Issues in Financing Dental Care for the Elderly

The elderly make up an increasingly larger segment of the patient population in dental practices. This article reviews recent epidemiologic, demographic, and health services research, and concludes that significant segments of the elderly are at high risk for oral disease and/or limited access to dental treatment, and consequently warrant classification as high-risk groups for policy considerations. It then proposes policy options to the dental community and public decision makers. Oral care can be viewed as having three components. Two basic components are the primary care component--which includes diagnostic, preventive restorative, and periodontal care--and the acute care component--i.e., the treatment of oral pain, trauma, and infection. The third, rehabilitative component, has to do with the restoration of oral function, including prosthodontics and cosmetic dentistry. Viewing dental care in this perspective may help link funding for dental primary care services with that for other primary health services, and link restoration of function and improvement of quality of life with similar health services, like hearing, vision, and social services. In addition, approaching dental care policy makers on several levels--i.e., federal, state, and local--will contribute to our ability as a profession, in the decades ahead, to meet the oral health needs of more elders: including the frail, those at high risk for oral disease, and those with limited access to care.     

Changing patterns of oral health and implications for oral health manpower. Responsibility to the public

This paper examines organized dentistry's responsibility for informing the public about changing patterns of oral disease. The public is divided into two groups: governments and other organizations that are responsible for allocating funds for dental treatment, education and research, and the general population that is eligible to use dental services. Some governments in industrialized countries apparently believe that with the decline in caries, monies for dentistry can be reduced without affecting the oral health of the population. This assumption can be challenged, since oral disease levels in lower socioeconomic class groups and the elderly continue to be very high. Further, the goals of the dental care system should be raised to eliminate edentulousness. Dentistry needs to make the public aware that adequate care for the poor and elderly and eliminating edentulousness will require increased support for dentistry. At the patient level, regular users of care who are healthy should be informed that more frequent visits and complex services may have little effect on oral health. In contrast, infrequent users of dental care should be made aware that dentistry has the technology to prevent disease and the loss of teeth. One phase in the history of dentistry is coming to an end but another is beginning. In the new era the dental profession can make even greater contributions to the quality of life of individuals and society.     

Aging and oral health care in The Netherlands. An explorative study

In order to investigate which initiatives are being taken in The Netherlands to anticipate a change in oral health care demands as a result of ageing, 9 experts in the field of oral health care for the elderly were interviewed. The experts were selected because of their varied expertise and involvement in geriatric dentistry. Those interviewed were unanimous in the opinion that the demand for oral health care among the elderly will increase in the years to come. National initiatives to improve oral health care for the elderly appear to be limited. This situation can be changed by getting professional homecare more involved in oral health care for the elderly, and by regular dental checkups, stimulated by more actively operating general dental practitioners. For those in homes for the elderly and nursing homes, there appears to be no national policy with regard to oral health care. Several initiatives have been undertaken to improve dental health care, but those differ from institution to institution. According to the interviewed experts, financing, government prioritization, and health care laws are major bottlenecks on the road to the improvement of oral health care for the elderly.     

Is dentistry at risk? A case for interprofessional education

The goal of interprofessional education (IPE) is to bring various professional groups together in the educational environment to promote collaborative practice and improve the health care of patients. Interest in IPE has been sparked by several factors in the health care system, including the increased awareness of oral-systemic connections, an aging population, the shift of the burden of illness from acute to chronic care, and lack of access to basic oral care. Increasingly, since the publication of the U.S. surgeon general's report in 2000, the dialogue surrounding IPE in dentistry has escalated. But how has dentistry changed regarding IPE since the report was released? This position paper argues that little has changed in the way dental students are taught and prepared to participate in IPE. The authors contend that academic dentistry and organized dentistry must take the lead in initiating and demanding IPE if dental students are to be prepared to work in the health care environment of the twenty-first century. Included are reasons why IPE is necessary and why dentistry must lead the conversation and participate in the solution to the oral health care crisis. It explores existing models and alternate approaches to IPE, barriers to implementation, and proposed strategies for academic institutions.     

National Health Care: Whither Goeth Dentistry?*

National health insurance is reemerging as an important issue on the national health policy scene. The continuing escalation of health care costs in the US and increasing numbers of individuals without access to health services are stimulating a variety of proposals to redesign the structure and financing of the American health care system. Some change in the current system toward a more national approach to health care is inevitable in the years ahead. While dental care is subject to pressures similar to other health care services, little attention is being accorded dental services in the various national health care proposals that are being advanced. This may be due largely to organized dentistry's reluctance to define a role for itself. If dentistry is to be included in such a plan, it is essential that concerted efforts start soon and that the various public and private sectors of dentistry work collaboratively to develop the dental component to such a plan. The future oral health of the public and the future health of dentistry as a profession depend on it.     

