A Best Practice Approach Report describes a public health strategy, assesses the strength of evidence on the effectiveness of the strategy, and uses practice examples to illustrate successful/innovative implementation.
Date of Report: ______
Best Practice Approach
Adult and Older Adult Oral Health
I. Description (page 1)
II. Guidelines and Recommendations (page 13)
III. Research Evidence (page 14)
IV. Best Practice Criteria (page 15)
V. State Practice Examples (page 16)
VI. Acknowledgements (page 17)
VII. Attachments (page 18)
VIII. References (page 19)
I. Description
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Best Practice Approach: Adult and Older Adult Oral Health 1
A. Adults and Older Adults in the U.S.
Table 12009 U.S. Population
http://www.census.gov/population/socdemo/age/2009_older_table1.xls
.Under 55 years / 229.4M
55 to 59 years / 18.8M
.60 to 64 years / 15.5M
.65 to 69 years / 11.8M
.70 to 74 years / 8.6M
.75 to 79 years / 7.3M
.80 to 84 years / 5.7M
.85 years and over / 4.4M
· In 2009, U.S. population was 301.5 million for all ages. There were 72.1 million adults aged 55 and over, 37.8 million adults aged 65 and older and 17.4 million adults aged 75 and over (Table 1). 1
· In 2009, 6.5 million (17.2 %) Americans age 65 and over were in the labor force (working or actively seeking work). They constituted 4.2% of the U.S. labor force.2
· The majority of older adults exhibit at least one medical problem. Disabilities associated with chronic illness increase sharply with advancing age.3 As individuals grow older, their physiologic functions decline, making them more susceptible to stress and infection and less able to perform activities of daily living (ADL). These factors are largely responsible for the spread of disease, particularly among institutionalized older adults.
· In 2006-2008, the most frequently occurring conditions among older persons were: hypertension (38%), diagnosed arthritis (50%), all types of heart disease (32%), any cancer (22%), diabetes (18%), and sinusitis (14%).2 The oral status of medically compromised older adults is largely the result of a combination of local and systemic factors. Poor oral health can exacerbate a medical condition, cause pain or discomfort, alter nutrition, and decrease a person’s self-esteem.3
1. U.S. Census Bureau, Current Population Survey, Annual Social and Economic Supplement, 2009.
http://www.census.gov/population/www/socdemo/age/older_2009.html
http://www.census.gov/compendia/statab/2011/tables/11s0034.pdf
2. U.S. Dept. of Health and Human Services, Administration on Aging. Profile of Older Americans 2010.
http://www.aoa.gov/aoaroot/aging_statistics/Profile/index.aspx
3. DeBiase CB, Austin SL. The American Dental Hygienists' Association, Continuing Education Series: Oral Health Older Adults.
http://www.adha.org/CE_courses/course11/common_conditions.htm
B. Significance of Oral Health for Adults and Older Adults
· The mouth is the gateway of the body. It serves as an early warning system for diseases (HIV/AIDS, Immune system problems, general infections, stress), signals nutritional deficiencies, and is associated with diseases such as diabetes, cardiovascular disease and stroke.
· Oral diseases and disorders affect health and well-being throughout life.
· Adult oral problems are extensive and may be particularly severe in vulnerable populations.
· Oral problems include the common dental diseases and other oral infections (which can occur at any stage of life with the chronic facial pain conditions) and oral cancers seen in later years.
· Oral diseases and conditions and their treatments may undermine self-image and self-esteem, discourage normal social interaction, and lead to chronic stress and depression as well as incur great financial cost. They may also interfere with vital functions such as breathing, eating, swallowing, and speaking and with activities of daily living such as work and family interactions.
· Oral health is essential to an older adult's general health and well-being.
1. Oral Health in America: A Report of the Surgeon General (Executive Summary)
http://www2.nidcr.nih.gov/sgr/execsumm.htm#partOne
C. Oral Diseases and Conditions
· There are threats to oral health across the lifespan:1
1. Nearly one-third of all adults in the United States have untreated tooth decay.
2. One in seven adults aged 35 to 44 years has gum disease; this increases to one in every four adults aged 65 years and older.
3. Nearly a quarter of all adults have experienced some facial pain in the past six months.
4. Oral cancers are most common in older adults, particularly those over 55 years who smoke and are heavy drinkers.
· Oral diseases and conditions include the following for adults and older adults:2
1. Tooth Loss: More older adults are retaining their teeth. Statistics show that nearly 40 years ago, 75% of those aged 75 and older were edentulous. Recent data suggests that no more than 40% of persons in this age group are edentulous. 3 Although edentulism is less prevalent, overall there is still a high incidence in those of lower socioeconomic status.
