Barriers and enablers to patient conversations about menopause in the dental surgery

Zelda Williamson¹ Debbie Reed²

Abstract

Introduction  Despite great efforts to raise awareness of the impact of perimenopause and menopause (peri/menopause) on women’s general health, few studies exist exploring the interaction of the dental team with peri/menopausal patients.

Aim  To explore the attitudes of dentists and dental hygienists (referred to as dental clinicians) regarding the impact of the peri/menopause on oral health, as well as perceived barriers and enablers to discussing peri/menopause with patients.

Method  A qualitative case study via three on-line focus group discussions. Ethical approval was granted by the University of Kent.

Results  Data revealed three themes in terms of dental clinicians’ perceived barriers and enablers to discussing the impact of peri/menopause on oral health with patients: [1] clinician training and education; [2] clinician perception of the impact of peri/menopause on oral-health; and [3] peri/menopause as a socio-cultural taboo to dental clinicians.

Conclusions  From this study, it has been determined that clinicians view their lack of knowledge around the impact of menopause on oral health as a barrier to communication with patients. Perception of the scale of the impact of menopause on oral-health influences the clinician’s motivation to discuss this with patients. The perception of menopause as a socio-cultural taboo further inhibits discussions about menopause.

Key words menopause, oral-health, communication, dental care

Introduction

The topic of perimenopause and menopause (peri/menopause) has gained prominence within the dental and general press, raising awareness in both sectors of the effects of peri/menopause.^1,2 Menopause is a recognised physiological process and health condition affecting women, diagnosed in the absence of a menstrual period for twelve consecutive months.³ The transition to menopause can often occur years prior to halting of menstrual periods and is commonly referred to as ‘perimenopause’. An average of around thirteen million women in the UK are perimenopausal or menopausal at any one time.⁴

In peri/menopause, the change in hormone production can have a significantly negative impact on a woman’s physical and psychological wellbeing, reducing quality of life for those going through it.⁵ With regard to oral health, psychological stress caused by peri/menopause can manifest as aphthous ulcers, lichen planus and xerostomia.⁶ Other physiological signs, a consequence of the reduction in oestrogen levels, result in oral manifestations due to the impact of oestrogen receptors in gingival tissue, leading to impairment of the barrier function of oral epithelium.^6,7 The most likely oral manifestation encountered by dental clinicians is deterioration of periodontal health due to increased inflammation.⁸ Dry mouth is commonly seen during peri/menopause leading to an increased risk of caries.⁷ Dysgeusia and paraesthesia (including  burning mouth syndrome), are also linked to the peri/menopause. ⁹ There is also an association with the lesser-known complication of osteoporotic jaw.¹⁰ Considered collectively, it may be concluded that peri/menopause can have a direct impact on oral health.¹¹

Whilst recently published papers in dentistry have focussed on improving the working environment of peri/menopausal women working in dentistry,¹² this study focussed on the communication skills of dental clinicians in relation to discussing the sensitive matter of peri/menopause with patients in primary dental care. The study sought to identify barriers to overcome, and enablers to build upon, both of which can empower dental clinicians to better meet the oral health needs of peri/menopausal women, by increasing their ability to recognise and treat oral discomfort, as well as offering overall support and signposting to other appropriate service providers.

In other areas, it is recognised that excellent communication between clinicians and patients plays a vital role when discussing health conditions, especially when they are considered a sensitive or ‘taboo’ subject.^13,14 Dental clinicians are well placed to identify and treat the oral manifestations of peri/menopause, and also ideally situated to support females psychologically and emotionally, by referring patients to other health care professionals specialising in women’s health.¹⁵

This study sought to explore the perceptions of dentists and dental hygienists regarding their practice of discussing peri/menopause with their patients, as well as to identify clinicians’ views of the possible barriers and enablers to their discussions with patients.

