There are not sufficient dental services for elderly people around the world. Yad Sarah is an Israel-wide network of volunteers aiding sick, elderly, isolated and housebound people with an array of services aimed at making home care possible. It provides medical and social services to more than 38 elderly persons per year and in addition, lends medical equipment free of charge, has day rehabilitation centres, legal aid council for seniors, provides transportation for the disabled, meal deliveries and geriatric dental services. Materials and methods: The latter are equipped with five dental units (one mobile unit) and a dental laboratory. During the 5 years from 2 to 24 the dental services provided dental care for 389 elderly patients with the main clinic located in Jerusalem. Patients pay an average of 7% of the cost price of their dental care, with the difference being subsidised by Yad Sarah. Of the 515 patients who applied for treatment in 24, 54% possessed natural teeth in both jaws, 28% were fully edentulous, 12% were edentulous in the maxilla and 6% were edentulous in the mandible. Females applied for dental treatment more often than the male population. Older patients (75 11 years old) required oral care at their homes or at old age residences, more frequently than the younger age groups (6 74 years old). Conclusion: Dental treatment was administered by 7 volunteer dental surgeons, two certified dental hygienists and dental hygienist students. The clinical staff was provided with a comprehensive in-service training in geriatric dentistry during the 3-year service learning period. A survey in 24 showed that 83% of the selected patients were satisfied, compared with 14% who were not. The reasons for satisfaction were, mainly, the personal relationship with the attending staff (41%) and the professional ability of the dental team (46%). Keywords: geriatric dental clinic, home care. Accepted 2 March 26 Introduction Elderly people are rapidly becoming a large, neglected and dentally under-treated population 1 and there is an urgent need for dental services for the elderly worldwide 1 7. Political authorities, government agencies, hospital directors and old age homes administrators do not regard the dental needs of the elderly as a priority 3 and consequently public attention and funding is scarce and insufficient. The older the individual, the greater the need for dental care, because of anatomical changes, wear and tear of teeth, changes to the surrounding tissues and restorations and dentures. Concomitantly, and as a paradoxical aggravating effect, the elderly have fewer economic resources to cover the extensive dental care required 1 7. Yad Sarah is a private non-profit-making institution serving the elderly population in Israel. It provides home-care support services for more than 38 persons per year. It is centred in Jerusalem with branches in 15 cities and villages and employs 18 persons, with more than 6 volunteers. There are no limitations for the services based on social status, economic condition, race or religious denomination 8. The institution lends medical equipment free of charge, such as wheelchairs, walking aids, hearing devices, baby cradles and nursing equipment. It has day rehabilitation centres, legal aid council 237
2 238 J. Pietrokovski, A. Zini for seniors, provides personal alarm systems, oxygen setup, cardiac apnea monitors, transportation for the disabled, laundry services for the incontinent, meals and meals-on-wheels deliveries, maintenance workshops and geriatric dental services 8. Geriatric dental services Geriatric dental services were established in 1992 to treat the elderly population in Israel. In 1999, Yad Sarah restructured its geriatric dental clinic to develop a multipurpose programme with the intention of providing dental care for the geriatric population and the training of volunteer dental surgeons in geriatric dentistry. These services are centred in Jerusalem and equipped with five dental units, including one mobile unit and a dental laboratory. The staff of the Yad Sarah dental clinic has 12 volunteers: dentists, dental hygienists, administrators and ancillary helpers. There are eight full time salaried employees: the director of the clinics, four dental assistants, two cleaning and maintenance personnel and one administrator. The services provide dental care for female patients over the age of 6 and male patients over 65, as well as younger, special cases, disabled people and/or indigent applicants according to criteria set by the institution authorities. The dental services provide all clinical treatments except orthodontics and paedodontics. The mobile dental clinic has been functioning since 23 providing dental care to house-bound persons, those unable to attend regular dental clinics. Immediate general medical back-up is given by the Hadassah-Hebrew University Medical Center when specific medical problems require detailed attention and advice. Patients pay an average of 7% of the cost price of the provided dental care with the reset being subsidised by the organisation. This cost is approximately half the price requested by Healthcare Funds and about a third of the price in private practices for equivalent procedures. Private donations provide for the majority of the basic dental equipment including the dental chairs and units, the dental mobile equipment, the laser facilities and the implants section instruments and basic materials. Services Between the years 2 and 24 the dental clinics (central and mobile units) admitted 389 new active patients for treatment. Active patients were considered as those who came for three or more consecutive appointments leading to visits to the clinic with dental treatments provided. More than 4 first aid appointments, limited to one or two visits, were also provided. Age and gender In 24, 724 active patients were admitted to the main and the mobile dental clinics. Of the 511 elderly attending the central dental clinic, 11% were 6 64 years old, 41% were years old, 38% in the year old group and 1% in the year old category. In the mobile unit there were 29 active patients, 13% between the ages of 6 64, 15% in the year old group, 36% in the year old category and 35% were years old. The gender distribution of 58% female and 42% male, is similar to geriatric dental clinics around the world and in accordance to gender distribution in Israel (Fig. 1a,b) 1 3,5,7,9. Women tend to form the majority of the elderly population and consequently apply in larger numbers to the dental clinics 4,5,1,11. (a) Male Female Total (b) Male Female Total Figure 1 (a) Distribution of patients by age and gender at the central geriatric dental clinic (24). (b) Distribution by age and gender at the mobile dental clinic (24).
