We studied three independent cases that we will refer to as clinics A, B, and C (Table 2). Clinic A had been operating for over 30 years and, at the time of the study, consisted of a dentist (owner), five associate dentists working part-time (two to three days per week), and two administrators who worked from their homes. Clinic B had been operating for only a year and a half and consisted of a dentist (owner), a dental assistant, and a secretary who worked from home. Clinic C had been providing domiciliary services for five years. It consisted of a dentist (owner), a dental assistant, a secretary who worked “on site” (by accompanying the dental team on all visits), and a part-time administrative assistant who worked evenings (from home) managing emails, voicemail, and other administrative tasks.
In the next sections, we will describe the physical and service features of the clinics we studied. In terms of the physical environment, we will describe what constitutes the “dental office” in domiciliary dentistry; the equipment used; and the domiciliary settings where service is provided. In terms of service features, we will identify who is involved and how; interaction and communication between those involved; what constitutes domiciliary visits; and the financial aspects of this service.
Main Actors: Roles, Attitudes, and Attributes. Roles of Service Providers. The history and organization of the clinics varied. In one clinic, the dentist started offering domiciliary services immediately after graduating from dental school and gradually grew his practice bringing associate dentists, dental assistants, and clinic managers into the team. While the owner and another experienced associate provided services independently, the dental assistants rotated among the other associates forming teams of two. The two full-time administrators (clinic manager and assistant-manager) managed the scheduling, billing, and coordination of appointments while remotely monitoring daily developments.
In the other two clinics, the dentists had made the shift to domiciliary dentistry after a few years of practicing in traditional clinics. They launched their services in teams of two, working closely with their dental assistants. One of them later hired a secretary who traveled with the dentist and the dental assistant in order to complete patients’ files on-site. This, according to the dentist, saved time and allowed them to see more patients per day.
Attitudes and Attributes of Service Providers. The dentists expressed different motivations for starting their mobile practice, their personal stories constituting a mix of altruism and self-interest. First, they described a desire to give and help others that was fueled by personal life events: one dentist was motivated by their work with geriatric patients before making the switch to mobile dentistry; another described having a “transformational” personal experience as a caregiver; and a third was inspired by a role model in the field. For these dentists driven by altruism, domiciliary dentistry was particularly appealing as it responded to the needs of people that they perceived as vulnerable and underserved. One dentist, for instance, highlighted the importance of helping seniors maintain their autonomy and reside in their homes as late as possible. Referring to the current COVID pandemic and its concentration in LTCFs, this dentist emphasized the importance of home-based domiciliary dentistry.
Besides altruism, some dentists described how mobile dentistry also fulfilled their own interests, mentioning the advantages of having flexible working hours and a profitable model of practice. One dentist, for instance, explained that the switch from a traditional to a mobile practice improved their work-family life balance and eliminated the high running-expenses of a fixed clinic.
I wanted a family and easier life, so it was easier knowing we don't have to work in the evening. If the baby is sick or something, it’s not a big structure to keep running. (Dentist, Clinic C)
The dentists and dental assistants shared some notable personality traits including patience, adaptability, and resilience that seemed essential for this type of practice. Patience was particularly needed when dentists were starting their mobile clinics. They described the process as a “big learning curve” due to the lack of resources for mobile clinics compared to traditional clinics (such as guidelines, equipment, and training). For this reason, they acknowledged, some dentists may give up quickly on the idea of providing domiciliary services because they may not find the support they need.
