GERIATRIC DENTISTRY AND PREVENTION: RESEARCH AND PUBLIC POLICY J. A. GERSHEN
Section of Public Health Dentistry, School of Dentistry, Center for the Health Sciences 63-045, University of California-Los Angeles, Los Angeles, California 900241668 Adv Dent Res 5:69-73, December, 1991
Abstract—Changing demographics, including the increase in life expectancy and the growing numbers of elderly, has focused attention on the need for dental research activities to be expanded for geriatric dentistry. The elderly are at greater risk for oral disease, since gains in longevity result in more medically compromising conditions or systemic disease with oral manifestations. Also, as edentulism decreases and as more teeth are retained by the elderly, the pattern of oral diseases and the treatment of dental conditions will be altered. Barriers to self-care and professional care must be removed, and prevention and early intervention strategies must be formulated to reduce the risk of oral diseases. Risk factors for oral diseases in the elderly can be reduced by personal home-care regimens, professionally provided preventive, diagnostic, and therapeutic care, changes in high-risk behavior, and a supportive environment. Generating new information about the prevention of oral diseases and conditions that have an impact on the elderly requires a substantial research effort. A research agenda for the elderly should include: epidemiologic studies of relevant oral diseases and related risk factors; investigations of patient and provider attitudes and behavior related to oral health; studies of the relationship between general health and oral health; development and testing of preventive and treatment strategies for conditions such as xerostomia, root caries, secondary caries, and gingival recession; and studies for the evaluation of the impact of the aging population on the dental delivery system. Public policy options to support geriatric oral health care and research are limited by the Government's pre-occupation with cost containment and the lack of visibility for dental programs. Many of the national health proposals for universal coverage and for elimination of financial barriers to health care do not include disease prevention or health promotion programs; dentistry is not mentioned even in those proposals that do include prevention. NIDR is gathering support for geriatric oral health research with its new initiative, entitled the "Research and Action Program to Improve the Oral Health of Older Presented during "Prevention Revisited", a Symposium at Eastman Dental Center s 75th Anniversary Celebration, Rochester, NY, September 13-14,1990
Americans and Other Adults at High Risk". Funding for this program may depend in part on changing national priorities and the dental profession's ability to become more intimately involved in the public debate regarding the future of the nation's health care system.
T
he population of the United States is aging. The proportion of people over 65 years of age is rapidly increasing, and the largest increases are occurring for those individuals over 85 years of age (Handera/., 1988; Gift, 1988; Hunt et ai, 1989). It is estimated that, by the year 2000, 13% of the US population will be over 65 years of age, increasing to 17.3% by the year 2020 (Institute of Medicine, 1988). With the increase in life expectancy, and changing medical, economic, and social factors, more attention is being paid to disease prevention activities for the elderly in order to improve the quality of life in old age (Lubben et ai, 1989). One area of growing interest is the oral health needs of older adults. Dental treatment needs for the elderly have changed in part because the patterns of oral diseases have changed. The National Survey of Oral Health in US Employed Adults and Seniors: 1985-1986, conducted by the National Institute of Dental Research (NIDR), indicates that the proportion of edentulous seniors has decreased over the past 25 years, and the number of teeth at risk for periodontal disease and caries has increased (NIDR, 1987). Also, the elderly are at greater risk for oral disease, since gains in longevity result in more medically compromising conditions or systemic disease with oral manifestations. In addition, speech, taste, swallowing, and chewing require optimal functioning of the orofacial complex. These functions depend on the health of the teeth, periodontium, and other intra/extra-oral structures. However, the health of the oral cavity can be impaired with the onset of tooth loss, soft tissue pathologies (including oral cancer), untreated severe caries, untreated severe periodontal disease, and orofacial pain (Gift and Barker, 1989). In order for optimal oral health to be maintained in later years, prevention and/or treatment of oral diseases must be emphasized throughout childhood and adult life. This paper will briefly review the common oral conditions that occur in older adults. Second, preventive and intervention strategies for minimizing the occurrence of oral disease will be described. Third, a research agenda for improving the oral health of the elderly will be presented. Finally, this paper will address public policy issues to be considered when seeking Federal support for geriatric research.
