The number of individuals 65 and older living in the United States is increasing substantially and becoming more racially and ethnically diverse. This shift will affect the demographics of the patient population seeking dental care. It will also impact the future treatment needs of older adults. In older adults, similar to the general adult population, oral health disparities continue to exist related to race, ethnicity, gender, and socioeconomic level. Dental practitioners must understand these changes in order to meet the challenges of providing oral health care to the increasing numbers of diverse, medically compromised, and cognitively impaired older adults.
Key points
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Oral health disparities exist in the US population and are among the most profound health disparities in the United States.
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As the US population ages and becomes more diverse, oral health disparities in older adults will likely increase. It is incumbent upon dental professionals to recognize the distribution of oral disease in all older adult subpopulations and how this impacts clinical care.
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As the population of older adults continues to become more racially and ethnically diverse, it can be expected that both the percentage and the absolute numbers of older adults with dental treatment needs will increase.
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Older adults are more likely to be dentally uninsured/underinsured, are less likely to receive timely care, and therefore, are more likely to have untreated disease become symptomatic.
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In order to eliminate oral health disparities in older adults, the dental profession must develop and ensure access to culturally appropriate clinical care and health policies that foster tooth retention and the successful maintenance of good oral health in all populations of older adults.
Introduction
In all populations, good oral health is essential to overall health and well-being; however, this is especially true in older adults. Despite improvements in the oral health status of the US population as a whole, not all groups have benefited from these improvements equally. A disproportionately higher burden of oral diseases and disorders is still borne by certain population groups, including patients with special needs, older adults, minorities, and individuals with low income. The differences in health status, health outcomes, or health care use between distinct groups are known as health disparities. There are many definitions of health disparities, including the one used by Healthy People:
“ … a particular type of health difference that is closely linked with social, economic, social, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion. ”
Although the Healthy People definition of health disparities links group differences to a disadvantage, by the strictest definition, a health disparity can be any difference in health status. In contrast, health inequities, a term used more commonly than health disparities in other countries and increasingly being used in the United States, are health differences that are avoidable, unnecessary, and unjust. Of course, not all health differences are avoidable, such as prostate cancer in men versus women, or unjust, such as the proportion of hockey players who have had fractured teeth compared with the general population. It is, however, unjust if individuals are unable to attain health or are denied quality health care because they belong to a particular group. It can also be said that equal treatment may still be unjust if some disadvantaged groups need and do not receive more resources or services than others to be healthy. A related concept, social justice, purports that everyone deserves equal rights and opportunities and often can be most effectively achieved by addressing systemic level factors, as seen in Fig. 1 . For example, an older adult with arthritis may need an adaptive aid in order to use their toothbrush, a resource not needed by an individual without arthritis, and a low-income elder at highest risk for oral disease who would benefit the most from brushing may not be able to afford a toothbrush at all. Making toothbrushes a Medicare benefit could provide everyone equal access to toothbrushes.
The factors contributing to health disparities and inequities are complex. When exploring the root causes of health inequities, the importance of the social determinants of health is clear. Social determinants of health are “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.” For example, access to dental care is influenced by public policies, insurance coverage, provider availability, transportation, ability to take time off from work, cultural norms, and perceived need. Other factors, such as bias, prejudice, discrimination, and stereotyping, at the provider, patient, institutional, and health system level, contribute to disparities in quality of care, which then translate into health disparities. The contribution of biology to health disparities has also been explored. For example, chronic stress experienced disproportionately by individuals with lower incomes can depress immune systems, activate inflammatory mediators, and shorten telomeres, all of which negatively impacts health. These factors exist at the individual, family, and community levels, , and their multifaceted interplay contributes to the challenges both in understanding their relative contributions to oral health disparities and in developing effective models to prevent diseases.
Disparities in oral health conditions are among the most profound health disparities in the United States. As the US population ages and becomes more diverse, it is incumbent upon dental professionals to recognize the distribution of oral disease in all older adult subpopulations and the factors that put vulnerable populations at increased risk for oral disease. Understanding these factors is particularly challenging because older adults often have additional risk factors, such as comorbid conditions, pharmacotherapy, functional disabilities, and/or cognitive impairments, that may hamper daily oral hygiene care and the ability to access regular dental care. Older adults who receive regular dental care are more likely to have decayed teeth diagnosed and treated before experiencing pain and other symptoms. However, older adults, their families, and even health care providers may not perceive that oral health care and dental visits are important, especially when the older adult is edentulous or has complex medical issues. Unfortunately, because in the United States insurance is tied to employment and Medicare does not cover routine dental care, older adults are also more likely to be dentally uninsured and underinsured, creating another barrier to dental care and exacerbating oral health disparities.