Dentists also needed to be patient and adaptable on a daily basis as they navigated through domiciliary settings and dealt with various challenges, such as poorly accessible buildings, uncooperative patients, or other external variables like bad weather and lack of parking space (more details on these issues in the following sections). The administrative dental staff also needed patience and good organizing skills as they coordinated the logistics, appointments, and payments with the patients or their caregivers, including family members or the LTCF staff. Adaptability and persistence were such prominent and somehow unusual qualities for dental professionals that one dentist concluded: “this type of practice is not for everyone!”. (Associate Dentist, Clinic A)
Our data also showed that the dentists and their staff were able to develop their skills over the years and that their type of practice even had positive impacts on their personal life. Acknowledging that working with a vulnerable population was emotionally demanding at first, the participants also explained they became more resilient with time and improved their ability to manage their emotions and handle difficult situations. Describing the transformational power of their practice, a dental assistant even described her work in domiciliary dentistry as “life-changing”:
We all will grow old and get to this stage, we will be like them. This made me re-evaluate my own life. I didn’t want to be in a bad relationship…we need to be happy now and live in the moment (Dental assistant, Clinic C)
Patients and their Networks. The clinics provided domiciliary services to older adults and people with disabilities or debilitating health conditions who faced challenges in accessing traditional dental clinics. Home visits were also provided to patients with major depression or agoraphobia. When necessary, family members, LTCF staff, or caregivers were involved in different aspects of the visit such as organizing the appointment or supporting the patient during the visit. LTCFs staff and nurses, for instance, facilitated dental appointments through scheduling, providing access to patient’s medical information, transferring the patient from wheelchair to bed or vice versa, and sometimes administering medication requested by the dentist prior to the visit.
Attitudes of Patients and Caregivers. Patients and their caregivers expressed gratitude towards the dentists for offering domiciliary on-site services. Having a mobile dentist was described by one caregiver as “marvelous! Just marvelous!”. A grateful 79-year-old patient diagnosed with Parkinson’s and arthritis described how quickly his physical condition deteriorated forcing him to switch from cane to walker to wheelchair over a short period of time:
I woke up one morning two years ago and was unable to walk. They took me to the hospital and from there to the nursing home. I had been very regular with my dental visits for over 20 years, so I was delighted to find [the mobile dentist]! He is very professional. I feel comfortable with him and trust his opinions
Furthermore, when asked what they valued the most, participants highlighted human qualities and competence of the dental team describing them as “kind” and “caring” and admiring their preparedness in terms of skills and equipment.
According to patients and caregivers, domiciliary dentistry eliminated the challenges they faced when seeking oral healthcare such as difficulties in “travelling” to a clinic; the physical barriers of inaccessible dental offices, and the lack of skills and negative attitudes of some dental professionals.
Getting to a dental clinic was one of the main reported challenges. According to one patient, getting to a dental clinic was “painful” because of old age, poor health condition, and fear of travelling. Additionally, unanticipated delays or no-shows of adapted transport may occur, leading to missed or cancelled appointments. Caregivers also described travelling as complicated, time consuming, and physically demanding for them too; since some caregivers were older adults themselves with varying physical abilities.
I took her in her wheelchair to the dentist…That was harder on me than her because I have a sore shoulder. I had to put her into the car and then the (wheel)chair, and I’m not able to that on my own. I actually adapted but it is just more physically demanding…(and) it’s definitely a longer process” (daughter of elderly patient)
Domiciliary dentistry also eliminated the challenge of accessing poorly adapted clinics and receiving quality dental care. One caregiver, for instance, highlighted the difficulties she used to experience when trying to maneuver her mother’s wheelchair in the small rooms of the dental clinic and how overwhelming this task was. Another caregiver, the daughter of 94-year-old patient with Alzheimer’s, recalled “[before finding the mobile dentists] I once thought about taking [my mother] to my dentist…he saw her and said No, I can’t!”. Finally, a bed-ridden patient deplored dentists' lack of competence and pointed out that it was hard to find “doctors who [were] specialized [in reference to her disability]”; she also believed that some dentists had negative attitudes and “[did] not want to treat elderly patients”.
Interactions, Logistics and Treatment. Interaction between the Dental Team, Patients, and Others Involved. The interactions of the dentists in domiciliary dentistry could take various forms: with patients and their families; with LTCF nurses and staff; and with the other members of the dental team (both in-person and remotely). Communication had several layers that were more complex than in traditional clinical settings and sometimes created challenges. In terms of interactions with patients, it was common to come across patients with dementia or Alzheimer’s leading to more complexed interaction. One dentist, for instance, explained that Alzheimer’s was “particularly challenging” for the dental team, as the patient may not recognize the dentist, even after several encounters, making it difficult to establish communication and trust.