ORAL CONDITIONS IN OLDER ADULTS Several oral conditions are commonly found in older adults. One oral condition in the elderly is tooth loss. Tooth loss has traditionally been used as an important measure of oral health
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status in the elderly. Katz and Meskin (1986) indicated that rates of edentulous persons in population-based studies conducted world-wide range from 37% to 80%. Comparisons of epidemiologic studies over the past several decades indicate a decline in the edentulousness rate for older Americans, and more elders are retaining their teeth (Weintraub and Burt, 1985). Despite these declines in rates of edentulousness, the 1985 NIDR Survey (1987) indicated that 42% of the senior population surveyed was edentulous and that edentulousness increased with age from 32% for 65-69-year-olds to 49% for those over 80 years of age. Partial or complete loss of the dentition can result in impairments to masticatory function. Also, systemic medical problems can be exacerbated when limitations are placed on the ability to chew or the ability to consume a well-balanced, nutritious diet. In addition, psychological well-being and quality of life can be compromised when tooth loss affects esthetics or the ability to speak clearly. A second condition, oral cancer, is mostly a disease of older adults. According to the American Cancer Society, about 30,000 people in the US develop oral cancer each year, and only about half of these individuals will survive five years after diagnosis (American Cancer Society, 1987). The low survival rate for most oral cancers results from metastasis to other sites prior to diagnosis. Oral carcinomas as a group are found twice as frequently in men than in women. Also, Hand and Whitehall (1986) reported an association between low levels of education and infrequent visits to the dentist for patients with oral mucosal lesions. In addition, epidemiologic studies indicate that heavy smoking, the chewing of smokeless tobacco, and heavy alcohol consumption are associated with the occurrence of oral carcinoma. Oral cancers can lead to disfigurement and the need for prosthetic appliances to restore function or esthetics. It should also be noted that the use of radiation therapy to treat oral carcinomas can lead to other oral diseases. For example, decreased salivary flow resulting from radiation treatment can lead to increased susceptibility to infection. A third condition, dental decay, affects older adults mostly as recurrent caries, cervical caries, and root caries (Banting, 1984). Dental caries can be disabling and can result in pain and discomfort as well as tooth loss. Studies indicate that the prevalence of root-surface caries increases with age, and there is an association between root caries and gingival recession (Katz and Meskin, 1986). The 1985-1986 NIDR Survey indicated that root-surface lesions were present in 67% of the males and 61% of the females in a senior population. In addition to gingival recession, other factors that place older individuals at risk for caries include poor nutrition, reduced salivary fluid, poor oral hygiene, various systemic conditions, and certain medications. Periodontal disease is another oral condition frequently found in elders and includes problems such as gingival recession, occlusal trauma, gingivitis, and periodontitis (Page, 1984). The 1985-1986 NIDR Survey reported that about 22% of the senior dentate population had periodontal pockets measuring 4 mm or more, and 88% of the seniors had at least one site with gingival recession. Also, the prevalence rates of calculus and gingival bleeding in seniors were higher than in younger
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adults. The severity and prevalence of periodontal diseases increase as individuals age. However, the prevalence of advanced periodontal disease in elders is less than previously believed (Hunt etaL, 1990). Severe disease can result in tooth loss, pain, and bleeding. Social functioning can also be impaired because of bad breath and poor esthetics (Gift and Barker, 1989). A fifth area of concern in older individuals is the oral manifestations of systemic conditions or oral conditions caused by pharmacological or therapeutic interventions. Xerostomia, for example, may be associated with Sjogren's syndrome, dysfunctional salivary glands, radiation therapy, or as a sideeffect of medications. Decreased salivary flow can increase susceptibility to infections, caries, and periodontal disease. Elders with poorly controlled diabetes may be more vulnerable to oral infection. Hematologic diseases such as leukemia often present with characteristic oral lesions. Neurological conditions frequently manifesting in older individuals—such as Parkinson's disease, Alzheimer's disease, and stroke—may have a negative impact on oral functioning and adversely affect chewing and swallowing.
PREVENTION AND EARLY INTERVENTION In order for the risk of oral disease to be reduced in the elderly, barriers to care must be removed, and prevention and early intervention strategies must begin in childhood and continue throughout adult life. Gift and Barker (1989) indicate that risk factors for oral conditions that affect the elderly can be reduced or eliminated through self-care practices, appropriate professional care, removal of high-risk behavior, and environmental manipulation. They also note that impairments caused by oral diseases and conditions may become disabling or handicapping if appropriate preventive measures are not instituted. Appropriate self-care practices—such as toothbrushing with a fluoride dentifrice, dental flossing, and maintaining a nutritious and well-balanced diet (low in refined carbohydrates)—are important preventive measures to be used as necessary by all age groups, including older adults. Also, seniors with highrisk, active caries may benefit from self-applied fluoride gels and fluoride mouthrinses (Leverett, 1989; Ripa, 1989). In addition, gingivitis can be prevented in older adults through the use of antimicrobial mouthrinses as well as by brushing and flossing to remove plaque (Horowitz and Frazier, 1988). For some elders, self-care may be hampered by physical limitations and diminished manual dexterity; these individuals can be assisted by specially designed toothbrushes and other oral hygiene aids. In any case, effective oral hygiene practices in elders help to prevent caries and periodontal disease (Mandel, 1989). Furthermore, other oral conditions can be prevented or reduced in severity by changing personal behaviors such as consumption of alcohol or tobacco usage. The dental health team plays a significant role in preventing oral diseases and preventing further deterioration of oral structures in elders. Professional services include head, neck, and intra-oral examination of the dentition and supporting structures for evidence of oral symptoms of systemic disease, oral cancer, caries, periodontal disease, and functional or
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esthetic impairments. Other preventive services include prophylaxes, oral hygiene instruction, fluoride applications, and appropriate restorative and reconstructive treatments. However, many barriers exist for elders attempting to obtain professionally provided dental care. Although increases in dental utilization by the elderly have been demonstrated in recent years, older Americans are considered low users of dental services (Wilson and Branch, 1986; Hay ward et aL, 1989). Dolan et al. (1988) reported that particular subpopulations of older Americans receive fewer oral health services and fewer dental visits; these subgroups include older adults with lower incomes, less education, more chronic diseases, problems with transportation, and health status perceived as poor. Antczak and Branch (1985) indicated that barriers to dental care for the elderly may include unavailability of dentists, financial concerns, and the need for assistance in daily living. Other commonly agreed upon barriers include lack of dental insurance, the failure of many insurance plans to reimburse for preventive services, and the lack of access for homebound, institutionalized, or indigent elders. In addition to self-care and professional care, environmental factors also have an impact on the prevention of oral disease in elders. The presence of optimum fluoride levels in community water supplies has been shown to reduce the incidence of caries in children. Recent studies have shown that root caries and coronal caries rates are lower for life-long residents of fluoridated communities as compared with non-fluoridated communities; there is also benefit for older adults who began exposure to fluoridated water in adulthood (Stamm et ai, 1990; Hunter a/., 1989).
