Dental team barriers and enablers for the dental management of adults with severe obesity: a qualitative analysis

doi:10.21203/rs.3.rs-4969593/v1

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Dental team barriers and enablers for the dental management of adults with severe obesity: a qualitative analysis

https://doi.org/10.21203/rs.3.rs-4969593/v1

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published 02 Nov, 2024

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Background Broad challenges regarding the dental management of people with severe obesity experienced by general dentists have been minimally explored. The perspectives of the dental team regarding these multifaceted issues are currently unknown and they potentially impede the delivery of optimal dental care to this population and contribute to poor oral and general health.

Aims Our qualitative study aimed to identify and explore barriers and enablers in the dental management of adults with severe obesity among dental professionals and support staff in Australia.

Methods Focus groups and semi-structured interviews (n=34 participants) were conducted with dental professionals (n=23) and support staff (n=11). Recordings were transcribed verbatim and synthesised using thematic, inductive analysis.

Results Multiple barriers to adequate provision of dental care for people living with severe obesity in both general and specialist dental settings were identified. Key themes emerged related to the clinical challenges reported by participants in providing dental management for people living with severe obesity, appropriateness of existing bariatric dental service provision and safety of care. Enablers to access were identified, including increased availability of bariatric dental chairs, environmental modifications, education of both patients and the entire dental team and for guideline development.

Conclusion The current study explored multiple barriers to optimal dental management of people living with severe obesity in both general and specialist dental settings. Enablers should be used to inform future practice. The optimisation of existing bariatric dental service provision requires urgent review with solutions guided by systemic change. Study findings suggest a review of current health systems, economics, access barriers, policies and procedures and education and training beyond the individual level are needed. Future directions to improve the dental management of people living with severe obesity are proposed.

Health sciences/Health care/Dentistry

Health sciences/Health care/Dentistry/Special care dentistry

Global obesity prevalence is rising rapidly, and is a major public health concern due to the increasing demand on the healthcare system.¹ Clinical obesity is a chronic relapsing progressive disease process, with this paper focussing on people living with severe obesity (those with a body mass index (BMI) of ≥ 40, or ≥ 35 with associated obesity-related health conditions).^{2, 3} Given the health impacts of obesity, and in particular severe obesity, it is imperative that people living at the severe end of the spectrum have appropriate access to all health service types, including dental services. This is important as obesity-related comorbidities often complicate dental management with some studies reporting poor oral health in people living with obesity compared with the wider population without obesity.^{4, 5} A study of 81 adults living with clinically severe obesity from a public hospital-based obesity service in New South Wales, Australia, found dental service utilization was poor, with more than half of the cohort (61.7%) reporting unfavourable visiting patterns;⁶ including dental attendance only for a problem, rather than for preventative care. Qualitative research exploring the perspectives of people living with clinically severe obesity has revealed several barriers to accessing dental services. These include feeling disempowerment to act to improve their oral health, experiencing weight related stigma and discrimination, unpredictability of the dental environment and a lack of tailored services.⁷

In Australia, people living with obesity receive oral healthcare services in public and private general dental settings. However, people living with severe obesity, specifically those with very high body weights management necessitating the use of bariatric dental chairs, are frequently referred to public dental specialists in Special Needs Dentistry (SND) for comprehensive dental.^{8, 9} Bariatric chairs are indicated for use when the safe dental chair working limits are exceeded, and are predominantly located within tertiary dental hospitals within SND departments.⁸ The experiences and challenges of general dentists managing people living with severe obesity has been minimally explored. Qualitative research in the United Kingdom (UK) involving a group of twelve general dentists reported barriers such as caution with weight discussions and challenges in identifying weight and organising appropriate care.¹⁰ A comprehensive literature review has failed to identify any existing literature exploring perspectives of the entire dental team, including both clinicians and support staff, in relation to the dental management of people living with severe obesity in Australia. Insights from dental specialists in SND are also currently unknown. These insights are key given their prominent role in current referral pathways.

This qualitative study aimed to identify and explore the barriers and enablers for dental management of adults living with severe obesity from the perspective of the dental team, including both dental professionals and support staff.

