Oral Health Disparities and the Elderly. people in the United States that were 65 years of age or older. By 2030, the elderly population in

Transcription

1 Jessica Brandt Julie Medeiros Heather Middleton Pam Piccione Oral Health Disparities and the Elderly According to the United States Department of Health and Human Services, elderly is defined as the chronological age of 60 to 65 that is associated with retirement and the eligibility to receive social security benefits.1 Statistically, in 2009, there were approximately 39.6 million people in the United States that were 65 years of age or older. By 2030, the elderly population in the United States is estimated to increase to approximately 72.1 million older individuals. By the year 2050, there may be up to as many as one in five Americans whose age is 65 or older.2 Due to the imminent exponential increase of the geriatric population, research of the elderly has been conducted to gather information about different characteristics of the ever-growing population. This research has produced insight that has helped redefine what it means to be elderly, going beyond the rudimentary classification by chronological age. For this reason, the definition of elderly has expanded to mean, a population with health care conditions and needs which differ significantly from those of younger people, which are often complicated by the physical, behavioral, and social changes associated with aging. 3 With a clearer definition of what elderly means, research has given light to the various health challenges faced by the geriatric population. With a certain percentage of elderly living in nursing homes, many older persons are forced to rely on their caregivers or nursing home facilities for daily living practices. More often than not, the patient s oral health care needs are not sufficiently managed. Although there may be dental hygiene services available in Page 1

2 approximately 80% of nursing homes, with far less of a percentage in government nursing homes, only 26% of the residents are estimated to receive oral health services in any given thirty day time period.2 As a result, the geriatric population faces many oral health problems such as periodontal disease and caries caused by dexterity problems, xerostomia from medications, defective restorations and dentures, as well as lack of knowledge regarding oral health by caregivers. Older adults face many barriers when trying to obtain a standard level of oral health. As the majority of Baby Boomers reach their seventies within the next decade, projections estimate that by 2050, eighty million people in the United States will be classified1as geriatric age group.4with more of the population falling into this older age group, the dental professional needs to understand the complexities of older people and what special needs they may have. Many physical, psychological, social and economic aspects must be well understood in order to provide satisfactory treatment within the standard of care for these patients. Besides the physical complexities associated with the individual older patient, barriers to dental care can also stem from how each new generation is introduced and educated about oral health and disease. For example, patients born in the 1930 s were the first to receive anesthesia for pain management during dental procedures. Reports show that in 1959 seventeen percent of geriatric aged patients had reported having a dental visit within the previous year. Comparatively, although dental care continues to use local anesthesia in treatment, patients today are educated by their dental care professionals in a more proactive manner, focusing more on preventing oral disease before pain ensues. Consequently, studies reveal that in 1989forty-five percent of people reported seeing a dentist within the previous year.5while dentistry historically was trying to manage their pain, the dental field today practices health promotion and disease Page 2

3 prevention. These social historical tendencies have had an effect on how geriatric patients feel, value, and ultimately internalize their view of oral health today.5 Financial barriers such as a lack of dental insurance are yet another obstacle geriatric patients face in their dental care. Many patients who are 65 years of age and older do not have dental insurance benefits. Once they retire, the dental insurance is no longer offered at an affordable price. To continue receiving dental coverage, senior patients are forced to purchase private dental insurancewhich can be very costly; however, retirement moves these patients into living on a fixed income. Additionally, social security benefits may be significantly lower than what the patient was earning prior to retirement. With the high cost of private insurance coupled with a lower income, many geriatric patients find themselves without many options for receiving the dental care they need. In fact, a number as low as ten percent of geriatric patients in the United States reported having dental insurance coverage of some type.5patients who have dental insurance are 2.5 times more likely to receive dental care than those who do not.5lack of dental coverage creates a significant barrier to older patients seeking dental care. Denti-Cal is a state dental insurance plan utilized by some senior citizens, however, Denti-Cal comes with many restrictions and limitations. Finding a dentist who accepts Denti-Cal has become extremely difficult as the reimbursement rate for the dentist is extremely low. Additionally, the dentist has to complete many forms requesting2 additional visits for his/her patient to receive the care they need. Denti-Cal also limits the services the dentist or dental hygienist can perform; consequently, despite the services that may be necessary and beneficial to the patient, dental health professionals are restricted to procedures that are less preventative and more palliative. Even though Denti-Cal may be an option, it has proven to be less helpful in Page 3