Also, it was often necessary for the dentists to involve family members or caregivers due to inability of some patients to consent to treatment. The legal representative or caregiver would give the approval to proceed with a treatment plan and guarantee payment. One dentist describes how he sometimes had to take intra-oral photographs as “evidence” of his work because family members may be skeptical or may question the dentist on what had been done.
Moreover, when patients resided in a LTCF, the dental team also communicated with the LTCFs nurses, attendants, and administrative staff to obtain information about the medical history and the list of medications or to give specific instructions (such as giving antibiotic medication pre/post dental treatment). The following Vignettes (created from our observation fieldnotes) illustrate examples of the particularities of communication in domiciliary dentistry.
Vignette 1: The dentist had a follow-up appointment with a 94-year-old patient with Alzheimer’s who resided in a LTCF. From previous encounters, the dentist was aware of the patient’s tendency for aggressive behavior (ex. biting). The patient’s daughter booked the appointment directly with the mobile clinic’s manager; the latter then called the residence staff to relay the dentist’s instruction to give the patient a small dose of tranquilizer prior to the scheduled visit. The patient’s daughter was not present at this appointment. Under medication, the patient was unable to engage verbally with the dentist and appeared in a light sleep. The dentist used non-verbal sensory stimulation to communicate certain commands (for example, applying slight pressure behind the corners of the lips to ask her to open the mouth). After completing the appointment, the dentist called the patient’s daughter to give her an update. He also wrote an update in the patient’s file at the center and then sent an electronic update to his clinic’s manager.
Vignette 2: Another patient in a LTCF was refusing to interact with the dental team. She turned her head away every time the dentist tried to approach and explain that the appointment was planned by her son. “My son did not tell me about this” the patient exclaimed repeatedly. The dentist tried to comfort her and asked if she would like to speak to her son to confirm that he had scheduled the appointment. The dentist used her own cell-phone and put the son on speaker to comfort his mother. The patient, relieved by hearing her son’s voice asked him repeatedly to “stay” with her. The dentist placed the phone near the patient’s bed and assured the patient that her son could stay with them for the entire session. Hearing the voice of her son comforted this person and allowed the dentist to perform the treatment (dental filling).
As shown in Vignette 1, some dentists resorted to prescribing small doses of tranquilizers to patients with aggressive tendencies. It is worth noting that one of the dentists in this study was not in favor of medicating patients and preferred them to remain aware of their presence and what they were doing. When attempts to gain patient’s collaboration fail, she preferred to stop and to reschedule the appointment for a different day.
In terms of interactions within the dental team, the dentists communicated updates with their administrative staff in different ways. One dentist would send an electronic image of the patient’s chart (in LTCFs, paper charts were retained in the patient’s medical file) via “Dropbox” to his administrative staff immediately after an appointment. Another dentist used a laptop to complete files after every appointment while the remotely-based secretary had online access to the same software. Conversely, in the clinic where the secretary accompanied the team, the dentist would dictate the updates to the secretary who completed patients’ electronic files during appointments.
Scheduling and Planning Visits. All administrative tasks (such as scheduling and billing) were performed on a dental practice management software, just like in conventional clinics. This said, these tasks were sometimes more complex and required more coordination and follow-up given: 1) the multiple levels of communication that were necessary; and 2) the need to consider the patients’ locations in order to geographically pool visits, reduce traveling time, and maximize efficiency.
