Oral Epidemiology & Access to Oral Care

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Oral Epidemiology & Access to Oral Care

Summary

Epidemiological studies in the US and other developed countries have shown a decline in rates of edentulism in newer cohorts of elders. For example, findings of the NCHS survey of oral health in 1960-1962 revealed that 46% of Americans aged 65-74 were completely edentulous, compared with 32% in 1984-1986 and 24% in 1991-1992, according to the WHO/NIH International Collaborative Study II (ICSII). This large epidemiological study compared several countries regarding the oral health status and behaviors of their young, middle-aged and older populations. Trends in most countries demonstrated a reduction in tooth loss, especially among middle-aged populations, indicating greater need for restorative and periodontal care in future cohorts. Rates of periodontal disease were low in most countries, ranging from 3% in Germany to 5% in the US and 8% in Japan.

Despite these improvements in oral health status on a population basis, there are great variations within the US (Andersen and Davidson, 1997). Indeed, the ICS II samples in the US included whites and African Americans in Baltimore, Hispanic and non-Hispanic whites in San Antonio, and two different American Indian tribes (Navajo and Lakota Indian Health Service users). Although white elders in Baltimore and San Antonio had the same number of teeth on average as those in the Navajo communities, the "D" component of their Decayed, Missing, or Filled Teeth (DMFT) scores was only 1/4 the rate of their Navajo counterparts and 1/3 the rate of Hispanic elders. The "F" component of San Antonio whites was 3.5 times higher than their Hispanic counterparts, while that of Baltimore whites was more than 4 times higher than their African American counterparts in the same community and that of Navajo and Lakota Indians in the same age range. These disparities among 65-74-year-olds in the US indicate better access to care during their younger years.

Periodontal measures revealed higher rates of disease among both American Indian groups; for example, 23% of Navajo elders had one or more periodontal probing depths of 6mm or greater, compared with 11% of Baltimore whites, while only 1% were deemed periodontally healthy, compared with 14% of whites. As a result, treatment needs among these American Indian populations were greater than among whites; 23% of Navajo elders were rated as needing complex periodontal treatment, compared with 11% of Baltimore whites. Dental problems were rated as being severe enough that extractions were the recommended treatment for 67% of Navajo elders, compared with 16% of their white counterparts.

Poor oral hygiene and irregular use of dental services may account for some of these disparities. Indeed, the ICS II revealed that 75% of older Navajo Indians never flossed, compared with 41% of whites. Even toothbrushing occurred less frequently among the former group, 69% reported doing so once or more per day, compared with 95% of the latter group. Differences in dental visits were even more striking: 78% of Navajo elders indicated that they had made no dental visits in the past year, compared with 43% of Baltimore whites. When asked specifically whether they had made a visit for preventive vs. emergency dental care, 64% of Baltimore elders reported that they had made preventive visits in the past year, while only 14% of Navajo elders had done so. This is particularly disturbing when one considers that the elders examined on the American Indian reservations were users of Indian Health Services, but not necessarily the dental clinics associated with these services. Disparities were found between Hispanic and non-Hispanic whites in San Antonio as well, with 37% of the former and 71% of the latter reporting any dental visits in the past year, if they had any natural teeth. No differences emerged among edentulous elders, with about 20% of each ethnic group in San Antonio reporting a dental visit. Rates were higher among Baltimore whites who were edentulous (22%), compared with 13.5% of African Americans and 10.8% of edentulous Navajo elders. Regression analyses concluded that the best predictors of dental visits among older adults in the US sample were gender, income, urban vs. non-urban residence, and having a usual source of dental care. Women in general were 20% more likely to visit a dentist. Low-income Navajo elders were less than half as likely as their higher income counterparts to use services, and those on Indian reservations who did not have a regular source of dental care were half as likely as others to seek dental care. In contrast, white elders without a usual source of dental care were 20 times less likely to obtain dental care if they did not have a usual dental provider.

When the researchers who conducted the ICS II tested the predictors of oral health symptoms in these older adults, they found that education level, income status, poor systemic health, and having a usual source of dental care were the best predictors of an older person's likelihood of having carious lesions or periodontal bleeding and significant probing pocket depth. These factors are all indicators of socioeconomic status that create disparities in access to and self-care for dental problems in the older population.

In our own research, we have found disparities in oral health status, knowledge, and behaviors across various ethnic groups, and between US-born elders and those who have immigrated to this country (Kiyak, et al, 2002). In a comparison of whites, African Americans, Hispanics, and Asian Americans 65 and older in the Seattle area, significant differences in dental and periodontal status emerged, such that whites had 22.7% of their coronal surfaces filled, vs. 17.2% in African Americans, 13.3% in Hispanics, and 10.7% of surfaces in Asian American immigrants. Community Periodontal Index of Treatment Needs (CPITN) scores, indicating severity of bleeding and probing depths in each sextant (division of the mouth into 6 areas with 5 teeth represented in each area; for example, teeth #1-5, #6-12, #13-16, #17-21, #22-27, and #28-32.), were highest among Hispanic elders, followed by African Americans and Asian Americans. White elders had only Â½ the number of sextants with significant periodontal problems as Hispanics and Â¾ as much disease as the other two ethnic groups. Income was highly correlated with disease rates, especially untreated caries (p<0.0001). Recent immigration was also a risk factor; the more recently an elder arrived in the US, the worse their caries rates (p<0.03) and periodontal pocket depth (p<0.03). This may also account for poorer home care by immigrant elders. In comparing Caucasian and Chinese elders in this study, the former were three times more likely to report flossing and twice as likely to report regularly examining their mouths for oral problems as their Chinese counterparts.

