Overview of Oral Health in Older Adults s populations in the United is critically important in speech, States and around the mastication, swallowing, and globe move toward a world digestion of foods as well as to one’s A Newsletter of A 1 in which 25% of people will be 65 appearance. Deficiencies in any of years or older, much attention is these functions because of disease being paid to the management of or injury can affect a person’s chronic diseases and maintenance self-image and desire to interact In this issue: of activities of daily living. with others, which in turn can lead , cancers, to social isolation and thereby Oral Health: Alzheimer disease, and immunologic contribute to depression. An Essential disorders are among the systemic In this issue of the What’s Hot conditions attracting the attention newsletter, published by The Element of of researchers, pharmaceutical Gerontological Society of America Healthy Aging companies, government agencies, (GSA), oral health is considered and health care professionals. as an essential element of healthy Often overlooked is the contribution of aging. The topic encompasses Overview of Oral Health a healthy mouth to a person’s overall the breadth of the human in Older Adults...... 1 well-being and its relationship with condition, including clinical, the disease processes occurring in scientific, psychosocial, and Mouth/Body Connection...... 4 the rest of the body. Yet the effects of policy considerations. poor oral health are similar to other Access and Barriers to Normal/Pathological Aging Dental Care...... 9 uncontrolled disease processes. In the aging process, , Without a healthy mouth, important gum disease, and other dental Workforce Issues...... 13 aspects of general and health-related problems have historically been quality of life are affected, including Oral Health and considered inevitable outcomes. nutrition, self-image, willingness to Healthy Aging: Areas But like many aspects of “normal” interact socially, mental health, and of Future Focus...... 15 aging, edentulism and poor oral all too often, physical health. References...... 17 health can be prevented. The The 32 adult teeth (including the outlook for oral health is changing third molars, or the “wisdom” teeth) because of shifts toward new ideas Developed by and associated tissues serve a wide in , including an integrated variety of functions in daily life. The preventive approach to care and mouth, tongue, and throat interface maintenance of the natural teeth Supported by with the external environment, and oral tissues whenever possible. GlaxoSmithKline Consumer Healthcare filter and process microbes and Rather than a norm of extracting antigens, and send signals to the teeth, followed by tooth replacement, brain about ingested foods and dental professionals today prefer other substances. The oral cavity conservative approaches aimed

Faculty Stephen Shuman, DDS, MS, Chair Paula K. Friedman, DDS, MSD, MPH Michèle J. Saunders, DMD, MS, MPH Associate Professor Emeritus Professor Adjunct Professor, Department of Psychiatry Director of Oral Health Services Former Director, Section on University of Texas Health Science Center for Older Adults Program and Gerontology San Antonio, Texas University of Minnesota Former Director, Geriatric Dentistry Fellowship Bei Wu, PhD School of Dentistry and Graduate School Boston University Henry M. Goldman Minneapolis, Minnesota School of Dental Medicine Dean’s Chair Professor in Global Health Boston, Massachusetts Director of Global Health and Aging Research Xi Chen, DDS, PhD Director for Research, Hartford Institute for Associate Professor, Department of Preventive Elisa M. Ghezzi, DDS, PhD Geriatric Nursing and Community Dentistry Adjunct Clinical Assistant Professor New York University University of Iowa College of Dentistry University of Michigan School of Dentistry Rory Meyers College of Nursing and Dental Clinics Ann Arbor, Michigan New York, New York Iowa City, Iowa © 2017 by The Gerontological Society of America. All rights reserved. Printed in the U.S.A. Figure 1. Global Burden of Major Oral Diseases in 1990 and 2010 as Measured in Health professionals Disability-Adjusted Life-Years (DALYs X 103) should routinely ask patients if they have a who they see 5,273 Edentulism regularly and when was 4,621 the last time they had their teeth cleaned.

Periodontal 3,440 disease 5,410 National Center for Health Statistics. Compared with 1988–1994, people in both younger and older age groups in 3,704 1999–2004 had fewer missing teeth, Dental caries 4,984 less severe gum disease, and fewer caries on the root surfaces of teeth, 0 1,000 2,000 3,000 4,000 5,000 6,000 according to National Health and Nutrition Examination Surveys during 1990 2010 those periods.2 However, more recent Source: Reference 5. data show a reduced or stagnated rate of improvement of oral health, especially among low-income and at preserving teeth, including conditions. Removal of teeth older adults.3,4 restorations (e.g., fillings, crowns) and prosthetic replacement are and preventive care for older considered only a last resort.1 Burden and Epidemiology patients with dental caries, gum Evidence of the impact of advances in of Oral Disease disease, injuries, or problems dentistry on oral health of older adults While overall oral health has such as temporomandibular joint was summarized in the 2007 report improved on a global level, dental (TMJ) disorders and other orofacial Trends in Oral Health Status from the disease remains one of the most

Dental Terms Used in this Article

Burning mouth syndrome: : Prosthetic devices that Periodontal: Relating to the gums Daily pain in the mouth lasting for replace some or all of the natural and other supporting structures months or years. Possibly related teeth. Dentures can be complete around the teeth. to diabetic neuropathy in neurons or partial. Dental prostheses that innervating the tongue, upper are supported through implants Periodontitis: Inflammation of palate, and mouth. in the tissues of the mouth are the gums and other supporting referred to as implant dentures. structures around the teeth. Caries: Dental decay. Caries Caused by chronic presence of can be located on the “crown” of Edentulism: Loss of all bacteria in nearby plaque. the tooth (coronal caries). More natural teeth. common in older patients are the Stomatitis: Inflammation of the more serious root caries, in which Gingivitis: Inflammation of the mucous membranes of the mouth. gingiva, or gums, of the teeth in decay is located on the exposed : Dry mouth. The root of the tooth. Root caries are a response to bacterial plaque on adjacent teeth. cause can be an actual decrease common cause of tooth loss. in salivary flow or a secondary Dentition: Natural teeth. Halitosis: Bad breath. factor that creates the perception of dry mouth. Both types are associated with increased risk for cavities and poor oral health.

2 The Gerontological Society of America Figure 2. Estimated Percentages of Edentulism in Reasons older Middle-Aged and Older Adults in the United States Americans don’t by Race/Ethnicity, 1999–2008 see

40

35 MONEY 30 INSURANCE 25

20 CULTURE

15 TRANSPORTATION 10 DISABILITIES 5

0 COGNITION 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Native American Black White Hispanic Asian American AVAILABILITY

Data weighted and adjusted for time, race/ethnicity, sociodemographic characteristics, and level of education.

