As the percentage of older Americans has rapidly expanded in recent decades, one of the major challenges has been providing access to adequate dental care for this demographic. As an important part of a healthy aging process, good oral health is imperative for older citizens. Policymakers, geriatric health care professionals, and especially dental care providers have been actively involved in the ongoing conversation of how to provide access to appropriate service for this group.
Dental care access has often been difficult to define, a challenge which has led to insufficient opportunities to care for many older Americans. At its most basic, access to care is defined as “the timely use of personal health service to achieve the best possible health outcomes.” However, simply having insurance or even a geriatric dentist in the neighborhood is not an adequate guarantee that patients are receiving the services they need.
Instead, a successful access program can be better described in three terms, known collectively as the “Access Triangle.” They include the following:
There has been growing concern about our nations current ability to meet the standards defined in this successful access triangle. In the past few decades, several calls to action have been issued to the various parties involved in this challenge.
In some regards, these actions have proved successful. In general, many independent elderly adults have effective access to dental care. Increasing numbers in the use of dental services by older patients further supports this optimistic trend. However, there are a number of unique factors shared by those with consistently effective access, including having dental insurance, being able to afford care, having mobility, the ability to effectively communicate with office staff, and others. Clearly, there a large number of older citizens who do not enjoy the same efficacy of access.
In fact, there are large groups of older adults who do not have access to the dental services which they need to support their oral and overall health. These “vulnerable elders” include, but are not limited to, those who are: poor, lack insurance or mobility, have lost all of their teeth, do not believe they need care, have difficulty communicating, or have functional and cognitive impairments.
Based on this assessment, it is clear that more responsive actions are necessary. From the education and training of the dental workforce to focus on geriatric dentistry to reimagining the current dental care delivery system, true process will take a multifaceted approach. Dr. Kauffman continues to be a leader in this development and implementation of better systems of dental care for elderly patients.
There is no time to wait to begin addressing the issue of effective access to dental care for elderly patients. Good oral health is strongly linked to benefits throughout the patient’s life, from the reduction of premature morbidity and mortality to the preservation of function and overall quality of life. As our nation’s demographics continue to shift in favor of a larger elderly population, continued action and reevaluation will be necessary.
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The utilization of dental services and dental expenditures by older adults has increased in recent decades. For example, in comparing National Health Interview Survey data, only 16.2% of people over 65 in 1957 reported having a dental visit in the previous year as compared to 54% in 2002. Mean expenses per person age 65 and older with a visit increased from $348 in 1996 to $620 in 2004. Approximately 70% of these dental expenditures were paid out of pocket, about 24% from private insurance, and about 6.3% from Medicaid. A report by Oral Health America noted the lack of public support for dental care for senior stating: “There are significant structural problems in our oral health care system, and the problems are getting worse due to demographic trends, workforce trends, public health infrastructure inadequacies, and the increasing number of children, adults, elderly and special populations not covered by Medicare or Medicaid.”
What procedures did older adults receive? In 2004, 16 millions older adults received about 74 million dental procedures. Among those with a dental visit, 85% receives a diagnostic service, 75% received a preventive service, and 29.7% had a prosthetic service. A report comparing trends from 1996 to 2004 are mixed, with a slight increase in the use of diagnostic and preventive services, but a slight decrease in the use of restorative and prosthetic services. What about vulnerable elder? Vulnerable elderly patients have been defined as patients over age 65 who have any or all of the following: limited mobility, limited resources or complex health status. Numerous studies have described the inadequacies of our dental delivery system in meeting with the oral health needs of subpopulations of elders, including the homebound and those living in long-term care facilities.
Federal legislation passed in 1987 was intended to improve access to dental care within nursing homes through the required use of minimal data set (MDS) and follow-up using resident assessment protocol (RAP). However, an Inspector General report in 2001 cited dental care as a “top 3“ area for which RAPs did not trigger a care plan. Model programs such as the Apple Tree Dental have refined delivery system issues, including the effective use of portable dental equipment, communication with patients and families, obtaining informed consent and billing for services. However, much work is needed to ensure adequate access to care for this subgroup of elders.
National reports have called for enhanced geriatric content in all health professions education, including dentistry. The 2005 White House Conference on Aging passed a resolution calling for legislative action to “attract and retain new health care providers with advanced training in geriatric medicine, mental health, social work, nursing, dentistry, allied health professional and direct care workers by establishing geriatrics as an underserved profession and by supporting expanded training opportunities and financial incentives, including loan forgiveness, benefits and appropriate…