Public health dentist Mark Nehring remembers attending a lecture on geriatric treatment 20 years ago. The speaker offered up slides of a patient with ample evidence of previous dental care: "crowns in place, very good fillings," Nehring recalls. "But there was gum recession, inflammation and decay that had undermined or even ruined some of the crowns."
The patient, it turned out, was no stranger to a dental office—he was a retired dentist. "Here's a knowledgeable person who spent a lot of time and effort to have good dentition, but the aging process took its toll on his ability to maintain his own oral health," says Nehring, the Delta Dental of Massachusetts Professor and chair of public health and community service at Tufts School of Dental Medicine.
The elderly dentist is typical of many in his age group. Whether through physical frailty, cognitive decline, financial hardship or the inability to get to a dental office, older Americans often cannot take good care of their teeth, even if they were model patients in their youth. This, in turn, affects not only their oral health, but their overall health and well-being.
The lecture Nehring attended two decades ago could easily have happened today. In fact, geriatric dental care has become more urgent than ever as the "silver tsunami"—the demographic tidal wave of Americans turning 65—floods the health-care system.
Compounding the issue is that the needs of older dental patients today are more challenging than in the past. "This is the first generation to anticipate dying with their teeth," says Ralph Katz, D69, a professor at NYU College of Dentistry and an expert in geriatric dentistry. People are reaching age 65 with better oral health than their parents, thanks to advances in dental treatment, the advent of implants and improved public health outreach. The baby boomers were the first generation to grow up with fluoridated water, for example. But maintaining a mouthful of teeth is more complex, and costly, than wearing dentures. And there is still great unmet need, particularly for low-income seniors.
The task for the dental profession, dental educators and policymakers will be to develop new models of care, to prepare a workforce to provide that care and to conduct research with geriatric patients in mind. At Tufts, where a geriatric dental program has been offered to predoctoral students for 30 years, training the next generation of dentists for the onslaught of aging patients is a priority.
The Graying of America
"A very broad team approach is what's needed," says Hilde Tillman, D49, professor and director of Tufts' geriatric dentistry program. "And what is absolutely clear is that the time is now, because we know what the increase in the elderly population is going to be." The U.S. population age 65 and older grew from 35 million in 2000 to 40 million in 2010—and is projected to jump to 55 million by 2020 and 72 million by 2030.
At the beginning of his academic career in geriatric dentistry in 1970, Katz saw the first inklings of what might be lurking 30 years down the road. In light of the shifting demographics, Katz and his peers thought commitment to an older patient population would surely grow—but that was not to be. "America got distracted," he says, and money for and interest in geriatric dentistry was not forthcoming.
Now that the silver tsunami is here—the first of the baby boomers, those born in 1946, turned 65 in 2011—interest has returned. "This is the second coming of the awareness of the graying of America, because it is upon us now," Katz says. "It's no longer a matter of trying to get ahead of the curve."
Every day, approximately 10,000 Americans retire—and with retirement often comes the loss of workplace benefits, including dental insurance. Dental coverage is not provided under Medicare, and supplemental private policies are often expensive. Dental plans are available in some states through the insurance exchanges established under the federal Affordable Care Act, but they are not mandated under the law.
The federal government estimates that 70 percent of seniors lack dental insurance. That's significant, because research has shown that seniors who have such coverage are far more likely to go to the dentist. A 2013 report from the nonprofit Oral Health America (OHA) presents a gloomy picture of the overall oral health of the nation's senior citizens, as reflected in the report's title, "A State of Decay." Contributing factors, the report says, are the lack of adult dental benefits through Medicaid programs in almost half the states and dental workforce shortages in almost two-thirds of the states.
In addition, poor or minority seniors are much more likely to have inadequate oral health, according to OHA. Older African Americans are almost two times more likely than their white counterparts to have periodontitis; low-income older adults have twice the rate of gum disease than more affluent seniors, and elders living below the poverty line are 61 percent more likely to be edentulous.
The implications of poor oral health extend far beyond the mouth. The inability to chew affects people's nutritional status, missing teeth or mouth pain affects speech and embarrassment over appearance can lead to social isolation. Plus, systemic health is endangered. "In dentistry, we've always known that oral health and general health are not disconnected," says Tillman.
That's particularly important for the geriatric population—approximately 80 percent of those over age 65 have at least one chronic condition. Diabetes, for example, affects 10.9 million people over the age of 65 in the U.S., or roughly 27 percent of that demographic. The connection between diabetes and periodontal disease has long been of concern to dentists—but there are now indications that controlling periodontal disease can help control diabetes, says Bjorn Steffensen, professor and chair of periodontology at the School of Dental Medicine.
Similarly, researchers are investigating the links between cardiovascular disease, the leading cause of death in Americans over age 65, and periodontal disease. Although it's still too early to reach a definitive conclusion, many studies raise suspicions that periodontal disease could contribute to inflammation throughout the body, which in turn could affect the heart, Steffensen says.
The Issue of Access
Benefits for routine dental care are not included in Medicare, the federal insurance program for older Americans. A package of dental-care reform legislation proposed last year by U.S. Sen. Bernie Sanders of Vermont includes a provision adding dental coverage to Medicare benefits, but it is not expected the measure will garner enough congressional support.
Some oral health advocates, including the American Dental Association, say the priority should be expanding dental coverage under Medicaid, the federal insurance program for low-income people of all ages, including seniors. Medicaid benefits are determined on a state-by-state basis, and can fluctuate from year to year, depending on budget needs and the political climate. Even in states that provide Medicaid benefits to adults, the covered services can be limited, and because of low reimbursement rates, many dentists do not accept Medicaid patients.