Source: Reference 7. common human ailments. Dental these two decades because of many • Older Americans are keeping their caries and are more people keeping their own teeth teeth at greater rates than in the among the most common chronic throughout the lifespan (Figure 1). past, but they are also developing conditions, and these along with other DALYs from oral cancer rose dental caries at rates equivalent to conditions of the oral cavity affect an by 45.1%.5 or higher than the high rates seen estimated 90% of people worldwide at As people age, dental problems in children. some point in their lives. accumulate, periodontal disease tends • Fifty-three million people have The Global Burden of Disease 2010 to worsen, and other oral conditions untreated caries and loss of all study shows that oral health problems appear. Evidence increasingly shows natural teeth remains relatively affect 3.9 billion people and are the that poor oral health is associated with common among Americans, most prevalent health conditions. Data functional disability that can lead to causing substantial disease burden from the Global Burden of Disease deficits and decline. studies conducted in 1990 and 2010, (Figures 2 and 3).7 Older adults as re-examined with respect to oral Despite the relative affluence of frequently have medical conditions diseases by Murray et al., show that Americans and widespread availability that worsen oral health as well the number of disability-adjusted of dental care and oral health products as oral health problems that can life-years (DALYs) increased by 20.4% in the United States, maintaining worsen medical conditions. for dental caries, periodontal disease, a healthy mouth throughout • Among Americans older than 65 edentulism, oral cancer, and cleft lip/ one’s lifetime is difficult for many years of age, 70% have periodontal palate, accounting for nearly 19 million Americans, especially older adults. DALYs in 2010.1,5 The prevalence based As part of its Oral Health Strategic disease, which is associated with on DALYs per 100,000 population Framework for 2014–2017, the U.S. colonization and infections of rose for dental caries by 34.5% and Department of Health and Human gum tissues by pathogenic gram- for periodontal disease by 57.3%; Services outlined the challenges faced negative anaerobic bacteria.3 One in edentulism decreased by 12.4% during by older Americans6: four older Americans is edentulous.

WHAT’S HOT Oral Health: An Essential Element of Healthy Aging 3 Prevention: Key to a psychological health and with Care in Older Adults sidebar). Healthy Mouth specific disorders. To maintain “An ounce of prevention is worth As discussed in more detail in the next oral health, older adults need a pound of cure” for health in section of this What’s Hot newsletter, adequate daily and general, and certainly this is oral health is connected with a routine preventive visits with the true with care of the mouth and person’s general physical and dental team (see Preventive Oral oral cavity.

Mouth/Body Connection

t is important to recognize that oral cavity. In this section, examples of life.21 Tooth loss is greater among the mouth is attached to the rest of the problems with poor oral adults with than among I of the body, and therefore can health and systemic diseases those without the disease.22 be reflective of, and contributory illustrate the operative Diabetes worsens oral health to, systemic conditions. Poor oral pathophysiologic mechanisms. primarily through its effects on the health is associated with a number body’s microbe-fighting capabilities; of physical and behavioral disorders. Diabetes as blood glucose levels rise, the Studies have even suggested that Diabetes is perhaps the “prototype” body is less adept at fighting the number of natural teeth could be condition that illustrates the pathogens and more susceptible a predictor of longevity and that loss bidirectional and interrelated to infections. Bacteria and fungi of teeth could signal increased risk nature of oral health and systemic 8–19 can proliferate in the oral cavity for early mortality. disease.20 Patients with poorly when hygiene is poor. Biofilms controlled diabetes have a threefold The interrelatedness of oral health form in plaque and tartar (calculus) greater risk of developing gingivitis and overall well-being should not be on the teeth, and these can more and periodontitis, and those a surprise, but it is easily overlooked easily extend into gingival tissues. with diabetes whose periodontal in a siloed, specialist-driven health Fungal infections such as thrush disease is treated have improved care system, and in a health care (candidiasis) can occur in the system that does not routinely metabolic control of diabetes, fewer mouths of patients with diabetes, include informed examination of the complications, and improved quality and lichen planus and lichenoid reactions can occur on the skin. Figure 3. Disability-Adjusted Life-Years for Major Oral Diabetes can reduce salivary gland Diseases Among Adults Aged 70 Years or Older in 2015, function and thereby produce dental United States caries. Taste is often impaired in patients with diabetes.23,24 Edentulism and 81,995 118,272 Diabetic neuropathy can produce severe tooth loss oral complications, including altered taste and smell, dry mouth, and burning mouth syndrome. Periodontal diseases 10,327 11,473 Neuropathy-associated reduction in salivary production can cause dental caries and gum/periodontal disease through xerostomia as Permanent caries 2,950 4,426 described below in the Chronic Oral and Systemic Conditions section.25

0% 20% 40% 60% 80% 100% In patients with diabetes, burning Women Men mouth syndrome is thought to result from disease-related damage Source: Global Burden of Disease Study 2015 (GBD 2015) Results. Seattle, WA: to neurons innervating the tongue, Institute for Health Metrics and Evaluation (IHME), 2016. Available from upper palate, and mouth; it can http://ghdx.healthdata.org/gbd-results-tool. Methods and related data published as: also occur in patients without GBD 2015 DALYs and HALE Collaborators. Global, regional, and national disability- adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy diabetes through poorly understood (HALE), 1990–2015: a systematic analysis for the Global Burden of Disease Study mechanisms. Symptoms of 2015. Lancet. 2016;388(10053):1603–1658. burning mouth syndrome include