A lack of knowledge about the causes and course of oral diseases may also account for these disparities in oral health status. For example, in our research, elders are asked to describe the causes of caries, periodontal disease, and tooth loss. In the study described above, significant differences were found across ethnic groups in knowledge regarding caries and tooth loss. White elders were least likely to give wrong responses (only 5% did so for caries, 10% for tooth loss), compared with far higher proportions of African Americans, Hispanics, and Asian Americans who either gave a wrong explanation for causes of caries and tooth loss, or said they did not know. Asian Americans were most likely to give wrong or "don't know" responses to the former (38.5%), followed by African Americans (18%) and Hispanics (15.5%). In contrast, only 5% of Asian elders and 10% of whites did not know the causes of tooth loss, compared with 31% of Hispanic elders. Thus, the first step in reducing oral health disparities among ethnic minorities in the US may be to educate them about the causes and progress of oral diseases, as well as the link between oral and systemic conditions.

Another significant disparity in oral health is between older adults who live independently in the community and frail elders who live in long-term care facilities or receive care from paid home health service providers. To some extent, these problems are caused by the multiple systemic diseases and medications used to treat these conditions among frail elders, as well as dementias that are found in almost half of institutionalized elders. Nevertheless, these populations often have poor oral health compared to their functionally healthy peers. The problem is compounded for those who live in long-term care facilities other than nursing homes. Although OBRA 1987 made annual dental exams mandatory for nursing home residents (although the extent of these exams and who conducts them was not specified), no such federal requirements have been instituted for residents of alternative facilities such as assisted living or adult family homes, nor for providers of home health services.

There are approximately 2 million nursing home residents and over 1.5 million people in assisted living facilities and homes for adults in the US; these numbers are expected to double by the year 2020. Health care issues in long term care (LTC), including oral health care, can be expected to grow as baby boomers reach 65 years and older, and as the proportion of individuals over age 85 continues to increase (NIH, 2003). Very little research has been done on alternative LTC populations. There is scant evidence on how dental services are provided in these alternative settings and the quality of life of residents in LTC facilities compared to those in nursing homes. For example, studies have sought to determine the effects of providing oral health services on older residents of nursing homes (Adachi et al., 2002), and have assessed the prevalence and experience of oral diseases and dental caries in nursing home residents (Chalmers et al., 2002; Wyatt, 2002). In addition, researchers have explored the effects of oral health education in nursing homes on caregivers' knowledge and attitudes (Frenkel et al., 2002), and the effects of educating caregivers on the oral health of institutionalized older adults (Frenkel et al., 2001; Isaksson et al., 2000; Matear, 1999). Studies have also been done in nursing homes to determine the priority of oral health care relative to other services (Wardh et al. 2000; MacEntee et al., 2000). Other studies have evaluated the oral health of nursing home residents and made recommendations about the type of dental care they should receive (Kalebjian et al., 2001; MacEntee, 2000; Ellis, 1999; Gift et al., 1998).

In a recently completed survey of 380 owners and operators of assisted living and adult day health facilities, as well as 32 home health care services in the state of Washington (Jones & Kiyak, 2004), only 21 % of survey respondents reported that their facility/agency has policies on providing dental care for their residents/clients. In addition, only 4 % said that their facility or agency has an agreement with a local dentist who visits regularly and only 5.5% said that their facility/agency has an agreement with a dentist who visits as needed or for emergencies. Only 32.3 % of respondents said that their facility/agency has one or more regular staff member(s) who are trained and/or assigned to do regular dental cleaning of patients/ mouths/dentures and/or screening. These findings are alarming, when considering that less than 50% of residents in these LTC facilities are able to perform oral hygiene tasks on their own. Only 12.3% of assisted living facilities and 22.6% of adult family homes reported that residents are taken to the dentist by a family member (p<.001). This requires facilities to find a dentist to treat their residents and transport them if emergency care is needed. In situations where residents are bedridden and cannot be transferred to a dental office for care, if a dentist does not visit them in the facility in which they reside, they likely do not receive dental care.

Medicaid was the most common source of payment for dental care in these LTC facilities; 27.8% of assisted living and 33.3% of adult family home operators reported that all of their residents use Medicaid to pay for dental treatment. If residents cannot pay out of pocket, the facilities reported that family members were expected to pay for dental care, since this was not part of their monthly fees charged for LTC. The problem is compounded by the widely recognized problem of finding dentists who will accept Medicaid coupons. Many respondents in this survey reported that they have been unable to find dentists who will treat residents with medical coupons. This is significant because 66.5 % of survey respondents said that at least half of their residents/clients rely on Medicaid to pay for dental services.

When asked what changes they would like to see in dental services at their facility/agency, 71% of facilities and 54% of home health care agencies were interested in finding volunteer dentists and hygienists to visit their clients. The majority also indicated an interest in obtaining oral health training for their staff. Free training for staff in how to provide daily oral health care for residents was selected as a desirable dental service by over 50 percent of respondents.

This summary of the oral health status of various segments of the US population, and the significant disparities that exist in access to dental care for low-income elders, those from ethnic minority groups, and those who require long-term care raise concerns about the need for better care of a large segment of older population. These disparities will only grow worse as more baby boomers reach their 70s, 80s and beyond with many teeth remaining but where these teeth require extensive dental care. It is incumbent upon dental professionals to take a more proactive approach to providing preventive dental services, including health education and home care instruction, to the broadest array of older adults as well as to younger Americans who will require complex dental services in the future.

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