A RESEARCH AGENDA FOR THE ELDERLY Generating new information about the prevention of oral diseases and conditions that affect the elderly requires a substantial research effort. This effort must include studies that cover the spectrum of dental science, from biomedical to behavioral to health services research. Several Federal projects and initiatives have described needed areas of geriatric research pertaining to preventive dentistry. A collaborative project of the National Institute of Dental Research, the National Institute on Aging, and the Department of Veterans Affairs has produced "A Research Agenda on Oral Health in the Elderly" (Veterans Administration, 1986). This document describes numerous research recommendations, many of which touch on preventive topics. For example, the paucity of current epidemiologic data on oral conditions affecting the elderly was noted. Epidemiology studies of elderly populations are needed to gather prevalence and incidence data and to identify risk factors for root caries, periodontal disease, soft tissue lesions, xerostomia, edentulousness, and chronic pain conditions. Preventive interventions cannot be adequately evaluated without a current and readily available data base from subgroups of seniors, including the well elderly, the frail elderly, the institutionalized, and the ''old-old". Also, epidemiologic indices that are sensitive to oral conditions common to older patients must be developed. Research recommendations developed by the NIDR/NIA/ V A collaborative project also include investigations of geriatric
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patients' attitudes and behaviors. Studies are needed to investigate the relationship between preventive behaviors, compliance with prescribed treatment regimens, and various psychological, social, and cultural parameters in elders. Future research should also examine the provider-patient interaction to identify factors that compromise or enhance the quality of the relationship or affect quality of care. Other research recommendations are directed at encouraging studies of health services, including utilization patterns of elders, the efficacy of various reimbursement methods, and evaluations of interventions designed to improve delivery of dental services to various subgroups of seniors. A final category of research recommendations described by the collaborative project is directed toward preventing oral conditions affecting the elderly. For example, methods to prevent root caries and secondary caries should be developed. Also, investigations should be conducted to evaluate the efficacy of slow-release intra-oral devices on compromised elders. Other investigations should be directed toward developing an artificial saliva with anticaries properties. The "Long-Range Research Plan for the Nineties" developed by the NIDR (1990a) identifies a number of preventive projects directed toward older Americans. Among the research recommendations are development of a caries vaccine; investigations to determine the mechanisms by which fluoride prevents root caries; studies to correlate nutritional status and dietary intake with oral health; investigations to determine the potential of a vaccine for periodontal diseases; development of other strategies and interventions to prevent periodontal diseases; and studies to improve epidemiologic indices and to determine the relationship between general and oral health. Additional research recommendations for the elderly have been described in a report by an ad hoc work group charged with delineating the future scope of research activities at NIDR (1990b). One initiative proposed by the work group was to support studies leading to the prevention or early detection of pre-cancerous oral lesions and oral cancer. Other initiatives directed toward the elderly include studies of oral complications in the medically compromised patient, and studies of taste and smell disorders.
PUBLIC POLICY AND GERIATRIC ORAL HEALTH CARE AND RESEARCH A long-term plan to address the oral health needs of older Americans has been developed by the National Institute of Dental Research (1990c). The objectives of this "Research and Action Program" include the elimination of tooth loss; the reduction in the prevalence of periodontal diseases and dental decay in adults; the removal of barriers to professionally provided services and to self-care, so that oral diseases can be prevented and oral health can be maintained; the reduction in tooth loss due to trauma; and the reduction in the prevalence of conditions common to elders, including soft tissue disease, salivary conditions, bone conditions, and conditions that involve pain. NIDR plans to achieve these objectives through basic, behavioral, and clinical research. Also, laboratory findings will be transferred to the dental profession through clinical trials and demonstration research.
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The "Research and Action Program" brings attention to the oral health needs of elders and lays forth important public policy directions for geriatric research. However, a research agenda designed to address the preventive dental needs of the geriatric community can only be realized with a massive influx of Federal and private funding. Unfortunately, opportunities for public support of dental research have been limited by the Federal Government's pre-occupation with cost containment. The US Congress and the President have been consumed with attempts to reduce and eventually eliminate the huge Federal deficit brought about in part by tax cuts and a defense build-up duringthe 1980's. During this period, non-defense discretionary programs (including research) have suffered. Another problem facing the research community is the low visibility of dental programs within the Government, making it difficult to compete for a limited pool of Federal dollars. For example, in the President' s FY91 budget the National Institute of Dental Research receives only 1.8% of the budget of the National Institutes of Health and only 0.27% of all research and development dollars spent by the US Government (1990). Also, dental benefits have historically not been included as part of Medicare, the health program with the largest Federal expenditure for the aged. In addition, it is difficult to muster support for dental programs in Congress because dentistry has mostly not been included in the public policy debate regarding health care (Adelson, 1988). For example, eight national health system proposals which address universal coverage and elimination of financial barriers to health care were recently reviewed by an American Public Health Association publication (1990). Disease prevention and health promotion programs did not appear in about half of the outlined proposals, and dental care was not specifically mentioned in any of them. The national associations that represent the dental profession are beginning to focus efforts on involving dentistry more visibly in the health care debate. For example, in order to raise the level of awareness of members of Congress to the need for Federal support for oral health services for older Americans, the American Association of Public Health Dentistry (A APHD) passed a resolution at its 1989 Annual Session (1990). This resolution encourages Congress to "enact legislation authorizing the addition of dental benefits to the Medicare program that would assure necessary preventive and emergency dental services to the Medicare-eligible population." The resolution also encourages Congress to assure that all state Medicaid programs provide dental benefits for eligible elders and that providers be reimbursed for services at a level that would increase dentist participation in the program and thus improve access to care. In addition, the resolution urges that oral health services for elders and all Americans be included in national health proposals. Future funding levels for oral health care and dental research (including geriatrics and preventive dentistry) will depend on changing national priorities, and on the ability of the US Government to address the Federal deficit by raising revenues and containing costs. Funding may also depend on the dental profession's ability to continue to strengthen its advocacy infrastructure. In recent years, the American Association for Dental Research, the American Association of Dental Schools,
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and the American Dental Association have increased the voice of dentistry in Congress by developing more effective legislative and Governmental affairs divisions and mechanisms. For example, highly visible networks of constituent letter-writers have emerged. Also, the national associations have fostered personal contacts with members of Congress and their staffs on Capitol Hill and in key Congressional districts containing dental institutions. In addition, the dental organizations have been more active in coalitions of interest groups outside of dentistry to work on common legislative agendas. As this advocacy infrastructure becomes more effective, it will be more likely that the dental profession will become more intimately involved in the public debate regarding the future of the nation's health care system.