This study received ethics approval from the Central Coast Local Health District (CCLHD) Human Research Office (number 1122-101C). Numerous participants were invited to take part including dental professionals (registered general dentists, oral health therapists) and support staff (dental assistants, dental receptionists) working in private and public regional practices in New South Wales, and dental specialists in SND who were registered to work across Australia. Recruitment was via email to all public based employees within CCLHD Oral Health Services and to registered dental professionals via the local mailing list from the Australian Dental Association. Recruitment for SND specialist participants was via email to the Australian and New Zealand Society of Special Needs Dentistry membership to include the 26 registered Australian specialist members at time of recruitment. The recruitment email included a focus group invitation letter and participant information sheet explaining the background to the research and research team.

Consenting participants were asked to sign a focus group confidentiality agreement form, to ensure privacy of discussions was maintained and encourage participation. A semi-structured interview schedule (Supplementary Figure S1) was developed by a multidisciplinary project team including dental specialists in the field of SND and Oral Surgery, an academic nutritionist and an endocrinologist obesity specialist). The focus group interview schedule was piloted with clinicians (n = 2) and deemed appropriate for use with both clinicians and support staff. Focus groups were either carried out via an online platform (Microsoft Teams™) or in person in a neutral non-clinical location.

Focus groups were scheduled with consenting participants, who were randomly allocated into groups with people of the same professional role. Data were collected between March and May 2023. Focus groups were conducted by ZM, who is a female dental specialist in SND and was working part time (2 days/week) in CCLHD at time of data collection. ZM has experience in qualitative data collection and the discussion topic and has clinical experience in the dental management of people living with severe obesity. A female research assistant (KK), with a research background in nutrition and qualified as an overseas trained dental professional, was present during each of the focus groups. KK moderated the focus groups to ensure they were transparently conducted, and assisted in reducing any bias with participants who were working or knew ZM prior to participation. Most interviewed participants were working at different sites to ZM within the public oral health service and unaware of the research prior to participation. All interviewed SND specialist participants were working at different sites to ZM, including interstate in Victoria, Queensland and South Australia. Non-SND specialist participants were unaware of the role of SND in managing people living with severe obesity prior to the research commencement. Field notes were made during and after each focus group by both ZM and KK. Data collection ceased once data saturation was reached, meaning when sufficient information had been obtained to replicate the study and no new further information was being collected. ¹¹

Focus groups and the two semi-structured interview recordings were transcribed verbatim using transcription software Trint™ 2022, Trint Limited, United Kingdom (UK). Participants were offered the opportunity to review the transcripts but no requests were made for review by participants. A thematic (inductive) analysis approach was undertaken to interpret the data and sort into themes and subthemes.¹² Following independent coding of two transcripts (10% of the data) by two researchers (ZM, KK), an initial coding framework was developed, with consensus checking conducted with researcher KM. Coding was performed using Quirkos 2.5.3 qualitative analysis software.¹³

Thirty-four participants were recruited across clinician and support staff groups (Table 1). Five focus groups of between 2–3 participants each were conducted with support staff, including dental assistants (n = 9) and reception staff (n = 2). Seven focus groups of between 2–3 participants were carried out with clinicians, including general dentists (n = 8), oral health therapists (n = 5) and SND specialists (n = 8).

Three key themes relating to clinical challenges reported by participants in providing dental management for people living with severe obesity, the inappropriateness of current bariatric dental service delivery and issues around safety of dental care, were identified. Example excerpts relating to each theme and subthemes are presented in Tables 2–4.

Clinical challenges related to the provision of dental care for people living with obesity

Clinical barriers in the provision of dental treatment for people living with severe obesity reported by clinicians and support staff, including work health and safety (WHS) issues, ability to optimally perform procedures, length of treatments and provision of appropriate care. Ergonomic concerns were reported (excerpt 2.1) regardless of whether a conventional dental chair or bariatric dental chair was used. This impacted on WHS, with participants in this study reporting pain after undertaking procedures on people living with severe obesity due to poor positioning. Dental assistant participants shared their own unique barriers, including challenges around retraction of soft tissues and suctioning, which influenced their confidence in assisting in procedures involving patients living with severe obesity (excerpt 2.2). They also shared their embarrassment of invading patients’ physical spaces to carry out these tasks (excerpt 2.3).