The evolving impact of aging America on dental practice

American dentistry has recognized for a quarter century that the growth in the proportion of elderly in the population is impacting on the profession. Multiple articles in the professional literature have speculated on the ways in which this change will be manifested. Data and projections from earlier articles are revisited and five trends are offered to guide professionals as they position their practices for the coming years. The increase in number and proportion of elderly in dental practices stems from successes in preventing and controlling infectious diseases during the last century. The trend has not peaked but will continue for at least two more decades. Retention of teeth into advanced age has resulted from emerging and improved preventive and restorative dental advances directed at children and adults beginning mid-century, and dental utilization studies confirm the elderly are seeking dental care at an unprecedented and growing rate. Chronic disease and infirmity that accompany advanced age make dental care more challenging for this group. Dentists and their staff will need to continuously undertake educational opportunities that will foster and maintain their facility in providing care to the elderly. They will need to do this because Americans of advanced age are becoming the dominant age group seeking, and able to pay for, sophisticated dental services. The blend of those services is shifting away from removable prostheses to a rising demand for restorative, periodontic, and endodontic care. Root caries, in particular, will be a growing challenge to both providers and patients. There is mounting evidence oral disease impacts endocrine, cardiovascular, and pulmonary health, particularly in frail elders, and will likely provide many elderly additional stimuli to seek dental care. Providers who seek an alternative approach for delivering their services will find growing demand for and satisfaction with traveling to patients, rather than the other way around.     

The dentist in the circle of care of dependent elderly

By preventing avoidable causes of death, man usually dies at advanced age after a prolonged period of increasing dependency often in homes for the elderly and in nursing homes. This dependency means problems in self care, walking, cognition, communication and in oral health. Geriatric dentistry can be incorporated in a model arranging care (the care circle) in which the dentist operates independently, or organised in teams with other caregivers or central directed by a nursing home doctor (so-called multidisciplinary dentistry). Multidisciplinary dentistry means that the dentist is a member of a multidisciplinary team, contributing to the reduction of individual problems with eating, drinking and oral health. The dentist involves the team in the indications of dental treatment. He operates within the rules of recent Dutch legislation. These laws are based on self-determination of the patient, institutional quality-assurance and individual skills-guarantees of the care provider.     

Dentistry in Japan should become a specialty of medicine with dentists educated as oral physicians

In Japan, the population of elderly individuals (those sixty-five years of age and older) will increase to over 30 percent of the total population by 2030. The elderly commonly have chronic diseases that result in individuals being biologically and pharmacologically compromised. Dentists must have a reliable knowledge of basic clinical medicine for these individuals to be safely and effectively treated. The isolation of dental education from medical education may have been advantageous in the past for the development of dentistry as a profession; however, changes in people's life expectancy and lifestyles, as well as rapid advances in the biomedical sciences, require dentists to have a thorough foundation in biomedical science and clinical medicine not dissimilar from a physician in any other field of medicine. A reformation of dental education is necessary if optimum oral health care is to be provided for patients in the future. It is thus advocated that dentistry should become one specialty of medicine known as oral medicine, and we propose that the education of dentists should be modified to produce oral physicians.     

The future of dental care for the elderly population

The U.S. population is aging, and the elderly are maintaining many of their natural teeth. Studies have shown that if older people have teeth, they tend to utilize dental services to a similar extent as younger cohorts. Geriatric dental care is the diagnosis, treatment, and prevention of dental and oral diseases for all older adults. A functional categorization of the aging population is more useful in dentistry than a chronological one, and 70 percent of this population, or 23.2 million people, is able to visit a dentist in his or her office. The oral health care of older adults has become more challenging because they will no longer accept extraction and dentures as a solution to complex restorative needs. This paper discusses these issues and looks at the future of geriatric dental care.     