For example, a clinic manager described how they sometimes had to wait for family members/legal representatives to give consent in order to schedule visits. Occasionally, seeking those approvals took longer than anticipated, depending on how responsive the families were. Once consent was obtained, for patients residing in LTCFs, the clinic’s manager had to contact the LTCF staff to inform them of the planned visit and to finalize scheduling. Then, a final confirmation call was usually done the day before the visits. Despite multiple confirmations, last minute changes occurred. For instance, one of the dentists explained that, one day, they drove over 30 minutes to a LTCF and discovered there that the patient had to be transferred to a hospital during the night.
An important consideration while scheduling appointments, according to several members of the dental team, was the pooling of visits by neighborhood or town, on any given day. A clinic manager highlighted how this was not an easy task, especially in the beginning of joining the mobile team. However, with experience, this team member explained, planning weekly and daily schedules became easier by learning to estimate length of visits and distance between locations, as well as considering other factors such rush-hour traffic. In the three clinics, the schedules were planned weeks in advance. The time allocated per visit varied between the three clinics. In LTCFs the duration ranged from 30minutes (Clinic C) to 60 minutes (Clinic A) per appointment. Home-visits, on the other hand, may require longer appointments of 1.5-2 hours (Clinic B) due to varying traveling and setup durations.
Subsequently, another logistics challenge that arose for mobile clinics was emergency appointments or urgent follow-ups. With carefully planned, area-specific schedules, the dental teams found it often difficult to “fit in” new appointments in random locations. One potential solution described by the dentists is to reserve a half or full day for emergency visits. However, given the high demand and low supply of domiciliary dentistry, they remained unsure about the most ideal approach and had not implemented anything particular in their clinics.
One dentist believed that the solution to increase availability of domiciliary dentistry would be the adoption of what they coined “proximity dentistry”. In this model, existing traditional clinics would offer a mix of fixed and mobile services within a one Kilometer radius of the clinic. When such a model is reproduced in different neighborhoods and locations, it would help with the issue of travel time for both dentists and patients, as well as increase the reach of mobile dentistry to those in need.
Accessing the Domiciles. Obstacles related to weather conditions and/or accessibility of domiciles sometimes complicated the process of domiciliary dentistry. Quebec’s winter weather conditions are sometimes harsh. Snow storms lead to reduced visibility for commuters and piled snow or icy sidewalks become a hazard for pedestrians. Such unfavorable weather sometimes complicated the drive and moving the equipment from the vehicle to the domiciles. Additionally, the type of domicile may further complicate access due to multiple stairs, lack of elevators, distance from parking to entrance, etc.
Both LTCFs and private homes had their unique advantages and disadvantages in terms of access. LTCFs typically offered: 1) designated parking spaces; 2) multiple patients in one location; 3) easy access to medical charts with detailed medical history and medication information; and 4) rooms equipped with electric beds and transfer-lifts (operated by the nurses), which facilitated positioning patients for treatment.
The disadvantages of LTCFs were mainly related to strict access protocols or dealing with staff. For example, during one of our observation rounds, the dental team had to wait at the reception for approximately 10 minutes to be granted access to a LTCF because the receptionist was not informed of the anticipated visit and had to make several calls before letting them in. In another LTCF, the dental team had to wait a couple of minutes at the door because the security guard was on break and they were not given the access code. Then, they had to make several stops inside the building to ask for directions to the patient’s room. Sometimes the staff seemed unhelpful or would just refer the team to another member of the staff. The dentists sympathized with the staff and pointed that they were probably “overworked” due to the centers being understaffed.
