Oral Disease in Older Adults and Public Health
Oral Disease in Older Adults and Public Health
NHANES data con"rm that, compared with the general elderly population, untreated dental disease is higher among persons reporting poor general health, racial/ethnic minorities, and persons living in low-income families. These same groups are also more likely to report oral pain; food avoidance; self-consciousness or embarrassment because of their mouth, teeth, or dentures; and that life is less satisfying because of poor oral health. These impacts tend to be higher among persons aged 50 to 64 years compared with the older age groups.
Our "nding that persons reporting poor general health have higher levels of untreated dental disease that diminishes their oral health–related quality of life suggests that oral health should be better integrated into medical care. Because persons reporting poor health are more likely to visit a physician than a dentist, it is important that primary care providers and geriatricians be educated on common oral conditions, risk factors, and healthy behaviors along with the medical, functional, emotional, and social consequences of poor oral health. It is also important that new integrated care models (e.g., health homes) incorporate oral health expertise into a comprehensive set of services, especially because persons reporting poor health are signi"cantly more likely to have multiple chronic conditions. Finally, the "nding that more than 35% of the youngest elderly group who reported poor health also reported avoiding certain foods suggests that educating clinicians to recognize common oral conditions and to refer for subsequent treatment would not only enhance quality of life but also encourage healthier eating patterns that could result in improved long-term health.
Several factors highlight the importance of developing community programs to prevent and control oral disease among the elderly. First, demographic trends coupled with the fact that current and future cohorts of older adults are more likely than previous cohorts to retain their natural teeth indicate a future increase in the number of elderly at risk for oral disease. Second, the high levels of untreated dental disease among certain segments of the elderly, especially those aged 50 to 64 years, as well as the potential future shortage of dentists (the number of persons per dentist is expected to increase from 1712 in the mid-1990s to 1898 by 2020) suggest that future dental treatment needs will remain at their current levels or increase. Finally, leaving oral disease untreated not only diminishes quality of life but also may place the elderly at higher risk for other adverse health outcomes.
To successfully implement and effectively target such programs, systematic collection of data on the oral health status of the elderly will be required. The Association of State and Territorial Dental Directors has developed and validated a simple population-based screening tool that can be performed by trained nondentists to provide key information to assess dental care needs comparable to data previously obtained in Kentucky and Massachusetts. Congregate meal settings are 1 of the 2 recommended data collection sites because they serve higher risk community-dwelling older adults and have a set location and times when multiple adults can be surveyed. The second recommended data collection site is LTC facilities.
Important components of community programs would include education and improved access to effective preventive services. Through partnerships with the aging services network and organizations addressing aging issues, messages on older adults' need for and the effectiveness of fiuorides in preventing oral disease could be more widely disseminated to elders, their caregivers, health care providers, and policymakers. Innovative strategies to increase access to preventive care through medical settings and community programs should be explored. Approaches such as replicating the North Carolina experiment of using physician offices to screen for oral disease and deliver fiuoride varnish to very young children should be implemented and evaluated for older adults. In a similar way, providing fiuoride varnish in pharmacy settings, which have been shown to be effective in increasing infiuenza vaccine coverage among older adults, could be piloted. For the vulnerable (homebound and LTC residents) elderly, the effectiveness of alternative modes of fiuoride delivery, such as dietary prescription supplements, for persons who cannot brush their teeth, and partnering with associations that serve the homebound elderly to deliver fiuoride, should be explored.
A comprehensive strategy to address the oral health needs of the vulnerable elderly is also needed. Valid and reliable data on oral health status as well as accountability for LTC facilities to provide adequate daily oral hygiene care and access to regular preventive dental care are especially important for this group of older adults—at present, there are few incentives to provide such care. In addition, LTC residents and the homebound elderly are likely in poorer states of health than the elderly in the general population. Poor self-reported health is associated with cognitive and physical limitations that hinder the ability to adequately articulate dental needs, performdaily oral hygiene, or access necessary care.
An essential element of this strategy would be to implement and evaluate different approaches to ensure that more homebound seniors and LTC residents bene"t from daily selfcare procedures, receive oral assessments as the basis for individualized care plans that address provision of preventive care by trained personnel, and have access to restorative services when appropriate. To ensure adequate access for persons with limited mobility, the feasibility of different models to provide dental care onsite at LTC facilities (e.g., staffing and equipping dental operatories or contracting with mobile dental clinics) should be evaluated. Two possible approaches to increase LTC staff knowledge about oral health include having dental hygienists provide standardized trainings to existing LTC staff and creating a new LTC staff position for a geriatric dental practitioner (e.g., create a geriatric advanced practice dental hygienist similar to nurse practitioners).
Finally, because of the high levels of untreated disease among the poor and vulnerable elderly, the feasibility of ensuring a safety net that covers basic preventive care and restorative services to eliminate pain and infections should be examined. At present, about half of the states provide no or minimal dental bene"ts for adults enrolled in Medicaid. A "rst step would be to document the costs and consequences of leaving dental disease untreated. These "ndings could then be used to support coverage of select groups of elders. It has been suggested that a possible funding mechanism could be to add adult dental coverage to the Medicaid "aged, blind, and disabled" provisions.
Good oral health is essential to healthy aging. Because effective interventions to prevent and control oral disease exist, good oral health can be achieved by older adults. The public health system can play a vital role in ensuring that this occurs.