4 offsetting the costs or allowing the standard of care to be administered due to its many limitations.6 Many geriatric patients lose their independence and are unable to drive a car. They depend on public services, public transportation and/or the driving services provided by the facility in which they reside. According to a 2011 report by Caregivers Library, 8.4 million seniors in the United States depend on other people for transportation; however, many nursing facilities have limited access to transportation services.7 As a result, an overwhelming need for adequate transportation options for older patients residing in nursing homes exists making dental care unattainable. In the absence of transportation, approximately ninety three percent of geriatric patients stated they would visit a dentist only if a problem arose.5without transportation, the population in senior communities would prefer direct delivery of oral health care services. And when studied, functionally dependent seniors benefit from on-site oral health programs.8consequently, older adults would more likely use dental services if clinics were within walking distance or care was directly delivered on site by dental mobile units. There can be substantial problems for the geriatric population in regards to nutrition. Many elderly people who live in a senior home are widows or widowers and may be unwilling to enter the common dining room alone and therefore, skip many meals. Some find it difficult to achieve good nutrition due to medical issues and the restricted diets associated with them. Moreover, oral factors such as the condition of the oral cavity and number of teeth remaining contribute greatly to the quality of nutrition a person can achieve. When there are many teeth missing or some form of prosthesis, it decreases the ability to chew and may also decrease the desire to eat. When mastication capacities are minimal, an overall reduction in function and general health and well-being occurs.9 Nutritional counseling and patient/caregiver education is Page 4

5 increasingly important as this segment of the population continues to expand. When more knowledge is obtained by the patient and their caregivers, the amounts of fresh fruits and vegetables consumed rises and a more balanced diet is achieved. As a result, the patient s nutritional status and overall health are greatly improved.9concurrently, many geriatric patients have other acute or chronic systemic diseases which may be treated by several medications. For example, high blood pressure, cardiovascular disease, respiratory disease, diabetes, osteoporosis, high anxiety, and arthritis are common conditions among this age group. Anti-hypertensives, anxiolytics, antipsychotics, as well as many other medications lead to a condition called xerostomia.8 Medications often have side effects that cause xerostomia, which is a condition commonly known as dry mouth. Xerostomia is present when there is a dysfunction of the salivary gland. A reduction of saliva alters chewing and swallowing which makes it difficult for the patient to eat. Additionally, xerostomia also causes patients to experience burning mouth sensations, and a decreased capacity to resist bacterial colonization forming dental plaque and caries. Xerostomia causes oral discomfort and a decreased quality of life.10 The correlation between oral health and systemic health is easy to identify especially in an older individual. It is well understood and accepted that as people age, their dexterity and mobility decrease. The change in dexterity usually results in poor oral hygiene.8 Infrequent and inadequate self-care directly relates to an increased susceptibility to periodontal disease. Not only is dexterity and mobility limited but also other systemic health conditions may be affected by their oral condition. Additionally, many systemic diseases that plague the older patient may need to be treated with multiple medications, such as antihypertensives, antipsychotics and anxiolytics have side effects that lead to xerostomia.3, 5The lack of saliva produced by the patient increases the risk of dental caries and other dental conditions. Consequently, dental diseases Page 5

6 have a negative impact on general health and the quality of life for those in the geriatric age group. In order to maintain optimal oral health, older patients need appropriate oral care instructions from dental health professionals. It is also critical to include the patient s caregiver in the oral health education discussion. Access to dental care becomes more important as the average life span increases. With an understanding of the various barriers to dental care, the need for on-site delivery of dental services is critical to enable the geriatric patient to obtain and maintain good oral health. Having dental care delivered to patients in the senior homes would be very effective in primary or secondary preventative measures. Even if most patients who reside in these types of homes need tertiary prevention, they would be assured of receiving the care they need if dental care was delivered on-site. A challenge to living in a fast-paced society is to slow down enough to educate caregivers about the proper way to care for their patient s oral health. The caregivers also have to take pause in their busy routines to learn about how to care for their patient s daily hygiene. It may be construed by many as one more task in an already overloaded schedule, however, dental hygienists are obligated to share their knowledge on how tomaintain good oral health status. Various programs, already in place across the country, have created a platform to bridge the gap between dental health professionals and patients in nursing homes. The University of British Columbia s Geriatric Dentistry Program has started removing some of the barriers geriatric patients face when trying to receive proper dental care. They identified three criteria for any program to be successful. First, each resident must have regular oral health assessment. Secondly, the patients need to have access to dental treatment and lastly, residents much have the opportunity for disease prevention through education, including daily Page 6