REFERENCES ADELSON,R. (1988): Structuring Policy Options in Geriatric Oral Health Care, Health Matrix 6:19-26. AMERICAN ASSOCIATION OF PUBLIC HEALTH DENTISTRY (1990): Newsletter: Communique 9:10-11. AMERICAN CANCER SOCIETY (1987): Cancer Facts and Figures, 1987. New York, 1987. AMERICAN PUBLIC HEALTH ASSOCIATION (1990): National Health Proposals: Do They Meet APHA Goals?, The Nation's Health, March. ANTCZAK, A.A. and BRANCH, L.G. (1985): Perceived Barriers to the Use of Dental Services by the Elderly, Gerodontics 1:194-198. BANTING, D.W. (1984): Dental Caries in the Elderly, Gerodontology 3:55-61. Budget of the United States Government-Fiscal Year 1991 (1990): Washington, DC: U.S. Government Printing Office. DOLAN, T.A.; COREY, C.R.; and FREEMAN, H.E. (1988): Older Americans' Access to Oral Health Care, / Dent Educ 52:637-642. GIFT,H.C. (1988): Issues of Aging and Oral Health Promotion, Gerodontics 4:194-206. GIFT,H.C. and BARKER, B.D. (1990): Oral Health Problems in the Second Fifty. In: The Second Fifty Years: Promoting Health and Preventing Disability, R.L. Berg and J.S. Cassells, Eds., Washington, DC: National Academy Press, pp. 119-135. HAND, J.S.; HUNT, R.J.; and BECK, J.D. (1988): Incidence of Coronal and Root Caries in an Older Adult Population, / Public Health Dent 48:14-19. HAND, J.S. and WHITEHILL, J.M. (1986): Oral Mucosal Lesions in an Elderly Population, J Am DentAssoc 112:7376. HAYWARD, R.A.; MEETZ, H.K.; SHAPIRO, M.F.; and FREEMAN, H.E. (1989): Utilization of Dental Services: 1986 Patterns and Trends, / Public Health Dent 49:147152. HOROWITZ, A.M. and FRAZIER, PJ. (1988): Promoting Oral Health Among Older Americans. The Role of Primary Prevention, Fam Commun Health 11:33-41. HUNT, R.J.; ELDREDGE, J.B.; and BECK, J.D. (1989): Effect of Residence in a Fluoridated Community on the
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Incidence of Coronal and Root Caries in an Older Population, / Public Health Dent 49:138-141. HUNT, R.J.; LEVY, S.M.; and BECK, J.D. (1990): The Prevalence of Periodontal Attachment Loss in an Iowa Population Aged 70 and Older, / Public Health Dent 50:251-256. INSTITUTE OF MEDICINE, COMMITTEE ON AGING SOCIETY (1988): America's Aging—The Social Environment in an Older Society. Washington, DC: National Academy Press. KATZ, R.V. and MESKIN, L.H. (1986): The Epidemiology of Oral Diseases in Older Adults. In: Geriatric Dentistry, P. Holm-Pedersen and H. Loe, Eds., St. Louis: The C.V. Mosby Company, pp. 221-237. LEVERETT, D.H. (1989): Effectiveness of Mouthrinsing with Fluoride Solutions in Preventing Coronal and Root Caries, / Public Health Dent 49:310-316. LUBBEN, J.E.; WEILER, P.G.; and CHI, I. (1989): Health Practices of the Elderly Poor, Am J Public Health 79:731734. MANDEL, I.D. (1989): Preventive Dental Services for the Elderly, Dent Clin North Am 33:81-90. NIDR (1987): Oral Health of United States Adults: The National Survey of Oral Health in U.S. Employed Adults and Seniors: 1985-1986. NIH Publication No. 87-2868. NIDR (1990a): Broadening the Scope: Long-Range Research Plans for the Nineties. NIH Publication No. 90-1188.
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NIDR (1990b): Recommendations of Ad Hoc Work Group on the Future Scope of NIDR Research Activities, National Institute of Dental Research, NIH, Memorandum of January 17, 1990. NIDR (1990c): NIDR Research and Action Programs to Improve the Oral Health of Older Americans and Other Adults at High Risk, National Institute of Dental Research, NIH, Internal Paper (May). PAGE, R.C. (1984): Periodontal Diseases in the Elderly, Gerontology 3:63-70. RIPA, L.W. (1989): Review of the Anticaries Effectiveness of Professionally Applied and Self-Applied Topical Fluoride Gels, / Public Health Dent 49:297-309. STAMM, J.W.; BANTING, D.W.; and IMREY, P.B. (1990): Adult Root Caries Survey of Two Similar Communities with Contrasting Natural Water Fluoride Levels, J Am Dent Assoc 120:143-149. VETERANS ADMINISTRATION (1986): A Research Agenda on Oral Health in the Elderly. Washington, DC: Veterans Administration, Department of Medicine and Surgery. WEINTRAUB, J.A. and BURT, B.A. (1985): Oral Health Status in the U.S.: Tooth Loss and Edentulism, J Dent Educ 49:368-376. WILSON, A.A. and BRANCH, L.G. (1986): Factors Affecting Dental Utilization of Elders Aged 75 Years or Older, JDent Educ 50:673-677.
