Oral Health for the Elderly: Challenges and Opportunities
According to Ed Schneider, MD, Dean Emeritus of the University of Southern California’s Andrus Gerontology Center and former Deputy Director of the National Institute on Aging, in four years, the first Baby Boomer turns 65, and 100 million more will soon follow. Most of these elders will live into their 90s, and many will have some cognitive impairment. Up to 30 million could have Alzheimer’s disease. The Santa Fe Group met on June 28, 2007, to discuss how best to meet the needs of this booming elderly population and to identify necessary actions to improve their oral health. Offered here are synopses from the Group’s four panel discussions.
Shortly after retirement, about 80% of the elderly continue to see their dentists, according to L. Jackson Brown, DDS, PhD, associate executive director of the American Dental Association (ADA). As they age and their income declines, however, their visits to the dentist decline. This may appear to be linked to race, with a huge decline in dental visits among aging African-Americans, but Brown said the trend is most clearly linked to socioeconomic factors. “The poorer you are, the fewer teeth you have,” he observed. Likewise, elders who are disabled, edentulous, institutionalized, or who do not have in-home caregivers do not go to the dentist, according to Brown. “Their utilization rate is so low that it is startling,” he explained. Yet, as he further pointed out, there is no corresponding decline in visits to primary medical care physicians.
Those elders who are institutionalized, have severe or several chronic medical conditions, and/or are poor are most likely to not receive oral healthcare. When patients are admitted to a nursing home, it often means that they will never again see a dentist. About five percent of the elderly population lives in a nursing home, with most of that group being the oldest of the old; one in five women aged 85 or older live in a nursing home. “We don’t have the institutional capacity to deal with institutionalized people,” Brown said.
Jocelyne Feine, DDS, of McGill University in Montreal, tackled the topic of denture disability for the Santa Fe Group. Feine said dental practices should concentrate on preventing extraction and, when that is not possible, provide implants to make the dentures as comfortable as possible. Osseointegrated intraoral implants for the lower jaw greatly improve the quality of life among wearers because they are more stable and less painful than standard dentures, she said. Feine’s research shows that inexperienced new dentists could provide simple mandibular implant overdentures as effectively as prosthodontists. “Yet they are not standard practice among dentists,” she said.
Because implants are seemingly more difficult to place and initially more expensive, costing about $200 to $400 more per year than dentures, they are not yet a standard practice, Feine noted. However, Feine said the improvement to patients’ quality of life outweighs these costs. Emerging research shows a link between edentulism and cognitive disorders such as Alzheimer’s disease among the elderly, perhaps because of a lack of nutrition once elders begin wearing dentures.
In Europe, implants are already the standard of care, Feine observed. To effect such change in the United States, Feine said advocates need to lobby on behalf of the older and poorer populations who cannot represent themselves to policy makers.
Kenneth Shay, DDS, of the Veterans Affairs (VA) Office of Geriatrics and Extended Care, addressed members of the Santa Fe Group about dental care for VA patients. Shay explained that dental care eligibility among veterans is fairly complex and largely legislatively dictated. VA nursing home residents are eligible for dental care by virtue of being in-patients. Yet the VA’s dental system—which prioritizes the recently discharged and those who receive sizable compensation for injury attributed to their military service—combined with provider preferences, often limits the degree to which this actually occurs.
With 42% of the nation’s 25 million veterans being over the age of 65, the department has definite experience in dealing with geriatrics. And, with 134 VA hospitals each boasting a dental clinic, it also has experience providing dental care to old and medically complex patients. Even so, according to Shay, most dentists in the VA environment are most comfortable working with patients who present straightforward dental challenges and gravitate away from veterans who are old and sick. “I don’t think most people want to be older or frail themselves and they transfer that feeling to not wanting to be around old and frail people,” said Shay, who continues to treat frail elderly patients at a VA hospital.
Furthermore, most VA dentists are not accustomed to working on the interdisciplinary teams that are the backbone of institutional medicine. What this means is that as long as there are not enough dentists to treat everyone, the less-desirable patients—the vulnerable elders—will be the most likely to not be treated, he said.
According to the findings of the Oral Health Equity Project (OHEP), the number one complaint of Boston elderly in home care is a lack of oral healthcare, said Michelle Henshaw, DDS, MPH, assistant dean for Community Partnerships and Extramural Affairs and an associate professor at Boston University’s Goldman School of Dental Medicine. OHEP was a pilot program that focused on 1,000 low-income elderly city residents whose mobility is severely limited and who lived in public housing. OHEP brought preventive care and screenings on-site to public housing. Those who needed further treatment worked with case managers to transfer them to facilities for care.
