The Future of Dental Care for the Elderly Population

The U.S. population is aging, and they 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.

Too often, dentists misunderstand the breadth and depth of geriatric dental care to the extent that some colleagues in private practice commonly say, "I have no interest in going to a nursing home, so I don’t have an interest in geriatric dentistry."

The Elderly Population

The 20th century has been witness to dramatic changes with regard to the health, disease, longevity, and mortality of the U.S. population. We are becoming an aging society. In 1900, 4 percent of the population (3.1 million people) was 65 or older; and by 1998 that number had grown to 12.7 percent (34.3 million), a more than tenfold increase.¹ Although the number and percentage of adults older than 65 is growing, it is important to remember that heterogeneity is probably greater among people 65 and older than among people of any other age grouping.² The vicissitudes of life cause people to become different from each other; yet all too often people 65 and older are considered one homogeneous group when program planning or data analysis are being designed.

Elderly people are a complex combination and expression of their individual genetic predispositions, lifestyles, socialization, and environments, all of which affect their health beliefs and, consequently, their health behavior. To understand an individual patient's attitudes, the dentist must evaluate the cultural, psychological, educational, social, economic, dietary, and chronologically specific cohort experiences that may have influenced that patient’s life. Similarly, oral status is affected by these same factors and is the sum of an individual’s life experiences with dental care, as well as with caries, periodontal disease, and iatrogenic disease. Oral status also reflects a history of the person’s behavioral attitudes and expectations for his or her own oral health. The skills, attitudes, and philosophies of the various dentists that people have seen will also affect their oral status.³ The oral health care of older adults is called geriatric dentistry and includes but is not limited to the diagnosis, treatment, and prevention of caries and periodontal disease as well as oral mucosal diseases; head and neck pain; salivary dysfunction; disorders of removable prostheses; and impaired chewing, tasting and swallowing.

In the not so recent past, the elderly made up a relatively small proportion of the population; the majority of these people were edentulous and utilized dental care infrequently and then only when previous unmet needs could no longer be ignored.^4,5 However, there is now ample evidence to show that new elderly dental consumers have emerged who are better educated, are more politically aware, and have some remaining teeth. The most recent national data (1995-97) indicates that 26.7 percent of people 75 or older are edentulous, whereas the younger elderly (65 to 74) have an edentulism rate of 22.9 percent.⁶ In California, these rates are even better with 18.4 percent of those 75 or older being edentulous and 14.9 percent of those 65 to 74 being without teeth.⁶ As dental patients, these people have a wider range of needs and expectations than younger patients and are demanding a greater variety of services.⁷ It is no longer appropriate to equate geriatric dental care with denture care because it also includes complex restorative procedures, esthetic dentistry, and implants.

Until recently, the elderly have been defined as a cohort of people 65 years or older. However, a chronological definition of the aging population is not particularly useful in dentistry. Rather, a functional definition, based upon an older individual's ability to seek services, seems more appropriate. The aging population can be functionally categorized into three distinct groups.⁸

* The functionally independent older adult;

* The frail older adult; and

* The functionally dependent older adult.

The majority of older adults (95 percent) live in the community; of these, it is estimated that about 5 percent are homebound and another approximately 17 percent have a major limitation in mobilization because of a chronic condition. This still leaves about 70 percent of the population 65 or older who are living in the community and able to go to a dental office.⁹ Caring for these people is also geriatric dentistry. Nationwide, this translates into 70 percent of 32.2 million people or 23.2 million elderly who need dental services. California, the most populous state, has more than 3.5 million people 65 or older,¹⁰ many of whom are likely to need dental services.

Use of Dental Services

There is an increasing number of dentate older adults seeking dental care. In recent years, the number of dental visits by this population and the cost of care they require has increased. Data from a national health study¹¹ during 1985-86 indicated that 58.5 percent of employed adults age 18 to 64 had visited a dentist within the past 12 months, while 54.5 percent of dentate adults 65 or older had visited a dentist in the same period. However, only 13 percent of edentulous adults 65 or older had such a visit (Figure 1). The majority (62.2 percent), of these edentulous older adults had not used the services of a dentist for at least three years. Therefore, older people with some natural teeth were using dental services in a manner similar to employed adults during 1985 and 1986. It seems that the differences in utilization of dental health services that have usually been attributed to aging are instead related to the absence of a natural dentition. It has also been shown that the value older adults place on dental care seems to influence utilization more than any other factor, including ability to pay for care.^12,13 A demonstration program in Minnesota¹⁴ designed for low-income adults living independently with an 80-20 cost sharing, found that 67.4 percent utilized the service within a two-year period. All services except removable prosthodontics showed decreased utilization with increasing age. Another study¹⁵ examined dental service utilization by independently living adults in private practice and showed that older adults sought dental services at rates greater than those expected by their representative percentage. It was also reported that "patient visits by older adults generated, on average, as much or more income than did visits by individuals from any other age grouping."¹⁶

The United States, like a number of other aging industrialized societies, can be characterized by the fact that it has a decreased caries rate in children and an increasing coronal and root caries rate in the aging population. Incidence data (Tables 1 and 2) shows that people 65 and older have more caries than children under 14 years of age living in a nonfluoridated area.^17-23 As might be expected, the percentage of teeth with decayed or filled root surfaces increases with each decade of adulthood, affecting more than half of all teeth present by the age of 75.²⁴ Dentists cannot afford to ignore older adults by not practicing geriatric dentistry.

