Geriatric oral health care in Taiwan: What do we need?

Review Article Geriatric oral health care in Taiwan: What do we need? TING-TING YANG CHEN-YING WANG JIIANG-HUEI JENG CHUN-PIN LIN YI-LING TSAI Department of Dentistry, National Taiwan University Hospital, Taipei, Taiwan, ROC. Graduate Institute of Clinical Dentistry, College of Medicine, National Taiwan University, Taipei, Taiwan, ROC. Elderly populations are rapidly increasing in many countries around the world. Dentists are increasingly facing patients with different kinds of systemic diseases and some dental diseases to which the elderly are particularly predisposed. In addition, some common dental problems in older people are extremely complicated and are not easy to treat. As we move into the 21st century, Taiwan is facing an aging population. To establish a geriatric oral healthcare system, well-trained dentists and dental teams are going to be in greater demand. Dentists should understand their leading role and assist other medical staff in consultation, technical support, and transfer services. Meanwhile, dentists should also play an important role in establishing systems of oral health care. Some policies and systems of geriatric oral health care in developed countries are worth learning about and emulating. (J Dent Sci, 2(2):59-64, 2007) Key words: geriatric dentistry, gerodontology, oral health care, elderly. Concomitant with advances in medical science over many decades, aged populations are increasing in many countries around the world. According to a report by the Department of Health, Taiwan (2003), the population aged 65 years or older accounted for 9.74% of the total Taiwanese population. The ratio is projected to increase to 14% by 2020. The rate of increase of the elderly population in Taiwan is second in the world 1. This indicates a rapid trend in this country toward an aged society. Geriatrics has become a very important issue in the 21st century. Oral health is considered to be closely related to the quality of human life and even to overall body health. Abundant evidence has shown that the greater the number of natural teeth which a person retains, the better his/her life quality will be. The remaining number of teeth of the elderly affects their diet and nutrition and in turn affects their general health condition 2. Helping senior citizens preserve more and healthier teeth is the ultimate goal of geriatric dentistry. Received: February 20, 2007 Accepted: May 25, 2007 Reprint requests to: Dr. Yi-Ling Tsai, Department of Dentistry, National Taiwan University Hospital, No. 1, Chang-Te Street, Taipei, Taiwan 10048, ROC The complexity of managing oral health problems of the elderly Periodontal disease is the most common oral disease of the elderly. Periodontal diseases are mainly caused by microorganisms which colonize the oral environment 3. This has been statistically linked with several systemic diseases 4,5. For example, the risk of myocardial infarction and stroke in patients with periodontitis is 3-fold higher than that of the general population. For frail older adults, periodontal infection predisposes them to aspiration pneumonia. On the other hand, some medical diseases, such as poorly controlled diabetes, may enhance the progression of periodontal diseases in these patients. Such a situation increases the difficulties of periodontal therapy. The most important factors determining a successful outcome of periodontal treatment are plaque control and the frequency of professional care 6. Periodontal diseases are indeed disturbing for older people. In fact, prevention of periodontal diseases is only 1 aspect of geriatric oral health care. Other common dental problems of the elderly include restoration demands due to missing teeth, decreased salivary secretions, and root caries. On the basis of a J Dent Sci 2007 Vol 2 No 2 59

T.T. Yang, C.Y. Wang, J.H. Jeng, et al. literature review, a decrease in salivary secretion is significantly associated with the oral health-related quality of life 7. Unfortunately, this disease is associated with several prescription drugs such as antihypertensives as well as certain medical diseases such as thyroid disorders 6. In addition, low salivary flow along with the oral hygiene status is a potential risk factor for root caries 8. Root caries occur mainly after exposure of the root cementum and is usually related to periodontal diseases. It is a multifactorial disease. Compared with coronal caries, possible etiologies and preventive methods for root caries are still unclear 9. However, root caries increase with advancing age and their prevalence is higher than expected. Furthermore, endodontic treatments of these carious teeth in the elderly have been considered to be challenging due to narrow or obstructed root canals 10. Therefore, root caries prevention is another critical issue related to periodontal diseases 11. According to a review by Dung and Liu, root caries prevention can be divided into 3 phases: a primary phase that is a truly preventive phase, a secondary phase to reverse an initial root caries, and a tertiary phase to manage