4 The Gerontological Society of America Preventive Oral Care dentin that can allow hot, cold, in Older Adults acidic, and sweet foods to create painful sensations. Older adults can maintain their dentition through daily home oral Dry mouth can be managed with hygiene and regular professional dentifrices (toothpastes) and mouth care. As noted throughout this issue rinses formulated to help stimulate of What’s Hot, these steps are very salivary flow. These products are important to patients’ longevity and fluoridated and alcohol free, and do oral health–related quality of life. not contain the harsh SLS detergent that can irritate oral soft tissues. With advice from dental and other health professionals (including Daily removal of plaque using dental mental health practitioners), floss or other interdental cleaners older adults can properly select is important. Without removal, gum toothbrushes, toothpastes, flosses, tissues can become inflamed and and mouth rinses. Older adults and caries can develop. their families need to remember that good dental care doesn’t have Waxed floss or floss made from to be complicated or expensive. polytetrafluoroethylene (a slippery material) is better for patients with For older adults with limited tightly spaced teeth, because it is dexterity and those who are more easily maneuvered into the disabled, powered toothbrushes interdental space. Woven floss offer distinct advantages over facilitates pick up and removal of manual models. Powered bacteria from tooth and gum surfaces. toothbrushes require less Patients might also have personal movement of the wrist joint, they preferences for mint or other flavors, have larger handles that are easier or for thicker or thinner flosses. to grasp, and the rapid rotation of the toothbrush head is more Mouth rinses contain many of the then be soaked in marketed solutions effective in removing plaque. same ingredients as dentifrices. For older adults, key differentiating that contain alkaline peroxide, Toothpastes generally contain characteristics of mouth rinses hypochlorite (bleach), or dilute acids mild abrasives such as calcium are fluoride content, antimicrobial for the length of time given in product carbonate or silicates, fluoride, actions, alcohol content, and instructions. The prosthesis can be humectants that prevent water usefulness for xerostomia. rinsed with water or nonalcoholic loss (glycerol, propylene, glycol, Alcohol-free mouthwashes and antimicrobial mouth rinse and the or sorbitol), flavoring agents those mouthwashes specifically mouth rinsed with an antimicrobial (saccharin or other sweeteners), formulated for dry mouth are mouth rinse for 30 to 60 seconds thickening agents (gums or preferable for many older patients. before reinserting the denture. colloids), and detergents (usually Even with the best home sodium laurel sulfate [SLS] or Fluoridated mouth rinses offer an care, adults still need regular its derivatives). A basic fluoride additional dose of protection in older professional dental care and toothpaste is all most people need. adults at high risk of dental caries. Several nonprescription products examinations. Dental professionals Adults with gum recession or are available, and more concentrated recommend twice-yearly cleanings periodontitis can require special fluoride formulations can be for most patients, but frequency is toothpastes. The abrasives in prescribed by dental professionals. determined on an individual basis regular toothpaste are too rough with regard to risk status. Some for the dentin and Removable dentures require the older adults with ongoing problems layers that are exposed when same cleaning regularity as natural secondary to caries or periodontal gums recede. Toothpastes for teeth but with different products. disease might need cleanings and sensitive teeth use less abrasive Dentures should be brushed twice examinations every 3 or 4 months. cleaners and contain minerals such daily with a denture brush and Many older adults with full upper as potassium nitrate that block minimally abrasive denture cleaners and lower dentures require only microscopic tubules in exposed or mild soap and water. Dentures can annual dental check-ups.

WHAT’S HOT Oral Health: An Essential Element of Healthy Aging 5 The passage of periodontal before initiating bisphosphonate Dental professionals bacteria into many tissues and therapy for ,30 expect to be part of an organs of the body supports a especially when high-dose therapy microbiologic basis for many of is planned for other bone diseases. interdisciplinary team. the connections between oral health and systemic disease.27 Association With Cardiovascular Disease Osteoporosis/ and daily pain lasting for months Bisphosphonates Periodontal disease has been or years. Psychological factors Osteoporosis is another disease with associated with atherosclerotic can also be involved in burning multiple potential effects on oral conditions such as ischemic heart mouth syndrome, as anxiety and health. Through its effects on bone, disease and ischemic stroke in depression appear to play a role in osteoporosis can produce weakness some case–control or cohort the condition.25 in the jaw bones that support the studies, probably because of general Periodontal disease is considered teeth, and patients taking medications inflammation in blood vessels detrimental to diabetes in one of the drug classes used for that each of these conditions can management. Infected gums and treating the condition are at risk for produce. Evidence to date indicates an periodontal structures produce a rare but serious adverse effect associative, not causative, relationship inflammation in the mouth as the involving the jaw. between periodontal disease and body attempts to fight invading Bisphosphonates, used for treating atherosclerotic conditions. It should bacteria. These inflammatory osteoporosis and bone cancers, be noted that both share some processes can challenge glycemic can contribute to osteonecrosis of common risk factors such as diabetes control in those with prediabetes the jaw, a painful and potentially and smoking, which can complicate or diabetes. Thus, meticulous oral disabling condition in which research. At this time, no evidence hygiene is imperative for older the bone is exposed for more indicates that treatment of periodontal adults with diabetes (see Preventive than 8 weeks. It can occur after disease can lower the risks of poor Oral Care in Older Adults sidebar). invasive dental procedures such outcomes of atherosclerotic disease, as a tooth extraction but can also and studies of primary prevention have 31 Respiratory Diseases/ occur in the absence of dental not been reported. Aspiration Pneumonia procedures (the condition can also As with diabetes, microorganisms be caused by other medications Chronic Oral and and inflammation are at the heart Systemic Conditions or radiation therapy of head and of interplay between periodontal Because of the multifactorial neck cancer). While the risk of jaw and respiratory diseases. nature of aging, most older adults osteonecrosis with lower doses of Pathogens can easily travel have one or more systemic chronic bisphosphonates typically used for between the mouth and lungs. conditions such as , preventing osteoporosis is quite Inflammatory overreactions to dyslipidemias, urologic problems, small in healthier older adults, microbes are involved in damage bone and joint disease, and/or additional comorbidities and to tissues in the gums and immunosuppression can elevate the cognitive changes. Chronic connective tissue of the lungs. risk. The risk of jaw osteonecrosis conditions require long-term Plaque in the mouth and biofilms remains more significant in management using pharmacologic, in the upper respiratory tract adults taking higher-dose surgical, and/or nonpharmacologic can also serve as a reservoir of bisphosphonates for treating bone therapies, and conditions such as respiratory pathogens, creating an disease and cancer. Most patients arthritis can affect older adults’ 26 additional source of infection. with the condition are treated ability to brush and floss their teeth. Case–control and cohort studies conservatively by discontinuance In addition, chronic oral conditions have shown an association of the bisphosphonate and the use can develop, and some of these can between various respiratory of mouth rinses and antibiotics. increase patients’ risk of developing disorders and poor oral health. Surgical interventions have also caries or worsening periodontitis. Bacteria from plaque can be been used, as has hyperbaric Medications are used most transported into the respiratory oxygen therapy. Scant evidence frequently for treating chronic tract and there produce aspiration supports any of these approaches.28,29 diseases. When multiple pneumonia or complicate It is now considered wise for medications are needed, several conditions such as chronic physicians to refer their patients adverse outcomes are possible. obstructive pulmonary disease. for dental evaluation and treatment Drugs could interact with each