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Section of Public Health Dentistry, School of Dentistry, Center for the Health Sciences 63-045, University of California-Los Angeles, Los Angeles, California 900241668 Adv Dent Res 5:69-73, December, 1991
Abstract—Changing demographics, including the increase in life expectancy and the growing numbers of elderly, has focused attention on the need for dental research activities to be expanded for geriatric dentistry. The elderly are at greater risk for oral disease, since gains in longevity result in more medically compromising conditions or systemic disease with oral manifestations. Also, as edentulism decreases and as more teeth are retained by the elderly, the pattern of oral diseases and the treatment of dental conditions will be altered. Barriers to self-care and professional care must be removed, and prevention and early intervention strategies must be formulated to reduce the risk of oral diseases. Risk factors for oral diseases in the elderly can be reduced by personal home-care regimens, professionally provided preventive, diagnostic, and therapeutic care, changes in high-risk behavior, and a supportive environment. Generating new information about the prevention of oral diseases and conditions that have an impact on the elderly requires a substantial research effort. A research agenda for the elderly should include: epidemiologic studies of relevant oral diseases and related risk factors; investigations of patient and provider attitudes and behavior related to oral health; studies of the relationship between general health and oral health; development and testing of preventive and treatment strategies for conditions such as xerostomia, root caries, secondary caries, and gingival recession; and studies for the evaluation of the impact of the aging population on the dental delivery system. Public policy options to support geriatric oral health care and research are limited by the Government's pre-occupation with cost containment and the lack of visibility for dental programs. Many of the national health proposals for universal coverage and for elimination of financial barriers to health care do not include disease prevention or health promotion programs; dentistry is not mentioned even in those proposals that do include prevention. NIDR is gathering support for geriatric oral health research with its new initiative, entitled the "Research and Action Program to Improve the Oral Health of Older Presented during "Prevention Revisited", a Symposium at Eastman Dental Center s 75th Anniversary Celebration, Rochester, NY, September 13-14,1990
Americans and Other Adults at High Risk". Funding for this program may depend in part on changing national priorities and the dental profession's ability to become more intimately involved in the public debate regarding the future of the nation's health care system.
T
he population of the United States is aging. The proportion of people over 65 years of age is rapidly increasing, and the largest increases are occurring for those individuals over 85 years of age (Handera/., 1988; Gift, 1988; Hunt et ai, 1989). It is estimated that, by the year 2000, 13% of the US population will be over 65 years of age, increasing to 17.3% by the year 2020 (Institute of Medicine, 1988). With the increase in life expectancy, and changing medical, economic, and social factors, more attention is being paid to disease prevention activities for the elderly in order to improve the quality of life in old age (Lubben et ai, 1989). One area of growing interest is the oral health needs of older adults. Dental treatment needs for the elderly have changed in part because the patterns of oral diseases have changed. The National Survey of Oral Health in US Employed Adults and Seniors: 1985-1986, conducted by the National Institute of Dental Research (NIDR), indicates that the proportion of edentulous seniors has decreased over the past 25 years, and the number of teeth at risk for periodontal disease and caries has increased (NIDR, 1987). Also, the elderly are at greater risk for oral disease, since gains in longevity result in more medically compromising conditions or systemic disease with oral manifestations. In addition, speech, taste, swallowing, and chewing require optimal functioning of the orofacial complex. These functions depend on the health of the teeth, periodontium, and other intra/extra-oral structures. However, the health of the oral cavity can be impaired with the onset of tooth loss, soft tissue pathologies (including oral cancer), untreated severe caries, untreated severe periodontal disease, and orofacial pain (Gift and Barker, 1989). In order for optimal oral health to be maintained in later years, prevention and/or treatment of oral diseases must be emphasized throughout childhood and adult life. This paper will briefly review the common oral conditions that occur in older adults. Second, preventive and intervention strategies for minimizing the occurrence of oral disease will be described. Third, a research agenda for improving the oral health of the elderly will be presented. Finally, this paper will address public policy issues to be considered when seeking Federal support for geriatric research.
ORAL CONDITIONS IN OLDER ADULTS Several oral conditions are commonly found in older adults. One oral condition in the elderly is tooth loss. Tooth loss has traditionally been used as an important measure of oral health
69 Downloaded from adr.sagepub.com at UNIVERSITE LAVAL on April 30, 2016 For personal use only. No other uses without permission.