2. Dental Caries (Tooth Decay): The most significant risk for tooth loss in older adults is dental caries, in particular, root caries. Xerostomia, fixed or removable partials, abrasions at the cementoenamel junction, and diets composed of soft, sticky and/or sugary foods are also contributing factors to root caries.4
3. Periodontal Disease (Gum Disease): Periodontal disease is another area of concern in the older adult population. Studies have reported that 40% of ambulatory older adults have gingivitis, while 33 to 60% have some degree of periodontal destruction.5
4. Oral Pain: When oral health care is neglected, many older adults face various problems, such as oral pain that can affect their quality of life and cause them to withdraw socially. Oral pain can lead to more severe dental and systemic problems by compromising nutritional intake.
5. Oral Cancer: Approximately 15,000 older adults are affected each year by oral cancer. CDC reports that oral cancer is responsible for nearly 8,000 deaths each year. More than half of these deaths occur among those aged 65 and older.4
1. CDC Website: Adult Oral Health
http://www.cdc.gov/OralHealth/topics/adult.htm
2. DeBiase CB, Austin SL. The American Dental Hygienists' Association Continuing Education Series: Oral Health and Older Adults.
http://www.adha.org/CE_courses/course11/characteristics.htm
D. The Burden of Disease
The burden of oral diseases and conditions include the following:
For Adults:1
1. CDC Website, Fact Sheet, Oral Health for Adults
http://www.cdc.gov/OralHealth/publications/factsheets/adult.htm
· Over the past 10 years, the number of adults missing all their natural teeth has declined from 31percent to 25 percent for those aged 60 years and older, and from 9percent to 5percent for those adults between 40 and 59 years. However, 5percent means a surprising 1 out of 20 middle-aged adults are missing all their teeth.
· Over 40 percent of poor adults (20 years and older) have at least one untreated decayed tooth compared to 16percent of non-poor adults.
· Toothaches are the most common pain of the mouth or face reported by adults. This pain can interfere with vital functions such as eating, swallowing, and talking. Almost 1 of every 4 adults reported some form of facial pain in the past 6 months.
· Most adults show signs of gum disease. Severe gum disease affects about 14percent of adults aged 45 to 54 years.
· Signs and symptoms of soft tissue diseases such as cold sores are common in adults and affect about 19 percent of those aged 25 to 44 years.
· Chronic disabling diseases such as jaw joint diseases (TMD), diabetes, and osteoporosis affect millions of Americans and compromise oral health and functioning.
· Women report certain painful mouth and facial conditions (TMD disorders, migraine headaches, and burning mouth syndrome) more often than men.
· Every year more than 400,000 cancer patients undergoing chemotherapy suffer from oral problems such as painful mouth ulcers, impaired taste, and dry mouth.
· Patients with weakened immune systems, such as those infected with HIV and other medical conditions (organ transplants) and who use some medications (e.g., steroids), are at higher risk for some oral problems.
· Employed adults lose more than 164 million hours of work each year due to oral health problems or dental visits. Customer service industry employees lose 2 to 4 times more work hours than executives or professional workers.
For Older Adults:2-3
2. New Series of Reports to Monitor Health of Older Americans
http://www.cdc.gov/nchs/pressroom/01facts/olderame.htm#ORAL HEALTH#ORAL HEALTH
· More older people are keeping their natural teeth than ever before. However, among those aged 65 years and over there are sharp differences by income, with those in poverty twice as likely as those with higher incomes to have lost all their teeth.
· Many older Americans take medications for chronic conditions that have side effects detrimental to their oral health. These include antihistamines, diuretics, and antidepressants.
· One-third of adults aged 65 years and over have untreated dental caries; slightly over 40 percent have periodontal disease.
· Only 22 percent of older persons are covered by dental insurance; most elderly dental expenses are paid out-of-pocket.
3. CDC Website, Fact Sheet, Oral Health for Older Americans
http://www.cdc.gov/OralHealth/publications/factsheets/adult_older.htm
· Older Americans with the poorest oral health are those who are economically disadvantaged, lack insurance, and are members of racial and ethnic minorities. Being disabled, homebound, or institutionalized also increases the risk of poor oral health.
· Many older Americans do not have dental insurance. Often these benefits are lost when they retire. The situation may be worse for older women, who generally have lower incomes and may never have had dental insurance.
