Access to Oral Health Care for Older Adults
Over the past few decades dentistry has transitioned to a more upstream preventative approach. Emphasis is placed on routine periodontal maintenance, improved homecare, and less invasive restorative care. This results in older adults retaining their natural teeth for longer. Older adults often lose dental insurance when they retire, creating a financial burden. Due to this preventative shift, the complex overall health status of older adults, their inability to access care, the oral health needs are often unmet for older adults within the community.
By the year 2036, older adults (aged 65 years or older) are expected to represent 25% of the Canadian population (Badewy et al. 2020). Adequate oral health is an integral component of nutrition, communication, systemic health, wellbeing, and is linked with frailty and mortality in older adults (Hoeksema et al. 2017). Poor oral health can be associated with several systemic diseases (Bailey et al 2005; Tavares et al 2014). When oral care is inadequate, both systemic and secondary health problems associated with poor oral health are addressed in primary healthcare resulting in a burden financially and logistically to the healthcare system (Badewy et al 2020).
Background
This fundamental preventative shift within oral care has led to older adults retaining their natural dentition and improved overall oral health for longer in life. In 1970, 23.6% of adults were edentulous, in 2010, only 6.4% were edentulous (Health Canada 2010). Oral health is a vital component of systemic health, allowing individuals to effectively eat, speak, perform daily activities, and relate to others. The number of teeth retained into older adulthood can be seen as a marker of a healthy lifestyle, as well as systemic health status (Lamster, 2016).
Poor oral health can be defined as the presence of pain, periodontal disease, xerostomia, inflammation, infection, oral cancer, inadequate function due to decayed and/or missing teeth, as well as ill-fitting or the need for dentures (Bailey et al., 2005). This is not an inevitable part of aging, it is instead experienced by those who do not have access to routine, quality dental care (Azzolino et al. 2019; Health Canada 2010). Older adults often place low priority on oral health and have difficulty expressing complaints regarding poor oral health until it become intolerable (Azzolino et al. 2019). Poor oral health has a negative impact on frailty, activities of daily living, quality of life, as well as systemic health (Hoeksema et al. 2017).
Tooth loss and poor oral health in older adults can be considered a disability and is linked to frailty and mortality (Badewy et al. 2020; Lamster, 2016). Tooth loss reduces mastication efficiency, can create swallowing dysfunction, poor dietary choices, challenges in daily functioning, and psychological stress (Lamster, 2016). The number of teeth retained into older age can be considered a marker for systemic health and a healthy lifestyle. Tooth loss is not a part of normal aging. Tooth loss is a result of a complex cumulation of biological and social factors, susceptibility to oral disease, oral hygiene practices, oral health literacy, economic resources, as well as an individual’s systemic health status (Assolino et al. 2019; Lamster, 2016).
Tooth loss within older adults is typically due to two factors: periodontal disease and/or dental caries. Periodontal disease is characterized as a chronic inflammatory disease that affects the supporting tissues of the teeth leading to the progressive destruction of periodontium, and surrounding bone. As it progresses it causes mobility, the eventual displacement and loss of teeth. Dental caries is a multifactorial infectious disease characterized by the demineralization and destruction of enamel, leading to the destruction and breakdown of enamel, followed by inner tooth structure, resulting in infection/abscess formation (Azzolino et al. 2019).
Many older adults present within the dental office with one or more chronic systemic diseases (Bakker et al 2018). While there is limited research, evidence suggests there is relation between poor oral health and systemic health conditions. There is a bidirectional relationship between periodontal disease and poor diabetic control (Montini et al. 2014; Tavares et al 2014). Periodontal diseass doubles the likelihood of having coronary artery disease, as well as is a predictor of aspiration pneumonia within hospitalized individuals (Badewy et al. 2020; Tavares et al 2014).
Multiple medications are commonly seen within older adults, which can have negative impacts on oral health (Hoeksema et al. 2017). According to the American Dental Association (2005) medications can cause bleeding problems during dental treatment, dysgeusia, inflammation, oral sores, gingival discoloration/enlargement, as well as oral candidiasis. There are over five hundred medications that can cause xerostomia, which is estimated to affect 25-50% of all older adults (Azzolino et al. 2019). Xerostomia lowers the oral pH, creates difficulty chewing/swallowing, as well as diminish the natural cleansing ability of the oral cavity, leading to inflammation, infection as well as a strong risk of tooth decay (American Dental Association, 2005; Lamster, 2016; Yves Cousson et al. 2012). Chronic disease, as well as the multiple medications required to treat them, can be associated with poor oral health (Bakker et al 2018).