6 The Gerontological Society of America other or with foods and nutrients. dental disorders. Conditions Medications for different diseases with similar presentations to GSA Interest Group on sometimes act through common TMJ disorder include trigeminal Oral Health neuralgia, temporal arteritis (an mechanisms of action; for instance, Collaborating, networking, extremely serious condition more first-generation antihistamines and staying informed are common in older adults), migraine, (such as chlorpheniramine key missions of the GSA other types of headaches, as well [e.g., Chlor-Trimeton] and Interest Group on Oral as parafunctional activities diphenhydramine [e.g., Benadryl]), Health. Participation in the such as nail biting and lip and antihypertensives, , Oral Health group provides cheek chewing.33 antipsychotics, and antispasmodic an opportunity for persons agents for muscle pain or One of the key goals of care interested in the issue of gastrointestinal complaints all have management of older adults is to oral health as an essential anticholinergic activity, and this prevent or delay development of element of healthy aging to affects many different neuronal functional disabilities, as these are meet, exchange information pathways and organ systems. associated with poor outcomes and resources, and make The Beers list of agents provides and a declining trajectory leading contacts with persons who guidance on medications that are to end of life. While not as well have similar interests. potentially inappropriate for use by recognized as geriatric syndromes older adults.32 such as incontinence, falls, GSA interest groups meet at the Annual Scientific Meeting A common condition that can result pressure ulcers, and delirium, and provide opportunities for from medication use is xerostomia. poor oral health and functional networking, collaboration Dry mouth complicates oral health disabilities often occur together. on research projects, and on many levels, from promoting Cross-sectional studies of older increased involvement for to impairing functions people have shown associations of members and nonmembers such as speaking, taste, chewing, functional disability with presence in the conference program. and swallowing. Insufficient of more untreated caries, higher Contact persons for the Oral salivary secretion can also produce prevalence of edentulism, and less Health group are: dry, cracked lips and lesions on regular use of dental services. the tongue and other oral soft Longitudinal studies have shown • Paula K. Friedman, tissues. Xerostomia predisposes that tooth loss can be a predictor DDS, MSD, MPH, Boston 34 patients to bad breath, which can of functional disability. The University Henry M. have significant social interaction association of functional disabilities Goldman School of Dental with poor oral health could be the implications, especially in older Medicine, [email protected] result of people being physically adults and residents of long-term • Elisa M. Ghezzi, DDS, PhD, or cognitively unable to brush and care facilities. University of Michigan floss, leading to poorer oral hygiene School of Dentistry, Teeth clenching and grinding, and declining oral health. Older [email protected] often during sleep, can lead to TMJ people with functional deficits could disorder as well as damage to teeth also be relying on poorly trained or • Michèle J. Saunders, and dental work. In its most severe unskilled caregivers for help with DMD, MS, MPH, form, TMJ disorder can restrict brushing, flossing, and rinsing University of Texas opening of the mouth (trismus), the mouth.35 Health Science Center, leading to difficulties with both [email protected] Insights into the functional eating and dental hygiene. With the deficits that could be occurring • Stephen Shuman, DDS, MS, older adult patient unable to remove in people with poor oral health University of Minnesota plaque and movement restricted, can be derived from studies of the School of Dentistry caries, gingivitis, and periodontal model in an increasing number of and Graduate School, disease ensue.33 survivors of head and neck cancer, [email protected] Radiation therapy of head and in whom a set of late symptoms • Bei Wu, PhD, New York neck cancer can also produce revolve around xerostomia, burning University Rory Meyers TMJ disorder. Clinicians engage pain in the mouth, mucosal College of Nursing, in differential diagnosis of other soreness, difficulty with chewing [email protected] conditions that sometimes produce and swallowing, voice alterations, orofacial pain when patients and decreased taste sensation. describe a toothache or other The high doses of radiation

WHAT’S HOT Oral Health: An Essential Element of Healthy Aging 7 of the most important reasons that conditions and medications can this effort is worthwhile. also reduce body metabolism and Since a major function of the mouth is alter taste, leading to impaired the intake and initial digestion of food, nutritional status. Absorption oral health and nutrition are inexorably of specific nutritional factors linked. Older adults with poor oral such as folic acid could be health often cannot consume a normal compromised. When making diet, yet eating a nutrient-deficient diet food choices, patients often avoid can affect the body’s ability to keep protein and other difficult-to-chew selections, fruits and vegetables gum tissues and teeth healthy. Poor that are fibrous, hard, or crunchy, oral health could be a risk factor for and other abrasive foods. In significant weight loss in community- such situations, the advice of a dwelling older patients.37 nutritionist who recognizes the Both oral health and good nutrition complex clinical scenario might are necessary for maintaining be needed to ensure the balanced health, independence, and quality of diet necessary for restoration used in treating head and neck life. Without either one, the other is and maintenance of oral tissues, cancer produce a permanent sure to suffer, along with functional supporting bone, and overall decrease in salivary output and decline that otherwise might not health.41–43 an altered consistency of saliva. have occurred.38 When a sufficient amount of pH- Dietary choices can be affected Quality of Life and buffering saliva is not available Psychosocial Health during a meal to correct the by many elements of poor oral Poor oral health can take away acidic environment associated health: sore and bleeding gums, more than the older adult’s with eating, the equilibrium of tooth loss and pain, xerostomia, physical health. A diet changed demineralization/remineralization difficulties and pain while chewing because of tooth loss and gum of the enamel of the teeth shifts and swallowing, mouth infections, disease can make a social outing toward demineralization, leading stomatitis, gingivitis, periodontal more of an embarrassment than to more caries and a faster disease, and discomfort with a fun time with friends. Halitosis, clinical course when decay dentures and implants. When common in poor oral health, can occurs. Combined with difficulty those conditions lead patients to affect social interactions and swallowing and mucosal sensitivity limit their dietary intake of foods quality of life. The resulting social that develop as late symptoms, and beverages with necessary isolation can lead to or worsen these cancer survivors often make macronutrients, vitamins and depressive states or contribute to alterations to their diets to avoid minerals (including calcium for the bleak outlooks on one’s life. pain and sensitivity. Maladaptive teeth), trace elements, or fluids, changes—including consumption malnutrition can develop and affect Community-dwelling older adults, of foods with a high refined both oral and systemic health of especially those living alone, are 39 carbohydrate content and a diet the patient. at risk for the detrimental effects lacking in fruits, vegetables, and Periodontal disease of social isolation. Social isolation protein—must be recognized and provides a window into the and associated psychosocial/ addressed to prevent nutritional interconnectedness of poor oral mental health disorders are often problems that can lead to general health and nutrition. As noted in overlooked factors and deserve functional deficits and overall a recent review,40 studies have more awareness and attention from patient decline.36 shown that factors common in clinicians, caregivers, and those older people can compromise both close to the older patient. Nutrition oral health and nutrition. Loss of Instruments such as the Geriatric Working collaboratively, dental care teeth puts increased functional Oral Health Assessment Index practitioners and professionals in pressure on the remaining teeth, have been developed and validated geriatrics and gerontology can do leading to decreased masticatory for measuring oral health–related much to give older adults the best efficiency and a reduction in quality of life among older people possible chance of maintaining a the choice of foods. Similar with varying degrees of dental healthy mouth throughout their results occur when dentures and function.44,45 As noted in a World lifetimes. The link between a healthy xerostomia interfere with the Health Organization report on oral mouth and nutritional status is one normal intake of food. Medical health of older people, daily life

