Access to and reducing disparities in oral health for older adults is a complex problem that requires innovative strategies. In addition to offering dental services in alternative settings, such as senior centers, places that are familiar to older adults, and where physical limitations can be better accommodated, alternatives to the traditional provider should be considered. Many states are changing laws and practice acts to allow dental hygienists to provide preventive services without the supervision of a dentist. Also, collaborations between dental and non-dental professionals can be a successful strategy for increasing access to oral health care for this high-risk population.
Key points
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Access to and reducing disparities in oral health for older adults is a complex problem that requires innovative strategies. Offering oral health care services in alternative settings, such as senior centers, places that are familiar to older adults, and where physical limitations can be better accommodated, is a key strategy to increase access and reduce disparities.
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The success of the strategy of oral health care in alternative settings necessitates supporting the utilization of dental hygienists in public health settings including long-term care facilities, creating new dental providers, as well as to a collaborative practice approach whereby both dental and nondental professionals coordinate care.
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It is incumbent on the dental professional to take the next steps by: (1) promoting the incorporation of the oral health needs of seniors in dental and dental hygiene education, in addition to continuing education courses; (2) training medical and other nondental professionals serving seniors on how to perform oral health assessments and promote collaborative care between the professions; and (3) supporting the development of new health policies that prioritize oral health for older adults as a primary health care agenda.
Introduction
The new cohort of seniors, those born between 1946 and 1964, are different from the older cohorts in that they are more likely to retain their dentition, placing them at a higher risk for oral diseases. However, older adults frequently do not access oral health care. According to the 1996 and 2004 Medical Expenditure Panel Survey, only 46% of older adults aged 65 to 74 and 39% of older adults aged 75 and older reported visiting a dentist.
Multiple factors contribute to low and limited access to dental care, including the supply and distribution of experienced dental professionals. Limited infrastructure particularly, in rural areas of the country, and the supply of dental professionals with the required training needed to provide for the particular needs of older adults play a key role, in addition to the limited interaction between dental professionals and other health professionals who regularly care for this high-risk population.
Introduction
The new cohort of seniors, those born between 1946 and 1964, are different from the older cohorts in that they are more likely to retain their dentition, placing them at a higher risk for oral diseases. However, older adults frequently do not access oral health care. According to the 1996 and 2004 Medical Expenditure Panel Survey, only 46% of older adults aged 65 to 74 and 39% of older adults aged 75 and older reported visiting a dentist.
Multiple factors contribute to low and limited access to dental care, including the supply and distribution of experienced dental professionals. Limited infrastructure particularly, in rural areas of the country, and the supply of dental professionals with the required training needed to provide for the particular needs of older adults play a key role, in addition to the limited interaction between dental professionals and other health professionals who regularly care for this high-risk population.
Dental and dental hygiene education
The number and distribution of dentists and dental hygienists within the population is an important factor in assessing how well the dental profession is meeting the current needs of the public, especially those 65 years and older, the fastest growing segment of the American population. Excluding the District of Columbia, the dentists to population ratio by state ranged from 31.3 to 69 per 100,000 residents. In the United States, there are more than 190,000 licensed dental hygienists, an average ratio of 50 dental hygienists per 100,000 population.
Owing to the number of experienced dentists retiring or dying, the number of new dental professionals entering the profession is just as important. In 2013 there were 66 accredited dental schools in the United States and 10 in Canada. Each year there are approximately 21,000 students enrolled in predoctoral education programs, and recent trends demonstrate an increase in dental school enrollment similar to that of the early 1980s. In 2010 there were about 4800 dental school graduates or a ratio of about 1 graduating dentist for every 64,000 Americans; and although many choose to practice within a specialty, few choose geriatrics. There are 332 dental hygiene schools in the United States, and annually, more than 6700 graduate from entry-level programs receiving an Associate’s or Bachelor’s degree. By 2020, it is expected that 44% more dental hygienists than dentists will graduate annually.
The practice of dentistry: is there a need to change?
While medicine has gradually shifted away from solo practice, leading to expanded skill levels and specialization within professions, an increased allied health care workforce, and the addition of new technicians and other assistants, this same shift has been slow in dentistry. Dentists primarily continue to work in small solo and group private practices, and the role and scope of practice of dental providers remain fairly static and well defined. In recent years, this traditional provision of dental care has been scrutinized, particularly in its inadequacy to meet the increasing oral health needs of older adults.
Long-term concern may be warranted for the 10,000 Americans retiring daily, as it is estimated that only 2% of the baby-boomers turning age 65 will have access to dental insurance benefits and admission to the traditional dental delivery system. For some older adults, dental care is being accessed through emergency rooms, a result of a shrinking workforce. Emergency room visits that were dental-related among adults older than 65 years rose from 1 million from 1999/2000 to 2.3 million during 2009/2010. Others access care through Federally Qualified Health Centers (FQHC), which provide comprehensive oral health care services to low-income and uninsured individuals in underserved communities. At the national level, the number of these FQHCs has increased 58% from 1997 to 2004, and totaled 1128 in 2011. With 31 states (62%) having high rates of dental Health Provider Shortage Areas (HPSAs) and meeting only 40% or less of dental provider needs, it is essential that alternative strategies for the delivery of dental care are implemented. This approach includes providing care in nondental settings such as senior centers, nursing homes, and long-term care facilities, and in the home. By expanding access to dental care into existing community venues that are already regularly frequented by the target population, key factors such as transportation costs, patient anxiety, and empty appointment slots, to name a few, are either reduced or eliminated.