· Medicaid, the jointly-funded Federal-State health insurance program for certain low-income and needy people, funds dental care for low income and disabled elderly in some states, but reimbursements for this care are low. Medicare, which provides health insurance for people over age 65 and people with certain illnesses and disabilities, was not designed to provide routine dental care.
· About 25 percent of adults 60 years old and older no longer have any natural teeth. Interestingly, toothlessness varies greatly by state. Roughly 42 percent of Americans over age 65 living in West Virginia are toothless, compared to only 13 percent of those living in California. Having missing teeth can affect nutrition, since people without teeth often prefer soft, easily chewed foods. Because dentures are not as efficient for chewing food as natural teeth, denture wearers also may choose soft foods and avoid fresh fruits and vegetables.
· Periodontal (gum) disease or tooth decay (cavities) are the most frequent causes of tooth loss. Older Americans continue to experience dental decay on the crowns of teeth (coronal caries) and on tooth roots (because of gum recession). In fact, older adults may have new tooth decay at higher rates than children.
· Severity of periodontal (gum) disease increases with age. About 23 percent of 65- to 74-year-olds have severe disease, which is measured by 6mm loss of attachment of the tooth to the adjacent gum tissue. At all ages men are more likely than women to have more severe disease. At all ages, people at the lowest socioeconomic level have the most severe periodontal disease.
· Oral and pharyngeal cancers, which are diagnosed in some 31,000 Americans each year, result in about 7,400 deaths each year. These cancers are primarily diagnosed in the elderly. Prognosis is poor. The five-year survival rate for white patients is 56 percent and for African American patients is only 34 percent.
· Most older Americans take both prescription and over-the-counter drugs. Over 400 commonly used medications can be the cause of a dry mouth. Reduction of the flow of saliva increases the risk for oral disease, since saliva contains antimicrobial components as well as minerals that help rebuild tooth enamel attacked by decay-causing bacteria. Individuals in long-term care facilities—about 5 percent of the elderly—take an average of eight drugs each day.
· Painful conditions that affect the facial nerves are more common among the elderly and can be severely debilitating. These conditions can affect mood, sleep, and oral-motor functions such as chewing and swallowing. Neurological diseases associated with age, such as Parkinson's disease, Alzheimer's disease, Huntington's disease, and stroke also affect oral sensory and motor functions, in addition to limiting the ability to care for oneself.
E. Access to Dental Care and Dental Service Utilization
National Trends for Adults and Older Adults in the U.S.1-2
· For every adult 19 years or older without medical insurance, there are three without dental insurance.
· A little less than two thirds of adults report having visited a dentist in the past 12 months. Those with incomes at or above the poverty level are twice as likely to report a dental visit in the past 12 months as those who are below the poverty level.
· Only 22 percent of older persons are covered by dental insurance; most elderly dental expenses are paid out-of-pocket.
Access to Dental Care3
· Concerns about the degree to which the dental workforce is prepared to meet the oral health needs of older patients
· Adequacy of the future workforce such as concern about training opportunities in gerontology and geriatrics for dental and allied dental practitioners.
Utilization of Dental Services4
· Understanding why some people continue seeking preventive dental care throughout their lives while others are lifelong irregular users and still others discontinue regular use after retirement or relocation to a new community or long-term care facility.
· Determinants of older persons' dental service utilization, both barriers and enablers. Based on the epidemiological and psychosocial literature available on this topic, barriers and enablers include cohort and age, race and ethnicity, income and education, availability of dental and medical insurance, urban vs. rural residence, physical access to a dental office, and systemic and functional health. Attitudes toward oral health and dental care and other psychosocial variables may override some of these demographic and structural variables.
Residents of Long-Term Care Facilities5
· The federal Omnibus Reconciliation Act of 1987 (OBRA) established some specific requirements for dental services in more than 20,000 nursing homes across the country. The Health Care Financing Administration (HCFA) mandated that all nursing homes receiving Medicaid and Medicare reimbursements provide routine and emergency oral health care to their residents.71 These regulations were effective on April 1, 1992 and specifically required long-term care facilities to 1) assist patients in obtaining routine and emergency dental care; 2) provide dental care internally or obtain this care from an external source for each resident; 3) assist in scheduling appointments for dental care and arrange transportation to the dentist; and 4) develop an oral health program that includes annual staff in-service training, an oral examination within 45 days of admission that is repeated annually for each resident, and a daily oral hygiene preventive care plan for each resident. Each facility should have an agreement with a dentist to deliver oral health care services and make referrals.72