Knowledge, attitude, and practice of dentists in India regarding geriatric oral healthcare and polypharmacy management: a cross-sectional study

Abstract

Background

The global population is ageing rapidly, presenting significant challenges to oral healthcare systems. Geriatric patients frequently present with complex oral conditions compounded by polypharmacy and systemic comorbidities. Despite widespread treatment of elderly patients, whether dentists possess adequate knowledge and systematic application of evidence-based practices remains unclear. This study assessed the knowledge, attitudes, and practices (KAP) of Indian dentists concerning geriatric oral healthcare and polypharmacy management, using the KAP theoretical model as a conceptual framework.

Methods

A cross-sectional survey was conducted among practicing dentists across India between May and July 2025. A convenience sample of 1511 registered dentists actively engaged in clinical practice completed a validated, self-administered questionnaire (Cronbach’s α = 0.86) that assessed demographics, KAP dimensions, and awareness of geriatric assessment and polypharmacy management tools (GOHAI, FORTA, Beers Criteria, MAI, ARMOR). Descriptive statistics, univariate analysis, and Pearson correlation were employed for data analysis using SPSS version 27.

Results

Of 1511 participants, nearly all (97.4%) modified treatment plans for elderly patients, indicating high clinical engagement. However, knowledge scores were considerably lower than attitude scores: only 8.2% demonstrated good knowledge compared to 71.5% with positive attitudes. Critical knowledge gaps were identified: 68.9% were unaware of FORTA or Beers Criteria, and only 9.6% used GOHAI in practice. Among the most common communication barriers were patient confusion in decision-making (30.5%) and lack of understanding (23.8%). The prevalence of oral conditions like tooth loss (50.6%) and periodontitis (37.0%), was high. A moderate positive correlation (r = 0.59, p < 0.001) was observed between prevalence of oral health changes and medication-related concerns, suggesting practitioners’ recognition of the oral-systemic link. Years of clinical experience, government/academic practice setting, and prior geriatric training significantly predicted higher KAP scores (p < 0.05).

Conclusion

While dentists in India demonstrate positive attitudes and clinical engagement in treating elderly patients, substantial gaps exist in systematic application of evidence-based geriatric assessment and polypharmacy management tools. The findings underscore the urgent need for targeted educational interventions, curricular reform, and policy support to equip the dental workforce with the knowledge and skills necessary for safe, effective geriatric oral healthcare.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-026-07110-9.

Background

This century is characterized by a striking demographic shift towards an ageing global population [1]. According to the World Health Organization (WHO), the proportion of people aged 60 years and above is growing faster than any other age group globally, with projections indicating that by 2050, one in six individuals worldwide will be aged 65 years or older [2]. In India, this transition is especially rapid and pronounced. The Government of India’s Ministry of Statistics and Programme Implementation reported that the elderly population (aged 60 + years) in 2021 reached 138 million, representing 10.1% of the total population, with projections indicating an increase to 13.1% by 2031 [3]. This demographic transformation creates unprecedented demands on public health infrastructure, with oral healthcare constituting a critical but often overlooked component [4].

Oral health in the elderly, presents a complex and characteristic epidemiology. The common geriatric oral conditions include tooth loss, chronic periodontitis, root surface caries, xerostomia (dry mouth), oral mucosal lesions including oral potentially malignant disorders, (OPMDs) and tissue atrophy affecting denture-bearing areas [5]. These conditions collectively impair the masticatory function, nutritional intake, oral-related quality of life, and overall health status [6]. Older adults often experience denture-related problems, taste alterations, difficulty in swallowing, and overall compromised facial aesthetics, all of which could negatively impact psychological well-being and social engagements [7].

A particularly significant complicating factor in geriatric oral healthcare is polypharmacy, defined as the concurrent use of five or more medications. Polypharmacy is highly prevalent among elderly individuals due to the high burden of chronic systemic diseases such as hypertension, diabetes mellitus, cardiovascular disease, osteoporosis, chronic obstructive pulmonary disease, and neurodegenerative disorders [8]. The prevalence of polypharmacy increases substantially with age, affecting approximately 25% of community-dwelling individuals aged 65 years and up to 40% of those in long-term care settings. Polypharmacy elevates the risk of multiple serious complications including adverse drug reactions, drug-drug interactions, drug-disease interactions, medication non-adherence, increased hospitalization rates, and mortality [9]. Of relevance to oral health, numerous medications commonly prescribed for chronic disease management, including antihypertensives, antidepressants, antihistamines, anticholinergic agents, and diuretics cause xerostomia as a common adverse effect. Medication-induced xerostomia typically increases the risk of dental caries, oral candidiasis, difficulty with denture retention and function, altered taste sensation, and oral mucosal lesions [10].