Students from the schools of dental medicine at Boston University, Harvard University, Tufts University, and the Forsyth dental hygiene program at the Massachusetts College of Pharmacy and Allied Health Sciences provided the care, proving that service learning and experiential education work in dental curriculum, Henshaw noted. The project also shows that triaging and educating the public increases demand for services in community settings. Simply put, advocacy increases care, Henshaw said.
Today the United States has about 200 geriatric dentists, although a 2005 survey showed a need for 7,000. That projected need jumps to 10,000 by 2010. The stage is set for a “brain drain” of geriatric dentist mentors as current mentors begin to retire and fewer new dentists take on that role, said University of Colorado professor Douglas Berkey, DDS.
All demographics suggest that the future of dentistry is geriatrics. Yet dental schools continue to reflect America’s youth obsession. Even when schools do integrate geriatrics, the focus is on younger, healthier elderly. Students are not prepared to deal with the oldest seniors, Berkey said. In fact, of the approximately 4,100 annual dental school graduates, only 2% pursue a career in geriatrics.
This apathy towards the aged is somewhat understandable, Berkey remarked. As students, dentists get little or no experience dealing with elderly patients who cannot get to a medical center. Dental students have few experiences with nursing home residents and little experience in dealing with family members who may be their patients’ caretakers.
Dental schools need a major overhaul to meet the oral health needs of the elderly, Berkey noted. Today, the curriculum is fragmented. Clinical requirements divert students’ attention away from caring for the patient as a whole to focus on caring for the tooth alone. Didactic reinforcement in geriatric dentistry is lacking. Interdisciplinary experience in geriatric dentistry does not exist in most curricula. “Students need to get eyeball-to-eyeball with older patients to understand their unique oral health issues,” Berkey commented.
Yet schools can be re-engineered with seniors in mind. Berkey shared the ADA Task Force on Geriatric Dentistry’s recommendations, which include a need for more advanced geriatric dentistry programs, the inclusion of dentistry in interdisciplinary geriatric settings, and seeking support for geriatrics from state and federal legislators.
Going beyond those recommendations, Berkey told the group that more emphasis on geriatrics needs to be included in postdoctoral programs and more clinical experience is needed for current students.
While working with seniors, most of whom have multiple health problems, may be more intellectually fulfilling, it is often more draining on a dentist’s budget. After all, geriatricians spend more time with elderly patients and get paid less. Recent graduates may think they will not be able to pay off their loans, said Ageless author Dr. Edward L. Schneider, MD, dean of the Leonard Davis School of Gerontology and the Santa Fe Group’s keynote speaker.
One of the first steps could be including dentists from the start on the idea of advocating geriatrics. “All dental schools should become unified on this issue,” said Dr. Arthur Dugoni, University of Pacific’s dean of dentistry, “because oral healthcare is important to general healthcare.”
Alice Horowitz, PhD, of the University of Maryland, talked with the Santa Fe Group about health literacy. Health literacy is dependent on the communication skills of both consumers and providers, she said. Culture and society influence literacy on both sides. Patients need to value oral health in addition to understanding the information dental professionals give them. Providers need to consider how they think or feel about racial, ethnic, and economic groups different than their own.
Just getting to the dentist requires health literacy, as patients need to be able to locate and navigate a health facility; read, understand, and complete medical forms; be able to express their symptoms; and know which health professional they need to see. Once at the office, communication is tricky because patients are often stressed about their condition and the doctor’s support staff may not be empathetic.
But lack of literacy is not just dangerous for patients. It is also expensive to the industry, Horowitz said. A 1998 study showed that the annual cost of poor health literacy is $30 billion to $70 billion. This includes the cost of treatment services vs preventive care that patients with poor literacy do not know how to use. Old, poor, uneducated, and non-English speakers have the poorest health literacy.
At the root, health literacy is about understanding, Horowitz said. Consumers need to understand medical and dental concepts. Dentists need to understand how to relate to their patients. Furthermore, people need to know how to be patients, Horowitz said.
