Dental Hygienists’ Perceived Barriers in Providing Domiciliary Dental Care to Institutionalized Older Adults in Switzerland: A Qualitative Study

ABSTRACT

Aim

The aim of this qualitative descriptive study was to identify the perceived barriers of Swiss dental hygienists (DHs) in providing domiciliary dental care (DDC) to care‐dependent institutionalized (LTCF) older adults.

Methods and Results

This study used a qualitative thematic analysis approach that elicited rich and in‐depth information from participants. Twenty‐two DHs (mean age: 46.5 ± 11.5) working in Switzerland were interviewed following a topic guide. The interviews were recorded, transcribed, and analyzed. Six overarching major themes emerged: patient‐related barriers, infrastructure‐related barriers, difficult working conditions, LTCF‐related barriers, financial factors, and factors related to training and education. Findings revealed that DDC provision required strong self‐motivation and a service‐oriented mindset, with care providers demonstrating empathy, dedication, and a genuine desire to help rather than solely for financial gain. The DHs who provided DDC were passionate about geriatric dentistry and/or strived to excel in this field.

Conclusion

This qualitative study concludes that improving domiciliary dental care by dental hygienists in Switzerland requires targeted strategies to enhance training, ensure adequate infrastructure, reduce workload, address financial and systemic barriers, and strengthen collaboration with long‐term care facilities.

1. Introduction

Population demographics reveal that people are living longer and natural teeth are being retained to an advanced age [1, 2, 3, 4, 5]. Although this suggests that oral health outcomes for the age‐advanced group have been successful, it also implies that dental professionals are faced with challenges in caring for an age‐advanced frail cohort [6]. Older individuals are increasingly prone to chronic dental issues such as root caries, in addition to periodontal disease and tooth erosion [7]. Poor oral health in older adults can significantly impact their overall health, potentially increasing the risk of respiratory and cardiovascular diseases, along with age‐related complications [8]. The neglect of oral health often culminates in tooth loss, which can impair speech, nutrition, and ultimately degrade the oral health‐related quality of life (OHRQoL) [9, 10].

The oral health of institutionalized older adults is usually poor [11, 12, 13]. This might be because institutionalized older adults are predominantly dependent on care for their activities of daily living (ADLs), including performing their oral hygiene. Preventive oral care tends to be inadequate in long‐term care facilities (LTCFs) because of insufficient knowledge, training, and/or awareness about proper oral care practices as well as the use of the correct oral hygiene tools [14]. Another compounding factor that contributes to the poor oral health of these adults is access to dental services. This is particularly challenging for the LTCF residents due to impaired mobility, physical disabilities, cognitive decline, and other health issues.

Domiciliary dental care (DDC) is a recognized care model for delivering dental services to dependent older adults residing in LTCFs. Implementing a mobile dental clinic service for LTCF residents is a viable model for delivering essential dental care to dependent older adults with limited access to traditional oral health care services [15, 16, 17]. Further benefit is that it offers significant cost savings for residents when compared to availing the same care from traditional dental settings including university clinics or private practices [18]. The significant cost savings primarily arise from residents not having to travel physically to the university clinics or to private practices, avoiding transportation expenses or costs involved for specialized transport for individuals with mobility challenges, as well as costs associated with arranging caregivers for accompanying the residents to the practices. However, it must be borne in mind that although beneficial to the institutionalized older adults, the initial setup and ongoing operational costs for the DDC care model are substantial, which is considered a notable barrier to its success [18].

DDC, in Switzerland, is primarily offered by specialist or general dental practitioners (GDPs) who are affiliated with dental hospitals or university clinics, with minimal participation from private practitioners. The number of GDPs that provide DDC is relatively low in many countries, including Switzerland. This limitation in personnel grossly restricts the oral care provision to the institutionalized adults. The most effective solution to improve the oral health of institutionalized adults, as well as improve their access to quality oral care, would be to increase the number of oral care providers in institutions. This may be accomplished by not only increasing the number of GDPs but also increasing or motivating other allied dental care professionals like dental hygienists (DHs) and/or prophylaxis assistants who can deliver timely and routine hygiene procedures to these residents. This planning for the role enhancement of the dental allied health care professional may be more cost‐effective to the stakeholders.