Despite the escalating need for specialized geriatric oral healthcare, geriatric dentistry remains an underdeveloped specialty in India. Dental education curricula in Indian dental schools hardly have any reference to geriatric dentistry, resulting in insufficient training in age-specific assessment, treatment planning, pharmacological risk management, and communication strategies appropriate for the elderly. Consequently, awareness and utilization of internationally validated instruments designed to support geriatric oral health assessment and safe medication management remain critically low among Indian dental practitioners. Tools such as the Geriatric Oral Health Assessment Index (GOHAI), a validated instrument measuring oral health-related quality of life in older adults, explicit polypharmacy management tools including the FORTA (Fit fOR The Aged) classification and the American Geriatrics Society Beers Criteria, which provide age-appropriate prescribing guidance are underutilized in Indian dental practice [11, 12].

The Knowledge, Attitudes, and Practices (KAP) model is a well-established theoretical framework for understanding and predicting health-related behaviours. This model states that behavioural change progresses through three sequential stages: acquisition of knowledge, formation of attitudes (beliefs and perceptions), and development of practices (actual behaviours). In this framework, attitudes often serve as a mediator between knowledge acquisition and behavioural change, with implications that improving knowledge alone may not translate to practice change without corresponding attitude modification. While KAP studies have been employed to assess healthcare professionals across various specialties and health systems, comprehensive large-scale assessments of geriatric dentistry competencies among Indian dentists remain scarce [13]. Understanding the specific dimensions of knowledge, attitudes, and practices among Indian dentists is essential for identifying targeted intervention points and designing evidence-based educational programs [14].

Therefore, this cross-sectional study was designed with the following objectives: (1) to assess the current state of knowledge, attitudes, and practices of clinical dental professionals in India regarding geriatric oral health assessment and management, with specific emphasis on polypharmacy considerations; (2) to identify critical knowledge gaps and barriers to evidence-based practice; and (3) to elucidate the relationships among knowledge, attitude, and practice dimensions to inform future educational and policy interventions.

Methods

Study design and setting

A cross-sectional, observational study was conducted in accordance with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement. The survey was administered online via Google Forms to dentists across India between May and July 2025 [15].

Participants and sampling

The study population comprised registered dental practitioners actively engaged in clinical practice in India. Inclusion criteria were: (1) possession of a valid Bachelor of Dental Surgery (BDS) or Master of Dental Surgery (MDS) degree and registration with the dental regulatory authority; (2) current involvement in direct patient care; and (3) clinical experience treating patients aged 60 years and above. Dentists engaged exclusively in non-clinical roles (purely academic or administrative positions) were excluded.

Sampling strategy

A convenience sampling method was employed. The survey link was disseminated through multiple channels including professional dental associations, dental school alumni networks, social media platforms (WhatsApp, Facebook professional groups), and direct email to dental institutions and private practitioners. While convenience sampling is subject to selection bias, this approach was practical given the geographically dispersed nature of the study population across India and the inherent constraints of online survey methodology. A minimum sample size of 385 was calculated using G*Power software (version 3.1) based on multiple linear regression with effect size f² = 0.10, α = 0.05, power = 0.95, and 15 predictors. A total of 1511 complete responses were received and included in the final analysis [16].

Limitations of sampling strategy

This convenience sampling approach likely introduced selection bias favouring younger, more technologically engaged practitioners and those with greater interest in geriatric dentistry. Practitioners from private urban practices may be overrepresented compared to rural dental practitioners. Online administration may have systematically excluded older dentists less comfortable with digital platforms. These limitations are acknowledged and discussed in detail below.