For clinician participants, elongated treatment times occurred due to the additional challenges with frequent breaks required. The experience of the dental chair not working or “getting stuck” was shared by many participants (excerpt 2.5). Logistic difficulty in scheduling appointments was also reported by several support staff participants, particularly dental receptionists. This was due to additional time required to cater for specific needs such as organisational delays with ambulance or community transport, awaiting specific equipment, or bariatric dental chair availabilities (excerpt 2.6). Other barriers to the provision of optimal care were patient factors, including patients presenting with anxiety and/or attending for predominantly emergency visits, with high burden of dental disease (excerpt 2.7), and challenges with assessing patient weight to determine safe dental chair selection (excerpts 2.10,2.11).

Barriers were also identified when delivering dental care to people living with severe obesity in alternate dental settings, such as residential aged care facilities (RACFs) or theatre environments. SND specialists highlighted the challenges of logistical planning for dental management under general anaesthesia due to higher anaesthetic risks for patients living with severe obesity (excerpt 2.8). In domiciliary service provision, for example in RACFs, rapport building was hindered by the limited interaction possible with patients and additional time was required to transport portable dental equipment when people living with severe obesity were unable to mobilise (excerpt 2.9).

Inappropriateness of current bariatric dental service delivery

Another key theme was the inappropriateness of current bariatric dental service delivery in Australia, which was reflected in existing referral processes and existing pathways to treatment and facilities including the provision rationale. A major subtheme for SND specialist participants were referrals, specifically inappropriate referrals. This included ‘automatic’ referral of people living with obesity who exceeded the conventional dental chair weights to SND specialists to access use of bariatric dental chairs. As a result, the dental care of people living with severe obesity can be delayed due to lengthy specialist waiting lists when the treatment needs were within the scope of a general dental service. This was highlighted in the example of the edentulous patient requiring denture construction, who was referred on the basis of their weight (excerpt 3.1). However, the dental treatment needs were not requiring SND specialist management and could have been carried out by any general dentist or dental prosthetist if the patient had access to a bariatric dental chair.

The ethical or moral dilemma of the specialist referral in itself was perceived as being stigmatising, in circumstances when appropriate care for people living with severe obesity could be provided in private or public general dental clinics if they were better resourced (excerpts 3.1, 3.2). A generalised lack of bariatric facilities in private dental settings was reported, leading to lack of exposure to this type of patient for private based clinicians (excerpt 3.3). SND specialists contributed further insights into inadequate facilities, even within specialist SND departments, including examples such as lacking suitable toilets for people living with severe obesity (excerpts 3.4,3.5, 3.6).

Referrals were deemed to be more appropriate and initiated in settings where equipment facilities were lacking, such as in the absence of a bariatric dental chair, in both private and public general dental settings (excerpt 3.7). Where bariatric dental chairs were available in a public setting, dental management was able to be carried out by general dentists and referral for specialist management in SND departments was often not considered by general dentists or oral health therapists (excerpts 3.8, 3.9). However, if the patient wasn’t eligible for public dental services and required a bariatric dental chair for management, referral pathways to SND were then unknown (excerpt 3.10).

Safety of dental care

Safety of dental service delivery was a key theme and challenge discussed by participants. This centred around medical risks and impacts on dental treatment planning, including aspects such as the physical environment and weight assessment. Predominantly SND specialist participants acknowledged the medical risk around procedures (excerpt 4.1) whereas in contrast, most of the other clinicians and support staff did not appreciate these risks (excerpt 4.2). Several felt they would be equipped for medical emergencies, though others admitted they did not know how emergency management would differ for the patient living with severe obesity. This suggested a lack of experience or knowledge of the complexities that people living with severe obesity may bring to the dental setting.

SND specialist participants were able to provide insights into treatment planning considerations under differing treatment modalities, such as intravenous sedation or general anaesthesia in greater detail and raise considerations of safety and risk (excerpts 4.3,4.4). Other clinician participants raised the dilemma for alternative treatment options, when patients were deemed not suitable for general anaesthesia if this was their initially planned treatment modality. The need for patients to have improved stability in their medical comorbidities ahead of planned surgical dental interventions for improved patient outcomes and safety was also reported by SND specialist participants (excerpt 4.5).