Methods

Part of an MSc study, this qualitative research project employed a relativist stance using a case study methodology. A case study was appropriate as the views from a purposively selected group of volunteer registered dentists and dental hygienists were explored. The cases were chosen because they have characteristics in common – in this instance being dental clinicians – and believed to be rich in knowledge that will help to achieve the aims of this study.  Invitations to take part in the study were sent to a practice managers’ group via the investigator’s practice manager. The managers forwarded the invitations to dentists and dental hygienists working in their practices. The response yielded an insufficient sample, so the invitation was also extended to personal contacts of the researcher. Ethical approval was granted via the University of Kent Ethics Committee.  Consent was obtained as part of a Participant Information Leaflet that was sent via e-mail correspondence, once participants showed interest in taking part. Participants were reminded that they could withdraw from the study at any stage. No requests for withdrawal were made. Data were collected during three on-line focus groups discussions, each lasting approximately 60 minutes. Study populations are summarised in Table 1. 

_{Table 1: Details of study populations}

To ensure suitability of the focus group guide, style and equipment to facilitate or record during data collection, a pilot focus group was conducted. The investigator formulated ‘prompt questions’ to stimulate conversations around clinicians’ current practices when communicating the possible impact of menopause on oral health. No changes were made to the prompt questions used during the pilot study; therefore data were included as part of the analysis. The Green et al.¹⁶ four-stage model of Thematic Analysis (TA) was used, as detailed in Table 2. The TA revealed seventeen codes, grouped into four categories, which then transferred into themes.

As investigator in the same profession as the group being researched, an ‘insider’ perspective was adopted by the author.  This potentially enhanced the depth of the research as the investigator easily built rapport with the participants, had a good understanding of what the job entailed and had intimate knowledge of the context of the study. One of the most common threats of insider research is validity due to bias. The investigator gave much attention to reflexivity to prevent personal experiences and knowledge influencing the data collected. To minimise bias, verification techniques were employed. Firstly, member-checking: an anonymised transcript was produced and verified as accurate by the members of the focus group prior to analysis commencing. Secondly, inter-rater corroboration (a form of inter-rater reliability) took place between the investigator and the supervisor, confirming codes, categories and themes during contact sessions.¹⁷ Thirdly, a draft copy of the analysis section was sent to the participants to confirm that they had not been misinterpreted or misrepresented. No notifications of redactions were received. Digital data were stored on a password protected, encrypted storage device and will be retained for four years. Retention beyond this time will only be with further approval of the University of Kent Ethics Committee.

Results

The analysis, based on the inter-rater corroboration described above, culminated in three themes, which the dental clinician participants perceived could act both as barriers and enablers to discussing peri/menopause in the dental surgery.

_{Table 2: Results from Thematic Analysis}

To illustrate the relationship between the themes, Figure 1 represents a model which depicts their mutual influence. The two-directional arrows indicate that all themes can act as barriers or enablers to discussing the peri/menopause in the primary care setting, at different times. The themes are detailed below.

_{Figure 1: A model illustrating the relationship between themes (enablers and barriers) drawn from the data analysis and how they impact discussions on peri/menopause}

Theme One: Training and Education

Training and education are defined as any form of knowledge received pre- or post-registration that would assist a dental clinician in identifying conditions caused by hormone fluctuations, treatment of associated symptoms, or aiding referral to the right health care practitioner for further investigation.

Participants in the study acknowledged considering the impact of hormone fluctuations during pregnancy but had never related it to peri/menopause:

“… you always ask the question, ‘Are you pregnant?’ but never ask the question… ‘are you in menopause’?” (P3F3)

The participants attributed their lack of awareness to receiving no education or training on the peri/menopause during undergraduate or postgraduate level training:

“… I probably have zero knowledge of the matter, absolutely no idea there is any kind of link or issue with menopause affecting … oral health… I can’t recall the topic being discussed ever … at dentist school or any course or anything like that ever.” (P3F1)

The participants believed that insufficient knowledge led to an underestimation of the impact of hormone fluctuations on general health. In some cases, this resulted in oversimplified solutions focussed on improving oral hygiene only:

“But… in terms of intra-oral disease, some things are overt, so oral hygiene is the drive for, for many oral diseases… So oral hygiene, all oral hygiene say, is the drive.” (P2F1)

Agnosis is a known communication barrier with a direct link between education, knowledge and the confidence to discuss peri/menopause with patients.¹⁸  Without the facts or understanding about the overall impact of peri/menopause on general health, opportunities could be missed to support the patient with more than just oral hygiene instruction, as summarised by a participant with personal experience:

“… people are going to be irritable. They might not like being told … how to brush their teeth… many women might be pleased that you’ve asked … it’s recognised as something that I can talk about and that it is having an impact on my health, and I’ve got somebody here who’s… knowledgeable about it… somebody is there, giving you a little bit of support with it.” (P2F3)

Theme Two: Clinicians’ Perceptions

Perceptions are formed through the process of translating sensory impressions into a unified view of the world.¹⁹ Perceptions help people to form knowledge and to learn about a subject. Repeated learning contributes to the formation of attitudes towards a subject and as such, perception and knowledge are inter-related. Within this study, participants recognised oral disease caused by hormone fluctuations as being multifactorial and complex. Participants perceived that there was no single treatment available to predictably treat the peri/menopause, which led to clinicians’ reluctance to enter discussions around symptoms caused by peri/menopause:

“I think it’s just a fact that, it’s multiple factors that play [a role] and in the end, it’s very difficult just to point out just one single thing, it’s a combination of multiple things. So, whether the menopause has a major role, it’s difficult to say.” (P1F1)

Perceptions that peri/menopause affects women to varying degrees, resulted in clinician reluctance to discuss this with all age-appropriate women, as some patients seemed to be unaffected:

 “… I think as you said the complexity of the situation is also then a barrier.” (P1F3)

Gender seemed to influence the perception participants had on the impact of peri/menopause on oral health. Male participants focussed on the fact that hormone imbalance was only a contributing factor, and that gingivitis was mainly attributed to poor oral hygiene:

“[Patients say] ‘I’m susceptible’ you know? And it’s a bit like giving someone a bit of a get-out clause from taking responsibility for their oral health because they can blame it on something they don’t have any control over.” (P1F1)

In contrast to this, women who participated in this study were empathetic to the indirect impact of symptoms caused by peri/menopause on general health, resulting in physical symptoms of tiredness (due to lack of sleep) and depression that contribute to the lack of self-care that potentially affect peri/menopausal women.²⁰  One post-menopausal participant supported this view by showing great sympathy for the extreme tiredness associated with peri/menopause, and described trying to keep home-care regimes easy and simple to follow for peri/menopausal patients:

“Tiredness… affects motivation to improve oral hygiene. You know, if you don’t sleep well, you don’t feel well… self-care goes down.” (P2F2)

Finally, some participants recognised that perceiving peri/menopause as a low priority condition could be a barrier to discussions, as also found in previous studies:¹⁴

“Post-COVID… menopause has gone further down …  their list of priorities… there’s a likelihood that it’s very low down on that list …” (P1F2)

Theme Three: Socio-Cultural Taboo

Socio-cultural taboo is defined as the way different groups of people in society have varying beliefs, habits and cultural traditions, all of which determine how easily individuals converse about issues associated with feelings of shame or embarrassment. Socio-cultural taboos routinely determine how males and females interact and contribute to the reticence individual clinicians may have in discussing certain topics. In common with some cultures, talking about peri/menopause falls into the ‘taboo’ category, comparable to sexual health, and traditionally more difficult for men to discuss with women:¹⁴

“… but it’s just such a taboo isn’t it, for men particularly, to mention menopause.” (P2F2)

  “I think it’s harder as a woman patient to approach a male dentist about it… But easier as a woman because you can relate.” (P3F2)

Male participants were asked if they found it embarrassing to talk to patients about peri/menopause.  They did not feel it was difficult to discuss in terms of oral health, but they did not mention the potential link with other mucosal areas. Female participants mentioned the correlation between dry oral mucosa, dry conjunctiva and dry vaginal mucosa. It was recognised that the nature of those enquiries potentially heightens the sensitivity of this issue and the reluctance of some practitioners to broach the subject. Underlining the potential sensitivity of the topic, a female participant shared her approach:

“I will say: ‘Well you know, if your hormones are changing and shifting, you may experience dry mouth, dry eyes, vaginal dryness.’ I say it nice and quick because otherwise my assistant blushes…” (P4F2)

Culturally, there is an emphasis on staying youthful and ageing is seen in a negative light, so insinuating someone is menopausal could be perceived as offensive to some:

“… it’s so deeply engrained in the version of females that we shouldn’t age… you almost see menopause coming as something you’ve done wrong…” (P1F2)          

Juxtaposed to this, feelings of being “too young” (younger than the average age of peri/menopause onset), was also mentioned as a potential barrier:

“[Some patients may say] ‘Oh, I wouldn’t even consider that because I’m only in my thirties’… So, I think age, age can be a bit of a barrier really to talking to  people.” (P2F2)

Discussion

This study confirmed previous findings that pre-registration training relating  to the impact of peri/menopause on oral health is sparse.²¹  With regard to training and education mentioned under Theme One, the lack of information is a known communication barrier with a direct link between education, knowledge and a confident attitude required to discuss the peri/menopause with patients.¹⁸  Recent publications recommend provision of training on menopause for consultants, dentists and dental care professionals in order to address this problem.¹²

Further training through continuous professional development (CPD) activities may build clinician confidence to engage in sensitive discussions with patients about peri/menopause. This would enable clinicians to offer compassionate support and empower peri/menopausal patients to achieve solutions to their health problems. Dental clinicians are in a good position to detect early signs of chronic disease presenting orally, which makes it even more important to integrate women’s health care into the training of dental professionals.²² 

Building knowledge related to peri/menopause has the potential to change attitudes and perceptions and advance the understanding clinicians have regarding the importance of peri/menopause impacting oral health, in a way that it has already done for general health.¹⁸ Whilst this knowledge forms a basis to communicate with patients about their oral hygiene during peri/menopause, developing a pool of knowledge has the potential to increase confidence in clinicians, to signpost patients to other service providers, to refer patients for consultations with medical practitioners, and to discuss their wider peri/menopausal health care needs and treatment options.

The complexity of the aetiology of oral manifestations of peri/menopause will still exist. However training and education may provide the means through which dental clinicians develop a greater appreciation of the peri/menopause as a health condition and, in so doing, enable themselves to support patients through empathic and emotionally sensitive communication. As such, an informed approach would be a positive starting point for discussions to diminish the taboo around peri/menopause and, in turn, change clinicians’ perceptions.¹⁹

This study revealed that when asked about potential enablers to discussing peri/menopause in the dental surgery, dental clinicians believed that initiation by patients was most favourable. However, dental clinicians also acknowledged that patients may not always recognise the link between peri/menopause and dental health, and therefore raising the matter of peri/menopause is incumbent on the dental clinician, as part of taking a full and detailed medical history.

It has been argued that female patients should be given a peri/menopause prompt list to gauge their information needs.²³ This list would also reduce the risk of a “two-way-taboo”¹⁴ where the clinician feels the patient should initiate any conversation involving taboo subjects and the patient feels reluctant to initiate conversation due to feelings of embarrassment and shame. This study confirmed embarrassment, lack of knowledge and low priority of disease as previously identified barriers inhibiting communication around sensitive topics.¹⁴

Conclusions

This study demonstrated that education, knowledge and confidence to discuss peri/menopause with patients are related. For those who took part in this study, increased knowledge about the impact of hormone changes on oral health was perceived to be the key to improved and informed discussions between dental clinicians and patients. Similarly, peer group discussions aided familiarity around peri/menopause and, even in the duration of the study, altered participants’ perceptions around peri/menopause that previously existed in their dental surgeries and started to break down the taboo around peri/menopause.

Whilst this small, purposively selected group study is limited in respect to the generalisable conclusions that can be drawn, it nevertheless offers insight into some of the barriers and enablers and may resonate with dental clinicians who wish to develop an understanding of peri/menopause. This study may also be of interest to researchers, who may wish to conduct broader or quantifiable studies to establish the extent of the training needed in relation to capabilities of the dental workforce to treat and support peri/menopausal patient populations.

Conflict of interest

There are no conflicts of interest for either author.

There was no funding for this study as it was part of the lead author’s MSc.

Authors’ contribution

1. ZW designed the study, conducted interviews, analysed interview data and writing of manuscript.
2. DR DR project supervisor, included co-design and analysis of data. 

Affiliations

1. Zelda Williamson BChd, Dip Clin Dent, DipRes, MSc. General Dental Practitioner, Chatham, Kent
2. Debbie Reed EdD, MSc, PGCHE, BA(Hons), Cert Ed, FHEA, CCIPD, FCGDent, ANCUP, GCGI Reader (Associate Professor) University of Kent

Correspondence

Zedla.williamson@googlemail.com

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Peer reviewed: Accepted 03 April 2023