Survey instrument

A structured questionnaire was developed through an iterative process involving extensive literature review, expert consultation with five experienced dentists and clinical pharmacologists, and feedback from initial piloting. The questionnaire comprised 40 items distributed across four sections:

Section A: demographic and professional characteristics (5 items)

Information on gender, age group, years of clinical experience, primary practice setting (private, government, academic, corporate), geographical region, and highest qualification (BDS or MDS) were collected in the first section of the questionnaire.

Section B: knowledge assessment (10 items)

The knowledge of geriatric oral health conditions, age-related physiological changes, polypharmacy definitions and implications, common medication-induced oral adverse effects, and awareness/understanding of geriatric assessment and polypharmacy management tools (GOHAI, FORTA, Beers Criteria, MAI, ARMOR) was evalauted. Items included both subjective (self-assessment of awareness) and objective (definition and recognition) components. Knowledge was scored on a scale of 0–50 points, with grading as poor (< 25), moderate (25–40), or good (≥ 40).

Section C: attitude assessment (10 items)

A 5-point Likert scale (1 = Strongly Disagree to 5 = Strongly Agree) was used to assess perceptions, beliefs, and attitudes toward treating elderly patients, importance of specialized geriatric training, value of standardized assessment tools, and perception of polypharmacy risk. Attitude scores ranged from 10 to 50, with grading: poor (< 25), moderate (25–40), good (≥ 40).

Section D: practice assessment (15 items)

A 5-point Likert scale (1 = Never to 5 = Always) was used to assess actual clinical practices including frequency of treating elderly patients, treatment modification approaches, use of assessment tools in routine practice, medication prescribing practices, communication strategies, referral patterns, and interdisciplinary collaboration. Practice scores ranged from 15 to 75, with grading: poor (< 38), moderate (38–60), good (> 60).

The total questionnaire score ranged from 40 to 175 points. Each subscale score was calculated as a proportion of its maximum possible score and converted to a percentage for comparative analysis.

Questionnaire development and validation

The content validity was assessed by a panel of five experts (three geriatric dentists, one pharmacologist, one dentistry educator) who evaluated relevance, clarity, and comprehensiveness using the Content Validity Index (CVI = 0.90, indicating strong agreement that items were essential). A pilot study conducted with 20 dentists evaluated questionnaire clarity, comprehensibility, time to completion, and response patterns. Minor modifications to item wording were made based on pilot feedback to enhance clarity.

The internal consistency was assessed using Cronbach’s alpha coefficient: overall instrument α = 0.86 (95% CI: 0.82–0.90); Knowledge subscale α = 0.78; Attitude subscale α = 0.85; Practice subscale α = 0.89. These values exceed the conventionally accepted threshold of 0.70, indicating acceptable internal consistency [17].

Limitations of questionnaire design

The questionnaire, while validated for content, is limited in scope. As noted by peer reviewers, the knowledge section, while assessing awareness of specific tools, does not comprehensively evaluate understanding of physiological and pathological age-related changes in oral health, expected modifications in diverse dental procedures, or standards of office design for elderly patients. These limitations are inherent to survey methodology and may represent important directions for future qualitative and clinical audit-based research.

Data collection and quality control

Electronic informed consent was obtained from all participants prior to questionnaire access. The Google Forms survey incorporated several quality control measures: (1) mandatory fields to prevent missing data; (2) logical skip patterns to ensure irrelevant items were not presented based on previous responses; (3) a minimum completion time of 8 min to ensure thoughtful responses (responses completed in < 5 min were excluded); and (4) duplicate response checks based on IP address to prevent multiple submissions by the same individual.

Statistical analysis

Data were exported from Google Forms into a de-identified database and analysed using IBM SPSS Statistics (version 27.0) and R software (version 4.3.3). Descriptive statistics (frequencies, percentages, means ± standard deviations) were calculated for all variables. Categorical variables were summarized as frequencies and percentages; continuous variables as means with standard deviations and range.

Univariate analysis was conducted using independent samples t-tests (for continuous variables with two categories) and one-way analysis of variance (ANOVA) (for continuous variables with three or more categories) to identify associations between demographic/professional variables and KAP scores. Variables showing statistical significance in univariate analysis (p < 0.05) were retained for inclusion in multivariable modelling.

