Prior to establishing the present GSP program, geriatric dentistry was taught at the postgraduate level by the prosthodontic department, because elderly patients commonly seek dental prosthesis treatment. The content was subsequently simplified and taken as a one-credit lecture by the fifth-year undergraduate students. The GSP program was initially developed as a knowledge-based curriculum. After the program had been in operation for 3 academic years, the present curriculum and patients’ information were re-analyzed with an aim to continually improve and transform the curriculum into a competency-based curriculum.
Previously, elderly patients with medical complexity or functional limitation underwent dental treatment at several departments, depending on the patient’s symptoms and dental treatment needs. Special care patients were managed at the pediatric department. After the age of 15, some of these patients were treated at other departments. However, there were some difficulties when referring patients to several clinics where the dentists lacked the required management skill. Currently, the GSP clinic serves as a one stop service center providing dental treatment for elderly and special care patients. The present and future curriculum of the GSP program are shown in Table 1.
Graduate geriatric dentistry education is available in several developed countries, but varies between universities and countries. Most dental schools provide a separate program in geriatric dentistry at the postgraduate level [10-12]. Some dental schools treat independent elderly patients in the prosthodontic clinic and frail elderly in the geriatric clinic [19,20]. Special care patient management is a part of the pediatric department or an isolated program [21,22]. The objectives of the GSP program focus on both elderly and special care patients to create a holistic oral health care center for patients with physical or psychological complexity, regardless of their age.
Presently, both physicians and dental professionals are responsible for classroom-based learning. Physicians provide lecture courses based on their specialties, but do not participate in a clinical section. Our results indicated that most patients attending the GSP clinic were elderly who had several complex non-communicable diseases consisting of sudden-degenerative (e.g. stroke) and slow-degenerative conditions (e.g. neurodegenerative diseases, dementia, and Alzheimer’s disease). The present curriculum already provides extensive lectures on systemic diseases of the elders in relation to their dental needs, but does not provide sufficient knowledge and clinical skill to manage special care patients. The current number of younger patients with special care conditions are low, but are expected to increase when the referral system is well-established. The future curriculum has to provide more information on special care conditions, ranging from degenerative diseases to genetic disorders. By collaborating with a medical school, students would have a greater opportunity to engage in various special care centers, allowing them to gain clinical experience in managing patients with various systemic conditions.
Currently, the first-year GSP students mainly observe and provide oral health care for dependent elderly and assist the second-year students. After having lectures and experience off-site, students are allowed to manage more complex cases, such as dependent and frail patients who have severe biological or psychological impairments. Based on our data, most elderly patients who attended the GSP clinic needed removable dentures, followed by periodontal and operative treatment. Currently, the GSP students provide all types of dental treatment, except for complex endodontic treatment, oral surgery, and sedation. However, performing comprehensive treatment may not be possible in the near future when the number of elderly and special care patients increase. The future curriculum will result in the GSP clinic being a one-stop service center that includes students from several departments to reduce fragmented care. Didactic geriatric content needs to be integrated into all relevant clinical departments that deal with elderly patient care. The curriculum will include more case-based and problem-based learning methods to improve decision-making, clinical skill, and problem-solving skills for students. The GSP students will be responsible for assessing, conducting, and organizing dental treatment plans. They will also act as a coordinator in communicating and encouraging family members, caregivers, and the healthcare team to form a holistic care approach.
As an international program, the curriculum includes a short course for visiting and observing the geriatric clinic and advanced technology at the collaborating dental school in Japan. The purpose is to broaden students’ experience in geriatric and special care dentistry in the other country. Because the GSP clinic at the dental faculty is independently located from a medical hospital, the GSP students lack clinical experience in managing dependent and frail elders. Dependent elderly and special care patients, registered at a hospital, are generally referred to the hospital dental department when dental treatment is needed. The dental department in the medical hospital provides treatment, but not education; however, it is a good learning site for our GSP students. Therefore, the future curriculum will incorporate more out-of-class learning and clinical experiences. The teaching sites will be expanded from the dental school to medical institutions, hospitals for disabled people, nursing homes, and community hospitals.
Our data demonstrated that, despite residing in Bangkok, more than half of the patients did not receive regular maintenance care. In accordance with other studies [23,24], a major obstacle in oral health care accessibility is due to the patient’s functional limitations and lack of family or care giver support. Some caregivers are unable to evaluate oral condition or provide basic oral health care [25]. Students need to provide additional clinical chair-time to provide a basic oral health care knowledge and skill for patients and their caregivers. Developing a certified caregiver training program is suggested to improve health attitudes and oral health literacy. In the future, an active approach for oral disease prevention and oral health promotion would be conducted through home visits, mobile dental units, and teledentistry. Using advanced communication technologies, we believe that teledentistry would benefit for elderly individuals who have difficulty in accessing oral health care by providing them dental consultations and oral health care advice [26].
Among the patients receiving maintenance recalls, 75% had emerging oral health problems. Moreover, many patients had more serious health conditions leading to poorer oral self-care or swallowing difficulty. In addition to oral rehabilitation, the curriculum needs to focus more on the behaviour management of uncooperative patients, oral disease prevention, and other oral care with adjunctive materials and special instruments. Dietary consultation and nutritional assessment should become a part of oral health care.
This study revealed the importance of continually analyzing patients’ information to improve the curriculum in geriatric and special patients care dentistry, to meet the changing needs of patients and social context. Oral health care concepts have to extend beyond oral rehabilitation to oral health promotion and prevention. A multidisciplinary team should be established to be responsible for the GSP program. The team should comprise collaborating dentists, physicians, pharmacists, nurses, and rehabilitation nutritionists who work closely with family members and social service agencies. Based on the concept of family medicine, students should learn how to create a personalized treatment plan by considering not only disease problems, but also the behavioural and social context of individuals [27]. The aim of the future GSP program is to produce a dental geriatrician who is an expert in oral health and able to integrate oral into general health.
The present study encourages other institutions to develop their own curriculum related to the oral health care of geriatric and special patients based on their patients’ needs and social context. The findings from the GSP program were data from an urban Thai dental school where patient characteristics and their needs could be different from those in rural areas. Further study is recommended to comprehensively review the geriatric curriculum in provincial Thai dental schools in order to develop core competency in geriatric dentistry postgraduate program. For further curriculum improvement, feedback from the present and past students of the program should be collected.