• Melladee F. Marvin, DMD, Dip. Pros. •
© J Can Dent Assoc 2001; 67(9):504-6
Seniors constitute the fastest growing population group in North America.1,2 The increase in their numbers, the movement from institutionalization toward community-based health care1,3 and increasingly limited government funding heighten concerns about access to dental health for our elders.1-4
Demographics
In Canada, 13% of the population is over 65 years of age,1 and healthy seniors who are 76 years old today have a life expectancy of more than 10 years.3
Most Canadian seniors live independently in the community. Only about 8% live in institutions.1,5
A substantial number of seniors feel that they have adequate income to direct toward their dental needs.5 In a survey to determine financial security, 82% of respondents believed that they had enough money for their old age.2 When surveyed about spending patterns, Canadians over 50 years of age were found to be responsible for spending more than 70% of all discretionary income.3
Although the perceived need for dental care among seniors is greater than for the general population, their use of dental services is less. Utilization statistics vary considerably among studies because of differing eligibility criteria, but all are low. Of homebound seniors, 60 to 90% have reported a need for dental services, but only 26% reported visiting a dentist at least once every 2 years and 12 to 16% had not visited a dentist in over 5 years.1,2,6 Depending on the criteria used, only 9 to 25% of seniors in institutions see a dentist once a year and 30 to 78% have not visited a dentist in over 5 years.1,2,6
Barriers to Care
No perceived need for dental care is the reason given most frequently by seniors and their caregivers for low utilization of dental services among seniors.1,2,6 Poor overall health can restrict access to care. Decreased cognitive ability, medications and limited ability to tolerate procedures may reduce the desire for care. Anxiety and fear of new situations or procedures may affect willingness to seek dental care. Existing esthetic factors, including missing teeth, may contribute to a reluctance to go out in public. Seniors may be unable or unwilling to be transported off-site to a treatment centre. Seeking care may just be too much bother for the individual or caregiver. Attitudes developed over a lifetime, expectations and previous patterns of dental service utilization all have a significant impact on whether a person will seek dental care.1
The cost of dental care, public health cutbacks and lack of dental insurance may influence access to care, but are not major deterrents. A substantial number of seniors have adequate discretionary income to direct toward dental care.2 Of Canadians surveyed about financial security, 28% reported an annual income of less than $15,000; 36% reported an income of $15,000 to 60,000 a year and 32% would not divulge their income.2 A separate survey revealed that 60% of Ontarians 15 years of age and older had some dental insurance.1 Yet another survey of disabled elders, found that 60% of respondents who had an annual income of less than $10,000 would be willing to pay for dental treatment if the cost was reasonable.2
Finally, there is a lack of willingness by dentists to treat elderly patients. Their reluctance is generated by a perception that seniors have insufficient patience, endurance or finances to undergo treatment; they require more chair time; and treatment is more difficult.1,6
Initiatives
Standards and regulations exist to protect and promote the dental health of seniors.1 There are federal, provincial and municipal funds for education and dental treatment; however, frequent changes in government policy affect eligibility, implementation and operation of the programs. In addition, onerous administrative requirements and low reimbursement levels for care providers discourage their use.1
National and provincial dental and dental hygiene associations have undertaken many initiatives to help elderly populations with special needs. Since 1982, the Ontario Dental Association, alone, has undertaken at least 7 initiatives, but follow-up has been sporadic and ineffective, primarily due to lack of funding.1
Most often, individuals and small groups have provided dental care for seniors at the grass-roots level. Seniors who are mobile seek treatment from local dentists and denturists on a fee-for-service basis. Some dentists, denturists, hygienists and other dental health personnel visit long-term care facilities or are involved in other community-based programs. Several societies and individuals organize time to service patients who cannot gain access to care in a traditional office setting or who cannot afford treatment (e.g., Dental Health Month, Valentine’s Day projects, etc.).
Some hospitals are equipped to service the disabled population and long-term patients. For example, Burlington Academy, the local dental society in Burlington, Ontario, has partnered with Joseph Brant Hospital Dental Clinic to service long-term care patients and other seniors residing in the community.1
The College of Dental Hygienists of Ontario is actively seeking support for its efforts with elders.7 The college hopes to produce a realistic funding model that will resolve the cost barrier associated with treatment for elders.1
The Elders’ Link with Dental Education, Research and Service group in British Columbia has developed 2 excellent educational booklets: one for lay people who provide preventive dental care to seniors7 and one for professional caregivers.8 This group has also developed a tool for assessing dental health over time.9 Although it was designed primarily for use in long-term care facilities, it is easily adapted for other groups. It can provide a very cost-effective written needs assessment for individual patients while also collecting statistical data for the group. It can be used to measure changes in dental health over time. The data gathered from measuring treatment results are important in determining the cost-benefit of programs introduced to groups.
