A MINDFUL Approach to Compassionate Community Care
***This story appears in the UCLA School of Dentistry's Spring 2024 Magazine***
By Nancy Sokoler Steiner
When Kiana Ghasemi, D.D.S. ’24, learned she would be dispatched to Anaheim, Calif., for a rotation through the UCLA School of Dentistry’s MINDFUL Project alongside its affiliate Golden Age Dental Care, she expected to feel out of her comfort zone. A mobile dentistry service, Golden Age contracts with long-term care facilities to care for residents’ dental needs.
“That’s not a population we have much experience working with at school,” said Ghasemi, a native of Toronto who left Canada two years ago to join the School’s Professional Program for International Dentists aspiring to work in the U.S. “This is not your typical brick-and-mortar dental practice, and these are not your typical patients.
Students get the opportunity to treat a unique and very underserved demographic,” said Health Sciences Assistant Clinical Professor Kelly Vitzthum, M.P.H., D.D.S. ‘20, and Director of the Community-Based Clinical Education (CBCE) initiative under which the MINDFUL Project falls.
MINDFUL stands for Mobile care IN Dentistry For Underserved populations Living in long-term care facilities. The project aims to increase access to oral health services for older adults and populations with special needs, particularly those in long-term care facilities.
Like Ghasemi, Lauren Chapman, D.D.S. ’24, found the MINDFUL experience eye-opening. She participated in the project’s spring 2023 pilot launch.
“Some of these patients were bedbound or had arthritis, making it difficult to grip a toothbrush to perform their own cleaning. Some had cognitive disabilities,” she recalled.
More than two-thirds of adults in the U.S. aged 65 and older have experienced periodontal disease, and nearly 40% of nursing home residents have no teeth, according to studies by the Centers for Disease Control and National Institutes of Health, respectively. The high demand for care exceeds the supply of providers willing and able to deliver comprehensive care to nursing home residents.
In addition to increasing UCLA Dentistry students’ proficiency in treating these atypical cases, MINDFUL aims to inspire D.D.S. graduates to pursue community-based dentistry.
“In general, dental education doesn’t do a great job teaching the next generation of dental providers about caring for patients with special health care needs, including those with significant medical complexities and those living in institutional settings,” stated Vitzthum.
“The buck stops with dental schools. Research shows that if students have hands-on experience treating these populations, they’re more likely to do so once they’re in practice. Our goal, over time, is to make these rotations something every dental student can experience.”
MINDFUL launched last year with Golden Age Dental Care, while a second MINDFUL rotation opportunity with Pacific Dental Services Foundation’s special needs clinic in Arizona comes on board later in 2024.
“We’ve partnered with the UCLA School of Dentistry because there’s a huge need for dental students to graduate with experience serving older adults and individuals with special needs,” said Thomas Lovinger, Golden Age’s CEO. “It’s an ever-growing demographic, and there’s a massive shortfall of dentists trained to serve them. Even if they won’t be providing services in mobile settings, students with training will be equipped to serve these populations wherever they end up practicing.”
The MINDFUL Program was made possible thanks to a $1.67 million gift from the Delta Dental Community Care Foundation, the philanthropic arm of Delta Dental of California and affiliates. It’s the organization’s largest-ever single gift to a dental school.
“UCLA Dentistry’s MINDFUL Project plays an integral role in confronting and transforming the public health crisis that prevents older adults from getting the oral health care that everyone deserves,” said Kenzie Ferguson, vice president of Foundation and Corporate Social Responsibility for Delta Dental of California and affiliates. “This project is part of our organization’s commitment to the health of our nation’s older adults and delivering on our purpose to improve health by providing access to quality care.”
“Delta Dental has been incredibly generous and supportive of our vision. [It] recognizes the role schools play in changing how dentistry is practiced. The grant will also help fund the development of new resources for existing dentists and needed research,” added Dr. Vitzthum, who noted that pre- and post-rotation assessment data is being collected to see how it affects students’ perceptions of care for nursing home populations.
The MINDFUL Project operates as part of the CBCE program, which Dr. Vitzthum directs. Launched in March of 2018, CBCE requires fourth-year dental students to complete at least six weeks of rotations in external clinical settings. Affiliates include federally qualified health centers (FQHCs), private practices, and corporate dentistry practices, all serving vulnerable populations.
The program has provided more than 67,000 dental procedures to approximately 28,000 patients in underserved communities, with practice sites throughout California, and as far afield as Michigan.
“Students get comfortable and see themselves practicing in these areas. It’s somewhat of a workforce solution and a pipeline of dental graduates "to these settings,” explained Dr. Vitzthum, who notes that one FQHC site is directed by a School of Dentistry graduate who had participated in CBCE herself.
Chapman’s three-week MINDFUL rotation took her from Westwood to long-term care and nursing facilities in Orange County, where she met each morning with supervising dentist Dr. Robert Khzouz and his assistant to review the day’s cases.
“Dr. Khzouz emphasized that we would be caring for patients who might not receive regular care and that we were often their only source of dental care. He prepared me for seeing more complex cases and for building a rapport with patients who might be resistant to care.”
In a stark departure from the School’s Westwood clinic, Chapman’s rotation involved performing exams on bed-bound patients or those sitting in a wheelchair. The appointments included a clinical exam with periodontal probing as well as cleanings and scaling procedures. She performed extractions and made impressions for dentures. She also removed tori, bony growths that develop in the lower jaw and can interfere with placing dentures.
“It’s impressive to have everything you need to perform these procedures without the equipment connected to a dental chair,” says Chapman. Instead, drills, air and water syringes, and other equipment come on a rollable cart.
At the end of each day, which can include visits to multiple facilities, she debriefed with Dr. Khzouz. This also involved paper charting, which she had not done before, and writing out prescriptions.
Chapman’s patients included those with physical disabilities as well as cognitive illnesses such as dementia and Alzheimer’s disease. Some were wary and confused.
Dr. Khzouz says dentists who work with these populations need to have compassion and a sensitive bedside manner: “They need to look at the patient as a whole. Their treatment plan will be informed by much more than what they see visually, including the patient’s health history, co-morbidities, and cognition.”
"He stresses to students the importance of checking geriatric and disabled patients for pain, swallowing disorders, and other factors that might interfere with their ability to eat. He also emphasizes how poor oral health can contribute to or worsen systemic diseases.
Ghasemi noted the need to adapt to the unique setting and population.
“Many of the treatments we do at School are very comprehensive. We have all the radiographs in the world, all the different specialties,” she says. “The treatment plans in a retirement care setting are very different. We’re looking at things like whether the patient is in pain, whether they have an active infection that's bothering them. These patients have acute heart failure. They just had a stroke. They're taking 10 different blood thinners. Our treatments have to take that into consideration.”
"Dr. Khzouz observed students’ skill sets subtly grow throughout their rotations. “They gained a lightness and comfort working with these patients,” he said. “When I asked if they saw this as a potential part of their future clinical practice, most said they did.”
Even after only two sessions (which involved doing anterior composite restorations and extractions) Ghasemi said she would feel comfortable working with this population at some point in the future.
Chapman, the Class of 2024 president and a U.S. Navy veteran, concurred: “I feel grateful to have had this experience and move forward into residency, having provided bedside dentistry and having worked with patients with complex health, dental and cognitive needs. I think it has made me a better provider who can provide care for a wider population. This rotation definitely prepares students to provide special patient care and treatment for the geriatric population, but it also shows us how far dentistry can reach beyond a typical dental clinic.