established lesions. In addition to maintaining good oral hygiene such as effective plaque control, preventive methods for root caries should also include diet modification, topical or systemic fluoride application, and periodic monitoring 9. Even if older people can maintain good oral hygiene without periodontal disease or dental caries, they may suffer pulp exposure, loss of vertical dimension, or root fractures from other dental problems such as severe occlusal wear and cervical abrasion. All of these problems are extremely complicated and difficult to treat. Not only are dental specialists required, good communication and coordination between doctors and patients are also needed to carry out these difficult treatments 12. Along with an increasingly aged population, dentists will also be facing patients with systemic diseases such as liver or kidney diseases, diabetes, and cardiovascular diseases. These patients pose a variety of management problems such as bleeding tendency, risk of infection, cardiovascular complications, and drug administration 13,14. Psychological problems also require a great amount of attention as well. Dentists should possess a knowledge of psychosocial problems associated with geriatric dental care, and a basic understanding of dementia. Several items should be considered before providing safe and appropriate dental treatment for patients with systemic diseases. To manage the attendant dental problems, well-trained dentists are needed. In addition, frail and functionally dependent older people are considered to be a high-risk group in the oral healthcare system, but they have special difficulties in accessing adequate dental care. Special dental programs for these frail and dependent older people within the established healthcare system are needed 15. Some recent studies have shown that oral health is statistically linked with some systemic disease such as atherosclerosis and diabetes 4,5. The risk of death of the elderly in urgent need of dental treatment was 3.9 times higher than that of other age groups 4. In other words, oral infections can contribute to the early death of elderly patients. Therefore, oral hygiene evaluation, dental disease prevention, and receiving treatment in time are crucial issues for geriatric oral health care. Numerous oral diseases from which the elderly are likely to suffer are preventable through appropriate oral hygiene measures, diet control, and fluoride supplements 16. Along with aging, elderly patients also face postural and stamina difficulties in receiving dental therapy. Dental chair positioning and comfort may be more important for older adults than for younger patients. Difficulty breathing and the gag reflex during dental procedures are other important issues that dentists should pay attention to. Some older people are hard of hearing, and it is difficult for them to communicate with others. Dentists should be patient with them at each appointment. Geriatric oral health care in developed countries A well-known activity, called the 8020 campaign (having more than 20 teeth at the age of 80) began in Aichi Prefecture in 1985 in Japan. This health promotion activity focuses on oral health. Its goal is to promote the health awareness by helping those older than 80 years to retain more than 20 of their natural teeth. They found that senior citizens with 20 or more teeth had better habitual dietary attitudes throughout their lives 17. People with this number of teeth tend to have a healthy diet and enjoy it better without the need for removable dentures 2. In England, the percentage of people 85 years of age who had no natural teeth was about 65% in 2005. According to predictions, the percentage of the 60 J Dent Sci 2007 Vol 2 No 2

Geriatric oral health care in Taiwan elderly who have lost all of their teeth will drop rapidly over the next 20 years. It is believed that the proportion of the elderly with a functional dentition of 20 or more teeth will increase in the future 16. In developed countries, some important legislation and policy developments concerning geriatric oral health care have taken place. These developments will have profound impacts on improving oral health care and dental services for the elderly, and will ensure that oral health is considered an integral part of general health care 18. In some European countries and the US, dental care for independently living older adults is primarily provided by private dental practitioners. In Sweden and the UK, a public dental service and the National Health Service are other choices. Dental treatment for independent senior citizens is not free of charge in any of these countries, but restorative and most preventive dental services are subsidized 15. The medical care systems of most developed countries are efficient and comprehensive. It is convenient for people to utilize these medical resources. However, younger people are generally better educated and more often utilize dental services than the elderly. The reasons for this may include inconvenience, illness, the cost of treatment, and inability to access appropriate dental care 19. When