Safety of dental care provision for people living with obesity was also related to the surrounding physical environments needed to meet their needs, such as having adequate facilities in the dental clinic (excerpt 5.6). Some participants relayed the differing environments available in public versus private settings and how weight assessments could impact on safety of dental care (excerpts 4.7, 4.8).

Enablers to access

Participants provided numerous suggestions for enablers to access for people living with severe obesity. This included facility-based recommendations, such as increased availability of bariatric dental chairs and other environmental modifications to ensure appropriateness of available facilities across both public and private settings (excerpts 5.1–5.6). Participants also emphasised the need for regular training in conjunction with bariatric chair usage to prevent injury to themselves, as well as regular breaks during appointments (excerpt 5.7).

Enablers to access suggested by SND specialists predominantly centred around education of their local teams, the wider profession and medical colleagues regarding the category of bariatric patients that ideally should be referred for specialist management, with characteristics not based on weight assessment alone (excerpts 5.8). Improving the appropriateness of referrals was perceived as being a primary measure to improve access. There was a desire to have guidelines and training for both clinicians and support staff in obesity dental management (excerpts 5.9, 5.10). Guidelines were recommended to cover the broad medical, physical and psychosocial aspects relevant to dental care. There was some confusion among participants around the weight limits of bariatric dental chairs, or of the general dental chairs within facilities, with most participants reporting that they were unsure of these. This reflects the need for further education and training before weight discussions can be initiated with patients.

This study found multiple barriers and enablers to providing dental management for people living with severe obesity, from the perspective of clinicians and support staff in the Australian context. Barriers in this study related to communication, access, resources, work health and safety and policies and procedures. There was consensus on the challenges and barriers from participants for the provision of dental care for people living with severe obesity, particularly when they presented with larger bodies, requiring management in a bariatric dental chair. The barriers in the Australian context were similar to those reported by UK based dentists with regards to difficulty broaching the topic of weight, equipment and safety and problematic referral pathways.¹⁰ However this study provided detailed insight into barriers to dental management for people living with severe obesity in differing settings, such as theatres or RACFs from SND specialist participants. Clinician and support staff participants raised concerns relating to WHS and patient safety, through their experiences of difficulty performing their work, airway and medical emergency risks which were previously unknown. Whilst the literature has reported barriers relating to WHS, this has been based on expert opinion.^{8, 9, 14, 15} This study uniquely provided insights into specific aspects of clinical management that are of concern relating to WHS and patient safety from a clinical perspective, allowing for practical strategies for the dental team to now be developed to overcome these barriers. These may include increased appointment times, strategic breaks, workplace stretching, equipment and training to ensure optimum ergonomics when managing patients living with severe obesity.

SND specialist participants expressed concern regarding existing referral pathways worsening current access barriers due to specialist waiting times. This is exacerbated by limited placement of bariatric dental chairs in public specialist SND departments in several states. This may be an Australian specific issue, but is likely to be of global relevance given the increasing worldwide obesity rates. Urgent attention is required given the moral and ethical questions it raises as it discriminates against patients due to their weight, particularly in settings where inappropriate referrals are being made based on weight alone. Additionally, specialist SND participants clearly identified that specialist dental facilities are also not well equipped and barriers to adequate care of patients with obesity still persist. The poor awareness, use and availability of existing referral pathways for specialist SND services across Australia remains problematic. Furthermore, inappropriate referrals, and confusion around the role of SND in bariatric dentistry make professional advocacy challenging despite the additional knowledge and training of SND specialists, making them well placed to provide the education that is currently lacking.

Increased education and the development of clinical practice guidelines has been recommended in the literature as an enabler to access for the medical management of obesity.¹⁶ This was also a key finding of this study, which further emphasised the need of practicing clinicians and support staff for clinical dental practice guidelines in Australia, which has previously not been identified.