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status in the elderly. Katz and Meskin (1986) indicated that rates of edentulous persons in population-based studies conducted world-wide range from 37% to 80%. Comparisons of epidemiologic studies over the past several decades indicate a decline in the edentulousness rate for older Americans, and more elders are retaining their teeth (Weintraub and Burt, 1985). Despite these declines in rates of edentulousness, the 1985 NIDR Survey (1987) indicated that 42% of the senior population surveyed was edentulous and that edentulousness increased with age from 32% for 65-69-year-olds to 49% for those over 80 years of age. Partial or complete loss of the dentition can result in impairments to masticatory function. Also, systemic medical problems can be exacerbated when limitations are placed on the ability to chew or the ability to consume a well-balanced, nutritious diet. In addition, psychological well-being and quality of life can be compromised when tooth loss affects esthetics or the ability to speak clearly. A second condition, oral cancer, is mostly a disease of older adults. According to the American Cancer Society, about 30,000 people in the US develop oral cancer each year, and only about half of these individuals will survive five years after diagnosis (American Cancer Society, 1987). The low survival rate for most oral cancers results from metastasis to other sites prior to diagnosis. Oral carcinomas as a group are found twice as frequently in men than in women. Also, Hand and Whitehall (1986) reported an association between low levels of education and infrequent visits to the dentist for patients with oral mucosal lesions. In addition, epidemiologic studies indicate that heavy smoking, the chewing of smokeless tobacco, and heavy alcohol consumption are associated with the occurrence of oral carcinoma. Oral cancers can lead to disfigurement and the need for prosthetic appliances to restore function or esthetics. It should also be noted that the use of radiation therapy to treat oral carcinomas can lead to other oral diseases. For example, decreased salivary flow resulting from radiation treatment can lead to increased susceptibility to infection. A third condition, dental decay, affects older adults mostly as recurrent caries, cervical caries, and root caries (Banting, 1984). Dental caries can be disabling and can result in pain and discomfort as well as tooth loss. Studies indicate that the prevalence of root-surface caries increases with age, and there is an association between root caries and gingival recession (Katz and Meskin, 1986). The 1985-1986 NIDR Survey indicated that root-surface lesions were present in 67% of the males and 61% of the females in a senior population. In addition to gingival recession, other factors that place older individuals at risk for caries include poor nutrition, reduced salivary fluid, poor oral hygiene, various systemic conditions, and certain medications. Periodontal disease is another oral condition frequently found in elders and includes problems such as gingival recession, occlusal trauma, gingivitis, and periodontitis (Page, 1984). The 1985-1986 NIDR Survey reported that about 22% of the senior dentate population had periodontal pockets measuring 4 mm or more, and 88% of the seniors had at least one site with gingival recession. Also, the prevalence rates of calculus and gingival bleeding in seniors were higher than in younger
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adults. The severity and prevalence of periodontal diseases increase as individuals age. However, the prevalence of advanced periodontal disease in elders is less than previously believed (Hunt etaL, 1990). Severe disease can result in tooth loss, pain, and bleeding. Social functioning can also be impaired because of bad breath and poor esthetics (Gift and Barker, 1989). A fifth area of concern in older individuals is the oral manifestations of systemic conditions or oral conditions caused by pharmacological or therapeutic interventions. Xerostomia, for example, may be associated with Sjogren's syndrome, dysfunctional salivary glands, radiation therapy, or as a sideeffect of medications. Decreased salivary flow can increase susceptibility to infections, caries, and periodontal disease. Elders with poorly controlled diabetes may be more vulnerable to oral infection. Hematologic diseases such as leukemia often present with characteristic oral lesions. Neurological conditions frequently manifesting in older individuals—such as Parkinson's disease, Alzheimer's disease, and stroke—may have a negative impact on oral functioning and adversely affect chewing and swallowing.
PREVENTION AND EARLY INTERVENTION In order for the risk of oral disease to be reduced in the elderly, barriers to care must be removed, and prevention and early intervention strategies must begin in childhood and continue throughout adult life. Gift and Barker (1989) indicate that risk factors for oral conditions that affect the elderly can be reduced or eliminated through self-care practices, appropriate professional care, removal of high-risk behavior, and environmental manipulation. They also note that impairments caused by oral diseases and conditions may become disabling or handicapping if appropriate preventive measures are not instituted. Appropriate self-care practices—such as toothbrushing with a fluoride dentifrice, dental flossing, and maintaining a nutritious and well-balanced diet (low in refined carbohydrates)—are important preventive measures to be used as necessary by all age groups, including older adults. Also, seniors with highrisk, active caries may benefit from self-applied fluoride gels and fluoride mouthrinses (Leverett, 1989; Ripa, 1989). In addition, gingivitis can be prevented in older adults through the use of antimicrobial mouthrinses as well as by brushing and flossing to remove plaque (Horowitz and Frazier, 1988). For some elders, self-care may be hampered by physical limitations and diminished manual dexterity; these individuals can be assisted by specially designed toothbrushes and other oral hygiene aids. In any case, effective oral hygiene practices in elders help to prevent caries and periodontal disease (Mandel, 1989). Furthermore, other oral conditions can be prevented or reduced in severity by changing personal behaviors such as consumption of alcohol or tobacco usage. The dental health team plays a significant role in preventing oral diseases and preventing further deterioration of oral structures in elders. Professional services include head, neck, and intra-oral examination of the dentition and supporting structures for evidence of oral symptoms of systemic disease, oral cancer, caries, periodontal disease, and functional or
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esthetic impairments. Other preventive services include prophylaxes, oral hygiene instruction, fluoride applications, and appropriate restorative and reconstructive treatments. However, many barriers exist for elders attempting to obtain professionally provided dental care. Although increases in dental utilization by the elderly have been demonstrated in recent years, older Americans are considered low users of dental services (Wilson and Branch, 1986; Hay ward et aL, 1989). Dolan et al. (1988) reported that particular subpopulations of older Americans receive fewer oral health services and fewer dental visits; these subgroups include older adults with lower incomes, less education, more chronic diseases, problems with transportation, and health status perceived as poor. Antczak and Branch (1985) indicated that barriers to dental care for the elderly may include unavailability of dentists, financial concerns, and the need for assistance in daily living. Other commonly agreed upon barriers include lack of dental insurance, the failure of many insurance plans to reimburse for preventive services, and the lack of access for homebound, institutionalized, or indigent elders. In addition to self-care and professional care, environmental factors also have an impact on the prevention of oral disease in elders. The presence of optimum fluoride levels in community water supplies has been shown to reduce the incidence of caries in children. Recent studies have shown that root caries and coronal caries rates are lower for life-long residents of fluoridated communities as compared with non-fluoridated communities; there is also benefit for older adults who began exposure to fluoridated water in adulthood (Stamm et ai, 1990; Hunter a/., 1989).