The reason dental care is not included in many insurance plans comes down to economics. “If there isn’t any money, it isn’t going to happen,” said Kathleen O’Loughlin, DMD, MPH, president and CEO of Dental Service of Massachusetts (Boston, MA), panel chair, and Santa Fe Group member. “For dental plans to be included in insurance and government programs, we have to find a way to pay for it. Right now, about half of seniors’ dental services are paid out-of-pocket, meaning dentists have to begin thinking of patients as price-sensitive consumers. And these consumers need to be able to see the benefits of treatments,” she added.
“We need to get this population to think of dental (care) as part of caring for the systemic general health,” said Dr. Lowell Daun, the senior vice president of Delta Dental of California.
Right now, the dental insurance world is “a ghetto” alongside life insurance, with medical insurance and retirement savings towering above in priority among consumers, said John Brouder, a political scientist and consultant in dental insurance. In fact, Oral Health America gave the nation a “D” grade for private dental coverage in a special 2003 grading report titled, “The Oral Health of Older Americans.”
Voluntary and American Association of Retired Persons (AARP) dental plans may meet the needs of affluent or even middle-class seniors, but the vulnerable elders—the ones who are frail and poor—likely fall into the cracks. They qualify for Medicare and may also qualify for Medicaid. But if these elders do qualify for both plans, they have to deal with separate organizations—one federal and one state. They have separate forms, qualifications, and standards. Add to this the fact that many in this population are health illiterate, and few are getting the best, most efficient care. Preventive care and quality of life are likely to be pushed aside.
Organizations like Senior Whole Health offer a viable alternative. The Massachussetts-based health plan was designed for those elders who qualify for both Medicare and Medicaid, the so-called “dual eligibles,” said John Baackes, CEO of Senior Whole Health (Boston, MA).
Care management for the clients, a third of whom do not speak English and 20% of whom are illiterate, becomes the focus, Baackes told the Santa Fe Group. The organization takes on the risk for Medicare and Medicaid benefits by offering a provider community to clients for physicians, emergency, social services, hospital, behavioral, and nursing home services, including dental care. It has become profitable by being able to better navigate the federal and state programs, and manage clients’ health optimally. Senior Whole Health aims to prevent a large drain of Medicare and Medicaid resources for more expensive services like hospitalization and nursing home care.
Under the Senior Whole Health plan, each client is given a nurse/care manager who acts as that person’s patient advocate. The manager checks in with patients, even conducting home visits, to monitor care. Managers will coordinate visits between patients, caregivers, and physicians, and a non-nursing staff member helps out with social issues. This may mean making sure that patients have transportation to doctors’ offices, food stamps, or heating assistance, and access to home- or community-based services. “It does take a village, even with these older folks, to do what needs to be done,” Baackes said.
When it comes to oral health, Senior Whole Health offers both clients and dentists advantages. For the clients, most of whom have been poor all of their lives and have limited restorative care, the plan means access to a dentist for perhaps the first time. For dentists, the care manager means assurance that missed appointments, which happen often with dual-eligibles, are curbed. It also means that they are up-to-date on polypharmacy issues that may otherwise have been overlooked.
Having personalized care sounds like more work for healthcare companies, but it actually makes the system much more efficient, Baackes said. Case management allows Senior Whole Health to take the public money allotted for seniors and use it more efficiently by emphasizing preventive care. While there is always the risk that clients will get sick and need hospitalization, many will be able to stay home through the end of life, enjoying a better quality of life than before they joined the program, he noted.
Traditional insurance companies are not going to acknowledge that the mouth is part of the body until enough funding can convince them of the connection. Those with the money—affluent or middle-class seniors—have options for dental insurance. But even those who can afford dental insurance may opt not to buy it if they are not given price-sensitive and outcome-based care. Those who are poor, frail, and rely on government programs for healthcare are not likely to visit their dentist at all. After all, those programs continue to view oral health as optional, despite the proven systemic health link.
Throughout the Santa Fe Group’s discussions, the need for advocates was echoed. The Group envisioned a leader who could blaze the way for the public and the government to reconnect the mouth with the rest of the body. Furthermore, it illuminated the need for advocates to speak on behalf of the poor, frail, and elderly who cannot make themselves heard. In addition, health education is needed to raise awareness about the relationship between oral health and quality of life. The Group saw the need for advocacy even in dental schools, where students’ idealism can become overshadowed by inexperience and where integrated healthcare concepts are not rooted.
As Dominick DePaola, DDS, MS, President & CEO of the Forsyth Institute and Santa Fe Group Founding Member, said during the meeting, "Reform won’t happen if no one believes there is a crisis, and if no one has created a compelling vision of the future."