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CDC Aims to Prevent Oral Diseases Among Older AmericansMarch 21, 2005 The eyes may be the window to the soul, but the mouth mirrors a person’s health and well-being throughout life and into old age. That is because oral diseases and conditions can affect many other aspects of an individual’s general health status, and have an impact on emotional and psychological well-being through speech, laughter and social expression. Several health conditions can, in turn, have an impact on oral health. Oral health and general health are therefore inseparable, experts agree. Many people erroneously believe that losing one’s teeth is an inevitable part of aging and that there is nothing they can do about it. While in the 1950s fewer than 50 percent of older adults retained their teeth, now more than 70 percent of the nation’s 36 million adults age 65 and over keep their teeth into old age. As a result, strategies for maintaining healthy teeth and gums -- such as good oral hygiene, fluoride in drinking water and toothpaste, and regular professional care -- are just as important for older adults as for children. Yet, while the growing number of older adults who are retaining their teeth is good news, they also face the challenge of preserving those teeth at a time when physical, cognitive or financial limitations may hinder their ability to maintain their oral health. There is more at stake for oral health than just having an attractive smile and cavity-free teeth. Oral problems can lead to needless pain and suffering; difficulty speaking, chewing and swallowing; loss of self-esteem; and higher healthcare costs. Each year about 28,000 Americans are diagnosed with mouth and throat cancers, which can result in disfigurement and death. In addition, periodontal (gum) diseases are associated with diabetes, and there is emerging evidence of a relationship between severe periodontal disease and cardiovascular disease and stroke. “All adults need to know more about what they can do to maintain their oral health,” explained Barbara Gooch, DMD, MPH, a dental officer in the Division of Oral Health within the Centers for Disease Control and Prevention’s (CDC) National Center for Chronic Disease Prevention and Health Promotion. “Older adults, along with caregivers, healthcare providers and policy makers, should be aware of effective ways to prevent and control oral diseases.” Teeth are lost due to tooth decay and gum disease, not aging alone. The risk for these oral problems may increase with age because of problems with saliva production, receding gums that expose “softer” root surfaces to decay- causing bacteria, or difficulties flossing and brushing, cognitive problems, chronic diseases or physical disabilities. Certain medications can impair the production of saliva, which is needed to lubricate the mouth and gums, reduce bacterial growth, and provide important minerals, such as calcium, phosphates, and fluoride to “heal” tooth surfaces where tooth decay is just beginning. The combination of dry mouth, receding gums, poor oral hygiene, and a lack of fluoride can lead to tooth decay that can result in the need for extensive and costly treatment. Maintaining good oral health is even more challenging for adults with chronic illnesses and disabilities. Often physical and cognitive limitations can make it difficult for them to brush their teeth. Older adults who are homebound or in nursing homes are likely to face even greater challenges. For many of these elders, daily assistance with oral hygiene is critical. The use of fluoride products also is important, particularly brushing with fluoride toothpaste and drinking fluoridated water, but mouth rinses, varnishes, or supplements may also be recommended. Homebound elders or those in nursing homes, even those who no longer have their teeth or wear dentures, should receive regular oral examinations and dental care. By the time people are in their 60s and older, they generally know the importance of brushing, flossing, and regular dental checkups to maintain good oral health. Older individuals also should be aware that fluoride is not just for kids, but protects against tooth decay at all ages. Older adults also should avoid smoking or other tobacco products, use alcohol only in moderation, and be conscious of maintaining a nutritious diet even if they have lost teeth and have a more difficult time chewing fresh fruit and vegetables. Lifelong dedication to these habits can help ensure healthy teeth and good oral health for a lifetime. For many older adults, their need for preventive and treatment services will continue and may increase at a time when their annual incomes are likely to diminish. In 1996, for example, typical annual costs for dental care among older adults in the United States were $428, according to research by Richard J. Manski, DDS, MBA, PhD, an associate professor at the University of Maryland-Baltimore College of Dental Surgery (American Journal of Public Health, May 2004). Most older adults pay for dental services out-of-pocket because dental insurance