Geriatric oral health issues in India

An overview of the demographics and oral health status of the elderly population of India is presented. India is a vast country with a population of one billion people. Of this, people older than 60 years constitute 7.6%, which in actual number is 76 million. There are several factors that affect the oral health of elderly. The dentist:population ratio is 1:27,000 in urban areas and 1:300,000 in rural areas, whereas 80% of the elderly population reside in rural India. Forty per cent of the elderly live below the poverty line and 73% are illiterate. Ninety per cent of the elderly have no social security and the dependency ratio is 12.26. Incidence of oral cancer, which is considered an old‐age disease, is highest in India, 13.5% of all body cancers are oral cancers. Preventive dental care is almost nonexistent to the rural masses and very limited in urban areas. Above all, there is no orientation of dental graduates towards the special needs of the geriatric population. Recommendations include: the establishment of Continuing Dental Education programmes on geriatric oral care; inclusion of a geriatric component in undergraduate and postgraduate curricula; initiation of a diploma, certificate and degree courses in geriatric dentistry; research on various aspects of ageing and age‐related oral health problems; provision of preventive and curative treatment for various oral diseases to the elderly.     

Promotion of oral health in the elderly. Use of a videotape

In dentistry dental health promotion of elderly people will be of growing interest. General health promotion is subdivided in two components: education and structural interventions. Stereotypes, dominating both (dental) health care providers and elderly people, are barriers for manifestation of elderly people's dental information needs. A recently developed videotape can be used as a start of such a structural intervention.     

Dental education in relation to the needs of the South African community.

The dental needs of a heterogeneous South African community are not being fully met because the majority of the already deficient dentist population is in private practice, mostly in urban areas, where they are rendering services to a small minority of the population who can afford comprehensive dental care. Contrary to public health services in general, public dental services are inadequate in extent and provide a limited range of treatment to some eighty-five per cent of the population. Millions of under-privileged people, particularly in rural areas, are not within range of any professional dental care whatsoever. Organized community preventive programmes and dental health education on a national basis are non-existent. Water fluoridation has not yet become a reality. Realizing the shortcomings in community dental services the Government recently adopted a national dental health policy which is aimed at limiting and preventing dental diseases and also at expanding the public dental service to bring it within reach of all sections of the community. In order to meet the dental needs of the community and also to give momentum to the national dental health policy, the following steps are being taken as far as dental education is concerned: (i) The Department of Health is planning to assist universities to establish departments of community dentistry with the object of promoting extended education in community dentistry at under-graduate and post-graduate level. (ii) Consideration is being given to a scheme whereby dental students will have to do one year compulsory intership. (iii) Additional dental schools are being established to enable more non-White dentists to qualify. (iv) With the extended education in community dentistry it is hoped to draw more dentists into community dental services. (v) Dental therapists are being educated to perform duties such as extractions, simple fillings, prevention and dental health education, under the supervision of dentists, in areas where the shortage of dentists is most crucial.     

Caries and the older patient

Ageing of the population, together with prolonged retention of teeth, has brought new challenges to dentistry. Whereas in the past oral care for the elderly was restricted to provision of dentures, older patients are now presenting with dental caries and failed restorations. These problems may have an impact on their general health and quality of life. Poor oral hygiene, xerostomia and diet are among the risk factors for caries in older patients and need to be addressed in order to achieve control of the disease. Carious lesions can be treated conservatively in many cases or may need surgical management. CLINICAL RELEVANCE: Caries is an oral health issue among older patients and can result in tooth loss. Oral health has a great impact on general health and quality of life of elderly people.     

Reducing barriers to older persons' use of dental services

In the United States elderly persons are the least likely of any age group to utilize dental services. With the increase in the elderly population and expansion of interest in their dental care, our understanding of the barriers to that care is particularly important. Studies have indicated that cost of treatment, fear of dentistry, functional independence and poor general health are of little significance in explaining the low utilization patterns of this age group. Perceived need seems to be the strongest predictor in deciding whether dental services are sought by an individual. Two programmes established by The University of Washington aimed to enhance the utilization of dental services by the elderly. One provided free screenings for over 65's on low incomes, coupled with a low cost dental care scheme. Although it was found that the convenient location of a dental clinic was a valuable incentive for the increased uptake of services, the difficulty remained one of patient perception of need. The second programme sought to overcome this latter problem by providing information on the importance of oral health to the independent elderly. This included a weekly class for small groups conducted by a health educator over a 6-week period together with a self-monitoring chart for each participant. It is anticipated that the heightened awareness aroused by this education programme will translate into perceived need and thus greater dental service utilization by the participants.     

