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Oral health in the elderly—what missing?

Jonathan A. Ship, DMD [MEDLINE LOOKUP]

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Older people represent the fastest growing segment of the American population. With diminishing birth rates, and survival of adults commonly reaching the ninth decade of life and beyond, developed nations are experiencing significant demographic shifts. These changes are beginning to affect developing nations as well. The “aging” of cultures, societies, and countries will require monumental changes in all aspects of daily life, including transportation, housing, finance, recreation, and health care. The world economy in the future will need to accommodate to an environment of fewer individuals in the work force and more retired adults requiring a gamut of services for a substantive and fulfilling life.

In order to modify health care practices and systems that will preserve health, optimize function, and limit morbidities in aging populations, considerable research has been directed toward understanding the aging process and its concomitant medical problems.

The dental profession has been part of this process. Many studies have examined the effects of aging, medical problems and their treatments on nutritional intake, communication, and host protection, the critical functions of the craniofacial and oral structures.

Scientists have demonstrated that the mouth is remarkably resilient to the passage of time. Yet oral and systemic diseases and dental neglect that have deleterious influences on oral health and function will accrue more and more as an individual ages.

Recognition that most oral diseases are preventable has led to an expanding majority of people arriving into the latter periods of their lives with much or all of their natural dentition. In many countries, complete edentulism, a sine qua non for the elderly at the end of the 19th century, is now observed in only a minority of older adults.

This has produced profound changes in the oral health care needs of the elderly

Greater retention of the dentition predisposes individuals to a continual risk of caries—new coronal and root surface caries develop in addition to recurrent decay in proximity to existing restorations. Greater tooth retention also extends the risk of developing gingivitis and periodontal diseases.

 Age-related recession produces a myriad of hard and soft tissue disorders and increases an older person’s difficulty in removing plaque from all tooth surfaces. Importantly, dental and periodontal concerns form only some of the stomatological concerns of the older adult. Salivary gland hypofunction and its accompanying xerostomia afflict approximately one-third of the elderly, increasing their susceptibility to caries, gingivitis, and oral mucosal infections, and to experiencing difficulty with mastication, gustation, and swallowing.

Olfactory and gustatory changes in the elderly, which may be related to both aging and disease, contribute to altered nutritional selections, thereby complicating certain medical conditions. Finally, oral mucosal conditions, such as infections (eg, candidiasis), vesicullobullous diseases (eg, lichen planus), and neuropathic conditions (eg, burning mouth syndrome) can be uncomfortable and even debilitating, while neoplastic diseases (eg, squamous cell carcinomas) are life-threatening.The older adult is in greater need for oral health care services, yet the number of qualified care providers and facilities is shrinking. There are few formal geriatric dentistry training programs.

Those that exist face problems with hiring and retaining faculty with expertise in geriatric dentistry. Experience in addressing the oral health care needs of the elderly is not in general a widely marketable clinical skill in a profession where the delayed income stream and higher indebtedness of postgraduate training is difficult to justify without a corresponding assurance for greater remuneration in the future.

 Traditionally, a common mechanism for exposing newly graduated dentists to the care of older and medically complex individuals is via community- or hospital-based training programs. Yet with a current dental shortage and the lure of reducing indebtedness immediately after graduation, interest in these elective programs is waning. As general health care costs rise, government funds for nonmedical training are becoming increasingly limited—accordingly, some programs have shrunken or even closed over the past decade. Several major metropolitan areas in the United States of America are served by only a single hospital-based dental program despite the presence of multitudes of acute and extended care medical facilities.In addition to the shrinking number of dentists trained in addressing the oral health problems of medically complex patients, extended care facilities (home to the most compromised adults who are most vulnerable to oral diseases) are often unappealing sites for practice, due to numerous financial, facility, and transportation challenges encountered in those settings.

In summary, older adults are in greater need for oral health care services than ever before, yet they may be the least likely to receive services due to multiple factors: impaired access to care, insufficient funds and insurance reimbursement, inadequate motivation on the part of patients and providers, and fewer clinicians and institutional-based dental programs providing oral care services to medically compromised and older adults. Increasingly complex dental needs combined with fewer qualified dentists and facilities portends considerable problems in the future for the geriatric dental patient.What is missing to correct this picture? Three items: finances, interdisciplinary collaboration, and education.

There are financial limitations to providing oral health care to the elderly, which will continue to prevent many older adults from receiving even a modicum of services. Reimbursements from government and other health care insurance programs for oral health procedures have been negligible for decades. In the United States of America, for example, Medicare is statutorily precluded from covering dental services. Over the years, regulatory decisions have been made to include coverage for a limited number of medically necessary oral health care procedures: exams prior to heart valve replacement and renal transplant and extraction of teeth prior to head and neck radiotherapy. However, the vast majority of older adults who require diagnoses and treatments for oral diseases that affect their overall medical health are excluded from health care insurance reimbursement. Further, many adults who retire from the work force lose their dental insurance benefits, requiring them to pay for services out of pocket when they must simultaneously adapt to a fixed income for their retirement years.

Some of these financial roadblocks are rooted in the disassociation between the mouth and the rest of the body; that is, the lack of multidisciplinary collaboration between dentistry and medicine. It is well recognized in the dental community that many oral diseases can cause as well as exacerbate many medical conditions. Further, the oral cavity can help diagnose a host of medical disorders. Nondental health care professionals, educators, and public health specialists are not generally familiar with oral diseases and their effects on general health and a person’s quality of life; this has perpetuated an artificial separation of the mouth from the rest of the body.

Older adults are also not familiar with many oral diseases and the benefits of preserving oral health as part of overall health. For example, while many citizens are cognizant of cancers as frequent as lung cancer and as obscure as pancreatic cancer, it has only been recently that large educational programs have been directed toward oral cancer, a disorder that kills 1 person/hour in the United States of America and 1 person/5 minutes in the world. Common medical disorders such as diabetes have significant oral complications, but most adults are not aware of these associations, nor are they aware that dental professionals can assist in their care.

Oral health in the elderly—what is missing? The answer is inadequate financial incentives and reimbursements, insufficient qualified dental practitioners and facilities, a deficiency in the demand of services by patients, and a lack of multidisciplinary collaboration on behalf of the elderly. Patients, health practitioners in dentistry and medicine, educators, scientists, and government leaders should work together to: (1) increase educational efforts on the importance of oral health as a function of overall general health, (2) formulate plans to ensure that current and future generations of older adults will have access to dental care services, (3) enable older adults to be financially able to obtain oral health care services, (4) improve reimbursements to dental professionals and facilities for the care of the elderly, (5) provide research funds to increase the understanding of age– and disease-associated oral disorders affecting the elderly and therapeutic trials to reduce or eliminate oral diseases, and (6) develop strategies to increase educational opportunities for dental health professionals in geriatric dentistry. The comprehensive care of the older adult requires a multidisciplinary team of health care providers that includes patients, educators, scientists and government leaders.

Dentistry must be part of this team to develop better strategies to ensure that the next generation of older adults will enjoy good oral health and function for their remaining lifetime.