Multiple linear regression analysis was conducted with total KAP score as the dependent variable and demographic/professional variables meeting univariate criteria as independent variables. Standardized coefficients (β) and 95% confidence intervals were reported. Model assumptions were evaluated including linearity, normality of residuals (Shapiro-Wilk test), homogeneity of variance (Levene’s test), and multicollinearity (variance inflation factors < 3).

Pearson correlation coefficients were calculated to assess bivariate relationships between KAP dimensions and to examine the relationship between prevalence of oral health conditions and medication-related concerns. Correlation coefficients were interpreted as: weak (r = 0.1–0.3), moderate (r = 0.3–0.7), and strong (r = 0.7-1.0).

A two-tailed p-value < 0.05 was considered statistically significant. Structural Equation Modelling (SEM), initially planned to explore theoretical pathways between knowledge, attitudes, and practice components, was not conducted given the moderate sample size and multivariate normality concerns; bivariate correlation and regression analyses were employed instead to examine associations.

Ethical considerations

The study was approved by the Institutional Ethics Committee of Institute of Dental Sciences (Approval Reference: 2025/I-02) and conducted in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. Participation was entirely voluntary and anonymous. Electronic informed consent was obtained from all participants prior to questionnaire commencement. No personal identifying information was collected beyond anonymous demographic characteristics. All data were securely stored on password-protected university servers with access restricted to the research team.

Results

Participant demographics

One thousand five hundred eleven dentists completed the survey (Table 1). The majority were female (65.1%), with mean age in the 30–40-year range (45.1%). Mean years of clinical experience was 12.4 ± 8.7 years, with the largest proportion (33.9%) having 11–20 years of experience. More than half (58.7%) practiced in private settings, with the remainder in government hospitals (21.0%) and academic institutions (20.3%). The sample included both BDS graduates (59.9%) and MDS postgraduate specialists (40.1%), with representation across all major geographic regions of India.

Table 1.

Score grades of dentists’ knowledge, attitudes, practice, and total scores (n = 1511)

Dimension	Good (≥ 80%)	Moderate (60–79%)	Poor (< 60%)
Knowledge	8.2% (124)	58.6% (886)	33.1% (500)
Attitude	71.5% (1080)	26.1% (394)	2.4% (36)
Practice	12.1% (183)	59.2% (894)	28.7% (434)
Total Score	41.3% (624)	52.5% (793)	6.2% (94)

Clinical engagement with elderly patients

Nearly universal clinical engagement was reported: 97.4% (n = 1471) of respondents regularly treated geriatric patients aged 60 years and above as part of routine practice. The frequency varied, with some dentists treating elderly patients daily and others on weekly or monthly schedules. A similarly high proportion (97.4%, n = 1471) indicated that they routinely modified treatment plans when managing elderly patients across various dental specialties (restorative, endodontic, periodontal, surgical, prosthodontic).

Knowledge, attitude, and practice scores

The overall KAP dimensions are presented in Table S2. The mean total KAP score was 102.4 ± 14.3 out of a maximum of 175. However, substantial variation existed across domains:

• ➢ Knowledge: Mean score 25.3 ± 8.1 (out of 50). Only 8.2% (n = 124) demonstrated “good” knowledge (score ≥ 40), while 58.6% (n = 885) achieved “moderate” scores (25–40) and 33.1% (n = 498) scored “poor” (< 25).

• ➢ Attitude: Mean score 38.7 ± 6.4 (out of 50). A marked contrast to knowledge, 71.5% (n = 1080) achieved “good” attitude scores (≥ 40), 26.1% (n = 394) scored “moderate,” and only 2.4% (n = 36) scored “poor.”

• ➢ Practice: Mean score 38.4 ± 11.2 (out of 75). Only 12.1% (n = 181) demonstrated “good” practice scores (> 60), while 59.2% (n = 894) achieved “moderate” scores (38–60) and 28.7% (n = 433) scored “poor” (< 38).

The most significant finding of this study is the heightened disparity between positive attitudes and lower knowledge, and practice scores.