On the other hand, in private homes or apartments, accessibility also varied depending on: 1) physical factors such as the location, lack of parking, and/or the presence of stairs; and 2) adaptability of the dental team to the various social contexts of home visits. Dentists with strong social communication skills could more readily navigate different norms and cultures inside patients’ homes. For some dentists this was considered an overwhelming and distracting task. Others, however, highlighted the value of such interaction for themselves and for the patients:
I am someone who loves to have contact with people, so my first appointment, before the pandemic, was to take a coffee, talk with my patient, to really understand the profile of my patient. It was my approach… They [the patients and their families] are usually tired and stressed, we are there for them… a mobile dentist is way more than just that. So, if I can provide social support, moral support, and indirectly, we can create a network with the nurse, the CLSCs [ French acronym for the local community service centers] (Dentist, clinic B)
It is a gift to go to homes. We enter their intimate space. They trust us and include us in their social life. (Dental assistant, clinic C)
Patients need them [home visits], there is a lot of demand. They are very appreciative, and the people are very nice… I got two cans of spaghetti last week! (Dentist, clinic A)
Set up and Treatment. After entering a domicile, the dental teams began the process of positioning the patient, stationing the mobile dental unit, and then preparing the patient for examination and treatment. At LTCFs, the patients were usually positioned in their hospital beds. Electric hospital beds were convenient for the patients and ergonomically well suited for the dental team. In homes, patients were usually set up in their own wheelchairs; beds (conventional or electric); or in reclining arm chairs (such as the popular “Lazyboy”). Sometimes the dentist requested and assisted the patient to transfer to a more convenient spot (for example from wheelchair to bed).
To station the dental unit, the dental team located a power outlet close to where the patient is positioned in order to connect the unit. Also, depending on the nature of the visit, the dental team would locate the nearest sink (to rinse a denture, for example).
The last step in the set-up process was to prepare the patient by brushing the teeth and/or gums to remove any residue and facilitate examination. This step was considered essential as patients typically had poor oral hygiene practices. One dentist used a high-concentration chlorhexidine toothpaste as a prophylactic first-step for every patient. Another dentist only used a wet brush to clean the oral cavity and provided a high-concentration fluoride gel to patients on a need-basis.
The range of treatments performed by the dentists included: cleaning, dental fillings, abscess drainage, extractions, and some denture repair. According to the dentists, all dental treatments could potentially be performed by a mobile dentist, including endodontics and implants. However, given the prohibited use of mobile x-ray devices in the province of Quebec, they were sometimes reluctant to perform certain procedures. The main characteristics of the dental treatments were: 1) the focus on prevention and preservation as most patients could not tolerate lengthy restorative procedures; and 2) the use of dental materials that are easy to manipulate and have favorable properties such as Silver Diamine Fluoride (SDF) or glass ionomer. One dentist described SDF as an ideal material for arresting and preventing caries, that is also easy to apply and did not require any specialized equipment.
At the end of each session, the dentist or dental assistant thoroughly disinfected the mobile dental unit and stored away any used instruments in a covered container. At the end of the day, the dentist or the dental assistant returned the containers to the storage facility for sterilization.
Financial aspects. The dentists acknowledged concerns among dental professionals over the financial viability of domiciliary dentistry. However, they emphasized that with patience they were able to build a profitable service model. They argued that although financial gain may be slow at the beginning, mobile dentists who are just starting need to give it time. One dentist explained that it took a lot of adjustment when starting: “it [was] very difficult to move around [LTCFs] at first…when I first began with my assistant, I remember it would take us half an hour just to get from the parking to the room!”. “At the beginning it’s slow, but now it’s very good!” said another dentist referring to financial returns after less than two years in mobile practice. The three clinics set their fees in accordance with the provincial syndicate fee-guide (just like conventional clinics). Additionally, two of the clinics charged a fixed displacement fee per patient ($100 and $110, respectively). According to a dentist who did not charge the extra fee, they compensated travel costs by pooling patients in LTCFs to maximize the number of appointments per location.
One dentist believed that the prevailing concerns about poor remuneration for mobile dental services among dentists are rooted in the approach dental schools take in training dental professionals and confirm the persistent inequities in access to oral healthcare:
Even in a conventional clinic, treating geriatric patients or patients with disabilities is not money making! it requires more time, more appointments… but that’s not what we were taught in school. At school we learn to do crowns, fill cavities, but we don’t learn to treat the human!... I don’t have a choice [regarding the displacement fee], if I don’t do it, it [the service] doesn’t pay back… A lot of people don’t take my services because it’s expensive, but what I charge is the least I can charge for my company to be running