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Source: Centers for Disease Control and Prevention, National Center for Health Interview Survey, Second Supplement on Aging. When the severity of impairment, whether physical, medical, or emotional, can no longer be managed in the home, institutionalization and loss of independence results. The 1995 National Nursing Home Survey describes elderly nursing homes residents as:
• Female.
• 75+ years of age.
• White, non-Hispanic.
• Widowed.
• Dependent in Activities of Daily Living (ADL; i.e. bathing, dressing, eating, transferring, toileting.)
• Dependent in Instrumental Activities of Daily Living (IADL; i.e. care of personal possessions, managing money, securing personal items, using the telephone.)
• Incontinent.
• Relying on Medicaid as primary source of payment.
Why Is Dental Care of Particular Importance for Them?
The U.S. Surgeon General’s report, Oral Health in America, emphasizes the fact that oral health is integral to general health and describes the disparities in the availability of dental care, especially for very young and very old populations.10 The report uses the phrase “silent epidemic” to characterize the disparity between the epidemic of oral disease and the silence from those who need care. This report highlights many reasons that dental care is of particular importance for frail older adults:
• Oral diseases are cumulative and become more complex over time. The older adult population has high rates of oral diseases, exacerbated by the fact that many elderly adults lose their dental insurance when they retire. Medicare does not reimburse for routine dental services, and many states do not have Medicaid dental coverage for the frail elderly.
• Oral problems have a negative effect on quality of life. Oral-facial pain and tooth loss can greatly reduce the quality of life and restrict major functions. Problems with the teeth and mouth can affect the ability to eat and communicate. Individuals with facial disfigurements due to oral diseases can experience loss of self-esteem, anxiety, depression, and social stigma. Diet, nutrition, sleep, psychological status, and social interaction are all affected by impaired oral health.
• Dental disease has a significant impact on general health. The oral cavity can be a portal of entry for microbial infections that affect the whole body. Oral diseases give rise to pathogens, which can be blood borne 11 or aspirated into the lungs,12 bringing about severe, even life-threatening consequences. Recent research findings have pointed to possible associations between chronic oral infections and diabetes, heart and lung disease, and stroke.
Why Do the Frail Elderly Need “Special Care”?
The frail elderly need special care because they suffer from extensive oral diseases, have medical problems that complicate their care, and also because their age and state of health complicate their diagnosis and treatment.13 Adding to these problems are a multitude of impediments to maintaining their oral health, as discussed in Section B of this report.
They Have Extensive Oral Diseases
Older adults suffer from the cumulative effects of oral diseases over their lifetime. This results in extensive oral disease.13 Berkey, Berg, Ettinger et al.14 in a comprehensive review of oral health studies of institutionalized elderly published between 1970 and 1989, described the compromised oral health status of nursing home residents. Up to 70 percent of residents had unmet oral needs, exhibiting high rates of edentulism (complete tooth loss), dental caries (decay), poor oral hygiene, periodontal disease (diseases of the supporting structures of the teeth), and soft tissue lesions.14 A survey conducted in 1993 on 3479 patients treated in Minneapolis–St. Paul, MN, nursing homes found that 39 percent of the edentulous had oral problems and 61 percent of the dentate (those with some natural teeth remaining) had oral problems. Of the dentate that needed care, 41 percent had dental caries, 14 percent had root caries (decay on the root surfaces), and 18 percent had retained root tips (teeth so damaged by caries that the tooth crown was no longer present) (D. Smith, personal communication / unpublished study, May 1993). Gift, Cherry-Peppers, and Oldakowski, reporting on the 1995 U.S. National Nursing Home Survey, reported that only 15 percent of the residents were described as having excellent or very good oral health. Over 30 percent of community-dwelling elderly in 1997 were edentulous with the rate rising to 43 percent of those over 85.7 Approximately one-third of community-dwelling elderly have untreated coronal or root caries, and other oral health problems including periodontal disease, attrition, unreplaced missing teeth, abrasion and erosion, broken or failing older dental restorations, dry mouth, mucosal diseases, oral cancer, and alveolar ridge atrophy.16 The homebound often face insurmountable dental access barriers. Among the elderly receiving home health services noted in one study, the majority reported their oral health was “fair” or “poor” and nearly 80 percent reported a perceived dental care need. In addition, only 26 percent reported having been to the dentist within the past 2 years, while 40 percent reported not having been to the dentist in more than 10 years.