coverage usually ends upon retirement. Furthermore, Medicare does not cover routine dental services and Medicaid coverage is limited and is available in less than half the states. UNDERSTANDING ORAL CONDITIONS AND DISEASES The two most common oral conditions are dental caries (commonly called tooth decay or “cavities”) and periodontal (gum) disease. Tooth Decay. Almost all older adults have experienced tooth decay and have many restorations (fillings), but what is less well known is that nearly one in five has untreated decay (cavities) (U.S. National Health and Nutrition Examination Survey, 1999–2002). Traditionally, dental disease prevention programs have focused on children. Now, as adults are increasingly keeping their teeth into old age and probably developing new decay at a higher rate than children (Journal of Dental Research, August 2004, Griffin), programs are starting to focus on the oral health needs of adults as well. CDC is trying to inform older adults about the benefits of fluoride, which reduces and prevents decay in persons of all ages. “People have the idea that fluoridation is only helpful for children, but it is effective throughout the lifespan,” said Dr. Gooch. Currently, 67 percent of Americans on public water systems receive optimally fluoridated water, according to the CDC Water Fluoridation Reporting System, 2002, leaving one- third of Americans at a disadvantage. Periodontal (Gum) Diseases. Gingivitis, the mildest of periodontal diseases, is an inflammation of the gum tissue resulting in gums that often appear red or swollen and bleed easily. It generally is the result of bacterial plaque, the sticky film that forms on teeth constantly. Without good daily oral hygiene, gingivitis typically develops. In addition, plaque left on the teeth too long will form hard deposits, also known as tartar. These hard deposits can only be removed in the dental office by a process known as “scaling.” Although with good oral hygiene early gingivitis is reversible, left untreated, it may lead to more severe periodontal disease -- infection of the soft tissues and bone that support the teeth. This, in turn, can lead to tooth loss. “Periodontal disease, like tooth decay, is a chronic infection in adults and both conditions are preventable,” according to CDC epidemiologist Paul Eke, MPH, PhD. About one fourth of older adults have advanced periodontal disease that can lead to tooth loss (Oral Health in America: A Report of the Surgeon General, 2000). Men are more likely than women to have more severe disease, as are people with diabetes and those in the lowest socioeconomic group. Cigarette smoking, known to be a strong risk factor for cancer, including oral cancer, as well as stroke and cardiovascular disease, is also a strong risk factor for periodontal disease -- accounting for up to half of disease. According to Dr. Eke, “It is clear that community effort on tobacco cessation for older adults is a strategy that not only will help prevent cancer, stroke and cardiovascular disease, but also reduce the burden of periodontitis.” Toothless (Edentate) Adults. According to 1999–2002 data from the U.S. National Health and Nutrition Examination Survey, about one fourth of older adults have lost all their natural teeth. Low-income elderly are twice as likely as those with higher incomes to have lost all teeth, according to these data. State-by-state analysis shows that the percentage of older adults having lost all their teeth ranges from a low of 13 percent in Hawaii and California to more than 40 percent in Kentucky and West Virginia (Public Health and Aging: Retention of Natural Teeth among Older Adults, 2002). One of the government’s Healthy People 2010 national objectives is to reduce to 20 percent or below the proportion of adults age 65 and older who are toothless. Good nutrition becomes difficult when people without teeth— even if they are denture wearers—seek out soft, easily chewable foods and avoid fresh fruits and vegetables. Dry Mouth (Xerostomia). Dry mouth—also known as xerostomia— is a sticky, dry feeling in the mouth, throat or lips. A lack of saliva will increase the risk for tooth decay and mouth infections. It also can cause problems with tasting, chewing, swallowing, and talking. Saliva contains some antimicrobial properties as well as minerals that not only lubricate and protect the soft tissues of the mouth, but also help to rebuild tooth enamel attacked by decay-causing bacteria (Oral Health in America: A Report of the Surgeon General, 2000). More than 400 commonly used medications—most notably antihistamines, diuretics, and antidepressants—can cause dry mouth. In addition, many medical treatments, such as head and neck radiation or chemotherapy, can cause inflammation of oral mucous tissues and reduce the flow of saliva. Dry mouth also can be a sign of certain diseases and conditions, such as Sjögren’s syndrome, diabetes or Parkinson’s disease. To relieve the symptoms of dry mouth and prevent oral problems, dentists and other health professionals recommend drinking extra water and reducing intake of