people become frail, domiciliary care is the most effective way of providing dental care even dental surgery. Nevertheless, domiciliary care is usually delivered by a mobile unit/van and portable equipment 19. For homebound, chronically ill and institutionalized elderly people, special dental care programs are available on-site in Denmark, Norway, and Sweden. Because the governments of these countries have made investments in equipment and dentists are paid a fixed salary, the public dental service may have a better basis for offering domiciliary dental care than private dental practitioners 15. In Japan, there are dental home services for frail and functionally dependent elderly people, especially in some towns in the countryside. All older people who live in care homes should receive a regular oral health and oral health risk assessment 19, which includes evaluating the detrimental effects of oral infections on general health 5. Nowadays however, most medical staff still do not know much about the actual needs of these senior patients. Many dentists have few chances to take care of severely ill elderly patients, so they have limited experience in providing suitable oral health care for them 20. Inadequate undergraduate and postgraduate training in geriatric dentistry may also discourage dentists from seeking opportunities to treat elderly patients because of the challenging oral health problems, medical challenges, and psychosocial concerns. Several European dental schools have undergraduate courses in gerodontology, and a few dental schools offer MS or PhD programs in gerontology and geriatrics. However, in Europe, there are no formal postgraduate specially training programs in geriatric dentistry 15. In Japan, gerodontology is 1 component of the undergraduate dental curriculum in some dental schools. Geriatric dentistry is also a subdivision of dental departments in some university hospitals. In the US, there is only a small core of well-educated dentists who receive special training to meet the needs of medically compromised, functionally dependent, and institutionalized elderly patients. The National Institute on Aging in the US has stated that all dental professionals should receive education in gerodontology as part of their basic professional education. Nowadays however, the shortage of skilled gerodontists is still a problem in the US and Europe 15. This reveals the high demand for gerodontists. Geriatric oral health in Taiwan For many people in Taiwan, aging is the main reason leading to loss of teeth. Since the loss of teeth is inevitable, most people likely think that geriatric dentistry is simply concerned with prosthesis fabrication. Fortunately, this misunderstanding has gradually decreased in recent years 12. Progress in preventive dentistry and the promotion of oral health care have made it possible for people to preserve their teeth throughout their life. In addition, due to improvements in overall social economic conditions and provision of dental insurance policies, the elderly working population has raised its motivation to seek dental advice. The factors described above can improve general oral health conditions and decrease rates of total loss of teeth in the elderly 12. Although the oral health condition of the elderly population has improved, the average number of teeth lost is still high. According to 1 investigation, which evaluated oral health of the elderly in southern Taiwan in 1992, the average number of missing teeth was 9.5 in the group aged 65~74 years. In the group 75 years J Dent Sci 2007 Vol 2 No 2 61

T.T. Yang, C.Y. Wang, J.H. Jeng, et al. old, the average number of missing teeth was 16. In addition, 57.0% of the elderly visit dentists only when they experience a bad toothache, and only 1.4% of the elderly population completely understands the importance of regular oral examinations. Based on what is presented in this report, one can conclude that the concept of early detection, early treatment of dental problems is still not widespread. Moreover, 2.5% of the older people involved in this investigation visit dentists only when gingival bleeding occurs. This means that the elderly still lack an awareness of periodontal diseases, and one can see that the concept oral diseases are preventable is still not well established. In addition, the elderly use dental services less than other age groups, and many of them do not have proper oral health care 12. An oral healthcare program was one of the earliest public health services provided in Taiwan. Although the government began very early to focus on oral health care, implementation has not always been easy. In addition, these policies are not aimed at geriatric oral health care. In the future, the aging population in Taiwan cannot be neglected. Older people will seek good health, including good oral health. The Department of Health of Taiwan has announced that prevention of periodontal diseases is the next major challenge 21. Perhaps this is the first step in promoting geriatric oral health care. At present, dental schools in Taiwan still lack faculty members with a specialty