3 The Yad Sarah geriatric dental clinic, a different model 239 Natural teeth in both jows 54% Fully edentulous 28% Edentulous at th maxilla 12% Edentulous at the mandible 6% Figure 2 Tooth presence and edentulism (24). Tooth presence and level of edentulism Of the 511 patients examined in 24 in the main clinic, 54% had natural teeth in both jaws, 28% were fully edentulous, 12% were completely edentulous at the maxilla whereas 6% were edentulous only in the mandible (Fig. 2). Forms of treatment During 2 24, 27% of the treatment sessions were devoted to maintenance or recall visits, 24% for scaling and/or oral hygiene instructions, 21% to restorative and root canal treatments, 12% for removable dentures (full dentures, removable dentures and repairs), 8% to minor oral surgery (mainly tooth/root removals), 7% to crowns or bridge maintenance and 1% for implant procedures (Fig. 3), the latter being introduced in 22. The first visit of each patient was usually for anamnesis and oral examination purposes with, occasionally, first aid, denture repair or pain relief. The procedures for denture construction followed the philosophy and the techniques used in the Department of Oral Rehabilitation, School of Dental Medicine, Hadassah-Hebrew University, Jerusalem 11. Academic manpower In 24, 7 volunteer dentists worked in the clinic. Volunteers aged years (29), years Anamnesis and examination Scaling and root planing Plastic fillings (amalgam & composite) Tooth/root exrtactions Root canal treatments Removable dentures repair Crowns and bridges Implants Removable partial dentures Full dentures Figure 3 Treatments at the central dental clinic (2 24).
4 24 J. Pietrokovski, A. Zini (27) and years (14) provide the professional manpower. The dentists treat patients in weekly shifts of 4 hour duration during a 3-year period. In addition, each clinician prepared one or two of his treated cases to be presented to a professional forum at the end of the 3-year period. Each volunteer developed an optional research project based on original work, a clinical report or a critical review of the literature. Since 1999 a total of 36 dentists completed postgraduate training in geriatric dentistry. As an integral part of the dental service, two certified dental hygienists, also volunteers, worked in the clinics, as well as dental hygienist students in their senior year from the Department of Community Dentistry, School of Dental Medicine, Hadassah-Hebrew University, providing dental scaling and oral health instructions. Teaching programme The teaching programme for the volunteer dentists comprised elective chairside instruction by the director and the advisor of the geriatric dental services. In addition, once a month, specialists in dentistry and/or medicine provide 4 hours of lectures or seminars to the entire staff. Twice a year, two full day demonstrations are given on a clinical subject to enhance clinical performance. The themes were updates on new techniques or different methods to be added to the clinic s repertoire as daily accepted procedures. All the teachers contributed their services free of charge The topics provided during the years 2 24, totalling 197 hours, were in removable prosthodontics (29%), oral medicine (17%), oral surgery (16%), periodontics (16%), operative dentistry (12%), public oral health (6%) and endodontics (4%) (Fig. 4). At the end of the 3-year curriculum, a certificate of participation in the Geriatric Dentistry Periodontics Prosthodontics Oral surgery Oral medicine Public health Operative dentistry Endodontics 6% 17% 12% 4% 16% 16% 29% Figure 4 Subjects of the teaching programme (2 24). 1% 8% 6% 4% 2% % 9% 36% 47% Programme was jointly conferred on each volunteer by the Faculty of Dental Medicine Hadassah-Hebrew University and by the Yad Sarah Institution. Patients satisfaction 3% 5% An external independent survey found that 83% of the 9, randomly selected, patients were satisfied with the treatments (47% very much and 36% satisfied), whereas 14% were not satisfied (9% were partly dissatisfied and 5% not at all satisfied) and 3% did not know (Fig. 5). The reasons for satisfaction were, mainly, the personal relation with the staff (41%) and professional ability of the dental team accounted for 46% 12. Present and future problems Do not know Not at all satisfied Partly dissatisfied Satisfied Very satisfied Figure 5 Patient s satisfaction after completion of dental care (24). Volunteer turnover At the end of the 3-year period most of the volunteers discontinued their work in Yad Sarah. They consider themselves already proficient in geriatric dentistry, felt that their personal and professional volunteer contribution to the people and to society had been partially fulfilled. They preferred to change to other dental specialties or increase their private practices. Quality work by the volunteers The dental surgeon volunteers came to Yad Sarah from various professional backgrounds: 3% are graduates from one of the two Israeli dental schools (Jerusalem or Tel Aviv). The additional 7% are from different dental schools around the world with different philosophies and treatment modalities that must be adapted to the Yad Sarah s clinical standards and demands. This required professional supervision and instruction, which together with the manpower turnover were necessary and timeconsuming procedures.