In Switzerland, the training of dental hygienists with an Advanced Federal Diploma of Higher Education is regulated by the State Secretariat for Education, Research and Innovation (SERI), which grants official approval to the national framework curriculum (Plan d’étude cadre, PEC). This curriculum serves as the foundation for accredited training centers to design their individual programs. Currently, four institutions offer this education: one in Geneva (French‐speaking), one in Bern (German‐speaking), and two in Zurich (German‐speaking). The program spans three years and comprises a minimum of 5400 hours of instruction, combining theoretical and clinical education. Approximately 70% of the training (about 3860 hours) occurs within school‐based settings, balancing theoretical instruction and preclinical/clinical practice, while around 25% (approximately 1540 hours) consists of a final internship in professional environments. This structure ensures that graduates acquire both the scientific knowledge and the practical competencies essential for professional dental hygiene practice in Switzerland. The dental hygiene schools attempt to incorporate geriatric care in both the theoretical and clinical components of the dental hygiene programs offered at the main campuses in Zurich, Bern, and Geneva. In Zurich, students begin hands‐on clinical training from the 1st year, working progressively with patients of all age groups. From the 2nd year, they receive theoretical instruction on age‐related medical conditions and follow a dedicated gerodontology module combining classroom learning and practical experience. Field placements include observation in clinical settings, collaboration with the mobile dental service (domiciliary dental care) provided by the Clinic of General‐, Special Care and Geriatric Dentistry in the Center for Dental Medicine at the University of Zurich, and internships in nursing homes, providing direct exposure to the needs of elderly patients. At Bern, the curriculum integrates geriatrics throughout the 3‐year program. Theoretical instruction covers subjects such as general pathology, dermatology, nutrition, preventive dentistry, placements in nursing homes, facilities for people with disabilities, and institutions for the visually impaired, enabling students to apply their knowledge, promote oral health among caregivers, and develop teamwork within interdisciplinary health settings. At Geneva, the program emphasizes community and public health dimensions of geriatric oral care. In addition to foundational courses and emergency medicine, students participate in nursing home internships, public health projects.

Although Swiss dental hygienists receive comprehensive education in geriatric oral health care and display positive attitudes toward treating older adults, as well as a clear understanding of the importance of domiciliary dental care (DDC) for institutionalized and homebound patients [19, 20], only a small proportion are actually engaged in providing such care. This discrepancy between knowledge, attitude, and practice highlights a critical gap and underscores the need to identify the attitudes of these auxiliary care providers in providing DDC to these older adults, as well as to identify their perceived barriers that might restrict their willingness to provide this care. Therefore, the aim of this qualitative descriptive study was to identify the perceived barriers of Swiss DHs in providing domiciliary dental care to care‐dependent institutionalized older adults.

2. Materials and Methods

This study used a qualitative thematic analysis approach that elicited rich and in‐depth information from participants.

2.1. Recruitment of DHs

DHs working in a university dental school, or in private practice settings, as well as those providing care in the institutions, were invited to participate in this study. The participants were chosen based on their employment categories and included those working as a principal dental hygienist (working in their own practices), or as an associate DH (do not own the practice they work in), or as a dental hygienist employed in a university clinic, as well as those who DHs who provided part‐time DDC. They were included if they were agreeable to recollect and express their opinions over a semi‐structured interview on providing oral care to care‐dependent LTCF residents. As the study continued, participants were selected through purposive sampling methods followed by snowball sampling [21]. Sampling continued until data saturation, i.e., when no more new information or themes were obtained from the final two interviews.

2.1.1. Ethics

The summary of the study plan was sent to the competent ethics committee in Switzerland [Cantonal Ethics Commission in Zurich (KEK‐Zurich)] for authorization, and it was decided that this study did not require formal ethical approval (BASEQ‐Nr. Req‐2021‐00997).

2.2. Interviews (Qualitative)

A total of 22 semi‐structured individual interviews were conducted by a single interviewer (M‐L.G.), each lasting between 30 and 50 min. Oral consent was obtained from all participants before the start of the interview. Before conducting the interviews, all participants received an information sheet detailing the purpose of the study. All participants were informed orally by the interviewer (M‐L.G.) about the nature of the study over the telephone. The participants were assured that participation was voluntary and that they could withdraw from the study and exit the interview at any given point of time. The interviews were recorded using a smartphone voice recorder, the audio file was transferred to a laptop for easy listening to carry out a word‐for‐word transcription, and was stored anonymously.