in gerodontology. Besides, fewer than 1/6 of the hospitals in Taiwan have special clinics for geriatric dentistry, and all of these hospitals are distributed in northern Taiwan. Geriatric dentistry in Taiwan, including education, clinical training, and policies, is just beginning. How to improve geriatric oral health care in Taiwan (Table 1) There are still many challenges for a national oral health policy in Taiwan such as caries, oral cancer, etc. Along with an increasing geriatric population, geriatric oral health policy is more and more important and cannot be neglected. Some policies and systems of geriatric oral health care in developed countries are worth learning about and emulating. Prevention is absolutely more important than treatment, and conducting regular oral examinations and promoting oral hygiene education are still the focal points of geriatric oral health care 12. The government should establish a practical and comprehensive oral health policy to establish systems with preventive principles. With regard to the complex nature and difficulty of geriatric oral health care, several common dental diseases in older people such as root caries, root fractures, and severe attrition should be thoroughly investigated. From those investigations, dentists may obtain the pathogeny, and then pursue treatment and preventive methods. The goal is to lower the oc- Table 1. Ways to improve geriatric oral health care by the government and dental teams in Taiwan The government Establish practical and comprehensive oral health policies Establish dental teams led by dentists Establish systems with preventive principles Dental schools Deliver the necessary education in gerodontology Provide postgraduate specialty training programs in gerodontology Train geriatric dental specialists Train all members of dental teams in ways of treating older people Investigate dental diseases from which the elderly are likely to suffer Hospitals Carry out regular oral examinations and promote oral hygiene education in elderly populations Treat dental diseases of the elderly Assist medical staff of the healthcare system with consultation, technical support, and transfer services 62 J Dent Sci 2007 Vol 2 No 2

Geriatric oral health care in Taiwan currence rate of such diseases and provide proper treatment for maintaining the quality of life of older people. For dental services and comprehensive education in gerodontology, a specialist training center for special care dentistry or gerodontology should be set up. There should be adequate expertise available within dental schools to deliver the necessary education in gerodontology at both the undergraduate and postgraduate levels 22. The content of post-graduate training includes dental knowledge as well as the oral care of patients with systemic diseases. The aim is to provide elderly patients with safe, proper dental treatment. Geriatric oral health care cannot be accomplished by dentists alone but must include dental teams. In addition to dentists, dental hygienists, dental technicians, dental nurses, and social workers should be included. All members should be aware of the dental needs of the elderly, and they should also receive appropriate training to extend their expertise in treating older people with complex treatment needs. Their abilities should be authenticated by certification 22. Requirements established for specialist training must satisfy the complicated dental treatment needs of the elderly. General practitioners with high interest in geriatric dentistry should compose a competency framework for special care dentistry. As for nursing staff, all qualified nurses should have basic knowledge of oral diseases and oral hygiene. They should also have the ability to estimate the oral condition and treatment needs of the elderly, even emergent dental needs. As for other healthcare and social workers, they can address such issues as maintaining good oral hygiene and avoiding oral infections of the elderly through education and creation of an appropriate understanding of the advantages of good oral health 23. Older people may need to utilize the healthcare system because of different systemic diseases, so medical staff members in the healthcare system must also understand the dental needs of elderly persons 12. Dentists, gerodontists, and other dental team members should assist the medical staff of the healthcare system with consultation, technical support, and transfer services. They should also assist medical staff in educating the elderly about proper oral health care. Meanwhile, dentists can also play an important role in establishing systems of geriatric oral health care. Establishing a leading role of geriatric oral health care is an important issue for all dentists in Taiwan 12. CONCLUSIONS An integral geriatric oral healthcare system can promote the oral health and life quality of the elderly. The system can help all older adults, including those independently living, homebound, chronically ill, and institutionalized, receive adequate and convenient oral health care. 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