sugar, caffeine, alcohol, and tobacco. They may also suggest purchasing artificial saliva, available at most drug stores, or sugar-free hard candy. To prevent tooth decay, use of additional preventive measures, such as fluoride rinses and gels and more frequent visits to the dental office, also may be encouraged. Finally, there are medications that can help the salivary glands work better. Mouth and Throat Cancer. Oral and pharyngeal cancers, which are diagnosed in about 28,000 Americans each year, result in about 7,200 deaths annually, CDC reports. Oral cancers involve the mouth, tongue, lips, and pharynx (throat).The average age of those diagnosed with oral cancer is over age 60 and up to 90 percent of these cancers are due to tobacco use and heavy alcohol consumption. Oral cancer occurs twice as often in males as in females. African-American males have the highest incidence of these cancers (SEER Cancer Statistics Review, 1975–2001, Reis LAG). Prognosis is generally poor, partly because these cancers are most often diagnosed at late stages. Early signs of oral cancer often are painless and difficult to identify. The five-year survival rate for these cancers is only about 50 percent. People who do survive are at increased risk for future cancers and often suffer from disfiguring surgery and psychological trauma. People diagnosed early, however, have a five-year survival rate of over 80 percent, and the American Cancer Society and other experts consider oral cavity exams important for early detection and treatment of oral cancer at localized stages. Despite this, 1990 data indicate that only 14 percent of patients say their dentist performed an oral cancer examination (Journal of American Dental Association, 1995, Horowitz). More public and professional education is needed to prevent high-risk behaviors that include cigarette, cigar or pipe smoking, use of smokeless tobacco, and excessive use of alcohol. Also, more research is needed on methods for detecting oral cancer. “We don’t know how accurate the physical exam is and we are looking for better tests,” Dr. Gooch said. The National Institutes of Health is working to develop biomarkers and other new tools to improve prevention, detection and treatment of oral cancer. WHAT CDC IS DOING FOR THE ORAL HEALTH OF OLDER ADULTS CDC currently is supporting state-based programs to promote oral health across the lifespan. Its activities focus on monitoring oral health status, implementing effective prevention programs, and stimulating public health research. CDC works with the states to track oral diseases and target prevention programs to populations at greatest risk. It supports web-based information systems such as the National Oral Health Surveillance System (www.cdc.gov/nohss) that link oral health data from various state-based systems, such as the adult-focused Behavioral Risk Factor Surveillance System. CDC also works with states to expand proven prevention strategies such as water fluoridation and tobacco cessation programs that can improve health and reduce healthcare costs. Yet, more than 100 million Americans still do not have access to water that contains enough fluoride to protect their teeth, even though the per capita cost of fluoridation over a person’s lifetime is less than the cost of one dental filling. CDC also funds community-based oral health studies through its national network of prevention research centers at academic health science centers. These projects intend to develop and test innovative strategies to promote oral health. One project at Columbia University is evaluating an oral health-training program for nurses and home health aides for homebound elders in Manhattan. Initially, investigators found that the oral health of elders was poor and that knowledge of oral health among nurses and home health attendants was limited. Through this project the home health agency has recognized the importance of oral health and daily provision of oral care and now includes oral health and function in quality performance measures monitored by the agency. “Daily oral care, including use of fluoride toothpaste, is a simple, but effective preventive measure that is often overlooked by the institutions and agencies that provide home care services for the elderly. It is important that daily oral care becomes a standard of care, and that the caretakers of homebound elderly—nurses and home care workers—receive improved oral healthcare education,” stated Principal Investigator Kavita Ahluwalia, DDS, MPH. In addition, CDC recently provided resources to expand partnerships among the aging services network and key stakeholders, such as state dental directors, dental and nondental professionals, such as nurses and home health aides and schools of dentistry and dental hygiene. For the first time in 2005, three states—Arizona, Iowa, and Rhode Island—received CDC-funded SENIOR (State-based Examples of Network, Innovation, Opportunity, and Replication) grants to implement pilot oral health projects for selected groups of older people receiving home-delivered meals or utilizing congregate meal centers. Recipients