Significant Unmet Oral Health Needs of Homebound Elderly Adults Katherine A. Ornstein, MPH, PhD,* Linda DeCherrie, MD,*† Rima Gluzman, DDS, MS,‡ Elizabeth S. Scott, BA,* Jyoti Kansal, BDS,§ Tushin Shah, BDS,§ Ralph Katz, DMD, MPH, PhD,‡ and Theresa A. Soriano, MD, MPH*†

OBJECTIVES: To assess the oral health status, use of dental care, and dental needs of homebound elderly adults and to determine whether medical diagnoses or demographic factors influenced perceived oral health. DESIGN: Cross-sectional analysis. SETTING: Participants’ homes in New York City. PARTICIPANTS: Homebound elderly adults (N = 125). MEASUREMENTS: A trained dental research team conducted a comprehensive clinical examination in participants’ homes and completed a dental use and needs survey and the Geriatric Oral Health Assessment Index. RESULTS: Participants who reported a high level of unmet oral health needs were more likely to be nonwhite, although this effect was not significant in multivariate analysis. Individual medical diagnoses and the presence of multiple comorbidities were not associated with unmet oral health needs. CONCLUSION: The oral health status of homebound elderly adults was poor regardless of their medical diagnoses. High unmet oral health needs combined with strong desire to receive dental care suggests there is a need to improve access to dental care for this growing population. In addition to improving awareness of geriatricians and primary care providers who care for homebound individuals, the medical community must partner with the dental community to develop home-based programs for older adults. J Am Geriatr Soc 63:151–157, 2015.

Key words: oral health; dental; homebound; homebased primary care

From the *Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai; †Mount Sinai Visiting Doctors Program, Mount Sinai Hospital; ‡Department of Epidemiology and Health Promotion, New York University; and §College of Dentistry, New York University, New York, New York. Address correspondence to Katherine A. Ornstein, MPH, PhD, Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1070, New York, NY 10029. E-mail: [email protected] DOI: 10.1111/jgs.13181

JAGS 63:151–157, 2015 © 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society


dvances in medicine and dentistry have resulted in people living longer and retaining more of their teeth. Similar to greater disability and morbidity associated with longer life expectancy, this extended retention of natural teeth results in greater occurrence of oral diseases in the general geriatric population and to an even greater extent in functionally dependent older adults.1,2 Because of chronic illness and functional impairment, an increasing number of older adults are permanently homebound and unable to access routine medical or dental care.3 Because homebound elderly adults typically do not see a dentist for years, if ever, their oral health deteriorates, resulting not only in pain and infection, but also compromised ability to eat and socialize. This compounds their already compromised overall physiological functioning and quality of life.4 In addition to logistical challenges in getting to a dentist for homebound elderly adults, Medicare does not cover dental costs. Although nursing facilities must provide or arrange for the provision of dental services for residents,5 there is no law mandating provision of oral health care for communitydwelling elderly adults. Although there have been a large number of published dental studies documenting the oral health status and needs of institutionalized elderly adults,6,7 little is known about the oral health status and needs of communitydwelling homebound elderly adults.8–11 The limited studies all indicate that there is high unmet need in this population. One study of 51 homebound individuals in a Department of Veterans Affairs housecall program found that the median length of time since participants had seen a dentist was 6 years, and they had an average of 3.4 decayed teeth.8 Of 50 community-dwelling, functionally dependent elderly adults, 50% had not seen a dentist in 6 years, 60% reported their oral health as fair or poor, and 44% were edentulous.10 Of 592 individuals receiving home-delivered meals, 41% were edentulous, and it had been an average of 4 years since they had seen a dentist.9 A recent review indicated that there is a high prevalence of dry mouth in




this population, which may significantly affect oral health and quality of life.12 To properly identify and assess the current dental needs of homebound elderly adults to most appropriately plan oral healthcare services for this growing and vulnerable population, larger and current studies of the oral health status and needs of this population are needed. This includes a formal assessment of oral health status and self-reported oral health needs and usage patterns. Medical diagnoses should also be included in analyses to better understand the needs of homebound populations with varied medical diagnoses and multiple comorbidities. The primary purpose of this study was to assess dental and oral health status, self-reported oral health problems, history of dental use, dental needs, and interest in home-based professional oral and dental care of homebound elderly adults. Building upon previously published work that reported on the detailed oral health findings of this study population in the dental literature,13 the current study reports on the relationship between the oral health status and medical comorbidities of these homebound individuals and was written for an audience of geriatricians and other medical professionals rather than dentists. Specifically, it discusses what medical professionals need to understand about the oral healthcare needs of the growing elderly homebound population. Finally, medical comorbidities and which clinical and demographic factors affect self-reported oral-health related quality of life (QOL) were measured using a validated questionnaire. It was hypothesized that there would be a higher level of unmet needs in this sample of homebound individuals than in other communitydwelling elderly groups described in the literature because of their inability to access care routinely and their high illness burden, regardless of disease status or demographics.