"The elder community is more diverse than other age cohorts," says Michael Monopoli, D81, director of policy and programs for the DentaQuest Foundation in Boston, the philanthropic arm of the dental benefits administrator DentaQuest. The "younger" elderly—the baby boomers and other newly retired people who are living on their own—"are the ones who have the most capacity to pay out of pocket; they will find a way to get care," he says.
Those who are older or those with significant medical problems, including cognitive issues such as dementia, are more at risk for not receiving regular dental care, Monopoli says. "They often have significant barriers to getting the care they need."
Elders who can no longer care for themselves, particularly those who live in institutional settings, are the most vulnerable. In 2009, according to the U.S. Department of Health and Human Services, approximately 13 percent of people over age 85 lived in nursing homes, where attention to oral health is notoriously undervalued and often ignored, geriatric dental experts say.
"In nursing homes, frequently the staff is not good about maintaining oral health, not like they are about preventing bed sores or preventing falls," says Athena Papas, J66, the Erling Johansen Professor of Dental Research at the School of Dental Medicine. "Somehow, going into someone's mouth is difficult for them." Or patients with dementia may recoil from having someone touch their mouth. The problem is not new, Papas says. "It's really sad. I did a survey of 28 nursing homes back in the '80s, and the same findings that I found then are still persisting."
In the past, in fact, most elders arrived at nursing homes wearing dentures. Now they are more likely to have their own teeth—opening the door to more complex dental woes. "In the past, you didn't have to deal as much with periodontal disease, tooth decay, infection, amputated crowns, things like that," Papas says. Another issue is that the vast majority—up to 88 percent—of all seniors take at least one medication, and most medications affect salivary flow, she says. Hundreds of commonly prescribed medications—including those used to treat hypertension, arthritis, depression and Parkinson's disease—can cause xerostomia, or dry mouth, which puts people at higher risk for tooth decay.
Oral care for nursing home residents has been mandated by federal law since 1987. But an "underlying flaw" in the system, says Katz, is that there is no consensus on the definition of neglect of oral health—and thus, lack of enforcement. "As with other social and health-care issues, there must be an enforceable law," he insists.
The ADA, as part of its Action for Dental Health campaign, has set a goal of developing a series of state programs to improve care for residents of nursing homes by 2015. As of the end of 2013, at least 17 state dental associations had either expressed interest or had begun developing a program, says Barbara Smith, manager of geriatric and special needs populations for ADA.
The ADA has also set a goal of training at least 1,000 dentists in nursing home care by 2020. The association is developing an online continuing education series to help oral health professionals better understand the nursing home environment, Smith says. The course will include material about the culture of long-term care facilities, legal and regulatory issues and reimbursement options, as well as advice on working with patients with complex medical problems.
Steps and Solutions
Of course, the best-case scenario is for seniors to be supported so they can maintain their independence and remain in their own homes—and out of institutional settings—for as long as possible. "The right supports can keep them at home and safe and healthy, and those supports should include access to oral health care services," says Monopoli.
One step toward that goal, Monopoli says, is increasing cooperation between oral health and other medical providers. "It is important that people are aware of the artificial separation of the mouth from the rest of the body," he says.
That concept flows well into the integrated model of health-care delivery that is beginning to take hold in the U.S. In Vermont, for example, leaders of a state health program known as Blueprint for Health hope to find ways to incorporate dental services into their network of primary care practice sites supported by community health teams, says Craig Jones, Blueprint's executive director.
A study of senior citizens in Ohio by researchers from Case Western Reserve University in Cleveland that appeared in the February 2014 issue of the Journal of the American Dental Association looked at what makes older adults more likely to visit the dentist. Previous research had established that factors such as having dental insurance, a higher income or more education played a role.
The authors also discovered that living in an area with more dentists made it more likely that seniors would seek out oral care, independent of other factors. "Focusing only on individual economic barriers without addressing community problems might be an incomplete strategy," the researchers wrote. "This finding implies that specific policies attracting dentists to practice in dental service shortage areas are necessary."
In Maine, which has the nation's highest median age and also ranks 35th in access to dental care, health-care officials are indeed interested in just that idea. "We've known for some time that there is a shortage of access to dental care in part of the state," says Peter Bates, senior vice president for medical and academic affairs at Maine Medical Center in Portland.
A new Tufts postgraduate Advanced Education in General Dentistry (AEGD) program at the medical center and community dental sites in five Maine towns was designed to train dentists to work with patients with complex needs, including the elderly—and to encourage them to stay in Maine. "One of the focuses for us was to help support the underserved population, while trying to convince professionals to come practice in the state," says Bates, a professor of medicine at Tufts.
More training opportunities are also needed for dentists who want to focus on geriatrics, says Tillman, who started Tufts' academic program more than three decades ago. Unlike in medical practice, geriatrics is not a recognized specialty within the dental profession, and one reason is there are not enough providers trained in it, she says.
Regardless, almost all of today's dental students will be treating a significant number of seniors in their practices as the silver tsunami crests. Approximately one-quarter of the patients seen in the Tufts predoctoral clinics in 2013 were over age 65, and in the postgraduate clinics, 16.6 percent were over age 65. As part of the geriatric program, Tillman also takes Tufts dental students on community outreach visits to 30 sites a year, including senior centers and assisted-living complexes.
For young students, those experiences are important, says Nehring, of the department of public health and community service, and not just for their clinical training value. "Visiting elders through outreach gives students an awareness of health conditions within the community we don't otherwise see, because many elders are behind doors we don't walk through on a daily basis," he says.
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