Despite their unique challenges, the oral health of older adults in the United States has received relatively little attention and few public health or public policy interventions. In fact, in California, the oral health status of older adults had not been documented at all until the Center of Oral Health (COH) released “A Healthy Smile Never Gets Old: A California Report on the Oral Health of Older Adults.” This landmark study provides key insights into the extent and severity of the problem and outlines strategic recommendations on how to address the oral health needs of our older population.
While dental disease is largely preventable and treatable, older adults (65 and up), alongside low-income, minority, and otherwise disadvantaged groups, struggle to gain access to quality dental care. As a result, many older adults suffer from untreated tooth decay (dental caries), gum disease, poor condition of natural teeth, xerostomia (dry mouth), and ill fitted dentures. These conditions are also fueled by natural changes associated with aging and other chronic health conditions.
Studies show oral health is an integral part of overall health, and poor oral health negatively impacts a person’s emotional and physical well-being by making it difficult to chew or speak. This undermines nutrition, leads to infection, exacerbates chronic conditions like hypertension and diabetes, impacts self-esteem, and lowers quality of life.
The COH study reveals that large numbers of older adults living in California are impacted by poor oral health. Specifically, it found that untreated tooth decay is highly prevalent, affecting half of the older adults residing in skilled nursing facilities (SNFs) and more than one in three community-dwelling older adults.
This decay is leading to many cases of tooth loss, with one in three Californians in SNFs having lost all their natural teeth. The study also found that tooth loss paired with lack of functional contact has made it so nearly 40% of nursing home residents cannot chew at all.
The report further highlights the widespread need for care, revealing that 65% of older adults residing in SNFs need treatment for tooth decay and/or periodontal (gum) treatment. Also, older adults residing in rural areas are more likely to suffer from oral health problems compared to their counterparts in urban areas.
Unique challenges to receiving preventive and dental treatment services, compounded by barriers of affordability and accessibility for low-income populations, are resulting in significant oral health challenges that must be better addressed. By looking at disease trends and disparities, the study helps improve the understanding of the oral health of older adults and inform the development of data-driven programs and policies. The COH report provides a series of recommendations that include increasing funding, building new partnerships, and improving workforce training.
An Integrated Care Approach
To break down healthcare silos, there needs to be increased cross-professional training through medical, nursing, and assisting providers to ensure maintenance, diagnosis, and timely oral health treatment. Staff at institutional facilities and senior centers should be educated about the oral health needs of older adults and should be equipped with information and resources to conduct regular screenings.
Conducting oral examinations during admission and repeating screenings semi-annually or annually is an important part of developing individual oral health hygiene and maintenance plans for older adults. Also, creating a need-based referral process at senior centers and other places where community-dwelling older adults congregate that accounts for insurance and payment mechanisms will help ensure that older adults with several oral health issues receive immediate dental care.
Another important element is encouraging managed long-term services and supports (MLTSS) and county organized health systems (COHS) to set oral health targets for facilities they are contracted with and to provide technical assistance and resources to meet these targets.
Expanding Innovative Practices
Silver diamine fluoride (SDF) is an inexpensive treatment used extensively in other countries to treat dental caries across the age spectrum. The Food and Drug Administration has approved the use of SDF for reducing tooth sensitivity, and in 2017 the American Academy of Pediatric Dentistry issued an evidence-based guideline that recommends SDF to treat active dental caries in primary teeth in pediatric and special-needs patients.
COH recommends assessing clinical guidelines to consider the use of silver diamine fluoride for dental disease management among frail older adults at high risk of dental caries and among those who face limitations to seeking dental care.
Many older adults also suffer from mobility issues. Promoting the expansion of the virtual dental home model, which is currently being piloted extensively with children who have limited access to dental care, would then help eliminate transportation barriers to care. Teledentistry can help improve the oral health of underserved populations, including at-risk seniors who may not have access to preventive and early intervention services.
Eliminating Barriers to Care
From a funding perspective, prioritizing older adults’ access to care and ability to pay for services through inclusion of benefits in Medicare will ensure that affordability is not a barrier to care. This includes setting utilization targets for older adults, both community-dwelling and institutionalized, to increase accountability in the Medi-Cal Dental Program toward low-income older adults who depend on it for their oral health needs.
Also, increasing provider participation in the Medi-Cal Dental Program, increasing reimbursement rates to reasonable levels that are comparable to other states, and prioritizing preventive services critical to older adults (periodontal care and maintenance) when rate increases are considered will ensure that low-income older adults have access to timely and high quality oral health care.
Implementing These Recommendations
The risk of poor oral health and its impact on the overall well-being of older adults is significant and deserves more attention. The recommendations in the COH report provide concrete steps to increase treatment, access, and awareness and ensure that older adults achieve optimum oral health outcomes.
To drive an informed public policy dialogue on ways to address this problem through funding, innovative practices, and new partnerships, it is critical that these recommendations are integrated into current and future policy and community-based interventions.
Dr. Bhaskara is director of public policy research at the Center for Oral Health. She graduated from the Maharashtra University of Health Sciences with a bachelor of dental surgery (BDS) degree in 2011. She also graduated from the University of Minnesota School of Public Health with a master of public health (MPH) degree specializing in epidemiology in 2014. Previously, she was a field coordinator and epidemiologist for the Minnesota Department of Health Oral Health Program and a dental public health resident with the Centers for Disease Control and Prevention. She has cleared the written exam to become a diplomate of the American Board of Dental Public Health and plans to take her oral exams in 2019 as well. She can be reached at SBhaskara@tc4oh.org.