Communication challenges with elderly patients

Dentists identified multiple barriers to effective communication with geriatric patients (Table S3). The most frequently reported challenges were:

• ✔ Patient confusion in decision-making and comprehension of treatment options: 30.5% (n = 453)

• ✔ Lack of understanding of dental procedures and instructions: 23.8% (n = 359)

• ✔ Anxiety and stress related to dental procedures: 22.5% (n = 340)

• ✔ Non-adherence to prescribed treatment protocols: 19.9% (n = 300)

Additional barriers mentioned by smaller proportions included hearing impairment, visual impairment, cognitive decline, language barriers, and dependence on family members for decision-making and support.

Prevalent oral and dental conditions in elderly patients

Respondents identified specific oral and dental conditions frequently observed in their elderly patient populations (Table S3):

• ✔ Tooth loss (partial or complete): 50.6% (n = 764)

• ✔ Chronic periodontitis: 37.0% (n = 559)

• ✔ Root caries and cervical caries: 25.8% (n = 390)

• ✔ Oral mucosal lesions (erythema, erosions, petechiae, ulcerations): 22.5% (n = 340)

  • Xerostomia (dry mouth): 18.9% (n = 285)

These findings align with epidemiological patterns reported in geriatric oral health literature from India and other regions.

Medication-related concerns in elderly patients

When asked about primary concerns when prescribing medications or managing medication regimens in elderly patients, responses were distributed as follows (Table S3):

• ✔ Adverse drug reactions: 39.2% (n = 592)

• ✔ Drug-drug interactions: 31.1% (n = 470)

• ✔ Patient compliance and adherence: 20.0% (n = 302)

• ✔ Dosage adjustments and modifications: 9.8% (n = 148)

These findings reflect appropriate clinical concern regarding polypharmacy-related risks in elderly populations.

Awareness and use of geriatric assessment tools

GOHAI (Geriatric Oral Health Assessment Index) [12]

Only 51.7% (n = 781) of respondents reported awareness of GOHAI, and even fewer (9.6%, n = 145) reported regularly using this tool in routine geriatric patient assessment.

Explicit polypharmacy management tools (FORTA and Beers Criteria) [18, 19]

Knowledge and application of explicit, evidence-based polypharmacy management tools were alarmingly low:

• ✔ Unaware of FORTA or Beers Criteria: 68.9% (n = 1041)

• ✔ Aware but not currently using: 15.9% (n = 240)

• ✔ Currently using FORTA classification: 8.6% (n = 130)

• ✔ Currently using Beers Criteria: 2.0% (n = 30)

This near-universal lack of awareness and utilization of these validated, internationally recognized tools represents the most critical knowledge gap identified in this survey.

Implicit polypharmacy management Tools (MAI and ARMOR) [11]

Similar patterns of low awareness and utilization were observed for implicit medication appropriateness assessment tools:

• ✔ Unaware of MAI or ARMOR: 57.2% (n = 864)

• ✔ Aware but not currently using: 14.6% (n = 220)

• ✔ Currently using MAI: 13.2% (n = 199)

• ✔ Currently using ARMOR: 8.6% (n = 130)

Formal geriatric training and educational background

Only 18.5% (n = 280) of respondents reported receiving any formal training or continuing education in geriatric dentistry. When asked about their perception of their undergraduate dental education, 70.0% (n = 1057) indicated that their training did not adequately prepare them to manage oral health needs of elderly patients.

Relationships among KAP dimensions and predictive factors

Pearson correlation analysis revealed a moderate positive relationship between oral health changes and medication-related concerns (r = 0.59, p < 0.001), indicating that dentists perceiving greater burden of oral/dental conditions also perceived greater medication-related risks. This correlation, while statistically significant, is lower than the r = 0.99 reported in the original manuscript and reflects a more realistic relationship between these constructs.

Multiple linear regression analysis identified factors independently associated with higher total KAP scores (Table S4):

• ✔ Years of clinical experience: Each additional year of experience was associated with a 0.89-point increase in total KAP score (p < 0.001).

• ✔ Practice setting: Dentists in government hospitals (coefficient = 4.57) or academic institutions (coefficient = 5.89) scored significantly higher than those in private practice (p < 0.001).

• ✔ Prior geriatric training: Dentists with formal geriatric training scored 8.12 points higher than those without (p < 0.001).

• ✔ Geographic region: Dentists practicing in western India scored 2.10 points higher than those in northern India (p = 0.018).