Our participants acknowledged that improved access to bariatric dental facilities is required, beyond just increased availability of bariatric dental chairs in both public and private general dental settings. Purpose built specialised bariatric dental facilities are urgently needed, underpinned by a focus on enablers to access and demand for services. Overall, the results of our study suggest systemic and physical environment changes need not be limited to SND specialist dental settings and that more needs to be done to improve access to dental care for people living with severe obesity. As such, to address the barriers reported by participants, interventions will required beyond only education, as has been the focus in the literature relating to obesity in the dental setting.¹⁷ There is a need to adopt an integrated, whole of system approach to overcome widespread access barriers, resourcing and to restructure existing referral pathways, policies and guidelines relating to occupational health and safety, education and training.

Future directions and recommendations

Incentives for private based dental practitioners or for new practices to make the physical infrastructure modifications to the clinical setting should be considered. Positive impacts of adequate services catering to people living with obesity have been observed in the medical sphere, where specialist multidisciplinary obesity medical services have had a significant impact on reducing acute hospital presentations for people living with severe obesity.¹⁸ Despite these significant benefits, these services are both limited in number as well as under-resourced, indicating that the general healthcare setting in Australia is under- equipped to manage obesity.¹⁹ Given the predictions for increasing prevalence of severe obesity in Australia, likely costs to the health system and disability adjusted life years,^20–23 adequate dental access and care for people living with obesity is imperative to prevent the reduction in quality of life associated with oral health problems.²⁴

Suggested future service revision could also include integration of dental services within existing multidisciplinary obesity services. Models of care for bariatric dental patients through government funded subsidies similar to the now defunct Medicare Chronic Disease Dental Scheme²⁵ may be another strategy for consideration. The narrative around obesity requires change to improve access to healthcare services, and is not unique to dentistry.

Strengths and limitations

Limitations of this study include the predominantly female sample of non-specialist SND participants recruited from a single regional geographical region. The sample may therefore not have been representative of all dental clinicians and support staff. There may also have been sampling bias as participants with lived experience of obesity, or experience of managing patients living with obesity, may have been more willing to participate in the study. The data is also limited by the inherently subjective nature of the qualitative interview data which may have contributed to an under reporting of weight stigma experiences by participants.

However, the current study had some important strengths. The piloting of the interview schedule and semi-structuring of focus groups used in this study ensured sensitivity in relation to this topic and that questions would be interpreted correctly. The focus group methodology employed was advantageous to elicit broad exploration of the topic of barriers and enablers to dental management for those living with severe obesity.²⁶ The number of focus groups carried out was sufficiently high to have ensured key perspectives from both clinician and support staff groups. Another strength of this qualitative study was the inclusion of perspectives of various dental team members. The study also uniquely considered the perspectives of SND specialists nationally, given their prominent role in existing referral pathways across Australia and they were able to provide their unique insights from differing contexts in their respective states. To the authors’ knowledge, this is the first investigation of the perspectives of Australian clinicians and support staff in managing people living with severe obesity. Given the differing context and limited access to SND services within Australia compared with community clinic access in the UK, the unique specialist considerations provide previously unreported data.

The current study explored numerous barriers for the dental management of people living with severe obesity in both general and SND specialist dental settings. Enablers should be used to inform future practice. The optimisation of existing bariatric dental service provision requires urgent review with solutions guided by systemic change. The findings of this study suggest review of current health systems, economics, access barriers, policies and procedures and education and training beyond the individual level. Future strategies to improve the dental management of people living with severe obesity are proposed.

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Tables 1-5 are available in the Supplementary Files section.

There is a conflict of interest ZM, KAM, DC and CEC have no conflicts of interest to declare in the publication of this paper. KW reports grants, personal fees and non-financial support from Novo Nordisk, grants and other from Boehringer Ingelheim, outside the submitted work; and is the Clinical Lead and Manager of the Nepean Blue Mountains Family Metabolic Health Service, a tertiary lifespan obesity service in Greater Western Sydney, New South Wales, Australia.

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Tables 1-5
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You are reading this latest preprint version

Dental team barriers and enablers for the dental management of adults with severe obesity: a qualitative analysis

Status:

Journal Publication

Version 1

Abstract

Introduction

Materials and Methods

Results

Clinical challenges related to the provision of dental care for people living with obesity

Inappropriateness of current bariatric dental service delivery

Safety of dental care

Enablers to access

Discussion

Future directions and recommendations

Strengths and limitations

Conclusion

References

Tables

Additional Declarations

Supplementary Files

Status:

Journal Publication

Version 1