Among the groups in the United States with the most limited access to dental care is the population residing in long-term care (LTC) facilities. When we think of a LTC resident, the mental image we have is of a wheelchair-bound elderly woman in a nursing home. While this is generally correct, it is incomplete because only about 5% (1.6 million) of those over age 65 are in nursing facilities.1 The remaining 95% live either at home or in an assisted living arrangement where, if long-term care is required, it is provided by a relative or by home health aides. These groups make up the LTC population. This article, however, focuses on LTC residents in nursing homes because they are the ones who are the most incapacitated and for whom dental care is often only marginally available. Once they enter a nursing home, their access to adequate dental care drops markedly. Estimates of the percentage of these patients with unmet dental needs range from 80% to 96%.2,3 This problem is likely to worsen when the baby-boom generation reaches the age when a substantial number will require LTC in a nursing home.
What are the dimensions of the problem today? According to the US Census Bureau,4 in 2000 there were nearly 35 million persons over age 65, with 16.6 million of them over age 75. Those over 85 (4.2 million) are now the fastest-growing group in the population. The 1,600,000 persons in the nation’s 17,000 nursing homes during 2000 were age-distributed as shown in the Table.
Studies during the past decade indicate the following statistics concerning those in nursing homes in 2000:
• women outnumbered men by approximately 3:15;
• the typical resident needed help with four activities of daily living (ADLs), which are bathing, dressing, eating, toileting, and transferring—as from a bed to a chair6;
• two thirds relied on Medicaid to pay for their care7;
• more than 50% had some form of dementia or memory impairment, and these residents are likely to have a length of stay ten times the national average for all other medical diagnoses8;
• 6% were confined to bed6;
• 80% took six or more medications daily9;
• up to 78% had untreated caries9;
• more than 40% had periodontal disease10;
• up to three quarters of those over 65 had lost some or all teeth9;
• more than half of those over age 75 were edentulous10; and
• 80% of those who had lost all teeth had dentures, but 18% did not use them.10
The typical nursing home resident today is a woman about 80 years of age who is likely to spend from 1 to 3 years in the facility. There are several reasons for the marked preponderance of women. A woman’s life expectancy is several years longer than a man’s, and most men in the United States marry women younger than themselves. If the husband reaches the point where he needs LTC, the wife is often the one to care for him at home. However, by the time the wife needs care, the husband has often died and children are frequently too far away or unable or unwilling to provide the care needed. The wife then enters a nursing home, unless she can afford to pay the high cost of trained home aides.
Once a person enters a nursing facility, his or her chances for adequate dental care diminish greatly. A 1995 survey of 16,000 nursing homes in the United States revealed that at least 60% had no regular dental services available, except on emergency call or off-site, and 1,700 offered no dental care at all.11 This is unfortunate for many reasons. There is a growing body of evidence that when adequate dental care is absent, patients are at greater risk for life-threatening conditions. A recent study from Japan indicated that compared with patients who did not receive such therapy, weekly dental hygiene visits administered to patients in LTC was associated with significant reduction in the occurrence of fever and pneumonia.12 The links that have been reported between periodontal disease and many systemic conditions, including diabetes,13 pneumonia,14 and coronary heart disease and stroke,15 and the failure to care for periodontal conditions, may place the residents at greater risk for these systemic disorders. Furthermore, as oral health worsens, enjoyment of food deteriorates. Loss and non-replacement of teeth has a major negative influence on self-image and quality of life, and oral discomfort is one more chronic disability that these patients must bear.
All patients admitted to a nursing home should have a complete dental examination by a dentist using a dental chair or other adjustable chair, a good dental spotlight, water, air, and suction. The mouth should be charted, including carious teeth, periodontal conditions, and oral lesions. Patients should be treated and then seen periodically, at least annually. Ideally, an oral hygiene program should be started and maintained at all nursing home facilities.