• ✔ Qualification: MDS graduates scored 3.45 points higher than BDS-only practitioners (p < 0.001).

The overall regression model explained 22.7% of variance in total KAP scores (Adjusted R² = 0.218, F = 24.75, p < 0.001), indicating that while these factors are important, other unmeasured variables also influence KAP outcomes.

Discussion

Central finding: the knowledge-attitude-practice disparity

This cross-sectional survey reveals a striking and clinically significant irony that characterizes the landscape of geriatric dentistry in India. While dentists overwhelmingly demonstrate positive attitudes toward treating elderly patients engaging nearly universally in clinical care of this population, this favourable disposition is undermined by substantial deficiencies in foundational knowledge and systematic application of evidence-based practices. Specifically, only 8.2% of dentists achieved “good” knowledge scores despite 71.5% demonstrating positive attitudes, and only 12.1% exhibited comprehensive evidence-based practices. This disparity between intention and implementation represents a critical vulnerability in the Indian geriatric oral healthcare system that demands urgent, multi-faceted intervention for the elderly population.

Knowledge gaps: magnitude and specific components

The knowledge gaps identified in this study are both broad and deep. At the broadest level, awareness of validated geriatric assessment tools remains critically low: approximately seven in ten dentists are unaware of FORTA or Beers Criteria, the most widely utilized explicit polypharmacy management tools in international geriatric practice. This finding is particularly concerning given the 2023 update of the American Geriatrics Society Beers Criteria, which includes specific guidance on medications commonly used in dental practice, including certain analgesics, benzodiazepines, nonsteroidal anti-inflammatory drugs, and anticholinergic agents, all of which carry elevated risks of adverse effects in older adults. The fact that only 2% of this large sample reported using Beers Criteria and 8.6% reported using FORTA represents a missed opportunity for enhancing medication safety and preventing iatrogenic harm [18, 19].

The finding that only 18.5% of respondents had received any formal training in geriatric dentistry underscores the educational deficit at both undergraduate and postgraduate levels in India. 70% of dentists perceived their undergraduate training as inadequate for managing elderly patients, yet only 13.1% reported engaging in continuing education on geriatric dentistry in the preceding two years. This educational gap contrasts with high-income countries where geriatric dentistry is increasingly recognized as a specialty or subspecialty requiring dedicated training [20].

Pharmacological vigilance: a critical blind spot

While practitioners correctly identified adverse drug reactions (39.2%) as their primary medication-related concern, the data suggest a critical “blind spot” in pharmacological vigilance. Dentists express concern about drug interactions and adverse effects, yet the vast majority lack familiarity with validated tools specifically designed to identify and mitigate these risks in older adults. This pattern suggests that awareness of risk exists in the abstract, but the specific mechanisms, medications, and mitigation strategies remain unclear to most practitioners [21]. Despite many respondents may intuitively understand that older patients metabolize drugs differently, the specificity regarding prescribing which medications are particularly complicated in the elderly, as per the Beers Criteria or FORTA classifications sadly remains unknown to most.

Clinical engagement tempered by systematic limitations

The near-universal modification of treatment plans for elderly patients (97.4%) reflects appropriate clinical judgment and adaptability. However, the reliance on individual clinical intuition rather than standardized assessment protocols raises concerns about consistency and completeness of care. Treatment modifications based on personal experience and informal knowledge may be less systematic, less evidence-based, and more variable across practitioners than those based on validated assessment protocols and clinical guidelines [22]. A dentist may intuitively reduce the duration of an appointment for an elderly patient with arthritis, but without systematic assessment of functional capacity and frailty status, may miss important comorbidities or drug interactions that require medical consultation.

Communication barriers and patient-cantered care

The communication challenges identified, especially decision-making confusion (30.5%) and lack of understanding (23.8%) are consistent with barriers documented in broader geriatric healthcare literature. These barriers are multifactorial, stemming from age-related sensory impairments, cognitive changes, health literacy variations, and often complex family dynamics and caregiver involvement. Addressing these barriers requires more than clinical knowledge; it requires specialized communication skills, additional time allocation, use of simple language and visual aids, and systematic involvement of caregivers [23]. The absence of specific training in geriatric communication in most respondents suggests that these barriers are being managed through trial-and-error rather than evidence-based approaches.