When looking at the oral health disparities in US older adult subpopulations, poor individuals almost universally experience a greater burden of oral diseases and conditions than those with more resources. Individuals from racial and ethnic minority groups, particularly blacks and Hispanics, also generally experience higher levels of untreated decay, periodontal disease, tooth loss, orofacial pain as well as higher oral cancer mortalities than non-Hispanic whites. Data about tooth loss, dental caries, periodontal disease, and oral and pharyngeal cancer are generally measured to track oral health status at the population level. This information is measured by structured oral examinations as part of the ongoing National Health and Nutrition Examination Survey (NHANES). NHANES is a series of studies that combines interview and physical examinations to assess the health and nutritional status of community-dwelling adults and children in the United States, thereby producing health statistics for the nation. The initiative began in the 1960s and is now an on-going program of the Centers for Disease Control and Prevention. Each year, the survey examines a sample of about 5000 individuals that are representative of the general US population. The interview comprises demographic, socioeconomic, dietary, and health-related questions. The examination includes medical, dental, physiologic measurements, and laboratory tests. NHANES data are stratified by age, race and ethnicity, poverty level, and gender, making it ideal data to assess health disparities in the United States. In the next few sections, NHANES data are used to provide information about the unequal distribution of the major oral diseases and conditions in the elder population: dental caries, periodontal disease, and tooth loss in the United States. Information about oral cancer comes primarily from the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute.
Dental Caries
Caries experience
To understand the extent of oral health disparities in older adults, reviewing the oral health status of younger adults as a reference can be useful. Of all dentate adults aged 20 to 64, 90% exhibited dental caries experience (either treated or untreated), and 27% had untreated decay. Not surprisingly, dental caries experience was even greater in dentate adults 65 and older, with almost all of those examined (96%) having had caries experience. Within the older adult population, there was no difference when comparing caries experience in those 65 to 74 years of age to those greater than 75 years of age. What is surprising is that in contrast to the adult population less than 65 years of age in which caries experience decreased from 1999 to 2004 to 2011 to 2016, the prevalence in older adults increased by 3% during that same timeframe.
Although there were no age disparities within the older adult population, racial and ethnic disparities existed. The prevalence of caries experience was higher among non-Hispanic white older adults compared with older non-Hispanic black and Hispanic adults. However, non-Hispanic blacks showed the largest increase in caries experience over time. Disparities in education level, income, and smoking status were also seen, with those with higher income, more education, and never smokers having more caries experience than those with lower income, less education, and a history of smoking ( Table 1 ). Unfortunately, trends in caries experience prevalence indicate the most vulnerable older adults in each category demonstrated a 3% to 5% point increase over time, and none had a statistically significant decrease. The exception was that caries prevalence in current smokers saw essentially no change.
| Characteristic | 1999–2004 | 2011–2016 | Change, % c | ||
|---|---|---|---|---|---|
| % | SE | % | SE | ||
| Total | 93.0 | 0.64 | 96.2 | 0.51 | 3.2 d |
| Age (y) | |||||
| 65–74 b | 93.2 | 0.80 | 96.4 | 0.65 | 3.2 |
| ≥75 | 92.7 | 0.90 | 96.0 | 0.65 | 3.3 d |
| Sex | |||||
| Male b | 93.6 | 0.90 | 96.1 | 0.67 | 2.5 d |
| Female | 92.5 | 0.82 | 96.3 | 0.62 | 3.9 d |
| Race and ethnicity | |||||
| White, non-Hispanic b | 94.8 | 0.72 | 98.2 | 0.44 | 3.4 d |
| Black, non-Hispanic | 79.8 | 2.98 | 85.7 d | 1.93 | 5.9 |
| Mexican American | 84.1 | 1.83 | 85.3 d | 2.86 | 1.2 |
| Poverty status | |||||
| <100% FPL | 83.7 | 2.49 | 88.1 d | 2.17 | 4.4 |
| 100% to 199% FPL | 90.9 | 1.38 | 94.0 d | 0.99 | 3.1 |
| ≥200% FPL b | 95.5 | 0.70 | 98.2 | 0.43 | 2.7 d |
| Poverty status | |||||
| <200% FPL | 89.1 | 1.13 | 92.4 d | 1.10 | 3.3 d |
| ≥200% FPL b | 95.5 | 0.70 | 98.2 | 0.43 | 2.7 d |
| Education | |||||
| < High school | 83.8 | 1.60 | 89.1 d | 1.52 | 5.3 d |
| High school | 94.3 | 1.24 | 95.3 d | 1.09 | 1.1 |
| > High school b | 97.2 | 0.63 | 98.3 | 0.33 | 1.1 |
| Cigarette smoking history | |||||
| Current smoker | 89.6 | 2.46 | 89.8 d | 2.66 | 0.1 |
| Former smoker | 93.5 | 0.95 | 96.2 | 0.79 | 2.8 d |
| Never smoked b | 93.0 | 0.90 | 96.8 | 0.57 | 3.8 d |
a Defined as having 1 or more untreated decayed or filled permanent teeth among adults with at least 1 permanent tooth.