2.3. Topic Guide

A topic guide, similar to the ones used in the previously published reports by the same research group, guided the interviews [21, 22]. The interviews primarily focused on opinions and perceived barriers in providing DDC to LTCF residents. Subjects explored included:

• Opinions and perceptions of the DDC provision for care‐dependent LTCF residents.

• Barriers to the provision of DDC to LTCF residents by DHs

• Experiences in providing DDC for care‐dependent LTCF residents

• Ways to promote, initiate, and motivate DHs to engage in DDC for LTCF residents

2.4. Data Analysis

The interviews were transcribed into written form, and the data were assimilated. The reliability of the data was verified and validated through member‐checking. By involving three participants in the verification process, it could be validated that the findings accurately reflected the perspectives and experiences of those interviewed. The data were coded using a reflexive thematic analysis using Braun and Clarke's (2006, 2007) step‐by‐step guide [23, 24]. The transcribed texts were reviewed several times by a single data coder (M‐L.G.). This ensured that repeated patterns were identified in the transcriptions. In the first phase, initial codes were generated by identifying unique features from the raw data. The next phase included the comparison of the extracted codes for similarities and/or for differences. The identified codes were then sorted into overarching themes. Themes formed the patterns of shared meanings and were the analytic outcomes of the entire coding process. The transcripts were checked by two reviewers (M‐L.G. & M.S.) before a consensus was reached for the final themes. The data were analyzed and reported, adhering to the criteria for reporting qualitative studies (COREQ) [25].

3. Results

3.1. Participants

A total of 22 DHs with a mean age of 46.5 ± 11.5 years (women: n = 22) participated in this study. Most participants (n = 9; 40.9%) worked in private practices, while four (18.2%) were working full‐time in university‐based dental clinics. Seven DHs (31.8%) worked part‐time in private practices and at LTCFs, while two DHs (9.1%) worked exclusively in LTCFs. The mean number of years of work experience after graduation from dental school was calculated as 22.14 ± 11.8 years.

3.2. Perceived Barriers: Themes

From the extrapolated data, six overarching major themes (comprising 55 codes) emerged from this study (Table 1):

1. Patient‐related barriers.

2. Infrastructure.

3. Difficult working conditions.

4. LTCF‐related barriers.

5. Financial factors.

6. Training and education.

TABLE 1.

Overview of the themes and the corresponding 55 codes used in the thematic analysis of the DDC interviews.