7 mouth care. In 2002, the University of British Columbia Geriatric Dentistry Program treated 51% of the residents they recommended care for. Although lower than anticipated, the program equated the lower than anticipated percentage to the lack of dental insurance available to the geriatric patient who live on a fixed income. Most of the revenue came from the services provided by the registered dental hygienists and consisted of scaling/root debridement5 and fluoride application.11 Another business model which provides on-site dental services in nursing homes is a non-profit organization, Apple Tree Dental. Apple Tree Dental was started in Minneapolis, Minnesota. They expanded over the last 30 year and currently have six locations across Minnesota with the newest sites located in San Mateo, California, which opened in January The mission of Apple Tree Dental is to bring dental services to those who would otherwise have great difficulty accessing care.12 Apple Tree Dental brings fully equipped portable dental units directly to the nursing home facility. Dental services include exams, fillings, crowns, root canals, dentures, dental cleanings, simple extractions, etc. With the portable units, accessibility to dental care is greatly improved.12 Residents can receive dental care which may help prevent oral infections that can lead to more complex systemic health issues. Over the last 28 years, Apple Tree Dental has shown continuous growth, demonstrating the sustainability of this business model. This successful model includes an educational program that teaches dentists, dental hygienists, and dental assistants how to improve the nutrition and oral health literacy in geriatric patients and to the caregivers who assist these patients in their daily oral hygiene routines.8 As discussed earlier, the elderly population has many barriers to achieving adequate oral hygiene especially those living in nursing homes. With additional education, caregivers of Page 7

8 nursing home residents can apply proper oral hygiene, potentially eliminating many of the barriers geriatric patients face. With our program and education, we are hoping to show a decrease in oral co)nditions such as susceptibility to periodontal disease, poor nutrition, xerostomia, dental decay, missing teeth and ill-fitting dentures. We plan to collaborate with other community programs that directly deliver dental care to the patients in senior homes. It is our belief when we partner with other well-known programs in our community, together we can be highly successful. Program Proposal Description of the program: Dental health education program conducted within nursing homes. Oral hygiene instructions and dental health education will be provided to caregivers and involved family members for the implementation of oral hygiene to the residents. An assessment of the caregivers and family members knowledge regarding oral hygiene and current oral hygiene practices within the nursing homes will be completed before the implementation of the program. The assessment will help determine specific areas of education and training needed. The same assessment will be used once the program has been implemented for the purpose of re-evaluating the effectiveness of our training. Target group description: The program will focus on caregiver s and involved family member s knowledge of dental health and how it relates to systemic health and periodontal disease. The ages of the Page 8

9 residents directly affected by the level of knowledge of their caregivers will range from 62 years old and older. Potential community partners: Apple tree Center, American Medical Association, Kaiser, Palo Alto Medical Foundation, Nursing Home Association, National Students Nursing Association, Dental supply companies. Goals: Educate caregivers about oral health care. Implement better oral hygiene practices within a nursing home facility. Objectives: Caregivers will understand the reasons for adequate oral hygiene care for the residents of nursing homes, and achieve a minimum of 80% on a post education survey. Caregivers will pass our CE course post-test with a score of 75% or higher by demonstrating their knowledge regarding periodontal disease and how it affects systemic health. The caregivers will be able to perform the Stillman s toothbrush technique using a toothbrush, a 2-minute timer and decrease plaque by 75% when re-evaluated with the OHI-s index. By conclusion of the pilot program, a division of the Olive Branch will be visiting nursing homes at six-month intervals. Lesson Plan and Activities: Type of Program: Page 9

10 Educational intervention - provide education and instruction about daily oral health care. Incorporate toothbrush technique, denture care instruction and dental health education. Focus is on the importance of plaque control and educating caregivers of nursing home residents. Program Activities: The anticipated effects of the program will be to improve oral hygiene practices and reduce the levels of plaque biofilm in the elderly. The required activities of the program will be to contact local nursing homes (Mountain View) for available dates and times to conduct a survey and provide a CE course. Once the data from the survey has been analyzed, a detailed CE course will be developed and implemented on another date to be determined. Lesson Activities: Comparison slides: young girl with soda vs. geriatric patient, who has higher risk of dental caries? Power point presentation: educating primary caregivers how to achieve adequate oral hygiene for their patients. o Oral-systemic link o Plaque and its role in progression of periodontal disease and the formation of dental caries o Preventive factors against periodontal disease and caries Nutrition (types of foods) Dental techniques and products such as brushing, flossing, and fluoride o Medications and xerostomia Drug interactions (common drugs that cause xerostomia) Page 10

11 Dental products/saliva substitutes (xylitol, Biotene) o Denture care Cleaning instruction (Polident and denture brush) Brushing demonstration: demonstration of Stillman s tooth brushing technique will be performed in front of the class and with large typodonts. Caregivers will have the opportunity to demonstrate their proficiency on each other while course instructors critique and modify their techniques when appropriate. A summary of important information will be given at the end of the course. A postcourse survey will be conducted to evaluate how much the caregivers learned at a predetermined date and time. Caregivers will be able to take any available handouts from the course with them at the end. Sequence of events: Phone calls to gain support for program (i.e. Apple tree Center, American Medical Association, Kaiser, Palo Alto Medical Foundation, Nursing Home Association, National Students Nursing Association, Dental supply companies.) Contact the desired Mountain View Nursing Home for participation in the program. Visit the nursing home to deliver pre-test survey. Analyze the results of the pre-test survey and develop precise plan for instruction of CE course for caregivers. Provide the CE course to caregivers. Evaluate results of post-test survey and success of program. Budget: Estimated cost of program = $2000. Page 11

