Oral Health and Older Adults

W4A Advisory Councils and State Council on Aging

October 16th, 2008

Seniors are at increased risk for oral disease

• Poor oral health throughout life – worsens with time• New disease due to:

• Breakdown of previous restorations• New health condition which affects the mouth (including dry

mouth)• Gum recession leaves tooth roots vulnerable to decay• Physical/mental conditions make home care challenging – must

rely upon caregiver• Lack access to preventive care

• Expectation to need dentures (seems to be fading)• Competing financial priorities – lower value on oral health

Magnitude of the Problem

• Nationwide, seniors’ oral health is improving:• Untreated decay is down 30%• Untreated root caries is down 36%• Edentulism (toothlessness) is down 20%

• However, too many seniors still experience oral disease:• 1 in 5 currently have decay• 1 in 4 have severe periodontal disease (gum disease)

• Jumps to 1 in 3 among low-income

Gum Disease Increases with Age

Racial/Ethnic Disparities

Income Disparities

Difficulties Accessing Care

• Medicare doesn’t cover dental• 75% of seniors in WA are dentally uninsured• Only ~20% on Medicaid access care• Seniors are age group most likely to have had no dental

visit in 5 years (BRFSS)

• Causes missed opportunities for prevention• Many seniors put off paying for care until problem is

significant

Oral Health - Overall Health Connection

“You cannot be healthy without oral health.”

Surgeon General’s Report on Oral Health

~May 2000

Periodontal Disease – Medical Link

• Diabetes:• Diabetes increases risk for gum disease• People with diabetes and severe gum disease are more likely to

have problems with glycemic control• Treating gum disease may improve glycemic control and prevent

costly diabetic complications

• Heart Attack/Stroke• Pnemonia

Gum Problems - Photos

4. Gingivitis

5. Periodontal Disease

Dry Mouth (xerostomia)

• Estimated that 25% of seniors have dry mouth• Saliva is protective:

• cleanses the mouth;

• neutralizes acid;

• kills bacteria and other germs

• remineralizes teeth (fluoride and calcium)

• Causes:• Health conditions (diabetes, Sjögren’s Syndrome)

• Cancer treatments

• Medications• 7 out of 10 most commonly prescribed medications• Antidepressants, antipsychotics, antihistamines, decongestants,

antihypertensives, diruetics, antiparkinsonian drugs

Dry Mouth Incidence

• Risk increases with the number of medications taken.

Nederfors, et. al, 1997

Dry Mouth – Side Effects & Photos

11. Root Decay

12. Cracks on Corners of Lips13. Dry, Painful Tongue

14. Possible Fungal Infection

Tongue

Dry Mouth Prevention and Remedies

• Saliva substitutes (Biotene, Orajel, etc…)• Increase water intake• Increase fluoride• Avoid alcohol (including in mouthwash), tobacco, sugary drinks• Xylitol:

• Plant-derived sugar alcohol.• Sugar alcohols - reduce tooth decay interferes with the production of

acids.• Xylitol the most effective sugar alcohol at reducing tooth decay.

Washington Dental Service Foundation

• Non-Profit Corporate Foundation

• Mission: to eliminate oral disease for all

• Values:• All people should have an equal opportunity to be healthy.• We strive to end racial, ethnic and income disparities as barriers to oral health.• We make a positive impact on people’s lives by influencing environments that affect

oral health over the long-term.• We are creative, innovative, adaptive and take calculated risks.• We are outcomes-driven.• We value teamwork, integrity, trust, diversity and shared purpose in our work

internally and externally.

Public values the importance of oral health; understands the mechanics and link to overall health; demands services and is motivated to conduct good oral health behaviors and nutrition habits

Policy/decision-makers buy-in to the importance of oral health and establish policies that support:• Prevention of oral disease• Access to services• Good oral health behaviors

Financial system provides incentives for and eliminates barriers to serving the underserved; all patients have coverage for care.

BiologyBiology

People routinely assess and manage their risk for People routinely assess and manage their risk for oral disease based on their individual biologyoral disease based on their individual biology

Physical EnvironmentPhysical Environment

The physical environment promotes good oral The physical environment promotes good oral health: WA residents drink fluoridated water, health: WA residents drink fluoridated water, healthy snacks are available in schools and work healthy snacks are available in schools and work placesplaces

Social EnvironmentSocial Environment

Social norms define behaviors and policies that Social norms define behaviors and policies that promote oral health as an essential element of promote oral health as an essential element of overall health as the accepted and expected overall health as the accepted and expected standard standard

Eliminating oral Eliminating oral disease in order to disease in order to

improve overall improve overall healthhealth

Adequate pool of providers, which contains the appropriate balance of disciplines (including medical professionals), offers oral health services efficiently in easily–accessible and geographically distributed settings.

Community systems and services facilitate access to care for everyone in their local community

Personal BehaviorPersonal Behavior

People regularly and effectively practice oral People regularly and effectively practice oral self-care and avoid practices that increase their self-care and avoid practices that increase their risk for oral diseaserisk for oral disease

Science-based best practices for prevention and treatment are understood and implemented by health professionals. . Science continually advances in the understanding of the biology of oral disease..