Roles and Priorities for Public Health System
NHANES data con"rm that, compared with the general elderly population, untreated dental disease is higher among persons reporting poor general health, racial/ethnic minorities, and persons living in low-income families. These same groups are also more likely to report oral pain; food avoidance; self-consciousness or embarrassment because of their mouth, teeth, or dentures; and that life is less satisfying because of poor oral health. These impacts tend to be higher among persons aged 50 to 64 years compared with the older age groups.
Our "nding that persons reporting poor general health have higher levels of untreated dental disease that diminishes their oral health–related quality of life suggests that oral health should be better integrated into medical care. Because persons reporting poor health are more likely to visit a physician than a dentist, it is important that primary care providers and geriatricians be educated on common oral conditions, risk factors, and healthy behaviors along with the medical, functional, emotional, and social consequences of poor oral health. It is also important that new integrated care models (e.g., health homes) incorporate oral health expertise into a comprehensive set of services, especially because persons reporting poor health are signi"cantly more likely to have multiple chronic conditions. Finally, the "nding that more than 35% of the youngest elderly group who reported poor health also reported avoiding certain foods suggests that educating clinicians to recognize common oral conditions and to refer for subsequent treatment would not only enhance quality of life but also encourage healthier eating patterns that could result in improved long-term health.
Several factors highlight the importance of developing community programs to prevent and control oral disease among the elderly. First, demographic trends coupled with the fact that current and future cohorts of older adults are more likely than previous cohorts to retain their natural teeth indicate a future increase in the number of elderly at risk for oral disease. Second, the high levels of untreated dental disease among certain segments of the elderly, especially those aged 50 to 64 years, as well as the potential future shortage of dentists (the number of persons per dentist is expected to increase from 1712 in the mid-1990s to 1898 by 2020) suggest that future dental treatment needs will remain at their current levels or increase. Finally, leaving oral disease untreated not only diminishes quality of life but also may place the elderly at higher risk for other adverse health outcomes.
To successfully implement and effectively target such programs, systematic collection of data on the oral health status of the elderly will be required. The Association of State and Territorial Dental Directors has developed and validated a simple population-based screening tool that can be performed by trained nondentists to provide key information to assess dental care needs comparable to data previously obtained in Kentucky and Massachusetts. Congregate meal settings are 1 of the 2 recommended data collection sites because they serve higher risk community-dwelling older adults and have a set location and times when multiple adults can be surveyed. The second recommended data collection site is LTC facilities.
Important components of community programs would include education and improved access to effective preventive services. Through partnerships with the aging services network and organizations addressing aging issues, messages on older adults' need for and the effectiveness of fiuorides in preventing oral disease could be more widely disseminated to elders, their caregivers, health care providers, and policymakers. Innovative strategies to increase access to preventive care through medical settings and community programs should be explored. Approaches such as replicating the North Carolina experiment of using physician offices to screen for oral disease and deliver fiuoride varnish to very young children should be implemented and evaluated for older adults. In a similar way, providing fiuoride varnish in pharmacy settings, which have been shown to be effective in increasing infiuenza vaccine coverage among older adults, could be piloted. For the vulnerable (homebound and LTC residents) elderly, the effectiveness of alternative modes of fiuoride delivery, such as dietary prescription supplements, for persons who cannot brush their teeth, and partnering with associations that serve the homebound elderly to deliver fiuoride, should be explored.
A comprehensive strategy to address the oral health needs of the vulnerable elderly is also needed. Valid and reliable data on oral health status as well as accountability for LTC facilities to provide adequate daily oral hygiene care and access to regular preventive dental care are especially important for this group of older adults—at present, there are few incentives to provide such care. In addition, LTC residents and the homebound elderly are likely in poorer states of health than the elderly in the general population. Poor self-reported health is associated with cognitive and physical limitations that hinder the ability to adequately articulate dental needs, performdaily oral hygiene, or access necessary care.
An essential element of this strategy would be to implement and evaluate different approaches to ensure that more homebound seniors and LTC residents bene"t from daily selfcare procedures, receive oral assessments as the basis for individualized care plans that address provision of preventive care by trained personnel, and have access to restorative services when appropriate. To ensure adequate access for persons with limited mobility, the feasibility of different models to provide dental care onsite at LTC facilities (e.g., staffing and equipping dental operatories or contracting with mobile dental clinics) should be evaluated. Two possible approaches to increase LTC staff knowledge about oral health include having dental hygienists provide standardized trainings to existing LTC staff and creating a new LTC staff position for a geriatric dental practitioner (e.g., create a geriatric advanced practice dental hygienist similar to nurse practitioners).
Finally, because of the high levels of untreated disease among the poor and vulnerable elderly, the feasibility of ensuring a safety net that covers basic preventive care and restorative services to eliminate pain and infections should be examined. At present, about half of the states provide no or minimal dental bene"ts for adults enrolled in Medicaid. A "rst step would be to document the costs and consequences of leaving dental disease untreated. These "ndings could then be used to support coverage of select groups of elders. It has been suggested that a possible funding mechanism could be to add adult dental coverage to the Medicaid "aged, blind, and disabled" provisions.
Good oral health is essential to healthy aging. Because effective interventions to prevent and control oral disease exist, good oral health can be achieved by older adults. The public health system can play a vital role in ensuring that this occurs.
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