Our featured AEGD residency program at the UTHealth School of Dentistry is one of the programs sponsored by Health Resources and Services Administration (HRSA) aiming to prepare the next generation of age-friendly practitioners (5). The Age-Friendly Health System (AFHS) framework is an initiative of the John A. Hartford Foundation and the Institute for Healthcare Improvement, in partnership with the American Hospital Association and the Catholic Health Association of the United States (17). It consists of evidence-based practices to improve wellness of older adults, known as the “4Ms": What Matters, Medication, Mentation, Mobility. In response to the growing aging population, HRSA provided funding to educational, community-based, and primary care institutions to improve the geriatrics workforce that are vital to deliver care in an age-friendly practice (18).

The AEGD program included didactic (three 4 h seminars) and four weeks of clinical education. Three seminars consisted of reviewing the process of natural aging, stereotypes and ageism, and the changes in the function of organs. During the seminars, faculty and residents also discussed in very detail how chronic health conditions may further impact the body as individuals live longer with chronic conditions. The third topic was about medications that may raise concerns in oral health such as opioids, anticholinergic, anti-psychotic drugs, as well as drugs used for diabetes and heart disease. Additionally, through clinical case reviews, the AEGD residents learned the most common chronic conditions in older adults and their impacts on oral health. Each resident was then assigned to a four-week clinical rotation in two Community Health Clinics (CHCs), one nursing home, and one memory care facility, respectively.

The program was evaluated each year for three consecutive years. The assessment tool was the same for the first two years but was modified in the third year to better evaluate residents’ level of knowledge and skills.

The AEGD program is a one-year post-graduate residency program to advance training in general dentistry. To be eligible for this study, residents must have graduated from an accredited dental school in the U.S or were accepted into the AEGD program as international residents. The program recruited six residents in each of 2019–2020, 2020–2021, and 2021–2022 and a total of 18 residents responded to pre- and post-rotation surveys. The study has been approved by the UTHealth Institutional Review Board.

The purpose of this study is to assess and evaluate the education and clinical skills of the AEGD residents, before and after the rotation. All residents participated in a 5-question survey before any exposure to the content of the program and the same 5-question after completion of rotations. The third cohort (2021–2022) of six residents has responded to five additional questions before and after the rotation. For questions 1, 7, 8, 9, and 10, the responses range from 1 = strongly disagree to 5 = strongly agree. For questions 2, 3, 4, 5, and 6, the responses range from 1 = strongly agree to 5 = strongly disagree. In all questions, a higher grade indicates that residents’ knowledge and confidence have been improved after the rotation. Residents’ personal identifiers were removed, and only aggregated outcomes were reported in this study.

A five-point Likert scale was used to rate each resident’s response to survey questions. We linked each resident’s responses to pre- and post-rotation surveys and then conducted Wilcoxon test with Fisher Exact modifications that better addressed our small sample (N = 18). Mean score, standard deviation, and p-value were presented in Table 1 to highlight changes in scores after residents completed the rotation. Mean scores were presented in Figure 2 and Figure 3 to show overall improvements in knowledge and confidence. Statistical analysis was performed by STATA v.16 and the significant level was set at p ≤ .05. The project has been approved by Institutional Review Board (#229293) of the UTHealth Houston.

The AEGD program as a post-graduate training was intentionally designed to enable residents to provide treatments based on the 4Ms model to meet oral health needs of older adults (19). The study sought to evaluate the current knowledge of age-friendly practices of recently graduated general dentists such as how comfortable they felt about treating medically vulnerable older adults with or without dementia. After the rotation, the study further tested residents’ confidence and competence in practicing under the 4Ms framework. Each cohort of residents in the initial survey were not sure if they had sufficient training in the past or felt unsure about how useful the training was if they had it. After participating in our AEGD program with didactic education and clinical rotations, more residents felt comfortable treating older adults and integrating the 4Ms to their treatment (based on their responses to Q1, Q7 and Q10). They also learned to consider chronic conditions and cognition of older adults while treating dental issues (based on Q2, Q4, Q5, Q8, and Q9). Third, more residents admitted that they did not have adequate training to treat medically vulnerable older adults (based on Q3 and Q6). They realized the threads within curriculum and isolated lectures are not sufficient for them to treat patients with special needs as defined by the Commission on Dental Accreditation (CODA) standard 2–25: Patients whose medical, physical, psychological, or social situations make it necessary to consider a wide range of assessment and care options (7). The finding of this study has clearly demonstrated that geriatric oral health education is missing from many dental education programs.

These positive improvements in residents’ competence are critical because as discussed earlier, over 22 million older adults will need special care by 2030 due to medical vulnerability, chronically being in poor health, and decline in quality of life (20). For example, 6.5 million Americans aged 65 and older are living with Alzheimer’s disease and this number will escalate to 12.7 million by 2050 (21). In addition, every 40 s, someone has stroke in the US and to date, there are approximately 795,000 stroke individuals of which about 610,000 cases are first time or new strokes (22). Almost all medications to treat Alzheimer’s disease, cardiovascular diseases, and stroke will cause dry mouth which is the single most important factor for dental caries due to creating a low acidic PH (23). Poor oral health is also seen in older adults due to factors including physical changes by getting older, poor nutrition, hormonal changes, and polypharmacy such as anticholinergic drugs (24). Physical changes like xerostomia are caused by decreased salivary flow and difficulty in maintaining a proper healthcare regimen like brushing and flossing and all these could be exaggerated by polypharmacy (25).

Medically vulnerable elders need special protection and different treatments from general population (26). Consequently, expanding geriatric oral health training in dental education programs is timely and necessary to meet the increasing demand of geriatric populations. Although more than 90% of 56 U.S. dental schools indicated that they have compulsory classes about medical problems of older adults, other topics such as nutrition, drug-induced dental issues are less likely to be covered in the training (9, 27). Geriatric dentistry like pediatric dentistry or other disciplines in oral health requires a designated training track within dental education. Without additional didactic and clinical geriatric education, general dentists graduating from dental schools will not be capable to provide care to geriatric population. Additionally, older adults with dry mouth may be seen in the form of bad breath, increased caries, poor retention of oral prostheses, difficulty eating, discomfort, fungal infections, and ulcerations. These poise a challenge to individual’s health outcome and interpersonal relationship. Therefore, a comprehensive dental training that covers geriatric care is needed. In short, this study suggested that all general dentists be trained to conduct person-centered treatment plans adopting the 4Ms framework. Advanced Education in General Dentistry should respond to the changing needs of older adults with complex chronic conditions. Integrating aging-friendly concept into undergraduate dental programs might also be helpful to bring more awareness of this specific skill and scope of practice for future dental professionals.

There is no standardized training to guide faculty members to establish a residency program integrating geriatric care and evaluate the effectiveness of such a program (10). The project team adopted the Rapid Cycle Quality Improvement model to adjust the curricula to incorporate more information and practice experiences along the way. As a result, the sample size in the Year 3 is insufficient to be generalized to other populations. However, combination of evidence-based practice (e.g., 4Ms model) and trainee-generated data has enabled us to design more appropriate measurements even during the pandemic. More studies in program evaluation will provide a better insight into how to teach students and residents to determine the best treatment for frail and functionally dependent older adults.