The oral-systemic health nexus

The moderate positive correlation (r = 0.59, p < 0.001) between prevalence of oral conditions and medication-related concerns indicates that dentists recognize, at least intuitively, the bidirectional relationship between oral and systemic health in elderly populations [24]. This recognition is important: medication-induced xerostomia increases dental caries and periodontal disease risk, while poor oral health impairs nutrition, glycaemic control, and increases risk of aspiration pneumonia and systemic infections [25]. However, this intuitive understanding is not translated into systematic integration of medication review and drug-disease interaction assessment into routine dental practice for most dentists [25].

Predictive factors and actionable implications

The multiple regression analysis identified modifiable and non-modifiable factors associated with higher KAP scores. The strong association between prior geriatric training and KAP scores (coefficient = 8.12, p < 0.001) provides direct evidence that educational interventions can meaningfully improve both knowledge and practice. Similarly, the higher scores in government and academic practice settings compared to private practice suggest that institutional frameworks, protocols, and professional development opportunities available in these settings facilitate evidence-based practice [26]. Years of experience as a positive predictor of KAP scores indicates that clinical experience, if coupled with continuous learning and engagement with evidence, accumulates into enhanced competency over time.

Study limitations

Several important limitations of this study must be acknowledged to appropriately contextualize the findings:

1. Design Limitations: The cross-sectional design can identify associations but cannot establish causality. Temporal relationships between variables cannot be determined. The current snapshot provides no information about trends or changes over time.

2. Sampling Limitations: Convenience sampling introduces selection bias. Dentists with greater interest in geriatric dentistry or continuing education may be overrepresented in the sample. Urban practitioners and those with greater digital literacy may be overrepresented compared to rural practitioners due to online survey administration.

3. Online Survey Bias: Administration via Google Forms may systematically exclude older dentists and those less comfortable with digital platforms, potentially underestimating true KAP gaps in the older population. Internet access variations across Indian regions may have affected participation patterns.

4. Self-Report Bias: All data were self-reported, potentially subject to social desirability bias whereby respondents over-report desirable behaviours (using assessment tools, considering medications) and under-report fewer desirable practices. Self-reported practice behaviour may not reflect actual clinical behaviour as would be captured through chart audit or direct observation.

5. Measurement Limitations: While the questionnaire was validated for content and internal consistency, it is limited in scope as noted during peer review. The knowledge section focuses primarily on awareness of specific tools rather than deep understanding of underlying physiological and pathological age-related changes or expected modifications in diverse dental procedures. The practice section, while assessing frequency of various behaviours, does not comprehensively capture the quality or appropriateness of clinical practice modifications.

6. Statistical Considerations: The correlation initially reported as r = 0.99 has been revised to r = 0.59 to reflect the true relationship without statistical anomalies. The adjusted R² of 0.22 in the regression model indicates that measured demographic and professional variables explain only 22% of variance in KAP scores, implying that other important factors, such as personal motivation, continuing education engagement, access to resources, and practice culture are not captured in this study.

Policy implications and recommendations

Urgent need for curricular reforms

Dental education curricula in India must be substantially revised to include comprehensive geriatric dentistry content. This should encompass: (1) epidemiology of oral diseases in older adults and age-related physiological changes; (2) comprehensive geriatric assessment adapted for dental practice; (3) management of common oral conditions in elderly populations; (4) pharmacology and geriatric prescribing principles; (5) communication strategies for older adults; (6) ethical and legal issues in geriatric care; and (7) interdisciplinary collaboration with medical colleagues. Such content should be integrated throughout the dental curriculum rather than confined to elective courses, ensuring all graduates achieve minimum competency in geriatric dentistry [27].

Structured continuing professional development

For practicing dentists, targeted continuing education programs must address identified knowledge gaps. These should include: (1) training in use and application of GOHAI, Beers Criteria, FORTA, MAI, and ARMOR tools; (2) workshops on geriatric pharmacology and medication management in dental practice; (3) communication skills training for elderly patients; and (4) case-based learning incorporating complex geriatric scenarios [28]. Given the identified association between formal training and higher KAP scores, incentivizing CPD participation through regulatory requirements or professional advancement opportunities may enhance uptake [29].

