INTRODUCTION

The number of elderly people worldwide is growing rapidly. In 2000, there were 600 million people who were aged 60 and over and this number is expected to increase to 1.2 billion by 2025 and 2 bil­lion by 2050, in which 80% are living in developing countries (Mujahid 2006). Data from the United Nations in 2002 showed that based on the 6 billion-world population, 7% of the world’s population were 65 years and above, whilst those aged 60 years and above comprised another 10% (United Nations 2002). The elderly population in Malaysia is pro­jected to increase from 6.6% in the year 2000 to 13.4% in 2025. Improved living conditions, better hygiene and advances in medical care have been reported as the reasons for a greater proportion of persons reach old age. However, as the population ages, there is an increased risk of this group developing systemic diseases like hypertension, heart dis­ease, diabetes and chronic obstructive pulmonary diseases (World Health Or­ganization 2003). As for oral health, re­ports have revealed that the condition of this group is far from optimal. Their treatment needs are high due to eden­tulism, missing teeth, caries, periodontal diseases and attrition resulting in im­paired oral function, affecting quality of life (Petersen & Yamamoto 2005). In Malaysia, report from the National Oral Health Survey of Adults 2000 (NOHSA 2000) stated that the prevalence of den­tal caries and periodontal disease was still high among this group. The preva­lence of dental caries for the age group of 65-74 years was 95.2% and DMFX of 23.2. More than one third of the popula­tion in the group was edentulous, reach­ing up to almost half of them edentulous by age more than 75 years, while for pe­riodontal disease, the proportion of healthy periodontium decreased as age increased (National Oral Health Survey of Adults 2000).

 As such, dental students need to be equipped with skills, knowledge and pos­itive attitudes towards the elderly, so that they are more confident when providing dental care for this group (Nitscheke et al. 2004; Preshaw & Mohammad 2005). In Faculty of Dentistry, UKMMC, geriatric dentistry is taught as part of a module which includes a series of lec­tures and field trip activities to several old folks or nursing homes around Kuala Lumpur and state of Selangor. The series of lectures introduce students to basic aspects re­lated to oral care and man­agement of the elderly patient. At the end of the module, students are expected to demonstrate understanding of general health and oral health needs of the el­derly and readiness to clinically manage an elderly patient.

In addition to clinical teaching, students are also exposed to the group of elderly in the community. Visiting the old folks’ or nursing home will provide opportunities for the students to meet and interact with the elderly in their own environment be­sides in the clinic, to provide health edu­cation in a community setting and to de­velop a caring attitude towards under­served communities.

Therefore, the main aim of this study was to assess the final year dental stu­dents’ knowledge about older people, as well as their perception towards the training in geriatric dentistry. The findings may help to improve the conduct of ge­riatric teaching in the faculty including the didactic courses, clinical rotation and field work, and to strengthen clinical man­agement and communication skills of the students.

MATERIALS AND METHODS

All the final year students of Faculty of Dentistry UKMMC participated in the study (n=83) in 2007. They were required to complete a written questionnaire in the classroom that took between 10 to 15 minutes. The questionnaire comprised of three sections: 1) Palmore’s Facts on Aging Quiz; 2) Oral health and social concerns of patients; and 3) Students’ perception towards the teaching of geria­tric dentistry.

Palmore’s Facts on Aging Quiz (FAQ II) (Palmore 1998), consisted of 25 items, used to measure the basic knowledge about elderly and aging, especially in the health-related professions (Table 1). The students were assessed whether the 25 item questions were true or false. Ques­tions in Section 2 were based on the questionnaire developed by Jude et al in 2005 (Jude et al. 2005). The information obtained from this section was used to assess the students’ knowledge about specific psychosocial and health prob­lems that can become barriers to the continuity of care. Questions in Section 3 were to assess the student’s perception in the management and communication skills with the elderly patients before and after completing the geriatric dentistry module. Students were also required to select the main barriers and limitations faced during the conduct of the geriatric module in the faculty.

In establishing the validity of content, items in the questionnaire were ex­amined and revised by our Dental Public Health consultant in Faculty of Dentistry, UKM. The questionnaire was pre-tested in a different group of clinical students prior to the actual study.