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eligibility criteria included active in MSVD for at least 6 months, aged 50 and older, mentally competent to provide informed consent; no signs of moderate or severe cognitive impairment, and without any potentially lifethreatening or progressive medical illnesses that would compromise participant safety or ability to undergo the oral examination. Finally, mental competence to give informed consent was assessed using a double-filter technique. The MSVD providers applied the first filter during initial selection of eligible individuals, and the dentist applied a second filter during the actual home-based dental visit by judging the individual’s mental ability to comprehend a consent form before conducting the oral examination.

Measures Previously described in detail,13 the oral health examination consisted of soft tissue examination; assessment of the subject’s oral hygiene; dental caries examination; periodontal examination for tooth mobility, bleeding, and inflammation; and for patients with dental prostheses, a denture assessment. Self-reported dental use, self-identified dental problems and needs, and the participant’s level of interest in professional home-based oral and dental care were measured. The Geriatric Oral Health Assessment Index (GOHAI), a validated, widely used 12-item questionnaire designed to measure frequency of self-reported oral health problems in elderly adults was administered.15 A higher cumulative score indicates better perceived oral health status (range 12–60). The GOHAI can be divided into three categories:16 physical function, psychosocial function, and pain and discomfort. Physical functions include eating, speaking, and swallowing; psychosocial functions include worrying about oral health and having difficulty with social contacts because of oral conditions; and pain and discomfort include the use of medication to alleviate pain in the oral cavity.

Subjects and Setting The Mount Sinai Visiting Doctors (MSVD) program is the largest academic home-based primary care program for homebound elderly adults in the United States.14 Beneficiaries are aged 18 and older and meet the Medicare homebound definition—able to leave home only with great difficulty and for absences that are infrequent or of short duration. Physicians and nurse practitioners provide primary care services at home, including palliative and endof-life care, to approximately 1,200 homebound residents of New York City every year. A research team from the Department of Epidemiology and Health Promotion, College of Dentistry, New York University, composed of one clinically experienced, trained, calibrated dental examiner; a trained recorder; and a third team member who assisted with any aspects of the home visit as needed visited homebound elderly adults in their homes between November 2010 and April 2011. (No intraexaminer reliability checks were planned or conducted at the time of the subject examination in consideration of the likely physical exhaustion limits in these homebound individuals.) Study

Participant Characteristics and Comorbidities The MSVD program electronic medical charts were retrospectively reviewed to abstract information on participant demographic characteristics, medical comorbidities, and length of time in the MSVD program. Ethnicity was categorized as white, Latino, black, or other in the medical chart. Comorbidity data at baseline were used to calculate a non-age-adjusted Charlson Comorbidity Index score using a weighted score based on the presence of 16 diagnoses (acquired immunodeficiency syndrome, myocardial infarction, congestive heart failure, peripheral vascular disease, dementia, chronic obstructive pulmonary disease (COPD), connective tissue disease, peptic ulcer disease (PUD), leukemia, lymphoma, tumor without metastasis, metastatic solid tumor, moderate to severe renal disease, cerebrovascular disease, liver disease, and diabetes mellitus with or without end organ damage (retinopathy, neuropathy, nephropathy, or brittle diabetes mellitus)).17 Similar to other studies,18 participants in the highest quartile of Charlson score (≥4) were categorized as a having high level of comorbidities.