The reasons that this sequence is not followed include:
(1) Minimal dental examination and follow-up. Nursing homes that receive Medicare or Medicaid reimbursement are required by law to perform an oral examination as part of a comprehensive physical exam when a new resident enters. This examination is part of a Minimum Data Set that is supposed to be performed within days of a resident being admitted to a facility, and then annually thereafter. Nursing homes are also supposed to prepare a Resident Assessment Protocol that requires automatic referral for dental care if any of the following conditions are found: “mouth pain; debris in mouth prior to going to bed at night; natural teeth lost and no dentures; broken, loose or carious teeth; infections; and no daily cleaning of teeth or dentures.”16 However, the oral screening involved is frequently limited and is often performed by a nurse rather than a dentist. Even when problems are found, there is evidence that little or no follow-up care is provided in many homes.17,18 Furthermore, some homes do not come under Federal statutes, and state laws vary greatly.
(2) Decreasing ability of the resident to care for self. Residents are often unable, because of stroke, arthritis, other medical disabilities, or cognitive deterioration, to perform oral hygiene procedures. They must rely on nurses and aides to perform oral hygiene for them or to help them to do it themselves. Many residents are preoccupied with the serious physical problems that brought them to the nursing home. Oral hygiene seems less important to them. The large number of patients with dementia are not concerned with the need for oral hygiene. Directors of nursing in a Nebraska study felt that it was the residents’ inability or lack of cooperation in oral hygiene procedures that was the major influence on their oral health.18
(3) Dementia and related conditions. The more than 50% of residents who have some form of dementia may be unable to report dental problems coherently, and such residents can be difficult to manage during treatment. Special training and skill are required to perform even simple procedures for a patient in the later stages of Alzheimer’s disease or related conditions. An aide must be very well trained and experienced to be able to consistently perform oral hygiene procedures for these residents. Because the over-85 population is growing rapidly due to advances in health care, the percentage with dementia is likely to increase.
(4) Ignorance on the part of the facility’s staff about oral health results in apathy and disregard of the residents’ dental needs. Staff members are more concerned with keeping the residents from becoming malodorous and cleaning those who are incontinent. As one administrator commented, “(If) they’re not complaining of a toothache, (if) we don’t see any massively red gums or bleeding, or what we know to be infection…and they seem to be eating OK…then we would say…things are fine….”19 Additionally, many nurses feel insecure about managing dental conditions and give oral health a low priority. There is little standardized training of nurses in oral care, and nurses’ organizations do not emphasize it. Many nurses would welcome more training and support by dental professionals.16
(5) Culture of the older age group. A nursing home administrator commented in a survey, “This is a generation that goes to the doctor or dentist as an absolute last resort.” They are often embarrassed to ask for care.18
(6) Shortage of nurses and nurses aides. The Joint Commission on Accreditation of Healthcare Organizations reported an ongoing nationwide shortage of 126,000 nurses. Ninety percent of nursing homes report an insufficient number of nurses, even to provide basic care.20
(7) Absence of on-site dental facilities. In a 1998 study of 200 nursing homes in Nebraska, only about one third had on-site dental treatment capability, and dental care was offered monthly or more frequently in only 26% of the homes.18
(8) Monetary reasons for failure of residents to seek dental care. By the time they reach the age when LTC is needed, most residents no longer have dental insurance. A large majority are receiving Medicaid to cover the cost of their nursing home occupancy. Medicaid rarely covers any but the most basic dental services, and most residents do not have discretionary income to pay for dental services.
(9) Shortage of dentists willing to care for the LTC population. The greatest single barrier to dental care for nursing home residents is inadequate or nonexistent funding by Medicaid and residents’ inability to self-pay.
Other reasons given for this shortage include:19
• poor or no dental facilities within the nursing homes;
• cost and difficulty of transporting portable equipment to LTC facilities;
• extra time required to care for frail and disoriented patients;
• existing practices are too busy for a dentist to devote time to what is usually an unprofitable part of practice;
• frustration with the apathy and poor oral hygiene of the residents;
• inadequate training in the management of geriatric patients, especially those with dementia problems (many of whom may require special management); and
• residents’ and the administrators’ desire to have care performed on-site, while dentists prefer to perform treatment in the familiar setting of their offices. Some nursing homes will only provide transportation to a dental office at the expense of the resident or the family.