As more older people age and keep more natural teeth, the complexity of their treatment will increase.²⁵ Thus, their treatment will depend directly upon their self-perceived need for care and their financial ability to pay for that care, rather than a need detected during an oral examination.²⁶ A 1994 study²⁷ of New England elders 70 and older found an 85 percent prevalence of periodontal pocketing with a mean of 5.3 teeth involved and 95 percent prevalence of moderate to severe loss of attachment with a mean of 6.7 teeth involved. Yet, more than 75 percent of these same elders stated that their oral health was good or excellent, and 65 percent did not perceive that they had a need for care. Once an individual seeks care, the treatment offered will depend upon the dentist’s training and his or her attitude toward the replacement of missing teeth, the extraction or maintenance of teeth with a poor prognosis, and the retreatment of teeth that have previously been heavily restored. A key component of the risk benefit assessment a dentist practicing geriatric dentistry should make is, what level of treatment is possible, and will the older patient have the ability to maintain oral hygiene independently or with help. Many older adults have never been taught how to adequately clean their dentition. Also, older adults often do not understand that the primary function of tooth brushing is to reduce plaque levels in the mouth. Many others have not had their mouths professionally cleaned or, if they have, only infrequently.⁵

Many older people are likely to have chronic diseases -- e.g., arthritis, diabetes, cardiovascular disease -- at increasing rates with increasing age and as a result be on an ever-expanding variety of medications. These chronic conditions can affect a person's quality of life, especially their ability to eat, speak, taste, and swallow; but they can also cause significant pain and discomfort. For instance, diabetics can experience severe periodontal disease, delayed wound healing, and susceptibility to candidiasis. Apart from the influence of the diseases, many systemic drugs can frequently cause adverse effects to the oral mucosa, such as hyposalivation. The patient may also experience xerostomia, bleeding disorders of the tissues, lichenoid reactions, tissue overgrowth, and/or hypersensitivity reactions.^28-31

No overview about geriatric care can be complete without the inclusion of the effect of cancer on this population. In the United States, the estimated incidence for oral and pharyngeal cancer for 1998 was predicted to be approximately 30,750 new cases and 8,440 deaths.³² The majority of these people are in the 55- to 74-year-old age group. Approximately 11 percent of all oral and pharyngeal cancers that occur in the United States are diagnosed in California patients.³³ Therefore, an annual oral examination of the soft and hard tissues must be incorporated as a routine preventive measure for all elderly people.

Summary

It is clear that the aging population is growing and that these older adults have more teeth and more oral problems that will make treatment increasingly difficult and complex. Dentists need to continue to look for better ways of handling the disease presentations they find in this population. The following information is for practitioners, researchers, legislators and academics to consider as they continue to care for the expanding population of elderly patients in the United States.³⁴

1. The influence of chronic systemic diseases such as cardiovascular disease, diabetes, and rheumatoid arthritis and their treatment on oral health and dental treatment has become more significant and will further complicate dental treatment decision making.

2. The dental health care system is moving toward managed care; and since prevention is cheaper than treatment, the skills to diagnose and treat caries and periodontal disease and other oral conditions (e.g., cancer, xerostomia) early will need to be developed and implemented.

3. Douglass and Furino³⁵ have predicted that the number of edentulous people will not decline, although their percentage in the population will. Nevertheless, these edentulous people will be older than the dentate community, have lower educational and socioeconomic backgrounds, and will have been edentulous longer and therefore be difficult to treat. General dentists may need extra training in diagnostic and technical skills to treat these individuals.

4. Periodontal disease will remain a problem for older adults. However, the "at risk" person cannot as yet be identified and more reliable predictive diagnostic tests are needed.

5. More natural teeth are being retained, and many of these teeth have large restorations that are at risk of fracture or recurrent decay. Restorative dentists will need to develop innovative and cost-effective ways of restoring teeth for older adults other than crowning the teeth.

6. Implants and fixed prosthodontics may be the treatment of choice in many situations. Clearly, the cost of care for these treatments must be dramatically reduced or the edentulous space will either not be restored or be restored with a removable prosthesis.

Authors/

Ronald L. Ettinger, BDS, MDS, DDSc, is a professor in the Department of Prosthodontics and Dows Institute for Dental Research at the University of Iowa.

Roseann Mulligan, DDS, MS, is professor and chair of the Department of Dental Medicine and Public Health at the University of Southern California School of Dentistry.

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To request a printed copy of this article, please contact/Ronald L. Ettinger, BDS, MDS, DDSc, Department of Prosthodontics and Dows Institute for Dental Research, University of Iowa, Iowa City, IA 52242.