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Table 1. Demographic and Clinical Characteristics of the Study Sample (n = 125) Characteristic

Demographic Age, mean  SD Age, n (%) 50–65 66–75 76–85 >85 Sex, n (%) Male Female Race, n (%) Black White Hispanic Other Education, n (%) < High school High school > High school Missing Has Medicaid, n (%) Yes No Missing Clinical characteristicsa Charlson Comorbidity Index, mean  SD Cancer, n (%) Congestive heart failure, n (%) Chronic obstructive pulmonary disease, n (%) Cardiovascular disease, n (%) Dementia, n (%) Diabetes mellitus, n (%) Hemiplegia, n (%) Myocardial infarction, n (%) Bedbound, n (%) Wheelchair bound, n (%)


81.4  12.3 16 18 34 57

(12.8) (14.4) (27.2) (45.6)

25 (20.0) 100 (80.0) 43 41 39 2

(34.4) (32.8) (31.2) (1.6)

45 24 32 24

(36) (19.2) (25.6) (19.2)

72 (57.6) 52 (41.6) 1 (0.8) 2.7 27 37 41 32 31 58 12 10 36 15

 1.8 (21.6) (29.6) (32.8) (25.6) (24.8) (46.4) (9.6) (8.0) (28.8) (12.0)

SD = standard deviation. a Participants may have had multiple diagnoses.


Analysis Descriptive statistics were calculated for each examined item. Two-sample t-tests were used to determine participant characteristics associated with higher GOHAI scores. Multivariate linear regression analysis was conducted using all variables with P < .10. Only variables that were not highly correlated (correlation coefficient (r)>0.5) were included. All analyses were conducted using SAS version 9.2 (SAS Institute, Inc., Cary, NC). The New York University School of Medicine and Mount Sinai School of Medicine institutional review boards approved the study. Written informed consent was obtained from all participants.

RESULTS Forty percent (n = 131) of the 334 eligible individuals agreed to participate, and 95.4% of these (n = 125) completed the survey. One hundred fifteen participants (92.0%) answered all 12 questions on the GOHAI Questionnaire. The mean age of participants was 81.4  12.3, and 80% were female (Table 1). Whites, blacks, and Latinos were fairly evenly distributed across the sample. Participants had been enrolled in the MSVD program for an average of 3.2  2.6 years at the time of oral health assessment. Almost half had diabetes mellitus, and onequarter had a clinical diagnosis of mild dementia. Mean Charlson score was 2.7  1.8 (range 0–8).

Clinical Assessment Of the 125 subjects examined, 76.0% (n = 95) were dentate, and 24.0% (n = 30) were completely edentulous. In the 95 dentate subjects, the mean number of teeth present per subject was 14.3  8.0 (range 1–32), with 78.9% having at least one decayed tooth, 40% needing restorative dental care (a filling), and 45.6% needing dental extractions (68.4% because of decay, 31.6% because of periodontal problems). Although no serious soft tissue

Table 2. Breakdown of Geriatric Oral Health Assessment Index Responses for Homebound Elderly Adults at Mount Sinai Visiting Doctors (N = 115) Category

Physical function

Pain or discomfort




Always or Often, n (%)

How often do you limit the kinds or amount of food you eat because of problem with your teeth or dentures? How often do you have trouble biting or chewing any kinds of food, such as firm meat or apple? How often were you able to swallow comfortably?a How often have your teeth or dentures prevented you from speaking the way you wanted? How often were you able to eat anything without feeling discomfort?a How often did you use medication to relieve pain or discomfort from around your mouth? How often were your teeth or gums sensitive to hot, cold, or sweets? How often did you limit contacts with people because of the condition of your teeth or dentures? How often were you pleased or happy with the looks of your teeth and gums or dentures?a How often were you worried or concerned about the problems with your teeth, gums, or dentures? How often did you feel nervous or self-conscious because of problems with your teeth, gums, or dentures? How often did you feel uncomfortable eating in front of people because your problems with your teeth or dentures?

19 (17.3)

Reverse-coded in total score.

36 78 16 51 18 14 12 52 37 25

(32.7) (70.9) (14.6) (46.4) (16.4) (12.7) (10.9) (47.3) (33.6) (22.7)

25 (22.7)



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Table 3. Bivariate Association Between Participant Characteristics and Better Perceived Oral Health Based on Geriatric Oral Health Assessment Index (GOHAI) Score (Range 12–60) Characteristic

Demographic Racea White Nonwhite Ageb >85 ≤85 Sex Female Male Medicaid Yes No Education ≥High school

Significant unmet oral health needs of homebound elderly adults.

To assess the oral health status, use of dental care, and dental needs of homebound elderly adults and to determine whether medical diagnoses or demog...
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