As difficult as this situation is now, the problem of providing care for LTC residents is likely to become far more severe in the next few decades as the baby boomers reach age 65. By 2031, these individuals will all be 65 or older and the oldest will be 85.21 As they age, and some enter nursing homes, these huge numbers will strain the dental care resources of LTC facilities. This will occur at a time when projections indicate that the proportion of dentists to the population will be shrinking.10
(10) The generation gap. An interesting, though undocumented, generalization about the baby boomers and their parents (the current residents of nursing homes) may be appropriate. Those now in nursing homes were children during the depression of the 1930s. They went through rationing in World War II and they tend to conform and accept the decisions of authorities. They are far less demanding about their medical and dental needs than their children. They are more accepting than their children of what life deals them. In contrast, the large population cluster within the baby-boom generation has led them to expect that society will generally meet their needs and wishes.22 They are more likely than their parents to insist on retaining their teeth and will demand dental services. They will expect to continue receiving it as they age, and some enter LTC facilities, but the numbers of dentists willing and able to provide such care will be far too low unless the problems listed previously are overcome.10,23
WHAT CAN BE DONE TO IMPROVE THE SITUATION?
ADA Resource Book
The ADA has recognized the problem of caring for this segment of the older population and has published a resource book for dentists who wish to consider treatment of patients in LTC. It points out that a relationship with a nursing home may be helpful to a young doctor just starting to build a practice because of the exposure it provides to the families of residents. The book describes several modes of dental care that are used to care for patients in LTC facilities. The first and most effective is to have the resident transported to the dentist’s office because of its more complete facilities, but other modes of care are also addressed, including portable and mobile equipment. The book suggests sources of information about the various problems involved, such as those mentioned previously. These include the dentist’s legal relationship with the nursing home as employee or independent contractor; informed consent for treatment that may have to be obtained from the patient’s family or guardian; infection control problems; and responsibility for adjustments to restorations or prostheses placed by the resident’s former dentist. This resource includes a suggested list of points to be considered in the contract between the dentist and the nursing home. The contract should be carefully reviewed by the dentist’s attorney and edited to meet the specific needs of the arrangement.9
An on-site dental treatment room makes treatment relatively simple and straightforward. However, the costs of construction, installation of utilities, equipment, radiation shielding, and supplies for a single dental treatment room are high, (even with second-hand equipment), and especially if sedation capability will be needed. The average nursing home in the United States has 107 beds and only 8% have more than 200 beds.10 The dentist, assuming there is one who comes on a regular basis, is usually there no more than 1 day per week, so that the dental operatory is likely to stand idle most of the time. It is not known how many nursing home operators would be willing to invest a substantial amount of money for such an underutilized asset, unless required to do so by statute. An alternative used by some dentists is to seat the patient in an adjustable chair in another location and to use a headlamp in place of a dental spotlight. While this arrangement might be barely adequate for an oral examination, it is unacceptable for any sort of meaningful treatment, and it makes no provision for radiographic services.
Even a rudimentary on-site dental facility might be adequate for most of the dental needs of ambulatory residents or those in wheelchairs, but some other arrangement must be made for the 10% of residents who are confined to bed. Here, portable equipment, including a spotlight or headlamp, is essential, and the dentist must be trained to operate in positions that are often awkward.
Transfer to the Dentist’s Office
This is the method of treatment that is preferred by most dentists because the care takes place where familiar and complete equipment and supplies are available. However, nursing homes do not favor such an arrangement. A staff member must usually accompany the patient and is therefore unavailable to help other residents. Excessively hot or cold weather or precipitation can present a hazard to frail patients. Many elderly patients cannot sit for long periods in a dental chair. Dental office personnel must be made aware of the special needs of these patients, including having to go to the bathroom frequently. A series of studies in the 1970s and 80s indicated that the percentage of patients who could be transported effectively from a nursing home to a dentist’s office ranged from 34% to 90%.24
Mobile Vans and Portable Equipment
Other means of delivering dental services to nursing home residents include mobile vans and portable equipment that may be set up in each facility. A typical van or trailer might have two dental chairs and much of the other equipment found in a dental office. However, problems that must be overcome include initial cost, maintenance, and the number of patients that may be seen per day. Portable equipment can be used within the nursing home, but setup and dismantling can be cumbersome and time-consuming, and only a limited number of treatment options may be available.25
Courses in Geriatric Dentistry
Increasing numbers of dental schools now provide training and experience at the predoctoral and continuing education levels in the care of elderly, fragile patients. The area where training is particularly necessary is in management of patients with various forms of dementia.