8 The Gerontological Society of America activities, self-esteem, and well- health in older adults. The interplay to brush and floss daily, caregivers being are affected by declining between depressive symptoms and must add these tasks to their daily oral health and complications poor oral health could be biologic routines. Online guidelines provide such as pain, dental abscesses, (proinflammatory cytokines), ideas for caregivers to consider in difficulties with eating and medication related (antidepressants providing dental care, dealing with chewing, and embarrassment can decrease salivary flow), or problematic patient behaviors during about tooth loss and the condition nonbiological (suboptimal oral daily care, and helping the patient of remaining teeth.46,47 hygiene and less use of dental accept cleaning and other services services).50 provided during regular dental Clinical Anxiety, check-ups.51 Depression, and Psychiatric conditions and their Other Disorders treatments can also contribute Overall, the relationship between Presence of psychiatric disorders, to other aspects of poor oral cognitive status and oral health including anxiety and depressive health. Patients with eating measures remains unclear, with conditions, in patients of all ages disorders may have inappropriate additional research in this area is associated with increased dental diets, leading to both systemic needed. In a systematic review decay, missing teeth, and the need and oral consequences of poor published in 2016, researchers for fillings, according to a systematic nutrition. Those being treated with reported that some of 16 studies review and meta-analysis of 26 psychotropic medications, especially have shown an association between published studies. A significant agents with anticholinergic effects, oral health (e.g., number of teeth, relationship was found between could develop xerostomia and the periodontal and caries problems, panic disorder and periodontal oral consequences of poor salivary denture use) and cognitive status, disease in this study.48 Further, flow and function. but others have not. Small sample social isolation, personality traits, sizes and variable outcome and factors such as poor adherence Cognitive Impairment measures limit interpretation. While to recommended therapy or use of In addition to anxiety, depression, weak, results indicated that “better tobacco products can deter these and social isolation, other mental oral hygiene and regular dental visits patients from seeking care for their health concerns tie into whether may reduce the rate of cognitive declining oral health.49 people can maintain a healthy mouth decline and the hazard of incident throughout their lifetimes. In the oral health module of the ,” the authors reported. Health and Retirement Survey Alzheimer disease and other forms They also note that patients with conducted in 2008, chronic of dementia occur with greater dementia can maintain dentition moderate depressive symptoms frequency in older adults, by decade with good dental care just as well as were associated with poorer oral of age. As patients lose the ability those without dementia.52

Access and Barriers to Dental Care f oral health and dental care Medicare does not provide coverage of oral health services could be are so important to people’s for oral health services, and many considered as amendments to I health and longevity, why doesn’t people lose their dental insurance bills or as separate legislation everyone take care of their teeth when they retire. The combination that could be supported by and mouth? For many people, of a fixed or reduced income and no dental professionals, oral health the answer is complicated and insurance deters many older adults organizations, associations multifactorial. from getting the professional dental concerned with the welfare of care they need.53 older adults, caregivers, and other concerned health professionals. Financial Costs and Currently, there is a movement Lack of Insurance to consider legislation to add Transportation, In the United States, Medicare is the preventive oral health care to Physical and Mental government-sponsored health care Medicare coverage.54 As changes Function, Setting, and plan for individuals who are 65 years are made to federal laws governing Cultural Competence of age or older (and certain others the health care financing system Lack of transportation and cognitive whose medical conditions fall in the 115th Congress that decline present challenges to within specified disease categories). convened in January 2017, addition obtaining routine dental care in older

WHAT’S HOT Oral Health: An Essential Element of Healthy Aging 9 needed across the dental and other program with a plan to provide Older adults and health professions. these services.55,56 their families need to Long-Term Care Care Delivery Models remember that good Long-term care residents are among Dental and other health dental care doesn’t those with the poorest access to oral professions are exploring additional have to be complicated health care. In addition, older adult alternative models of oral health nursing facility (NF) residents who are care, including more expanded or expensive. unable to feed themselves generally functions for dental hygienists and will also have difficulty with daily tooth assistants and emerging roles for brushing, flossing, and denture care, mid-level providers (see Dental increasing their risk for oral health Therapists sidebar).57 patients. Those with limited mobility problems. Increased training for NF Some current successful models or who are more frail and susceptible staff, caregivers, and administrators of care that address access issues about the importance of maintaining to falls could have difficulty getting include the dental components of and improving residents’ oral health to dental offices. While dental Programs of All-Inclusive Care for and tools and techniques for doing professionals are increasingly offering the Elderly (PACE) such as On Lok so would provide critical foundational on-site services to those residing in PACE, other integrated medical elements for successful oral health long-term care facilities, oral health and dental clinics such as the Gary program implementation. services are not generally available and Mary West Senior Medical and for most home-dwelling older adults While many states have Medicaid Dental Clinics, rural outreach dental and many aging-in-place locations. programs that cover some programs such as the University emergency, preventive, and routine of Washington RIDE Program, and Despite a perception that dental oral health services for NF residents, the Alpha Omega Henry Schein care is widely available in the United many more do not, even though Cares Holocaust Program providing States, access can be limited in rural federal law requires NFs that accept dental care to older adult World areas, and culturally competent care Medicare and/or Medicaid funds to War II Holocaust survivors.58–61 Many is in short supply for an increasingly be directly responsible for the dental more models of care are needed to diverse U.S. population. Additional care of their residents. Ideally, NFs begin to make a large dent in the training in cultural competence is should develop an oral health care tremendous unmet and projected