Code	Themes
	Theme 1: Patient‐related barriers
1	Complex patients require different approaches than disabled or dementia patients
2	Fear: DHs are afraid or reluctant to deal with elderly and disabled audiences
3	Elderly person requires a lot of energy, effort, and time.
4	Patient behaviors are difficult for DHs to cope
5	Complex medical status, including multimorbidity, dementia, and polypharmacy, requires extra care and attention.
	Theme 2: Infrastructure
6	Equipment storage: The equipment takes up a lot of space, and dental hygienists must store it at home or in other places.
7	Dedicated room for dental work (DHs) is not present in the LTCFs
8	A lack of a fixed dental unit in LTCFs
9	Sterilization equipment or the possibility is not available in LTCFs
10	The newly constructed LTCFs also do not take into account the dental services required, and also do not plan and have a room for the dental professionals.
	Theme 3: Working conditions
11	Compromised treatments: we do the best we can with the means and the patient's situation, but the treatment performed is not the best and is compromised.
12	Ergonomically not comfortable because I have to work on hairdresser's chair
13	The mobile unit is heavy for me and is difficult to transport.
14	It is difficult to work on chairs and very uncomfortable.
15	Working with a mobile dental unit is very uncomfortable and too tiring.
16	Ergonomically, it is more comfortable to work on a fixed unit than a mobile unit.
17	Even though a podiatrist's chair is available but it is difficult for the patient and for me.
18	Treating patients in LTCF is physically demanding.
19	The mobile unit is not comfortable for an elderly person because there is no support, and the head is not comfortably positioned or in place.
20	It is very hard work and is only possible on a part‐time basis, maybe once or twice a week.
21	Treating patients in the LTCFs requires a lot of logistics, which can be quite difficult and tiring.
22	The work is not professionally engaging as it is mainly just plaque removal and fluoridation with some maintenance care for the prostheses. This is not stimulating work for a young and ambitious person.
23	It is difficult to travel to and from, and when you use your own car, parking is a problem and costly.
24	It is not an attractive line of work and doesn't fulfill the dream of becoming a dental hygienist.
25	Working in LTCFs is very different from working in private practice, in terms of comfort, care delivery, type of patients, and financial aspects.
26	It involves a lot of complicated administrative work.
	Theme 4: LTCF‐related barriers
27	Lack of friendly collaboration from nursing staff and the management. They are not interested to help or make the work pleasant.
28	Access to the LTCF, including the routes and reachability, is sometimes complicated. This is more difficult if we have to use public transport.
29	Requires a lot of canvassing with the LTCF to build a working partnership. Most times this is not achieved, and it is very difficult because of a lack of interest from the LTCFs.
30	Caregivers do not like the DHs because they feel criticized and undermined.
31	LTCFs management has a lot of bias against the dental hygienists and state that it is difficult to work with DHs.
32	Dental hygienists are poorly received in the LTCFs. They would prefer a dentist rather than a hygienist.
33	It is important to have the support of the management of the institutions for starting and continuing an effective collaboration.
34	There is problem with a lack of adequate LTCF personnel. They are understaffed, and because of this they are overworked. This affects their quality of work and their willingness to collaborate.
35	There is a huge turnover of LTCF personnel who are important for the system.
	Theme 5: Financial aspects
36	Overhead costs for sterilization that must be outsourced are high and cannot be billed or charged separately.
37	Treatment costs, along with the additional costs for providing domiciliary care, are expensive for the patient.
38	Family members or guardians do not want to pay additional costs for routine care and expensive toothpastes (high‐fluoride toothpastes). They prefer only minimal necessary therapy.
39	The investment required for the setup of infrastructure and purchasing of the equipment (mobile unit + equipment, charges) is too high for a DH.
40	The complicated and excessive administrative work required for working in the LTCF cannot be billed.
41	Most of the items have the appointments cancelled, and usually at the last minute. There is no compensation for these cancelled appointments, nor is there compensation for the allotted time. So, the DH loses a lot of time and money.
42	The time taken for the treatment of these patients is not adequately reimbursed. The dental hygienist earns more in a private practice with less stress and easier work.
43	Travel costs and travel time are not compensated, and these cannot be billed as well.
44	It must be financially attractive to encourage a DH to go and work on patients in LTCFs. The ratio between the time spent, efforts made, hardships, and the income renumerated is not proportionate.
	Theme 6: Training and education
45	Professionally, you must have a lot of experience to be able to work and treat patients in the LTCFs
46	The family members and guardians must be educated to realize the importance of oral hygiene and the role the DH plays in accomplishing this in dependent older adults.
47	The gerodontology module in the initial training was not adequate and not well developed
48	There was a lack of hands‐on experience and concrete practical courses during our initial years of education and in our study curriculum.
49	The gerodontology modules present are not adequate and do not prepare us for the real patient scenarios in the LTCFs, for example, dealing with a patient with severe dementia.
50	The options and training in gerodontology I had received during my study, I have never used in practice.
51	We were always taught to collaborate with the dentist but no interdisciplinary collaboration was taught with other non‐dental personnel.
52	Special licensing (independent) is required for DHs to be able to work in LTCFs.
53	We must be able to do training in LTCFs for several months in initial training.
54	There is a lack of education and understanding by the LTCF and the personnel on the importance of prevention, oral hygiene, and the important role of a DH. This greatly affects the possible collaboration between the LTCF and the DHs.
55	Training and education: offered training in EMS from DH curriculum and study.

3.2.1. Theme 1: Patient‐related Barriers

The health status, cognitive profiles, and resistant behaviors of the care home residents were perceived as very tasking and complicated to allow hygienists to comfortably provide the DDC service.

“Due to the complexity of the medical statuses of the elderly and disabled patients residing in the nursing homes, I am a bit reluctant and afraid to deal with them.”

Participant #14 (58 years)

“Patients’ behaviors are difficult for a hygienist to handle, in particular, the patients with dementia and those with care‐resistant behaviors.”