Recommendations
Government funds may be insufficient to meet the medical and dental needs of aging baby boomers, although some health economists disagree with this notion.10 Regardless, to succeed, health care initiatives must include funding structures as core features. Fee-for-service, private insurance and innovative funding models must be integral to dental health care initiatives to even maintain, let alone improve, access to dental care for seniors.
Education is a relatively inexpensive, but effective method of addressing some funding concerns. Use of dental services is strongly correlated with income, level of education and existence of dental insurance. Studies cited earlier indicate that the majority of seniors live independently, are moderately well educated, have adequate income and will pay for dental care if they feel the cost is reasonable.2
Education must focus on quality of life; this is a central issue for the aging population.2 Education that increases patient awareness of how dental health enhances self-image and social interactions will influence attitudes toward care. Union negotiators must be encouraged to develop funding for retiring employees; working people must commit financial resources to dental care after they retire; and family members and other caregivers must be educated to support access to dental health care for elders.
Education is also needed for dentists and other dental professionals. Seniors can be assets to a dental practice, not liabilities. Dentists and auxiliaries must learn how to provide dental care for this population group in a timely, conscientious and cost-effective manner.
Although funding for dental programs from government agencies may be limited or unavailable, many public health centres have a great deal of educational material, expertise and a willingness to help volunteer and other community groups become active in health care.
Coordinated non-partisan efforts among existing dental associations and government agencies can minimize the costs of providing dental care in community and institutional programs. Those coordinating access to care need not be costly dental personnel. Individuals who have time, interest and skills in organization, recruitment and fundraising may be better suited to coordinate local projects.
Dentists should carry out periodic dental examinations for seniors groups. Using a specific repeatable protocol, like the CODE instrument,9 would standardize the method and make efficient use of the dentist’s time and expertise. With this tool, a treatment plan can be provided for the patient and data can be collected simultaneously to help streamline future dental care. The goal here is sustainable oral health.
Dental associations — national, provincial and local — must continue in their most important and effective role, lobbying. They must co-operate and redouble their lobbying efforts for increasingly limited health care dollars. They must continue to lobby for more responsible regulation of health care services and better access to dental care on behalf of the individuals and groups that depend on them, and those who support them.
Dr. Marvin is a prosthodontist in private practice and co-chair of the geriatric dental program for the North Bay and District Dental Society.
The views expressed are those of the author and do not necessarily reflect the opinions or official policies of the Canadian Dental Association.
References
1. Ontario Dental Association. Health Policy and Government Relations Core Committee. Final Report of the Access to Care Working Group. February 2000.
2. MacEntee MI. Dental epidemiological considerations in the elderly population. Presented at the Symposium On Aging, Osteoporosis and Dental Implants. Toronto, November 24, 2000.
3. Shay K. Dental care for older adults: clinical challenges and practical approaches. Presented at the Ontario Dental Association Annual Meeting. Toronto, April 19-21, 2001.
4. Statistics Canada. A portrait of seniors in Canada: third edition. 1998.
5. MacEntee MI. Clinical epidemiologic concerns and the geriatric prosthodontic patient. J Prosthet Dent 1994; 72(5):487-91.
6. Berkey D B, Berg RG, Ettinger RL, Merskin LH. Research review of oral health status and service use among institutionalized older adults in the United States and Canada. Spec Care Dentist 1991; 11(4):131-6.
7. Wyatt C, MacEntee M. Mouth care for persons in residential care. Elders’ Link with Dental Education and Research. Faculty of Dentistry, University of British Columbia. Copyright 1998.
8. Wyatt C, MacEntee M, Williams M. Oral health care for persons in residential care. Elders’ Link with Dental Education, Research and Service. Faculty of Dentistry, University of British Columbia. Copyright 2000.
9. MacEntee MI, Wyatt CC. An index of clinical oral disorder in elders (CODE). Gerodontology 1999; 16(2):85-96.
10. Evans RG, McGrail KM, Morgan SG, Barer ML, Hertzman C. Apocalypse no: population aging and the future of health care systems. Can J Aging 2001; 20(Suppl 1):160-91.