Dental Therapists: Improving Access to Services

A new member of the dental programs were launched in Minnesota, Maine, Vermont, and services team is emerging as a Minnesota with the first classes parts of Alaska recognize dental midlevel practitioner who can graduating in 2011. A Bachelors therapists, according to an article provide services beyond those and Masters in Dental Therapy in the December 2016 issue of typically provided by dental were offered by the University Health Affairs.57 Enabling legislation hygienists. Dental therapists could of Minnesota and an Advanced has been introduced in other prove to be especially important Dental Therapy degree by states. In addition to practicing in Metropolitan State University/ in the provision of mobile services dental offices, dental therapists Normandale Community College. that are needed in long-term care can see younger patients in In 2016, the University of facilities and in improving access schools and older patients who Minnesota program was changed to services as the large number of are homebound or residents of baby-boomer dentists retire from to a Bachelor of Dental Hygiene/ long-term care facilities for whom general practice. Master of Dental Therapy dual- degree program. Students can traveling to dentists’ offices is Like most midlevel health enter the new program after difficult and expensive. Dental providers, dental therapists completing 30 semester hours therapists offer promise for usually practice under of prerequisites and complete meeting an increased demand for collaborative practice agreements both degrees over 32 consecutive dental services as the population with licensed dentists. In 2009, months of didactic and ages if the number of available two new dental therapy training experiential courses. dentists is inadequate.

10 The Gerontological Society of America need for oral health care services in oral health. Regular reinforcement the older adult population with poor during routine preventive visits helps access to care. refine the techniques employed at home and keeps the patient on track Oral Health Literacy over time. Dental professionals for Older Adults employ educational materials and a Many older adults deal daily with a focus on prevention to leverage these number of conditions and concerns moments and improve the health beyond oral health, and dental and quality of life of patients. care is not always the first priority Educating patients about steps for them.62 Some older adults (as they can take at home is critical. well as caregivers) might believe Resources for dental education of that it is no longer necessary to go older adults are available from dental for regular dental check-ups. In professionals as well as on nonprofit, addition, cultural factors affect the government, and industry websites. use of dental care (e.g., perceptions flipbook that can be used to show of oral health and need for daily Older adult patients should be patients what is happening inside hygiene and periodic care by dental instructed that they should bring a their mouths. This publication is professionals).63 Caregivers can help list of their medical conditions and also available in Spanish and via a supplement or provide oral hygiene medications (with doses) to their smartphone app.66 64 regular dental check-ups, and be care to older adults. Caregivers The ADA’s Mouth Healthy website ready to discuss any discomfort or should be aware of the need to help (www.mouthhealthy.org) has other symptoms they have noticed aging adults with these necessary sections for adults older than in their teeth or mouth. In addition daily activities and be sure that 60 years (and for pregnant women to examining and cleaning the appropriate oral hygiene supplies as well as babies/children, teens, teeth during these visits, dental (e.g., toothbrushes, flossing devices, adults younger than 40 years, and professionals check for gum mouthwash) are available. These adults 40 to 60 years old). Users can disease, oral cancer, and other soft are detailed in the Preventive Oral also search for dental providers in tissue disease. The American Dental Care in Older Adults sidebar of this their area. What’s Hot newsletter. Association (ADA) recommends that all patients, including those The nonprofit organization An active process is needed to older than 60 years of age, drink Oral Health America encourage older adults to maintain fluoridated water and quit smoking (https://oralthealthamerica.org) their oral health on a daily basis and use of other tobacco products. is another important resource for throughout the life cycle. Patient Both of these are important ways patient education materials and education is important in this effort, of guarding against tooth decay, information useful for tailoring and health promotional efforts are periodontal disease, and other dental services. Its Wisdom Tooth needed to reach those who are not problems in the mouth.65 Project (www.toothwisdom.org) accessing dental services regularly focuses on the needs of older and to enlist all health professionals Resources for Older Adults adults. It seeks to reach 40 million as well as family members/ and Their Caregivers caregivers and support them in caregivers in the effort to improve Among nonprofit organizations, maintaining healthy mouths. Oral oral health as part of the healthy the ADA leads the patient Health America’s A State of Decay aging concept. education effort regarding oral report details state-specific rates Education in Clinical Settings health. The organization has of edentulism, adult Medicaid consumer-facing material available dental benefits, community water Routine visits to dental offices and to all visitors to its website fluoridation, and state oral health other clinical settings can be key (www.ada.org) and provides plans, and it summarizes responses opportunities for older adults to be to basic services surveys. made more aware of the need for content that dental practices can change and motivated to maintain incorporate into patient education Within the federal government, and improve oral health. Education materials. Its publications the Administration for Community and motivational interventions catalogue includes many products Living (ACL; www.acl.gov) brought provided when a tooth has broken or useful in patient education. together several programs in the another event that has the patient’s An ADA publication, The Chairside U.S. Department of Health and attention can make a difference in Instructor, is a well-illustrated Human Services when it was created