Malnutrition is defined as a state of nutrition in which a deficiency of energy, protein, or other nutrient causes measurable adverse effects. It can impact weight loss, frailty, and mortality (Badewy et al. 2020; Yves Cousson et al. 2012). Oral health problems such as pain, tooth loss, and chewing problems are contributing factors to malnutrition (Bakker et al. 2018). Studies have shown that older adults with less than 20 teeth (or wearing dentures) had lower nutritional intake, as well as more frequent problems chewing and speaking than those with more than 20 teeth (Bakker et al. 2018; Yves Cousson et al. 2012).
In Canada, most primary health services are publicly funded. However, only 6% of total dental expenditures are publicly funded, none of which is allocated to older adults. For all ages, dental insurance is the primary indicator of access to oral health care (Estrada et al. 2018). Specifically, within older adults, 53.2% do not have dental insurance. Older adults are often on a fixed income which can create a financial barrier to receive vital oral care (Health Canada 2010). Difficulties eating, the effects of malnourishment, frailty, and oral pain have been associated with increased hospitalization, emergency service usage resulting in increased healthcare costs in older adults. Preventative and timely dental care could avoid these repercussions (Badewy er al 2020; Bailey et al. 2005). Increasing access and treating oral health preventatively within the oral health sector can reduce strain on the systemic healthcare system (Badewy et al. 2020).
Alternative Policy Response
Many older adults lose their dental insurance when they retire, therefore putting financial strain on a fixed income. There is growing evidence on how oral health affects systemic disease and vice versa, as well as how polypharmacy negatively affects oral health. Preventative oral care can aid to maintain older adults health, maintaining their quality of life and ability to function within their communities, outside of the healthcare system for longer.
There are multiple ways that access to oral care could be improved for older adults. The simplest would be to create a program similar to the NIHB (Non-Insured Health Benefits). The NIHB is a federal program providing funding for many dental services for First Nations and Inuit patients. It covers routine dental exams, routine x-rays, preventative services (such as scaling/root planing and fluoride application), basic restorative costs, and partial dentures (Government of Canada, 2010). With a program similar to NIHB, existing oral health care providers would be able to provide care for older adult’s oral health needs within their communities with no additional cost to patients.
A second policy solution could be reintroducing dental therapists with specific training for older adults with the aim to provide care to older adults within the existing healthcare system. Currently dental therapists are employed within Saskatchewan. They are trained to perform basic clinical treatments, and preventative services such as the diagnosis of caries and dental abscesses, restoration of teeth, scaling and root planing, provide local anesthetic, perform uncomplicated extractions, as well as manage dental emergencies (Dental Therapist Association of Saskatchewan, N.D). Dental therapists are trained within specific government funded colleges, so their training could be adapted to the needs of the position.
Recommendation and Key Points of Analysis
Introducing a program based upon the NIHB will allow older adults to continue receiving oral care in their communities, with providers they are familiar with. Both the Nova Scotia (2021) and Canadian Dental Association (2010) have expressed the need for improved access to oral health care for older adults in discussion with both provincial and federal government decision makers. The Canadian Dental Association (2010) has also acknowledged the potential health risk of undiagnosed oral diseases (caries, periodontal disease, oral cancers), as well as the cost to the healthcare system if poor oral health remains for extensive periods.
Utilizing the 3I’s framework (Gauvin, F., 2014) the stakeholders with interest in this potential policy solution are older adults, dental providers, geriatric specialists and provincial governments. Older adults stand to benefit the most from creation of this policy. They would receive financial support for costly preventative oral care. The provincial government would bear majority of the cost for this policy, with a potential return on investment by older adults thriving within their community. Publicly funded programs such as the NIHB require significant work for dental providers, however many dental professionals acknowledge the need and advocate for funding on many stakeholder levels. The important ideas surrounding this policy include several factors. Canada’s older adults population continues to grow, putting a strain on the healthcare system, which this policy aims to alleviate. There is a growing body of knowledge surrounding the bidirectional link between oral health and systemic health, which creates a greater need for oral health to be included within Canada’s healthcare coverage, especially for vulnerable populations such as older adults. Healthcare spending is determined by the institution of individual Provinces & Territories. Nova Scotia has already acknowledged and places emphasis on oral health by participating in the NIHB program, as well as funding a children’s oral health program. By funding an oral health policy for older adults Nova Scotia can continue to set precedence for oral healthcare throughout Canada.
Potential opposition may come from provincial government as the primary financial stakeholder. All stakeholders will need to understand the importance of oral health, its relation to systemic health, particularly within older adults and the potential savings to the primary healthcare system.
Conclusion
This policy problem aims to bring awareness to the importance of adequate oral health care for all groups of the public, specifically older adults. Older adults need improved access to oral health care for many reasons. Including the substantial impact poor oral health has on systemic health and the impact it can have on keeping older adults residing and thriving withing their communities. By funding a provincial program similar to the NIHB, older adults will be able to receive timely oral care to maintain their oral health, to benefit their systemic health.
References
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