Culturally competent and diverse workforce increases the comfort and quality of care for all populations and participates in efforts to improve oral health at the community level

Determinants of Oral HealthDeterminants of Oral Health

Access to Quality HealthcareAccess to Quality Healthcare

People access oral health care including People access oral health care including preventive and restorative servicespreventive and restorative services

Conditions for SuccessConditions for Success WDSF MissionWDSF Mission

The Theory of Change for Eliminating Oral Disease

WDSF Role

Identify and drive strategic changesin systems to improve oral health

WDSF Initiatives

• Seniors’ Dental Access Pilot Project

• Caregiver Curriculum

• Media Campaign

Seniors Dental Access Pilot

• Goal: Improve oral and overall health of seniors through increased access to preventive and restorative dental care in medical and dental settings.

• Medicaid-insured adults age 55 and up

• 3-Year Pilot project• July 09 – June 2010: systems, training, provider recruitment• July 2010 – June 2012: Medicaid payments

Pilot Sites

Clark County- Clark County Health Department

Southeast Region- Southeast WA Aging and LTC

Whatcom

Snohomish

Okanogan

Chelan

Douglas

Franklin

BentonYakima

Lewis

Thurston

Island

Mason

Spokane

Whitman

Columbia

Garfield

King

Skagit Stevens

Klickitat

SkamaniaCowlitz

Wahkiakum

Kittitas Grant

Pierce

Clark

FerryPendOreille

Lincoln

Adams

WallaWalla Asotin

Clallam

Jefferson

Grays Harbor

Pacific

San Juan

Kitsap

Partners

WASHINGTON SENIOR CITIZENS’ LOBBY

ELDERCARE ALLIANCE

University of Washington

School of Dentistry

How it will work

• Based on Access to Baby and Child Dentistry model • Links with other chronic disease management programs• WDSF funds local coordinating agencies to conduct

patient outreach and provider recruitment• UW School of Dentistry offers training events for dental

and medical providers • Medicaid provides enhanced rates to dentists and

payments to physicians for oral health services• Track utilization rates and study improvements in health

for patients with diabetes

Key Metrics

• Dental utilization rates - are more seniors accessing care in dental setting?

• Preventive oral health services - does improved network lead to more preventive screening and services in medical and dental settings?

• Attracting participating providers - are more dental and medical providers serving Medicaid-insured seniors?

• Medical and dental costs – will increased dental care for this population that is at risk for chronic diseases reduce medical costs associated with those diseases?

Caregiver Training

• Curriculum developed in 2004,pilot-tested by PRN, certified by DSHS to qualify for 10 hour c.e. rolled-out to caregiver training agencies

• Goal is to engage caregivers in oral health and teach skills for improving oral health of clients/family members

• 6 modules: tooth decay, gum disease, oral cancer, dentures, nutrition, dry mouth

Caregivers Can Improve Oral Health!

Prompt, assist, or perform the oral health care.

Monitor client’s mouth for changes.

Educate client about oral health information.

Refer problems to supervisor or case manager.

Tooth Decay - Process

Germs + Refined Carbohydrates = Acid

Acid Attacks + Tooth = Decay

Untreated Decay Infection, Abscess, Loss of Tooth

Activity: Check Your Mouth

Look at your gums, teeth, and tongue

What do you see?

Normal?

Not normal?

Evaluation

• Conducted in 2007 – 96 participants• Key Question: Does training impact how caregivers

provide oral health care to clients/loved ones?• Qualitative design:

• 14 focus groups –• 6 trained, 6 untrained, 2 mixed

• 11 IPs, 3 agency

• 2 Russian

• 17 phone interviews• Survey

• King, Pierce, Lewis, Yakima Counties

Partners

• Professional Registry of Nursing• AAAs:

• LMT AAA• Pierce County AAA• King County Aging and Disability Services• Southeast Washington Aging and LTC

• ResCare HomeCare (formerly Armstrong)• Elite International

Key Findings

• Trained caregivers are more active participants in their clients’ oral health care (60% vs. 20%)

• Trained caregivers are more likely to:• Look in the mouth – screen for problems• Help clients access dental care• Prompt or assist with brushing • Prompt or assist with cleaning dentures• Encourage wearing dentures• Recommend dry mouth remedies

Key Findings continued

• Trained caregivers are more confident in ability to care for client’s teeth and mouth

• Trained caregivers mentioned improvements to their own oral health care following the training:• Eating healthier• Brushing right after meals• Flossing more regularly• Making a dentist appointment• Using gum with xylitol

Challenges

• Caregivers experience the following challenges in providing oral health care for their clients:

• Client resistance • Conflict of roles with family members• Client dementia• Access to dental care for clients

Implications/Recommendations

• Need tips and support for overcoming client resistance• Need additional content on providing oral health care for

clients with dementia• Oral health needs a greater role in care plans – currently

falls in personal hygiene section, not health• Develop programs to improve access to dental care for

this population• Engage medical community

Media Campaign

• Television and radio spots • Summer 2007: greater Puget Sound area• Fall/Winter2007 and early 2008: Major WA markets

       

• Op-Ed pieces • Tacoma News Tribune• Spokane Spokesman Review• Seattle PI• Tacoma News Tribune

Resources

• Geriatric Dental Group – Federal Way (253-839-1300)• Community Clinics• Local Health Jurisdictions/Oral Health Coalitions• WSDA Senior Discount Program – through I and R• Preventive services by hygienists in senior centers• Dental societies – community access programs

Vision…

• Public and leaders understand the link between oral health and overall health

• Medical providers screen and provide preventive services• Pharmacists counsel on dry mouth • Oral health services available in community-based settings• Medicare includes dental benefit

Anything else????????