WHAT’S HOT Oral Health: An Essential Element of Healthy Aging 11 Health Statistics (www.cdc.gov/ as a means to increase retention Educational Resources nchs/pressroom/01facts/ of natural teeth and maintain good olderame.htm),69 the Centers for oral health; and (4) develop and Mouth Healthy: Consumer- Disease Control and Prevention improve culturally competent dental facing website of the American (CDC; www.cdc.gov/oralhealth/ services by increasing recruitment Dental Association index.html),70 the National Institutes of underrepresented minorities into (www.mouthhealthy.org) of Health (www.nidcr.nih.gov/ the dental profession.83 Smiles for Life: Resources OralHealth/OralHealthInformation/ Programs seeking to improve 71 useful for professionals in OlderAdults/), and the Health oral health among older adults teaching students in the Resources and Services and their caregivers should be Administration (www.hrsa.gov/ health professions or designed to meet the needs of publichealth/clinical/oralhealth/ interacting directly with target communities. ElderSmile index.html).72,73 patients about oral health is an example of a program (www.smilesforlifeoralhealth.org) Many companies marketing established in 2004 at Columbia dental devices and products University to meet the needs Love the Gums You’re With: have websites useful to both of older adults in sections of Patient resources on the patients and dental professionals. 84,85 website of the American Manhattan. Other oral health Consumers can research the Academy of promotion efforts from around recommendations made by dental (www.perio.org/consumer/ the world can be identified in the professionals and learn how to patient-resources) and the published literature. Depending best care for their mouths. organization’s GUMBLR on the needs of a state or local website for “all things gums” community, such programs can be Oral Health adapted and customized. (www.loveyourgums.tumblr.com) Promotion Programs A CDC report74 shows clear oral Working with individual older adult Oral Health: Federal resources health disparities in 2014 among patients who are already in the dental are listed on the Health some groups of Americans 65 years chair is rewarding, but what about Resources and Services or older. These provide insights the more than one-third of older Administration website for public health practitioners to Americans who say they have not (www.hrsa.gov/publichealth/ consider when assessing a state visited a dentist in the past year?74 A clinical/oralhealth/) or community. The percentages of number of studies demonstrate clear respondents reporting any dental Tooth Wisdom: Health disparities in groups of Americans visit in the past year were within the resources, developed by the based on race, ethnicity, educational, following ranges: nonprofit Oral Health America, and socioeconomic factors.22,75–80 for older adults regarding the Community-based programs • Race—From 42.7% for blacks to importance of oral health, promoting oral health, especially 78.4% for multiracial individuals finding dental care services, water fluoridation combined with of white and black descent. and paying for care dental education, have shown positive • Poverty level—From 35.1% among (www.toothwisdom.org) 81,82 effects in children. Translating those with incomes under 100% this success to the reluctant older of the federal poverty level to adult and those with financial, 81.5% for those in the 400% or in 2012, including the Administration transportation, dental literacy, and more category. other challenges remains an area for on Aging. Oral health is an area of • Disability difficulty (including future research. emphasis for ACL, which will be activities of daily living)—From releasing a Community Guide to Included in a review of the literature 49.4% of those with any complex model oral health programs for on dental health disparities among activity limitation to 71.7% of older adults in 2017.67 older adults was a proposed those with no disability. four-part solution: (1) improve Patient education materials on oral • access to dental care for minority Geographic region—From health in older adults and other elders; (2) increase older adults’ 58.7% in the South to 67.7% in patients can also be found on the dental literacy, which includes the Northeast. websites for the Healthy People 2020 knowledge of the link between oral • Population density—From 54.8% program (www.healthypeople.gov/ health and systemic conditions; (3) for people living outside a 2020/topics-objectives/topic/oral- develop more programs to improve metropolitan statistical area (MSA) health),68 the National Center for people’s overall health behaviors to 64.2% of those within an MSA.

12 The Gerontological Society of America Targeting Health Toward this end, state and Studies show that dental care Professionals local dental organizations can provided to frail older patients and In working with one patient at a conduct outreach efforts to those in the last year of life needs time to increase dental literacy and their members and opinion to be improved88,89; oral health collaborating with others to design leaders in education and in education and promotion should oral health promotion campaigns, practice. Dental professionals target staff of long-term care dental professionals need to enlist are an integral part of an facilities and hospice in particular other health professionals in these interdisciplinary team that includes to ensure provision of a consistent efforts. Even within dentistry, more physicians, nurse practitioners, quality of dental care. Access to education and health promotion physician assistants, occupational dental care is a challenge, and effort might be required. “As a and physical therapists, speech– patients with dementia might profession, we need to change language pathologists, nurses, have special considerations since our philosophy from being a pharmacists, dietitians, and they sometimes refuse procedure-driven profession to one social workers.87 These groups care or become combative during that focuses on prevention, which demands changes in how patients of professionals must be educated routine dental cleanings or and doctors interact,” said John D. about the oral health needs other procedures. However, a B. Featherstone, dean of dentistry of older adults and enlisted study in a community-based at the University of California, San as partners in health promotion geriatric dental clinic showed Francisco. “This requires a whole campaigns. Other health that most patients with dementia different set of skills, including professionals must also be trained can maintain their dentition just effective patient education to work with older adults to as well as those without dementia and behavior management to improve their dental hygiene when dental care is provided encourage compliance.”86 and use of dental care services. in a supportive setting.90

Workforce Issues

large number of current of Americans older than 65 years would be desirable for the dental practitioners who were of age skyrockets. In addition, older profession to develop and study new A educated in the 1970s and adults demonstrate the highest models of intraprofessional care 1980s are starting to retire, thus utilization rate of any age group, for dental services for older adults decreasing the number of practicing which suggests that demand as well as expanding the training, dentists (see Dental Therapists for oral health services by older functions, and licensing for dental sidebar). A large proportion of adults might exceed the supply hygienists (see Dental Therapists dentists specially trained in caring of providers educated to care for sidebar) and dental assistants, in for geriatric patients via geriatric this special population.91 Thus, it addition to supplemental training for fellowship programs are also nearing the end of their careers, and many of those still active professionally are in academic settings or in other positions that do not involve as much direct patient care. There are multiple medically/ dentally underserved areas and dental health professions shortage areas in every state, resulting in poor access to dental care, as well as disparities in dental care, in most rural and inner city locations. All these factors could limit the supply of dentists available to older patients in coming years, which is unfortunate timing as the number

WHAT’S HOT Oral Health: An Essential Element of Healthy Aging 13 Ethical Challenges With Oral Care of Older Adults

As in other aspects of the lives about treatment. When questions For older adults in the care of of older adults, dental and other arise about elective procedures for others or institutions, potential health professionals can encounter older adults who cannot express abuse and neglect are possible moral and ethical challenges in their own preferences, principles of concerns, and dental professionals the provision of oral care to those substituted judgment can be applied are frequently in a position to with declining cognitive abilities, with the help of designated family identify and report them. Subtle or functional impairment, and multiple members, loved ones, and involved obvious oral health manifestations chronic conditions. Consent to dental or health professionals. of abuse must be evaluated, and treatment, proxy decision making, reporting to authorities is required behavior management, and abuse If an urgent dental problem has in many states. A lack of adequate and neglect are some of the sufficiently serious consequences, daily oral care or necessary dental significant areas of concern that health professionals can provide treatment can constitute neglect can arise in providing routine and care in the best interest of the older under some circumstances for preventive oral care for older adults. adult. Behavioral management residents of care facilities. strategies should be used in the In obtaining informed consent for provision of oral care only after Identification and resolution of therapy, older adults with known or moral and ethical oral health suspected cognitive dysfunction can alternative solutions have been dilemmas require a team approach require additional evaluation and considered carefully and the to care focused on the goal of assistance from others. Practitioners benefits of intervening to control respecting individual autonomy can ask simple questions to behavior outweigh the risks of no and preferences for care while determine whether the individual care. In no case should physical ensuring oral health care needs can understand relevant information, restraints be employed to provide are still reasonably addressed for appreciate the situation and potential dental care for older adults because consequences, weigh treatment of the risk of increased stress, vulnerable older adults. options, and communicate a choice agitation, and physical injury. Source: Reference 97.