Participant #15 (57 years)

3.2.2. Theme 2: Infrastructure

Infrastructure includes buildings, rooms, equipment, technology, and essential amenities required to deliver DDC services effectively to the LTCF residents. Barriers related specifically to the physical structures, spaces, resources, and technical facilities available within the LTCF for the provision of DDC are grouped under this theme.

The absence of proper infrastructure and equipment in the LTCF was perceived as a major limitation to providing quality care to the residents.

“A dedicated room or space, with relevant equipment, is not allocated in the LTCF to perform dental hygiene treatments. However, there are special rooms and chairs for coiffures as well as podiatrists to perform their work comfortably, but not for dentistry.”

Participant #2 (66 years)

“There is no fixed dental unit to work properly and provide the necessary care. The patients are quite complex, and a lack of the fixed unit does not help improve the situation. Even the newly constructed LTCFs do not take this aspect into account and tadd a provision in their constructions. ”

Participant #18 (34 years)

3.2.3. Theme 3: Difficult Working Conditions

This theme differs from infrastructure in that it encompasses the broader environmental, organizational, and operational aspects under which individuals perform their roles. This includes workload management, scheduling, staffing, occupational health and safety, ergonomic factors, workplace culture, administrative support, and overall job demands.

3.2.3.1. The Working Conditions Were Considered to be Suboptimal

“Considering the facts that the LTCF patients are complex and require more efficient care. The lack of appropriate equipment, workspace, as well as the working situation, etc., all allow a compromised form of care. We do the best we can under testing circumstances, but this cannot really be of high quality.”

Participant #5 (64 years)

3.2.3.2. Ergonomically, the Work is Demanding and Uncomfortable, Raising Concerns for the Health and Well‐Being of the Caregiver

“Transporting and assembling the equipment is hard. The equipment is heavy and requires extra personnel to help with the setting up and dismantling. It gets very tiring to work on patients with a mobile dental equipment. Work is not satisfactory and becomes physically very difficult.”

Participant #16 (57 years)

“Working on a regular chair is demanding for the care provider and extremely uncomfortable for the patient. A hairdresser's or a podiatrist's chair is slightly better but still not ideal.”

Participant #10 (44 years)

3.2.3.3. The Organizational Logistics Were Cumbersome and Time Consuming Along With a Considerable Number of Administrative Tasks as Well as Paperwork

“A lot of administrative work was required before the patient treatment even began. This took a lot of time and was not billable. Also, the scheduling and organizing the visits to the LTCFs were cumbersome and frequent cancellations were common.”

Participant #6 (55 years)

3.2.3.4. The Work Performed on the Patients of the LTCFs, Was Not Professionally Engaging/Stimulating or Considered Attractive

“The elders in the LTCFs require mostly simple hygiene procedures, fluoridation, or denture hygiene. This definitely is not stimulating or attractive when you are motivated to learn new things and perform slightly more complicated procedures.”

Participant #21 (41 years)

3.2.4. Theme 4: LTCF‐Related Barriers

The lack of cooperation and motivation of the LTCF personnel, along with the restrictions in accessing the residents, were major reasons for impeding the provision of the DDC by hygienists.

“We observe that the nursing staff and other members of the carestaff are not really cooperative when we come in to do our work. There is real no cooperation or an interest for them to help with our work.”

Participant #3 (40 years)

“Hygienists are not welcome with open arms in institutions. It is important to receive support from the management of the LTCFs, and they should motivate the staff to collaborate with us. The care staff and the nursing professionals do not understand or appreciate the importance of oral hygiene in elders, because they have not received proper training, are understaffed, and overworked. They are not cooperative in trying to learn how to improve the oral care they provide to the residents, and are not very meticulous while performing oral care. When comments to improve are provided, they perceive it as criticism and do not appreciate it.”

Participant #4 (64 years)

3.2.5. Theme 5: Financial Factors

The costs for investing in the necessary infrastructure and equipment to provide the DDC, as well as the remuneration for providing the service, were perceived as not economically viable or sustainable.

“The costs to buy a mobile dental unit, and other instruments are too high and is not easy to compensate. The time spent for travel, setting up, administration work involved, are not billed, and cancelled appointments cannot be billed. In comparison to renumerations from regular private practice for less work and effort, this service is unfortunately not profitable.”