will work with multiple partners to learn more about the oral health needs of these predominantly low-income and ethnically diverse elders. Programs will use an array of approaches—use of fluoride products, patient education, and referrals to caregivers—to raise awareness about oral conditions and effective preventive services and increase the likelihood that older adults with limited resources and functional abilities receive dental services. More resources are needed, however, to expand the focus of state oral health programs to older adults. The primary barrier to the provision of prevention services to older adults is a lack of designated funding. “The majority of state oral health programs target children as federal and state funds are earmarked for these specific populations,” said Lewis N. Lampiris, DDS, MPH, president of the Association of State and Territorial Dental Directors. State oral health programs have addressed the prevention and treatment of oral diseases in children for many years, and federal and state funds have been directed toward the maternal and child population. According to Dr. Lampiris, “Multiple state oral health plans and coalition have identified older people, adults living with developmental disabilities, and low-income adults as populations in need of interventions designed to prevent and control oral disease. There is a disconnection between funding streams and these older populations at risk for oral disease.” If resources were available, states could add to and adapt their oral health messages and approaches to address the oral health needs of adults. In addition, CDC could expand the number of states it provides with funds and direct technical assistance for oral disease prevention. Currently, CDC funds 12 states and one territory. BARRIERS TO DENTAL CARE The U.S. Preventive Services Task Force recommends regular dental visits for all people age 65 and older, yet only 43 percent of older adults reported a dental visit in 1996, according to Agency for Healthcare Research and Quality data (Medical Expenditure Panel Survey, 1996). As they enter their retirement years, most elders lose employer-based dental insurance, and at the same time are dealing with a reduction in income, explained Dr. Manski. That means that most elderly people pay their dental expenses out of pocket and for many, these expenses come at a time of reduced income. Unfortunately for retirees, Medicare does not cover routine dental care and Medicaid provides only limited coverage in certain states. Other reasons why older adults do not regularly use dental services include lack of perceived need for care; mobility limitations and transportation difficulties; fear of dental visits; limited availability of dental services in certain rural and urban areas; and diminished physical, cognitive and functional status associated with multiple complex medical conditions and disabilities. Other issues that affect certain populations include low-literacy skills that can keep an older adult from understanding information and services. These barriers to dental care will be compounded as the 76 million baby boomers reach retirement age, creating the largest cohort of older adults this country has ever seen. Barriers to good oral healthcare are especially prominent in long-term care facilities due to a lack of insurance coverage, limited patient mobility, the inconvenience of making trips to the dentist, and the lack of funding and expertise within facilities to provide complete dental care. Although about 80 percent of nursing homes report that dental services are available in their facilities, only 19 percent of all nursing home residents received dental services (National Nursing Home Survey). Clinical studies show an absence of oral hygiene and the existence of widespread oral health problems among nursing home residents. Tooth decay rates are very high among the nursing home population, especially for those who depend on others to do their oral hygiene care, according to Judith A. Jones, DDS, MPH, DScD, who heads the general dentistry department at Boston University School of Dental Medicine. Yet, most oral health problems for people living in nursing homes “could be prevented just by good daily oral hygiene and regular preventive care,” Dr. Jones explained. “But it is just not available.” Teresa Dolan, DDS, MPH, dean of the University of Florida’s College of Dentistry, pointed out that there are few dentists trained specifically in the oral healthcare of the geriatric population. The U.S. Health Resources and Services Administration supports only a few university dental training programs that have a geriatric component, Dr. Dolan observed. “The funding for those programs has decreased dramatically,” she noted. “While most dental school curriculums include some geriatric content, there is not much clinical experience in nursing home settings for the more compromised patients that you would find there.” There also are fewer dentists from underserved racial and ethnic groups, which may be a disincentive for those populations to seek dental