those conditions would be averted. A unique area of risk assessment Risk assessment is Oral disease management also comes at the end of life, including particularly important involves secondary and tertiary palliative and hospice care. Although preventive approaches as well as older adults can have changes in when older adult ongoing maintenance of existing health status that necessitate a patients acquire dental restorations (fillings, crowns, move from hospice to , comorbid illnesses implants, bridges, full and partial and vice versa, it is most important dentures) and treatment when to keep those patients pain- and and lose the ability for they fail. infection-free, and to manage any adequate oral self-care. Risk assessment is particularly xerostomia while allowing as much important when older adults acquire oral communication and quality of comorbid illnesses and lose the life as can be assured, during this dentists themselves.60,92 Furthermore, ability for adequate oral self-care. most stressful time at the end of life. nondental health professionals Dental professionals should conduct Both dental and nondental health require more training in oral health both caries and periodontal risk professionals should be better 89,94–96 to be able to participate more fully in assessments for their older patients trained in this area. inter- and intra-disciplinary health and not only young patients. By Lastly, one should not underestimate 93 care teams. using risk assessment, appropriate the importance of ethical Disease prevention is always prevention, management, and considerations in approaches to oral preferable to treatment. maintenance plans can be tailored to health care for older adults. See the In dentistry, prevention would the individual older adult to minimize Ethical Challenges With Oral Care of spare older adults from dental negative sequelae of oral diseases and Older Adults sidebar for a summary problems, and the cost of treating maximize oral function and outcomes. of this vital topic.97

14 The Gerontological Society of America Oral Health and Healthy Aging: Areas of Future Focus

s an essential element of areas might include examples such healthy aging, oral health as these: A in older adults deserves • Including oral health benefits expanded attention in clinical, as part of Medicare plans and economic/financial, and humanistic examining oral health service aspects of care as well as in the utilization increases in that curricula for dental and other population compared with a health professionals. control group of older adults. Table 1 summarizes key ideas • Mandating oral health services presented in this issue of What’s Hot for adults as part of Medicaid and makes recommendations about coverage and evaluating oral oral health in older adults. While health outcomes in older tooth loss and poor oral health in Medicaid populations. general might seem inevitable during The Gerontological Society of • Developing effective models for the aging process, older adults can America (GSA) launched an improving oral health in long- maintain their dentition throughout initiative called Oral Health: An term care, including extent of an expanded lifespan by means Essential Element of Healthy involvement of dentists versus Aging as part of its commitment of daily oral hygiene and periodic other dental professionals (e.g., to improving the oral health of professional care. Prevention and hygienists, therapists). patient education strategies—both older adults. Focusing on an for individuals and communities— • Assessing engagement of interprofessional approach and are critical in oral health for older community dental health guided by a team of oral health coordinators with underserved adults. When possible, maintenance experts, GSA’s goals in this effort populations and evaluating and restoration procedures should are to enable older adults to their relative impact on dental maintain their oral health as part be planned before patients lose service utilization. of a healthy aging process and employer-sponsored dental coverage. to assist researchers, educators, Practical, inexpensive home care • Improving attitudes, skill levels, practitioners, and policymakers strategies and professional attention and knowledge of nondental to identify areas of needed can help maintain oral health for health care providers about activity and research on the topic many older adults. normal and pathological findings of oral health in older adults. in the oral cavity. Further study of the underlying GSA has also added a special connections between systemic In education systems, dental section on its website conditions and oral disease can professionals need more (www.geron.org) to house shed more light on pathophysiologic coursework and practical resources that assist members mechanisms. Oral health–related experience in caring for older and other stakeholders with quality of life should be included adults with complex medical and providing interprofessional oral in studies using instruments dental needs. Dental professionals health care to older adults. also need more training on working such as the Geriatric Oral Health as part of interdisciplinary teams, Assessment Index. Researchers including how to interact with and clinicians should collaborate their training programs would also other health care professionals to develop behavioral interventions enhance the dental team approach to improve their oral health for promoting oral health in family, in addressing oral health needs. knowledge and willingness to community, and health care settings. support dental interventions. A healthy mouth is an important Systems of dental care and Evaluations of interprofessional element in healthy aging. Through its financing can be improved. education and interactions can adoption of a more integrated model Research projects in this area assess the success of these of care that is properly researched might include studies of education efforts. Revisiting the educational and funded, millions of Americans programs, treatment provision, experience of dental students can keep their teeth throughout their prevention strategies, and working with dental assistants lifespans and enjoy the far-reaching knowledge base. Specific research and dental hygienists as part of benefits of better oral health.

WHAT’S HOT Oral Health: An Essential Element of Healthy Aging 15 Table 1. Action Steps to Improve Oral Health for Older Adults Preventive care • Daily home care of the mouth and oral cavity • Tooth brushing twice a day with fluoride toothpaste • Use of floss or other interdental devices • Denture cleaning • Routine preventive visits with dental professionalsa • Reduce intake of sugary foods • Limit access to between-meal snacks • Encourage sugar-free or low-sugar snacks • Adjunctive therapy • Health care providers can promote oral health and engage dental professionals as appropriate Oral health care supplies • Recommendations for gifts (e.g., electric toothbrush) from families and friends • Distribute oral health care supplies through local meal distribution programs Education • Sponsor oral health education for older adults through senior day programs • Sponsor continuing education courses on oral health in older adults for health professionals through organizations or universities • Sponsor in-service educational opportunities (didactic and hands-on) for caregivers and staff of long-term care facilities Survey questions • Add these questions to health care professionals’ history intake forms and long-term care facility admissions form: • “Do you have a dentist you see regularly?”a • “When was the last time you had your teeth cleaned?” Social services • Use and coordinate social services to provide transportation for older adults to dental practices for oral health care • Work with local dental and hygiene schools to coordinate lower cost care for older adults while providing valuable educational opportunities for students • Often older adults could use assistance with contacting dental offices to determine an office that participates in their insurance plan and to schedule appointments for care Research • Incorporate oral health measures into population surveys to assess access and barriers to care, oral status, and treatment needs • Use the Geriatric Oral Health Assessment Index to measure oral health–related quality of life

a Most people benefit from two preventive visits per year, while those with stable oral health or who are edentulous may need only one preventive visit per year. Those with periodontal disease, caries, or other problems may need more frequent cleanings and examinations.

16 The Gerontological Society of America References

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