A RESEARCH AGENDA FOR THE ELDERLY Generating new information about the prevention of oral diseases and conditions that affect the elderly requires a substantial research effort. This effort must include studies that cover the spectrum of dental science, from biomedical to behavioral to health services research. Several Federal projects and initiatives have described needed areas of geriatric research pertaining to preventive dentistry. A collaborative project of the National Institute of Dental Research, the National Institute on Aging, and the Department of Veterans Affairs has produced "A Research Agenda on Oral Health in the Elderly" (Veterans Administration, 1986). This document describes numerous research recommendations, many of which touch on preventive topics. For example, the paucity of current epidemiologic data on oral conditions affecting the elderly was noted. Epidemiology studies of elderly populations are needed to gather prevalence and incidence data and to identify risk factors for root caries, periodontal disease, soft tissue lesions, xerostomia, edentulousness, and chronic pain conditions. Preventive interventions cannot be adequately evaluated without a current and readily available data base from subgroups of seniors, including the well elderly, the frail elderly, the institutionalized, and the ''old-old". Also, epidemiologic indices that are sensitive to oral conditions common to older patients must be developed. Research recommendations developed by the NIDR/NIA/ V A collaborative project also include investigations of geriatric
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patients' attitudes and behaviors. Studies are needed to investigate the relationship between preventive behaviors, compliance with prescribed treatment regimens, and various psychological, social, and cultural parameters in elders. Future research should also examine the provider-patient interaction to identify factors that compromise or enhance the quality of the relationship or affect quality of care. Other research recommendations are directed at encouraging studies of health services, including utilization patterns of elders, the efficacy of various reimbursement methods, and evaluations of interventions designed to improve delivery of dental services to various subgroups of seniors. A final category of research recommendations described by the collaborative project is directed toward preventing oral conditions affecting the elderly. For example, methods to prevent root caries and secondary caries should be developed. Also, investigations should be conducted to evaluate the efficacy of slow-release intra-oral devices on compromised elders. Other investigations should be directed toward developing an artificial saliva with anticaries properties. The "Long-Range Research Plan for the Nineties" developed by the NIDR (1990a) identifies a number of preventive projects directed toward older Americans. Among the research recommendations are development of a caries vaccine; investigations to determine the mechanisms by which fluoride prevents root caries; studies to correlate nutritional status and dietary intake with oral health; investigations to determine the potential of a vaccine for periodontal diseases; development of other strategies and interventions to prevent periodontal diseases; and studies to improve epidemiologic indices and to determine the relationship between general and oral health. Additional research recommendations for the elderly have been described in a report by an ad hoc work group charged with delineating the future scope of research activities at NIDR (1990b). One initiative proposed by the work group was to support studies leading to the prevention or early detection of pre-cancerous oral lesions and oral cancer. Other initiatives directed toward the elderly include studies of oral complications in the medically compromised patient, and studies of taste and smell disorders.
PUBLIC POLICY AND GERIATRIC ORAL HEALTH CARE AND RESEARCH A long-term plan to address the oral health needs of older Americans has been developed by the National Institute of Dental Research (1990c). The objectives of this "Research and Action Program" include the elimination of tooth loss; the reduction in the prevalence of periodontal diseases and dental decay in adults; the removal of barriers to professionally provided services and to self-care, so that oral diseases can be prevented and oral health can be maintained; the reduction in tooth loss due to trauma; and the reduction in the prevalence of conditions common to elders, including soft tissue disease, salivary conditions, bone conditions, and conditions that involve pain. NIDR plans to achieve these objectives through basic, behavioral, and clinical research. Also, laboratory findings will be transferred to the dental profession through clinical trials and demonstration research.
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The "Research and Action Program" brings attention to the oral health needs of elders and lays forth important public policy directions for geriatric research. However, a research agenda designed to address the preventive dental needs of the geriatric community can only be realized with a massive influx of Federal and private funding. Unfortunately, opportunities for public support of dental research have been limited by the Federal Government's pre-occupation with cost containment. The US Congress and the President have been consumed with attempts to reduce and eventually eliminate the huge Federal deficit brought about in part by tax cuts and a defense build-up duringthe 1980's. During this period, non-defense discretionary programs (including research) have suffered. Another problem facing the research community is the low visibility of dental programs within the Government, making it difficult to compete for a limited pool of Federal dollars. For example, in the President' s FY91 budget the National Institute of Dental Research receives only 1.8% of the budget of the National Institutes of Health and only 0.27% of all research and development dollars spent by the US Government (1990). Also, dental benefits have historically not been included as part of Medicare, the health program with the largest Federal expenditure for the aged. In addition, it is difficult to muster support for dental programs in Congress because dentistry has mostly not been included in the public policy debate regarding health care (Adelson, 1988). For example, eight national health system proposals which address universal coverage and elimination of financial barriers to health care were recently reviewed by an American Public Health Association publication (1990). Disease prevention and health promotion programs did not appear in about half of the outlined proposals, and dental care was not specifically mentioned in any of them. The national associations that represent the dental profession are beginning to focus efforts on involving dentistry more visibly in the health care debate. For example, in order to raise the level of awareness of members of Congress to the need for Federal support for oral health services for older Americans, the American Association of Public Health Dentistry (A APHD) passed a resolution at its 1989 Annual Session (1990). This resolution encourages Congress to "enact legislation authorizing the addition of dental benefits to the Medicare program that would assure necessary preventive and emergency dental services to the Medicare-eligible population." The resolution also encourages Congress to assure that all state Medicaid programs provide dental benefits for eligible elders and that providers be reimbursed for services at a level that would increase dentist participation in the program and thus improve access to care. In addition, the resolution urges that oral health services for elders and all Americans be included in national health proposals. Future funding levels for oral health care and dental research (including geriatrics and preventive dentistry) will depend on changing national priorities, and on the ability of the US Government to address the Federal deficit by raising revenues and containing costs. Funding may also depend on the dental profession's ability to continue to strengthen its advocacy infrastructure. In recent years, the American Association for Dental Research, the American Association of Dental Schools,
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and the American Dental Association have increased the voice of dentistry in Congress by developing more effective legislative and Governmental affairs divisions and mechanisms. For example, highly visible networks of constituent letter-writers have emerged. Also, the national associations have fostered personal contacts with members of Congress and their staffs on Capitol Hill and in key Congressional districts containing dental institutions. In addition, the dental organizations have been more active in coalitions of interest groups outside of dentistry to work on common legislative agendas. As this advocacy infrastructure becomes more effective, it will be more likely that the dental profession will become more intimately involved in the public debate regarding the future of the nation's health care system.