Participant #12 (48 years)

“The work involved is hard and requires a lot of effort, time, energy, and the remuneration received is not interesting or profitable for the dental hygienist.”

Participant #8 (41 years)

3.2.6. Theme 6: Training and Education

The factors limiting hygienists in providing adequate domiciliary dental care (DDC) are insufficient hands‐on training during their studies and a lack of awareness or education about the importance of oral care among family members and caregivers.

“The gerodontology training in our curriculum when we were in dental hygiene schools was not really good or well‐developed. Moreover, what we were taught could never be applied in real clinical scenarios. We had no practical hands‐on training with these patients during our education, and that really is what is necessary to prepare us for this type of care provision.”

Participant #22 (40 years)

“We have always been trained in the know‐how to communicate and collaborate with dentists and other members of the dental faculties, but we were not trained on how to effectively collaborate with non‐dental experts, caregivers, nursing staff, and the LTCF personnel. This is an important aspect that would help improve the collaboration between the stakeholders and improve the situation.”

Participant #20 (26 years)

3.3. Positive Attributes and Facilitators for Future Development

The interviews unmasked several provider‐related positive attributes and facilitators for the development and promotion of the DDC in LTCFs.

3.3.1. Positive Attributes of Care Provider Towards DDC

The participants distinctly agreed on the following:

1. This work requires a service‐oriented mindset and self‐motivation. The individuals providing care for residents in LTCFs are empathetic and passionate, driven by a genuine desire to help rather than solely by financial gain.

2. Having a background in social services or a strong inclination towards social service activities appears to be a significant factor in undertaking this type of care provision.

3. Those who provide this care often have personal life experiences that have profoundly transformed their mindsets, leading them to offer this care out of genuine passion.

4. Individuals who have a passion for geriatric dentistry or strive to excel in this field take on this task.

3.3.2. Facilitators to Improve DDC

The facilitators that were identified and suggested which could improve or promote DDC are listed below:

1. A key factor stated was to ease the DHs’ access to the LTCFs and promote collaboration amongst the care‐staff and the management of the LTCFs. This would facilitate perennial, continued oral care for the residents and reduce complications and emergencies. Representatives from the LTCFs could be specifically trained to liaise with this collaboration.

2. Educating the LTCF staff and caregivers on the importance of regular oral hygiene care in the frail older adults through courses. These courses should be conducted free of charge and at regular intervals. Refresher courses should also be provided periodically to the staff and caregivers.

3. Offer internships to graduating DHs or practicing hygienists in LTCFs to provide care for the residents. The LTCFs can also promote and invite DH candidates for a posting at their centres. This would provide a mutually beneficial solution and a great service benefit to the LTCF residents needing oral care. A partnership with a willing dentist or teaching institutions could further help to promote this.

4. Development of new techniques and approaches to providing this oral care in the most ergonomically safe conditions must be promoted. This will ensure that the DHs are willing to take up the DDC to work comfortably and efficiently.

5. Finally, access to the mobile dental equipment must be made easy and affordable. Equipment rentals would be a great solution for those DHs who want to do this work but are limited in finances to afford their own equipment.

4. Discussion

This study is the first of its kind to examine the factors influencing the attitudes of Swiss DHs towards providing DDC using a qualitative approach. The perceived barriers to providing DDC were identified and categorized into six distinct themes: patient‐related barriers, infrastructure, difficult working conditions, LTCF‐related barriers, financial factors, and training and education.

4.1. Patient‐Related Barriers

Challenges stemming from patients' health conditions, cooperation levels, and personal preferences were considered as a major setback from the DH's point of view to willingly undertake this provision of care. All participants highlighted the challenges of treating domiciliary patients, emphasizing that the difficulty lies more in the complex environment rather than the complexity of the treatments themselves. Previous studies have not clearly distinguished this aspect [26, 27, 28]. These aspects are further complicated by the limitations due to the availability and quality of facilities and equipment necessary for effective oral care.