The Geriatric Nurse Practitioner
A new group of nursing professionals, the geriatric nurse practitioner, has been introduced into nursing homes in recent years. These are nurses who have received advanced training in the care of the elderly, with emphasis on management of residents with dementia, and who have some of the prerogatives of the physician.26 They can perform daily assessments and issue medication and treatment orders. They are a potentially excellent resource for the dental care of the residents because they are respected by the rest of the staff. Once they are properly trained by a dentist or hygienist, they can be utilized to train the staff in how to care for the residents’ oral hygiene needs and how to do a more complete screening examination.
While some of the measures mentioned may help to overcome the inadequacies of dental care, the greatest obstacle to dentists’ participation is the issue of payment for services. Until dentists can be adequately compensated for the time needed to care for the nursing home population, most are unlikely to participate. Recently, a step was taken to address the problem of loss of dental insurance by older persons. Delta Dental, in cooperation with the American Association of Retired Persons (AARP), has introduced a trial open-enrollment PPO plan in Maryland, Texas, and the District of Columbia.27 Enrollees are given a list of Delta participating dentists in their area and receive maximum benefits if they are treated by one of these dentists. They are free to go to other offices, but benefits are reduced. Premiums apparently vary by locale. Further information may be found at the Delta website, www.deltadentalins.com/aarp/plan. The description of this plan does not mention care of nursing home residents, but if it is successful and extended throughout the country, there would appear to be no reason why it could not be utilized by LTC residents if they or their family can afford the cost of the premiums. While this plan does not answer many of the other difficulties of providing care for residents in LTC facilities, at least the funding problem would be partially overcome.
This article reviews many of the obstacles and some possible solutions to providing adequate dental care to LTC residents. The existing barriers to dental care need to be removed and solutions introduced before the aging of the population results in a marked increase in the number of individuals in LTC facilities.
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18. Johnson TE, Lang BM. Preferences for and influences on oral health prevention: perceptions of directors of nursing. Spec Care Dent. 1999;19:173-180
19. MacEntee MI, Thorne S, Kazanjian A. Conflicting priorities: oral health in long-term care. Spec Care Dent. 19:164-172.
20. Joint Commission on Accreditation of Healthcare Organizations. Nursing shortage poses serious health care risk: Joint Commission expert panel offers solutions to national health care crisis. News release. August 7, 2002. www.jcaho.org/news+room/news+realease+archives/nursing+shortage.htm. Accessed on September 1, 2002.
21. Tilly J, Goldenson S, Kasten J. Long-term care: Consumers, Providers, and Financing—a chart book. Urban Institute. March 2001. http://www.urban.org/UploadedPDF/LTC_Chartbook.pdf. Accessed on September 15, 2002.
22. Wylde MA. Customer expectations, today and beyond. Provider: for Long-Term Care Professionals. January 2000. www.ahca.org/news/provider/pdf/mgmtJan00.pdf. Accessed on September 18, 2002.
23. US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General— Executive Summary. Rockville, Md: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.
24. Holm-Pedersen P, Loe H. eds. Textbook of Geriatric Medicine. Copenhagen, Germany: Munksgaard; 1996:540-543.
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27. Palmer C. Dental benefits for seniors: AARP, Delta team to market plans in Maryland, Texas, and District of Columbia. ADA News. August 19, 2002:6.
Dr. Schwartz is clinical professor of dentistry, associate director of the Division of Periodontics, and attending dental surgeon at Presbyterian Hospital, New York. He has presented lectures and seminars on more than 40 periodontal and practice management subjects in the undergraduate and postgraduate programs. He is the coauthor (with Drs. Ira B. Lamster and James B. Fine) of Clinical Guide to Periodontics, 1995. He is also the author of Designing and Building Your Professional Office (2nd edition), 1989, and Remodeling Your Professional Office, 1985. He has authored journal articles on a variety of subjects in periodontics and in the fields of practice management and office planning, and he has presented invited lectures in the United States and many foreign countries.