REFERENCES ADELSON,R. (1988): Structuring Policy Options in Geriatric Oral Health Care, Health Matrix 6:19-26. AMERICAN ASSOCIATION OF PUBLIC HEALTH DENTISTRY (1990): Newsletter: Communique 9:10-11. AMERICAN CANCER SOCIETY (1987): Cancer Facts and Figures, 1987. New York, 1987. AMERICAN PUBLIC HEALTH ASSOCIATION (1990): National Health Proposals: Do They Meet APHA Goals?, The Nation's Health, March. ANTCZAK, A.A. and BRANCH, L.G. (1985): Perceived Barriers to the Use of Dental Services by the Elderly, Gerodontics 1:194-198. BANTING, D.W. (1984): Dental Caries in the Elderly, Gerodontology 3:55-61. Budget of the United States Government-Fiscal Year 1991 (1990): Washington, DC: U.S. Government Printing Office. DOLAN, T.A.; COREY, C.R.; and FREEMAN, H.E. (1988): Older Americans' Access to Oral Health Care, / Dent Educ 52:637-642. GIFT,H.C. (1988): Issues of Aging and Oral Health Promotion, Gerodontics 4:194-206. GIFT,H.C. and BARKER, B.D. (1990): Oral Health Problems in the Second Fifty. In: The Second Fifty Years: Promoting Health and Preventing Disability, R.L. Berg and J.S. Cassells, Eds., Washington, DC: National Academy Press, pp. 119-135. HAND, J.S.; HUNT, R.J.; and BECK, J.D. (1988): Incidence of Coronal and Root Caries in an Older Adult Population, / Public Health Dent 48:14-19. HAND, J.S. and WHITEHILL, J.M. (1986): Oral Mucosal Lesions in an Elderly Population, J Am DentAssoc 112:7376. HAYWARD, R.A.; MEETZ, H.K.; SHAPIRO, M.F.; and FREEMAN, H.E. (1989): Utilization of Dental Services: 1986 Patterns and Trends, / Public Health Dent 49:147152. HOROWITZ, A.M. and FRAZIER, PJ. (1988): Promoting Oral Health Among Older Americans. The Role of Primary Prevention, Fam Commun Health 11:33-41. HUNT, R.J.; ELDREDGE, J.B.; and BECK, J.D. (1989): Effect of Residence in a Fluoridated Community on the
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Incidence of Coronal and Root Caries in an Older Population, / Public Health Dent 49:138-141. HUNT, R.J.; LEVY, S.M.; and BECK, J.D. (1990): The Prevalence of Periodontal Attachment Loss in an Iowa Population Aged 70 and Older, / Public Health Dent 50:251-256. INSTITUTE OF MEDICINE, COMMITTEE ON AGING SOCIETY (1988): America's Aging—The Social Environment in an Older Society. Washington, DC: National Academy Press. KATZ, R.V. and MESKIN, L.H. (1986): The Epidemiology of Oral Diseases in Older Adults. In: Geriatric Dentistry, P. Holm-Pedersen and H. Loe, Eds., St. Louis: The C.V. Mosby Company, pp. 221-237. LEVERETT, D.H. (1989): Effectiveness of Mouthrinsing with Fluoride Solutions in Preventing Coronal and Root Caries, / Public Health Dent 49:310-316. LUBBEN, J.E.; WEILER, P.G.; and CHI, I. (1989): Health Practices of the Elderly Poor, Am J Public Health 79:731734. MANDEL, I.D. (1989): Preventive Dental Services for the Elderly, Dent Clin North Am 33:81-90. NIDR (1987): Oral Health of United States Adults: The National Survey of Oral Health in U.S. Employed Adults and Seniors: 1985-1986. NIH Publication No. 87-2868. NIDR (1990a): Broadening the Scope: Long-Range Research Plans for the Nineties. NIH Publication No. 90-1188.
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NIDR (1990b): Recommendations of Ad Hoc Work Group on the Future Scope of NIDR Research Activities, National Institute of Dental Research, NIH, Memorandum of January 17, 1990. NIDR (1990c): NIDR Research and Action Programs to Improve the Oral Health of Older Americans and Other Adults at High Risk, National Institute of Dental Research, NIH, Internal Paper (May). PAGE, R.C. (1984): Periodontal Diseases in the Elderly, Gerontology 3:63-70. RIPA, L.W. (1989): Review of the Anticaries Effectiveness of Professionally Applied and Self-Applied Topical Fluoride Gels, / Public Health Dent 49:297-309. STAMM, J.W.; BANTING, D.W.; and IMREY, P.B. (1990): Adult Root Caries Survey of Two Similar Communities with Contrasting Natural Water Fluoride Levels, J Am Dent Assoc 120:143-149. VETERANS ADMINISTRATION (1986): A Research Agenda on Oral Health in the Elderly. Washington, DC: Veterans Administration, Department of Medicine and Surgery. WEINTRAUB, J.A. and BURT, B.A. (1985): Oral Health Status in the U.S.: Tooth Loss and Edentulism, J Dent Educ 49:368-376. WILSON, A.A. and BRANCH, L.G. (1986): Factors Affecting Dental Utilization of Elders Aged 75 Years or Older, JDent Educ 50:673-677.
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