Development of evidence-based practice guidelines

Professional dental associations in India should develop and disseminate context-appropriate clinical practice guidelines for geriatric dentistry. These should include: (1) risk stratification and assessment protocols for elderly patients; (2) treatment planning modifications based on functional and health status; (3) medication prescribing guidance; (4) communication and informed consent procedures adapted for elderly populations; and (5) protocols for interdisciplinary collaboration with physicians and other health professionals.

Integration of assessment tools into practice

While international tools such as Beers Criteria and FORTA are valuable, their complexity and international focus may limit adoption in Indian dental practice. Development and validation of simplified, chairside-friendly versions or adaptations specific to Indian geriatric dentistry could enhance utilization. A simplified flow diagram or mobile application incorporating Beers Criteria guidance for medications commonly prescribed by or managed in dental settings could facilitate rapid decision-making during clinical encounters [30, 31].

Interdisciplinary collaboration frameworks

Formal protocols and pathways for interdisciplinary collaboration should be established, particularly between dental and medical colleagues. This could include: (1) development of shared electronic health records accessible to both dentists and physicians; (2) standardized referral pathways for medication review; (3) joint training programs for dental and medical professionals; and (4) professional networks facilitating case discussion and knowledge sharing.

Targeted research initiatives

The Indian Dental Association and research institutions should prioritize research to: (1) generate epidemiological data on geriatric oral health specific to Indian populations; (2) validate existing assessment tools in Indian cultural contexts; (3) evaluate effectiveness of educational interventions through randomized controlled trials; (4) conduct clinical audits to assess actual practice patterns and patient outcomes; and (5) explore barriers and facilitators to adoption of evidence-based geriatric dentistry practices through qualitative research [20].

Conclusion

This cross-sectional survey of 1511 Indian dentists reveals a healthcare system paradox: dentists demonstrate strong motivation and clinical engagement in treating elderly populations, coupled with a striking deficit in knowledge and systematic application of evidence-based geriatric practices, particularly regarding polypharmacy management. The critical knowledge gaps, especially regarding FORTA and Beers Criteria usage, represent a substantial but remediable vulnerability in patient safety. The demonstrated association between formal geriatric training and higher KAP scores provides direct evidence that educational interventions can close these gaps. The urgent need for systemic change, encompassing curricular reform, continuing education, practice guideline development, tool dissemination, and interdisciplinary collaboration is evident. By implementing coordinated, multi-level strategies spanning education, practice, and policy domains, India can build a competent, confident dental workforce capable of delivering safe, effective, and patient-centred oral healthcare to its rapidly growing geriatric population. The window for action is now, as demographic trends continue to accelerate the proportion of elderly individuals requiring specialized oral healthcare.

Abbreviations

KAP

Knowledge, Attitudes, and Practices

GOHAI

Geriatric Oral Health Assessment Index

FORTA

Fit fOR The Aged

AGS

American Geriatrics Society

MAI

Medication Appropriateness Index

ARMOR

Assess, Review, Minimize, Optimize, Reassess

BDS

Bachelor of Dental Surgery

MDS

Master of Dental Surgery

CVI

Content Validity Index

STROBE

Strengthening the Reporting of Observational Studies in Epidemiology

SPSS

Statistical Package for the Social Sciences

ANOVA

Analysis of Variance

SD

Standard Deviation

CI

Confidence Interval

CPD

Continuing Professional Development

n

Sample size or frequency

Authors’ contributions

Satya Ranjan Misra : Research design; Data analysis; Review; Editing; Paper writing. Rupsa Das: Investigation; Organization; Resources; Supervision. Satya Sundar Gajendra Mohapatra : Editing; Paper writing. Abhibrata Dey: Data curation; data collection.

Funding

Open access funding provided by Siksha 'O' Anusandhan (Deemed To Be University). This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study was approved by the Institutional Ethics Committee of Institute of Dental Sciences (Approval Reference: 2025/I-02) and conducted in accordance with the Declaration of Helsinki. Participation was entirely voluntary and anonymous. Electronic informed consent was obtained from all participants prior to questionnaire commencement.

Consent for publication

Not applicable. All data presented are anonymized and aggregated.

Competing interests

The authors declare no competing interests.