RESULTS

Demographic characteristic

A total of 83 final year students partici­pated in the study. Their age were be­tween 23 to 26 years old, with the mean age of 24.5 years. There were 14 male students (16.9%) and 69 female (83.1%). The ethnic group showed that majority of the students were Malays (63%; n=52), followed by Chinese (36%; n=30) and one Bumiputra-Kadazan.

Knowledge on aging

Results from the Palmore’s Facts on Ag­ing Quiz (FAQ II) showed that 24.1% of the students (n=20) scored more than 70% correct answer for all items while 73.5% (n=61) scored between 50-70%. Based on individual items, the FAQ II items that fell within the high correct re­sponse group were those that were re­lated to the health of older adults (Table 1). These include knowledge on hyper­tension, stress, physical strength, mem­ory loss and osteoporosis. For moderate range of correct items, the issues were on clinical aspects like bladder capacity, clinical depression and constipation. Stu­dents also had moderate knowledge on social aspects of aging like role of mod­ern family members in taking care of the elderly (67.5%) and feeling of anxiety towards death among elderly (45.8%). The low category of correct response rate items mainly focused on behavioural aspects of the elderly. Less than 30% of the students answered correctly on items that included knowledge on health care practices between gender (26.5%), ability to change (24.1%) and practice of reli­gion in old age (19.3) (Table 1).

Awareness towards patients’ social concerns

The nine items that prevent older people from keeping appointment were ranked in order of students’ selection from the items (Table 2). The top three barriers were identified as: physical disability, transportation problems and complex and overlapping priorities (97.6%, 94% and 83.1% respectively). Students also per­ceived financial barrier (79.5%) as an important factor that made the elderly missed their appointments compared to fear of the dental procedures (56.6%). More than half of the students also agreed that abuse or neglect by family members or caregivers was not the rea­son for the elderly to miss their dental appointments.

Students’ perception towards teaching of geriatric dentistry in UKM

Table 3 showed the results of students’ perception towards the teaching of geria­tric dentistry in UKM prior and following the educational intervention. Comparison between both scores (pre-and post-tests)revealed very little changes on the per­ceived understanding and abilities of the students upon completing the module. About 88% of the students reported that they had understood the general con­cerns of the elderly before the interven­tion, while 92% agreed during post-eval­uation. After undergoing the geriatric module, the students also showed some increase in the percentage on what they perceived to be the barriers faced by older adults in getting dental treatment (88.0% and 98.7% respectively). Com­munication was one of the barriers hig­hlighted when managing the elderly pa­tients. However, the results showed that the proportion of students who perceived to have overcome the barriers communi­cating with the elderly did not change greatly after the intervention. Thirty-six percent of the students reported that they were still having problems in communi­cating with the elderly after undergoing the module. No improvement was ob­served on their perceived level of confi­dence in management of older adults during dental treatment (pre- 72.2% and post- 69.3%).

As for the barriers and limitations faced during the module, the students ranked lack of educational materials specific to geriatric dentistry (80%) and lack of clini­cal sites experience for geriatric patient care (80%) as the main source. Other barriers that were reported include lack of clearly articulated geriatric curriculum (72%), insufficient number of full-time faculty members (72%), lack of interest in the field (68%) and the overloaded dental curriculum (54.6%).

DISCUSSION

One of the objectives of this study was to assess the knowledge of undergraduate dental students on aging. The assess­ment was based on the Palmore’s Facts Aging Quiz II (Palmore 1998), and the social concerns factors were based from the questionnaire developed by Jude et al in 2005 (Jude et al. 2005). The FAQ II has been widely used in the health-re­lated disciplines to evaluate knowledge about the elderly. From this study, evalu­ation of each individual item in the FAQ II showed that the high correct response group was those items which relate to the health of the elderly, while the moderate category were those items which were involved with clinical and social aspects of aging. These findings may reflect that the students had good to moderate knowledge about medical and general aspects of aging. Correct responses in the low category items that involve beha­vioural aspects may reflect perceived insufficient knowledge about these is­sues among the students. It is also im­portant to note that dental students are often un­der pressure to meet their edu­cational and clinical requirements for graduation. Therefore, the need to em­phasize certain issues in geriatric denti­stry teaching like psychological and be­havioural aspects among older people has to be looked into. Recently, geriatric dental pro­grammes in the United States have fo­cused on a broader range of top­ics in the management of elderly pa­tients. A survey conducted to 54 dental schools in the U.S showed that all schools taught about the barriers to dental care that may be experienced by elderly, while the psy­chosocial problems and socioeconomic difficulties were taught in 96 and 94 per­cent of schools, respectively (Mohammad et al. 2003). It appears that the geriatric dentistry teaching in many schools now has put more emphasis on social prob­lems re­lated to aging.