5 The Yad Sarah geriatric dental clinic, a different model 241 Manpower at all levels Quality dentists and dental hygienists are usually in high demand in all the professional sectors: universities, sick patient funds, public clinics and private practice. However, in this geriatric dental clinic where the personal satisfaction of helping needy elderly patients was not accompanied by economical remuneration, the continuous recruitment of good, highly qualified professionals was a difficult unsolved task. Additional resources The waiting list of patients in December 24 for examination was 2 3 months and estimated admission time for treatment was 3 weeks after examination. Because of budget and manpower shortage, beginning in March 25, the admission rate has been limited to four active patients per week. This was an undesirable situation for elderly patients in need of dental care and the lack of additional, qualified, competent volunteers and economical resources was an acute and fundamental problem in the management of an open private geriatric dental clinic. Conclusions Over a 5-year period, 1999 until 24, Yad Sarah developed and accomplished an original multipurpose programme: a private, subsidised, geriatric dental clinic staffed by volunteer dentists, oral hygienists and ancillary helpers. The main aim of the project was to provide dental care for the geriatric population in Israel. Emphasis was put on high quality clinical services for the elderly and the training in geriatric dentistry of the volunteer dental surgeons and dental hygienists. The programme provided the development of a comprehensive geriatric dental service and teaching agenda. Elderly patients were successfully treated and a large number of dentists completed postgraduate training in geriatric dentistry. References 1. Rivlin JM. Caring for the Disabled Elderly. Washington, D.C.: Brookings Institution, 1988: Langer A, Michman J, Librach G. Tooth survival in multicultural group of aged in Israel. Community Dent Oral Epidemiol 1975: 3: Pietrokovksi J, Tamari I, Mostavoy R, Levi F, Azuelos J, Tau S. Oral findings in elderly nursing home residents in selected countries. Gerodontology 199; 9: Meskin LH, Dillenberg J, Heft MW, Katz RV, Martens LV. Economic impact of dental service utilization by elder adults. J Am Dent Assoc 199; 12: Moskona D, Kaplan I. Oral health and treatment needs in a non-institutionalized elderly population: experience of a dental school associated geriatric clinic. Gerodontology 1995; 12: Meskin L, Berg R. Impact of older adults on private dental practices, J Am Dent Assoc 2; 131: Carter G, Lee M, McKelvey R, Sourial A, Halliwell R, Livingston M. Oral health status and oral treatment needs of dependent elderly people in Christchurch. N Z Med J 24; 117: Yad Sarah s Annual Activities Report. Jerusalem, Israel: Yad Sarah, 24: Ettinger RL, Mulligan R. The future of dental care for the elderly population. J Calif Dent Assoc 1999; 27: Bureau of Statistics. Annual Reports for Years Ministry of the Interior, Israel: Bureau of Statistics, Pietrokovski J, Seltzer J, Azuelos J, Shem Tov A. Manual on Complete Dentures. Jerusalem: Academon Press, 21: Zini A, Pietrokovski J. Survey of patient satisfaction at the Yad Sarah Geriatric Dental Clinic. J Israel Dent Assoc, 26; 22: Correspondence to: Professor Jaime Pietrokovski, 12 Haeshel Street Moshav Nir Zvi, PO Box 144, Israel. Tel.: Fax: pietro@netvision.net.il
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