The term “Age-Ism” was introduced in the year 1969 by Robert Butler (in the USA) [1] who described it as “prejudice by one age group against another age group”, namely, thus focusing on the generation gap [2, 3]. Ageism was defined as negative attitudes or prejudice toward older adults [4]. Later, the WHO (2015) provided a broader definition. WHO defined “ageism” as “the stereotyping and discrimination against individuals or groups on the basis of their age” [5].
The phenomenon of ageism is a significant threat to older people’s well-being, which is highly prevalent and widespread across many cultures [6] and, may be more importantly, that this phenomenon may be socially acceptable [7]. Not surprisingly, ageism is often subtle [8]. However, Wyman et al. put it best in saying that older adults “tend to be negatively stereotyped in the media, which leads to mistreatment, loneliness, patronising speech, discrimination in the workplace and discrimination in the healthcare systems” [9].
Ageism is increasing, with the increasing ageing of populations worldwide [10]. Cultural factors may significantly influence the agism rates in a population [3, 11]. There are differences across nations and cultures about the respect for the older adults and the value of their lives. The attitudes towards older people across different countries may be dependent on whether a country is high-income or low-income [12, 13]. World Values Survey found that in 57 countries 60% of the older people do not receive the respect they deserve [14]. It has long been argued that in Europe, ageism is more common than gender or race discrimination. Note, however, that there are differences across nations in Europe [15].
“Ageism is a multifaceted concept including three distinct dimensions: a cognitive (e.g., stereotypes, namely, beliefs about older people in general), an affective (e.g., prejudice) and a behavioural dimension (e.g., discrimination, namely, detrimental treatment of older people)” [16].
Self-directed type of ageism regards the beliefs held by older people about their own aging. It is argued that a variety of determinants contribute to other and self-directed types of ageism. Marques et al. identified a total of 14 possible determinants of ageism (13 related to other-directed ageism and only one related to self-directed ageism) [6]. Anxiety of ageing and fear of death are suggested to be determinants of ageism [6].
As regards other-directed ageism, contact with older people seems is suggested to be the most important determinant at the interpersonal / intergroup levels (the greater the contact the lower the ageism rates), while scarcity resources in society and the percentage of older people in the country are suggested to be important determinants at the institutional/cultural levels (tensions over resource allocation in a context of increasing percentage of older adults in the population increases the ageism rates) [6].
Recently, Chang et al. underscore ageism as a social determinant of health. They examined significant mediators between ageism and older persons’ health drawing on stereotype embodiment theory. The authors suggest that three “distinct, yet interrelated”, components of ageism (discrimination, negative stereotypes and self-directed ageism) can negatively impact health “through psychological, behavioral, and physiological pathways” [17].
Ageism among health professionals and students induces various "age biases" which may reflect society’s negative stereotypes towards older adults [18, 19]. Health professionals’ ageism may negatively impact on the older adults’ health status assessment, the treatment decisions which may be based on patient’s age alone (e.g., health professionals may restrict or discourage access to care or avoid shared decision making when it comes to older patients) [4, 5, 16, 20, 21]. The Royal College of Physicians stated that the hospital care system “continues to treat older patients as a surprise, at best, or unwelcome, at worst” [22].
Dentists, by providing oral health care, make important contributions to the overall health and general well-being of older adults [23]. Inadequate oral health can negatively impact not only the patient’s oral health, but also their general health / well-being (quality of life), especially when it comes to multi‐morbid care-dependent patients [4, 24, 25]. Moreover, as in elderly people systemic health problems and polypharmacy may often affect their oral health, dentists may identify problems that disturb systemic health [26]. Dental needs of elders may vary considerably from one country to another [10]. For instance, edentulism rates (tooth loss) have decreased significantly in the last decades in Finland, Sweden, England and Canada (though not in Brazil) [10].
Domiciliary dental care services are needed to be developed so that it can be provided oral health care for noninstitutionalized, disabled elderly people [27]. Note, however, that institutionalized care-dependent elderly people are more likely to be in need of daily oral health care than community-dwelling elderly people [11]. Indeed, maintaining effective oral hygiene routine for institutionalized care-dependent elderly people remains a perennial problem [11, 28–30]. Neglected oral health of institutionalized elders who are dependent for care is most likely to result in health complications such as pulmonary infections, aspiration pneumonia (due to dysphagia) and pneumonia‐related deaths, bacterial septicemias or bacterial endocarditis [31–35]. Regular periodic oral health examinations of care-dependent elders could prevent medical emergencies [36]. Good oral health for institutionalized elders requires provision of routine dental health care services. However, many dentists are reluctant to visit these elderly people [37]. They consider this an unpleasant task [38, 39]. Furthermore, dentists often are reluctant to treat elderly people or prefer to perform conservative dental treatments rather than mutilating procedures [40, 41]. Note, however, that it is not certain whether this attitude is due to a lack of knowledge in geriatric dentistry or experience in managing the complex clinical problems in the field of Gerodontology, or just in ageism [42, 43]. Studies have suggested that “older dentists make more conservative treatment decisions”, which however, might be due to their better clinical judgments because of their work experience accumulated over years [44]. Note that it is argued that the number of young dentists in the workforce are at increase [45].
At any rate, it is argued that ageism may explain why few dental practitioners dedicate at least some of their time to providing dental care for frail older adults in settings other than conventional dental offices, such as in a patient's home and in nursing homes” [46]. It has long been argued that ageism has implications in dental care delivery [4].
Neither elderly patients nor dentists may be conscious of their own ageist attitude. However, it is argued that it is important that dentists recognize these attitudes as well as their possible implications [4].
Studies conducted in different places in the world found that many dentists have a low level of knowledge about Gerodontology and suffer from a lack of training in this field of Dentistry. This may further limit the possibility of providing effective oral health care [19, 37, 47, 48]. Importantly, it is argued that “ageism may explain both why fewer dentists worldwide are choosing to pursue postgraduate studies or advanced training in geriatric dentistry” [49].
There have been developed different scales to assess ageism in healthcare professionals [50]. Note, however, that a systematic review revealed a “general lack of psychometric assessments of existing ageism scales” [51]. Moreover, the same review concluded the need for “the development and validation of a new ageism scale that covers all dimensions of ageism” [51].
Ageism among health professionals is a widely discussed topic. The attitudes of dentists towards the elderly people have been explored for the last 40 + years “showing modestly positive, moderate or in many cases negative attitudes” [10, 41, 52, 53, 54]. However, dentists’ negative attitudes towards older people (a vulnerable group of population) are an important issue of public health and medical ethics that remains to a large extent unexplored. Furthermore, a systematic review conducted by Ayalon et al. (2019) reveals a general lack of psychometric assessments of existing ageism scales, which moreover, fail to cover all dimensions of ageism [51]. The development of a universally accepted (tested in diverse populations) ageism scale that covers all dimensions of ageism, includes self- and other-regarding ageism, both positive and negative ageism, as well as explicit and implicit manifestations of ageism is desirable.
To our knowledge, there is a literature gap regarding the topic of ageism among dental professionals in Greece. We attempted to contribute to filling this gap.
Research questions
The primary research question that defined the focus of this study was as follows:
Is the Greek ageism scale for dental students (ASDS_Gr) applicable for use in assessing dentists’ attitudes towards elderly patients?
The secondary research questions were as follows:
-
What is the current ageism score among dentists in Greece?
-
How are the dentist ageism scores (total score and score for each item) associated with certain socio-demographics in Greece?