4.2. Infrastructure and Financial Barriers

A common limitation reported by DHs was the lack of access to necessary equipment, often due to financial constraints, which hindered their ability to provide domiciliary dental care. Moreover, the remuneration received was not considered proportionate to the workload and stress involved. Even though the payment for the treatment performed aligned with the tariffs by the Swiss Dental Hygienists Association (SDH), the additional costs involved could not be billed and adequately compensated for the time and effort required for each visit. Treating a domiciliary patient in the home often requires more time than managing a similar patient in a dental clinic. In addition, the remuneration for the care is comparably lower [21, 22]. In order to maintain financial viability, DHs would need to treat a high volume of residents. Consequently, the DHs are effectively contributing their own personal time and resources to support the provision of oral healthcare for older adults. This financial imbalance clarifies why participants believe that university‐setting‐based DHs who receive a fixed salary may be more suitable for providing DDC, as their activity levels are not driven by financial incentives. However, this assumption may not be entirely accurate, as maintaining such a service involves associated costs [18]. Therefore, it is in the best interest of all the stakeholders that the policy makers proactively engage in this dilemma and try to find a solution or define a policy where it is mutually beneficial to all stakeholders. This situation highlights the need for systemic changes to ensure that both DHs and dentists can sustainably provide essential oral care to elderly patients without financial detriment.

4.3. LTCF‐Related Barriers

The LTCFs were not sufficiently motivated to invest in appropriate or adequate infrastructure for the provision of dental care, although they were always equipped for a hairdresser or a podiatrist. Several DHs emphasized the need for improved infrastructure within LTCFs to facilitate effective DDC, a need that has also been recognized in other countries. The workplace and professional environment profoundly impact the perceived quality of care provided by the DHs. Establishing dedicated dental units within LTCFs could enhance oral care for older adults and potentially encourage more dental hygienists and dentists to offer these essential services. Lack of proper equipment, facilities, and support from the LTCF personnel made the already complicated work conditions further stressful, affecting the ability of DHs in providing efficient care. Gaps in education and training programs leave DHs inadequately prepared to deliver specialized oral care to these adults. More importantly, these gaps need to be filled regarding the caregivers, guardians, and the LTCF personnel to really make an impactful change. The DHs indicated that a collaborative approach to prevention, particularly involving long‐term LTCF staff, could significantly improve the oral health of dependent older adults and potentially decrease the demand for DDC related to acute oral health issues [21, 29]. The responsibility for a patient's oral health should not rest solely on the dental professional, and the LTCFs also need to be held accountable for the oral care of their residents [30]. Enhancing DDC would be much more feasible if nursing homes collaborated more effectively with dental professionals especially the DHs. This could involve providing a dedicated treatment area, maintaining up‐to‐date medical histories, and establishing a reliable point of contact for dental‐specific concerns, such as notifying a new resident's dentist/DH of their change of address. Moreover, further research into the resources required by LTCFs to effectively promote oral health would be beneficial. This approach would not only facilitate the work of dentists/DHs but also ensure a more seamless and comprehensive care experience for the patients.

4.4. Training and Education Related Barriers

The ambiguity and insufficient training regarding DDC have left dental professionals, mainly DHs, questioning their role or future regarding their responsibilities in this field. At a clinical level, it is uncertain as to who is ultimately responsible for the neglect of the oral health in older adults who cannot access conventional dental practices. Almost all the stakeholders (dental professionals, LTCFs, DHs) report that the difficult treatment environment and lack of sufficient hands‐on training are major barriers. It is questionable whether dental professionals should be held accountable for the oral health of patients who are too frail to open their mouths properly or whose medical conditions make effective treatment challenging. This situation suggests a need to rethink the oral care system. One possible reform is to adjust the compensation structure to ensure dentists/DHs are fairly reimbursed for the time and effort required for DDC. Additionally, expanding the role of university‐setting‐based professionals in DDC provision could help distribute the workload more evenly and ensure that vulnerable patients receive adequate care [31, 32]. However, the majority of the DDC care providers are university‐based in Switzerland. Therefore, this needs to be expanded more into the community practitioners. Moreover, LTCFs should take on greater responsibility for their residents' oral health. This could include regular staff training, establishing consistent oral hygiene routines, and integrating oral care into the overall health care plan. By addressing these issues, the oral care system can better support older adults, ensuring they receive necessary care while also alleviating the burden on dental professionals. The training gaps often stem from the limited integration of domiciliary care scenarios into dental and dental hygiene curricula, leading to a lack of preparedness in managing complex geriatric cases in non‐traditional settings. The absence of structured clinical rotations in LTCFs further contributes to a theoretical rather than practical understanding of the challenges involved. To address this, educational reforms could include dedicated modules on geriatric and domiciliary dentistry, interprofessional training with nursing and caregiving staff, and mandatory placements in LTCFs or home care environments. Such curricular enhancements would foster practical competence, interdisciplinary collaboration, and a stronger sense of professional responsibility in delivering care to the frail, institutionalised, care‐dependent older adults.