Infrastructure and workforce barriers limit older adults from obtaining appropriate care, driving health care costs higher and the quality of life lower. The need for better oral health care for the seniors is readily apparent. Against this backdrop, these issues may be addressed through innovative models and policies focused on the delivery of oral health care. Increasing access to oral health care for older adults is a complex problem that requires creative solutions. A key strategy that addresses this problem is to alter the traditional provision of dental services by creating new environments that facilitate easy access.
New trends in dental education and practice
In most dental programs, predoctoral dental students are trained in medicine for as long as 2 years; however, once they matriculate their medical knowledge is underused. An encouraging step in the renaissance in dental education is to allow dentists to be trained at the capacity of a mid-level medical provider. Today, a dental resident who is doing a rotation in internal medicine is required to function at the level of a third-year medical student (conducting patient interviews, doing basic medical examinations, and making referrals); thus a dentist is a de facto oral physician (OP).
The Cambridge Health Alliance (CHA) Windsor Street Health Center (WSHC) is actively implementing a training model known as the OP. The CHA is a large safety-net organization with 3 hospitals and 12 clinic sites west of Boston, Massachusetts, with its catchment area consisting of approximately 400,000 residents. Within the Oral Health Department, more than 90% of patients seen receive public health dental benefits. A General Practice Residency program, affiliated with the Harvard School of Dental Medicine, exposes recent graduates to a 1-year general dentistry program with an emphasis on public health.
If medicine, in a limited capacity, were incorporated into a dental practice it could have an impact on primary care to strengthen best overall health practices. In addition to conducting the medical interview, the OP takes blood pressure, oxygen level, height and weight to measure body mass index, and dental radiographs, and conducts extraoral and intraoral examinations. With this information, the provider discusses the findings and makes recommendations for treatment. Blood tests and/or urine tests can also be ordered if they are in the best interest of the patient. Often this decision is driven by the lack of access to a primary care physician (PCP). Most importantly, the OP can expedite the recommendation for patients to see their PCP for follow-up care or can directly contact that PCP to discuss the best approaches to treatment. These encounters develop rapport, and cross-training stimulates interprofessional learning for the benefit of the patient. Reinforcing the application of medical knowledge and demonstrating the relationship between mental health, oral health, and systemic health in everyday clinical care is ongoing. Surveys are being developed to ascertain whether patients are comfortable with an OP (dentist) asking in-depth health questions as part of the medical interview.
Additional benefits of this model include an increased knowledge to dental providers of how medications interact with oral health treatment, and improved communications with physicians and allied health professionals. By educating physicians and nurses at grand-round presentations, CHA is not only raising oral-systemic health knowledge, it is also bridging the gap between medicine and dentistry, and thus revising and complementing the interdisciplinary patient-centered health care model.
In addition to the interdisciplinary efforts, a more effective patient history and physical workup model has been implemented using patient interview techniques, such as in studies by Rosenthal and Rosnow. These studies demonstrated that a face-to-face medical interview is significantly more reliable than the written questionnaire. For example, when treating older adults it is not uncommon for clinicians to encounter problems with incomplete or inaccurate medical forms. The stimulation provided by the open dialogue leads to better recall about the patient’s health history. The OP validates the patient as an individual by spending more time conducting the medical interview and demonstrating a caring attitude, promoting the first stage of “healing.” The knowledge gained potentially increases health literacy for both patients and providers. This increase has a positive impact on health care outcomes and costs.
Collaborative practice among dental providers
The success in altering the traditional provision of dental services may be linked to collaborative practice arrangements among both dental providers and nondental professionals. This approach also entails expanding the scope of practice of both dental and nondental providers, and creating new types of dental providers altogether. In particular, the dental auxiliary personnel, including the dental hygienist and the dental therapist, can play a pivotal role in increasing access to oral health care for older adults.
Collaborative practice is a health care workforce innovation designed to coordinate care among providers, and its use in dentistry is a form of practice that is only just taking shape. Collaborative practice in a dental setting involves the dental auxiliary personnel, usually a dental hygienist or a dental therapist, and the dentist. Although several states have currently arranged some form of collaborative practice, there is no single model. Across several states, a collaborative practice between the dental auxiliary personnel and the dentist can differ in its level of agreement between the providers, the extent of supervision the dentist provides, special education and/or experience requirements for the dental auxiliary personnel, and types of services that the dental auxiliary personnel can provide to specific types of populations ( Box 1 ).
Direct access means that the dental hygienist can initiate treatment based on his or her assessment of patients’ needs without the specific authorization of a dentist, treat patients without the presence of a dentist, and maintain a provider-patient relationship.
| Alaska | Arizona | Arkansas | California | Colorado | Connecticut |
| Florida | Idaho | Iowa | Kansas | Kentucky | Maine |
| Massachusetts | Michigan | Minnesota | Missouri | Montana | Nebraska |
| New Hampshire | New Mexico | New York | Nevada | Ohio | Oklahoma |
| Oregon | Pennsylvania | Rhode Island | South Carolina | South Dakota | Tennessee |
| Texas | Vermont | Virginia | Washington | West Virginia | Wisconsin |
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