care. CHALLENGES FOR THE FUTURE The trend toward better oral health among older adults is expected to continue, as each new generation becomes better educated and more affluent. Baby boomers, born in the late 1940s and early 1950s when water fluoridation began in the United States, are more likely to retain their teeth and have better oral health than their predecessors. But challenges remain. Experts on oral health, who attended a September 2004 summit on older adults in Boston organized by Dr. Jones called for building the science base for what works for elder dental care. They also recommended highlighting “best practice” models; determining the economic costs of poor oral healthcare; beefing up the dental workforce (especially specialists that work with institutionalized and frail elders); increasing collaborations with the aging network, AARP, Older Women’s League and other organizations; and creating a role for oral health in the continuum of care for the elderly. Dental care advocates have been pushing for legislation to extend coverage to groups without dental insurance. Such legislation would amend the Social Security Act to require states to provide oral health services to aged, blind or disabled individuals under the Medicaid program or add dental benefits to Medicare. In 2003, U.S. Senator John Breaux of Louisiana held a roundtable meeting of the Senate Special Committee on Aging on the topic of oral healthcare for older adults. But to date, Congress has taken no action on specific legislation addressing the needs of this population. Future solutions to dental access problems will embrace a patchwork of new approaches, insurance issues and alternative delivery programs, Dr. Jones predicted. “Financing is an important piece of the access puzzle. It is not the only piece, but an importance piece, of access,” Dr. Jones said. “Clearly there is a need to look at new models and find out which ones would really work, and where in the existing aging network we could piggy-back oral health to actually develop effective programs.” Dr. Gooch and others at CDC point to the need for new paradigms of care delivery for older adults. “Certainly, access to care is very important, but there are other interventions that can happen at the community level and among individuals, that can begin to reduce the burden of disease,” Dr. Gooch said. Besides regular dental visits and home care, these interventions include avoiding tobacco, limiting alcohol use, using fluoride toothpaste and drinking fluoridated water. “These are all healthy practices that will improve your oral health over time,” Dr. Gooch explained. “That is our major message.” This media background paper was written by Nancy Aldrich. William F. Benson was senior editor and project manager. MODELS OF OLDER ADULT ORAL HEALTH CARE State Health Department Programs Several states have initiated promising dental care model programs targeting older adults. Two such programs are highlighted here. Since 1977, the Colorado Department of Public Health and Environment, Oral Health Program, has administered a statewide, oral health program for low-income elders. The Colorado Dental Care Act of 1977 initiated the program, providing an alternative to the present Medicaid system, which does not cover adult dental care services. Since that time, the program has been able to provide preventive, restorative, and prosthetic services for over 600 older adults each year. Dental care is provided to help maintain nutritional and overall health status, thereby enabling them to have more independence and better self-care. The program currently provides limited preventive services, fillings, and dental appliances (full and partial dentures) to individuals 60 years and older whose income and resources are insufficient to the meet the costs of treatment. Regional coordinators with Area Agencies on Aging assure that older adults are matched with participating dentists, convene dental committee members for review and approval of treatment plans, and send claims into the central office for payment. The maximum state payment is 80% of maximum fee; elders pays 20%. According to the State of Colorado Oral Health Program Director, Diane Brunson, RDH, MPH., “I have found that while providing dentures takes a large bite out of the budget, the majority of low-income elders require preventive and restorative care. By carefully analyzing state data, I hope to show that the oral health needs of even our most needy seniors has changed since 1977, with more of them requiring preventive and basic restorative services, which would provide impetus for amending the legislation and designing a program to meet the needs of a majority of our neediest seniors.” Dental OPTIONS (Ohio Partnership To Improve Oral health through access to Needed Services) is a partnership between the Ohio Department of Health and the Ohio Dental Association. Administered by the Ohio Department of Health, Bureau of Oral Health Services, the program links people in need of dental care with dentists who have agreed to treat qualified patients for reduced fees or free of