4.5. Limitations of the Study

The primary data collector and interpreter for this study was a practicing DH with over a decade of experience in the domain, who has worked in private practice, university‐based practices and has significant experience in DDC in Switzerland. While her personal background may have introduced some bias, it also served as a considerable strength. Her deep understanding of practical dentistry allowed her to quickly establish rapport with the interviewees, facilitating more detailed and insightful responses. To minimize response bias, several measures were taken. Participants were assured of their anonymity, reminded that there were no right or wrong answers, and encountered no judgment during the interviews. These steps helped create a comfortable environment, encouraging honest and open communication. Additionally, the reliability of the data was enhanced through member‐checking. By involving three participants in the verification process, the researcher ensured that the findings accurately reflected the perspectives and experiences of those interviewed. A purposeful sampling method was employed for the selection of the three participants who exhibited diverse and representative perspectives during initial data collection were selected for member checking to review and validate the findings. The participants’ involvement was voluntary, and they were included after informed consent. The participants could withdraw at any stage, and total confidentiality was assured. This process bolstered the credibility and dependability of the collected data, providing a robust foundation for the study's conclusions. The methodology followed was like the previous published qualitative studies following the accepted methodology [21, 22]. Nevertheless, it should be acknowledged that the number of participants in this study was limited, which may reduce the strength of the conclusions in a field that demands broader and more representative investigations. However, as in comparable studies, recruitment was discontinued once data saturation was reached and no new information emerged. Thus, in this context, the relatively small sample size may still be considered adequate.

While the reliance on a single researcher to conduct the entire coding process may be viewed as a limitation, it also ensured consistency and methodological rigor throughout the analysis. The researcher who performed the coding was highly experienced in qualitative methods and considered reliable, thereby strengthening the credibility of the findings. A single‐coder approach minimized discrepancies that can arise from differing interpretations among multiple coders, while reflexivity, iterative code checking, triangulation with existing literature, and peer debriefing were employed to reduce bias and enhance transparency. This limitation has nonetheless been acknowledged, and future studies will adopt a more robust methodology by incorporating multiple coders to further enhance analytical depth and mitigate potential subjectivity.

Numerous reports and studies have underscored the growing public health issue of managing oral health in dependent older adults [33]. Due to the current lack of adequate care for this population, it is crucial to develop strategies to prevent and manage dental caries. Oral health interventions should be readily available and administered promptly, rather than waiting until emergency situations arise, potentially requiring general anesthesia. An analysis of DHs' attitudes towards providing DDC revealed a strong consensus on its critical importance for dependent older adults. The participants underscored the significance of oral health in their elderly patients, highlighting that it is the result of years of diligent preventive care. They emphasized that good oral health is not only fundamental for effective chewing and proper nutrition but also plays a vital role in facilitating social interactions and maintaining overall health. The DHs clearly believed that ensuring good oral health is a cornerstone for enhancing the quality of life and well‐being of older adults, reinforcing the necessity for continuous and comprehensive oral care in this population. Maintaining good oral health can act as a protective factor against loneliness among older adults, and promoting DDC can significantly enhance community health for homebound individuals [34, 35]. However, transitioning to a DDC‐focused model requires strong motivation from DHs, as many have identified inadequate remuneration as a significant barrier.

5. Conclusions

This qualitative study concludes that improving domiciliary dental care by dental hygienists in Switzerland requires targeted strategies to enhance training, ensure adequate infrastructure, reduce workload, address financial and systemic barriers, and strengthen collaboration with long‐term care facilities.

Funding

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Grandjean M.‐L., Jeannot E., Stillhart A., Angst L., and Srinivasan M., “Dental Hygienists’ Perceived Barriers in Providing Domiciliary Dental Care to Institutionalized Older Adults in Switzerland: A Qualitative Study.” Special Care in Dentistry 45, no. 6 (2025): e70118. 10.1111/scd.70118