12 Copying costs for duplicating surveys and handouts Typodonts and toothbrushes Laptop Projector Personal Protective Equipment (PPE) for caregivers to use while showing proficiency in performing the Stillman s tooth brushing technique during the CE course. Method of Program Evaluation: Type of program evaluation: pre and post survey demonstrating the effectiveness of our program. The survey about daily oral health care education and instruction of caregivers to nursing home residents will be given before and after the program to see if knowledge level has changed and increased. Data will be analyzed to see if any areas of the program can be improved. Survey Name: Facility: Instructions: Please circle the best answer. 1. A person should brush their teeth at least time(s) a day and floss time(s) a day. a. 1,1 b. 2, 1 c. 1, 0 2. When dentures are removed,. a. Place them on the counter. Page 12

13 b. Place them in a cup of water. c. Place them in a dry napkin. 3. How often should a person see the dentist? a. 1 time a year b. Every 6 months c. When something hurts Instructions: Please circle True or False to answer the following questions: 4. Dry mouth causes dental decay True/False 5. Plaque biofilm forms immediately on teeth after brushing. True/False 6. It is normal for gums to bleed when brushing. True/False 7. Dentures should be taken out every day. True/False Instructions: Please circle yes or no to answer the following questions: 8. Do you brush your patient s teeth? Yes/No 9. Do you floss your patient s teeth? Yes/No 10. If you answered yes to Question #8 or #9, do you feel confident that your technique is effective? Yes/No 11. Does the nursing facility provide transportation for patients to their dental visits? Yes/No 12. Do dentists or dental hygienists provide dental care at your nursing facility? Yes/No 13. Would you be interested in taking a class or learning more about how to care for your patient s oral health? Yes/No Instructions: Check all that apply. 14. Why do your patients seek dental care? o Tooth pain o Broken teeth o Ill-fitting/broken dentures o Sensitivity o Infection o Other: References Page 13

14 1. Administration of Community Living [Internet]. Washington (DC); U.S. Department of Health and Human Services; 1600 Dec 31 [updated 2015 Mar 6; cited 2014 Oct 19] Available from: 2. Dolan T, Atchison K, Huynh T. Access to Dental Care among Older Adults in the United States.J Dent Educ[Internet] Sep [cited 2014 Oct 19];69(9): Available from: 3. Stein PS, Aalboe JA, Scott AM. Strategies for communicating with older dental patients. JADA [Internet] Feb [cited 2014 Oct 19];145(2): Available from: 4. U.S. Census Bureau, Population Division [Internet]. Washington (DC);Economics and Statistics Administration, U.S. Department of Commerce; 1995 May [updated 2011 Oct 31; cited 2014 Oct 19] Available from: 5. Kiyak HA, Reichmuth M. Barriers to and Enablers of Older Adults Use of Dental Services.J Dent Educ [Internet] Sep 1 [cited 2014 Oct 19];69(9): Available from: 6. Jones JA. Financing and Reimbursement of Elders Oral Health Care: Lessons from the Present, Opportunities for the Future. J Dent Educ [Internet] Sep [cited 2014 Oct 19];69(9): Available from: 7. National Center of Elder Abuse; Administration for Aging [Internet]. Washington (DC); U.S. Department of Health and Human Services; 2011 Report [cited 2014 Oct 19]. Available from: 8. Singla N, Singla R. Oral Health Care In Aging: A Review. Manipal, India; Manipal College of Dental Science [Internet] 2013 Nov [cited 2014 Oct 19];6(12):64. Available from: 9. Prakash N, Kalavathy N, Sridevi J, Premnath K. Nutritional status assessment in complete denture wearers.gerodontology [Internet] Sep [cited 2014 Oct 19];29(3): Available from: Page 14

15 10. De Lima Saintrain MV, Goncalves RD. Salivary tests associated with elderly people s oral health. Gerodontology [Internet] Jun [cited 2014 Oct 19];30(2): Available from: Wyatt CC, So FH, Williams PM, Mithani A, Zed CM, Yen EH. The Development, Implementation, Utilization and Outcomes of a Comprehensive Dental Program for Older Adults Residing in Long-Term Care Facilities. J Can Dent Assoc [Internet] Jun [cited 2014 Oct 19];72(5):419. Available from: Apple Tree Dental [Internet]. Minneapolis (MN); 2015 [cited 2014 Oct 19]. Available from: Page 15