charge. The partnership was formed in 1996 to improve access to dental care for Ohio’s poor and working poor adults and children, low-income elders, and persons who are medically, mentally, or physically challenged. Low-income Ohioans over age 65 years represent a substantial portion of OPTIONS patients and are a target group. Program services to this group include examinations, x-rays, cleanings, fluoride treatments, dental sealants, fillings, extractions, and full or partial dentures. Almost 800 (13%) Ohio dentists and more than 90 dental laboratories participate in the program. OPTIONS referral coordinators accept applications and qualify eligible clients, facilitate care by matching program clients with providers and offer them case management services. During 2004, more than 5,400 people were served by the program, with more than 4,200 people referred to other programs such as safety net clinics or Medicaid and approximately 1,200 matched with OPTIONS providers. Dentists reported treatment value of over $1.3 million for the services given to OPTIONS patients. Mark D. Siegal, DDS, MPH, Chief of the Ohio Bureau of Oral Health, observed, “State dental programs rarely have substantial funding streams to address the needs of older adults. While OPTIONS is a relatively small program in comparison to the need, it is a beautiful program. The beauty of OPTIONS comes from the partnership from which it was born, the lessons learned as the program matured and the very personal and caring relationships that unfold on a daily basis between all combinations of patients, referral coordinators, dentists and their office staff.” Other care models and insurance programs for older adults Other states, dental care providers, and insurers also are focusing efforts on increasing access to dental services for both community-dwelling elders and those in long-term care facilities. A selection of these is presented below. --> In September 2004, the American Dental Association Foundation received a $250,000 corporate grant to establish an Initiative on Older Adult Access to Oral Health Care to stimulate development of programs to help older Americans who face financial or other challenges in accessing dental care. --> In California, AARP piloted a dental coverage program, which has been expanded to about 30 states (see list at www.deltadentalins.com/aarp/states.html). AARP plans to offer dental insurance nationwide through a major insurer by 2005. The plan limits out-of-pocket costs for preventive and emergency care, fillings and crowns. --> Also in California, the California Dental Association launched Senior-Dent in 1979, which offers reduced dental fees for regular preventive care to uninsured older adults (over age 60) whose income is $20,000 or less. --> Apple Tree Dental, a nonprofit clinic in Minneapolis, Minn., provides dental care for underserved populations, including older adults, nursing home residents, and people with disabilities. The clinic contracts with facilities, operates dental-equipped vans, hires dentists, and delivers services using its own model of care. Most patients are ages 85 to 99 years. --> Health Source Associates (HSA) has launched a business model for delivering dental care to nursing home residents in Florida, according to Teresa Dolan, DDS, MPH, dean of the University of Florida’s College of Dentistry, who helped HSA develop the model. The company contracts with facilities, hires dentists and organizes the delivery of care. “They put a lot of thought into it from a business perspective,” Dolan explained. Except for major oral surgery, HSA provides most dental services in the nursing home, including cleanings, digital X-rays, filling, root canals and dentures. Costs are comparable with the average of dentists practicing in the immediate neighborhood of the facility. --> Boston University has a feasibility study looking at bringing preventive dental services into elderly housing projects. “We screen people, do preventive services on-site such as cancer screening and fluoride treatments and denture labeling, and make referrals for treatment at dental schools for low-cost care,” explained Judith A. Jones, DDS, MPH, DScD, who heads the general dentistry department at Boston University School of Dental Medicine. “It’s a mobile program: we bring in equipment in carts and tubs and set up in the common room in the elder housing.” This approach could also be adopted by setting up monthly preventive dental programs at senior centers, which most towns have, Jones suggested. --> To help improve dental care in nursing homes, the Alpha Omega International Dental Fraternity, an international dental organization, developed for its members a free training program for nurse aides. The training program included a 13-minute video, Oral Care in the Nursing Facility: A Beautiful Smile Is Ageless, followed by discussion and demonstration of tooth cleaning techniques. The organization has distributed 200 videotapes worldwide to member organizations and is now offering the tape to other organizations.
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