b Reference group for comparisons within each characteristic, 2011 to 2016.
c Change in percentage points from 1999 to 2004 to 2011 to 2016. Positive value = increase; negative value = decrease.
d P < .05 based on t test for differences between 2 periods or 2 groups within each characteristic.
Untreated tooth decay
According to the NHANES data collected from 2011 to 2016, 16% of adults aged 65 and older had untreated tooth decay. Similar to caries experience, there were disparities in the prevalence of untreated decay based on race/ethnicity, income, education, and smoking status; however, the patterns of the disparities are different. Although the percentage of untreated decay in older adults was less than in the younger adult population, the relative differences in the subpopulations were larger, meaning that subpopulations of older adults experience higher levels of disparities in untreated caries as compared with adults less than 65 years of age. In fact, older adults who were non-Hispanic black, Mexican American, poor, near poor, or current smokers had about 2 to 3 times the prevalence of untreated decay compared with those who had never smoked or were non-Hispanic white or not poor ( Table 2 ). It is important to note that there was a nonsignificant decrease in the prevalence of older adults with untreated decay compared with NHANES data collected in 1999 to 2004. However, 1 in 6 dentate older adults or 7.9 million people are estimated to have untreated decay. Because this population continues to become more racially and ethnically diverse, given the significantly higher prevalence of untreated decay in non-Hispanic blacks and Mexican Americans, it can be expected that both this percentage and absolute numbers of older adults with dental caries will increase.
| Characteristic | 1999–2004 | 2011–2016 | Change, % b | ||
|---|---|---|---|---|---|
| % | SE | % | SE | ||
| Total | 18.1 | 1.01 | 15.9 | 1.20 | −2.2 |
| Age (y) | |||||
| 65–74 c | 17.0 | 1.37 | 15.4 | 1.55 | −1.6 |
| ≥75 | 19.5 | 1.28 | 16.5 | 1.40 | −3.0 |
| Sex | |||||
| Male c | 20.4 | 1.34 | 18.0 | 1.53 | −2.4 |
| Female | 16.4 | 1.18 | 14.2 d | 1.25 | −2.3 |
| Race and ethnicity | |||||
| White, non-Hispanic c | 15.8 | 1.24 | 13.4 | 1.25 | −2.4 |
| Black, non-Hispanic | 37.1 | 3.48 | 29.1 d | 2.49 | −8.0 |
| Mexican American | 42.1 | 3.07 | 35.9 d | 3.24 | −6.2 |
| Poverty status | |||||
| <100% FPL | 33.4 | 3.42 | 33.1 d | 3.18 | −0.3 |
| 100% to 199% FPL | 23.8 | 1.75 | 26.9 d | 2.64 | 3.1 |
| ≥200% FPL c | 14.2 | 1.20 | 9.9 | 1.27 | −4.3 d |
| Poverty status | |||||
| <200% FPL | 26.2 | 1.75 | 28.6 d | 2.30 | 2.4 |
| ≥200% FPL c | 14.2 | 1.20 | 9.9 | 1.27 | −4.3 d |
| Education | |||||
| < High school | 26.2 | 2.33 | 30.8 d | 2.76 | 4.7 |
| High school | 17.7 | 1.39 | 18.8 d | 2.22 | 1.1 |
| > High school c | 14.2 | 1.27 | 11.7 | 1.35 | −2.5 |
| Cigarette smoking history | |||||
| Current smoker | 27.6 | 3.66 | 33.9 d | 5.10 | 6.3 |
| Former smoker | 18.6 | 1.31 | 15.3 | 1.67 | −3.3 |
| Never smoked c | 16.5 | 1.30 | 14.2 | 1.37 | −2.4 |
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