The second objective of this study was to determine the main social factors that prevent older adults from keeping to their dental appointments. By identifying the social concerns that may affect the utili­zation of dental services by older people, dental students can now try to under­stand the bio-psychosocial issues among this group and thus develop a positive attitude towards them. Similar to findings from this study, Fabiano et al. also re­ported that transportation problem and complex and overlapping priorities were ranked high by the students as reasons why older adults failed their appoint­ments. Abuse and neglect by family members were also ranked lowest (Fabiano et al. 2005).

About 79.5 percent of students in this study also perceived financial barrier as one of the important factors that made the elderly missed their appointments. This is true as several studies have re­ported that income was a significant pre­dictor of utili­zation among older adults. Kiyak and Reichmuth (2005) examined some determinants of older person’s dental service utilization and revealed that poor older adults were less likely to seek dental care compared to those in the high income group (Kiyak & Reichmuth 2005). A similar pattern was also seen among the Chinese el­derly whereby those who were better educated and wealthier had more visits to a dentist (Lo et al. 2001). However, further re­search to look into the relation­ship be­tween perceived and actual rea­sons why the elderly do not use the dental services or keep to their dental appointments need to be established.

This study also revealed that there were not many changes in the perceived competencies of managing older patients upon completing the geriatric module. Similar finding was observed in a study by Wood and Mulligan in 2000 that aimed to assess changes in the knowledge and attitude of dental students towards aging after receiving geriatric training. Overall, the study showed only a small increase in knowledge and unchanged attitudes toward elderly patients upon receiving the course (Wood & Mulligan 2000). Therefore, additional research is needed to confirm whether this trend is actually true at the faculty level. Should it be con­firmed, dental educators in the faculty need to identify strategies to improve the students’ competencies of managing older patients.

In the present study also, almost one-third of dental students were still unable to overcome barriers and did not gain more confidence in dental management of elderly patients. These findings were observed as the dental students were exposed to various types of elderly pa­tients, with different level of complexity in relation to their clinical management. For example, some of the elderly patients presented in dental clinics would have multiple medical problems and impaired physical abilities. The number and type of patients treated in the polyclinic and the visits to multiple old folks’ home for each group would have some influence on and provide a variety of exposure for the stu­dents. Therefore, the level of per­ceived competencies about elderly indi­viduals may vary due to the differences in clinical as well as community exposures. How­ever, in a qualitative analysis follow­ing a clinical rotation in long-term care facilities for the elderly, positive insights were ob­tained from the dental students. They described the rotation as an important contributor to their clinical maturation, very worthwhile and enhanced their ap­preciation of a dentist’s professional re­sponsibilities (MacEntee et al. 2005).

In the faculty, geriatric dentistry is taught within its module, and coordinated by the department of Dental Public Health. Exposures in community settings are greatly needed whereby the students can actually feel and experience the real life situation. Besides oral health, stu­dents also obtain knowledge on other areas like behavioural sciences and quality of life. A rotation programme in outreach clinics where students will have the opportunity to treat and manage the oral health conditions of elderly patients is one of the strategies that can be un­dertaken to improve geriatric teaching (Chavez & LaBarre 2004). Therefore, collaboration with other clinical depart­ments in the faculty is greatly needed. These departments can assist the stu­dents by helping them to develop the skills needed (clinical and communication skills) when managing elderly patients. Then the training of geriatric dentistry will
not only focus on the techniques but also on other generic skills.

CONCLUSION

Future interventions should focus on im­provingthe educational process, thus providing dentalstudents with positiveexperiences when dealing with el­derly patients. This will then initiate the devel­opment of positiveattitudes re­garding the elderly among dentalprofes­sionals.Early exposure to geriatric teaching for pre-clinical students may also be beneficial in the improvement of knowledge and per­ception toward the elderly as they move to the clinical years.