The face of a child: children's oral health and dental education

Dental care is the most common unmet health care need of children. Those at increased risk for problems with oral health and access to care are from poor or minority families, lack health insurance, or have special health care needs. These factors place more than 52 percent of children at risk for untreated oral disease. Measures of access and parental report indicate unmet oral health needs, but do not provide guidance as to the nature of children's oral health needs. Children's oral health needs can be predicted from their developmental changes and position in the life span. their dependency and environmental context, and current demographic changes. Specific gaps in education include training of general dentists to care for infants and young children and those with special health care needs, as well as training of pediatric providers and other professionals caring for children in oral health promotion and disease prevention. Educational focus on the technical aspects of dentistry leaves little time for important interdisciplinary health and/or social issues. It will not be possible to address these training gaps without further integration of dentistry with medicine and other health professions. Children's oral health care is the shared moral responsibility of dental and other professionals working with children, parents, and society. Academic dental centers hold in trust the training of oral health professionals for society and have a special responsibility to train future professionals to meet children's needs. Leadership in this area is urgently needed.     

The ageing UK population--considerations for the restorative dentist

The scope of gerodontology and more specifically that of restorative dentistry (which in the UK includes the disciplines of endodontics, periodontics, prosthodontics and operative dentistry) within gerodontology, is expanding. This is true for several reasons. Firstly, the population, in both the UK and most of the western world is generally living longer. Secondly, more elderly patients are retaining their natural teeth longer into old age--thereby necessitating ongoing restorative dentistry input for their maintenance. In addition, many patients' expectations are increasing with regards to restorative dentistry. Natural teeth that were erstwhile considered as automatic candidates for extraction may now be regarded differently, especially if they are considered a 'strategic' tooth within the arch. The aim of this paper is to give a perspective as to how some of the more common restorative dentistry issues that beset the elderly population are addressed in the UK. This paper will focus on operative dentistry and prosthodontic aspects of restorative dentistry for elderly patients.     

Oral health care for nursing home residents in The Netherlands – a national survey

Abstract – In order to be able to develop adequate oral health care programs for nursing home residents in The Netherlands, currently available arrangements and problems experienced by dentists participating in this field of dentistry were evaluated in a national survey. One questionnaire was mailed to the managements of all nursing homes and a second to all dentists known to be involved in nursing home dentistry. The response rates were very high. The study indicated that, in almost every nursing home, dental care for residents was available, at least in cases of dental emergency. On average the dentists were spending only limited time on nursing home dentistry. The majority of dentists examined or treated the residents only when either the patients or others experienced or discovered an oral health problem. In delivering this kind of care the dentists experienced a lot of problems. These findings suggest that the oral health care for nursing home residents in The Netherlands must be evolved by research, special training of dentists, and through development of special care programs.     

Dental educational trends in Africa with special reference to southern Africa

Sub-Saharan Africa is experiencing a population growth unparalleled in the rest of the world. This is placing severe constraints on health care education and especially on dental education. The 16 or so dental schools in this part of the continent cannot train sufficient dentists for Africa's needs. In consequence, many states are developing training programmes for auxiliaries in an endeavour to meet their oral health care needs. Emphasis is placed on community involvement in the various dental curricula and it has been suggested that the African dentist should also be equipped to render basic medical care. At most schools the dental course is a 5-5 1/2 year programme with considerable emphasis on the basic medical sciences so that a student can easily be trained to act in a dual capacity as dentist and basic physician. This will, however, require the availability of more operating auxiliaries to meet the basic oral care demands of the population. In the dental course at South African schools the major portion of curriculum time in the clinical years is occupied by restorative and prosthetic dentistry. Although this is still appropriate, caries prevention and the availability of operating auxiliaries may soon make this approach redundant. Integrated courses in which the advanced disciplines of dentistry receive more emphasis seem to offer exciting prospects for the future, especially if the benefits of such integrated courses are fully exploited.     

The role of hospital-based dentistry in providing treatment for persons with developmental delay

Hospital dentistry is important to the delivery of oral health care to persons with disabilities. Recent cuts in funding for hospital dentistry in Ontario have placed a great strain on the health care system"s ability to meet the demand for such care. General anesthesia is an accepted treatment option for patients who are uncooperative, but involves inherent risks. In this paper, we present the case of a person with developmental delay who received dental treatment under general anesthesia and subsequently developed complications to support the position that a dental program for persons with special needs should be provided in a hospital setting to minimize their risk of suffering serious complications and to ensure their safety.