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IMPEDIMENTS TO MAINTAINING AND IMPROVING THEIR ORAL HEALTH STATUS
Lack of Effective Dental Care Delivery Systems
It has been said that the greatest failure in modern dentistry is the failure to treat. At the same time that dentistry is able to provide implants, esthetic veneers, and other “high-tech” treatments that would have been unimaginable only a few years ago, large segments of the population, including the frail elderly, lack access to necessary basic care. Why are current dental care delivery systems failing to meet the needs of the frail elderly?
Inadequate Facilities and Equipment
Inadequate facilities and equipment in nursing homes, private dental offices, and many portable dental services create a significant dental access barrier. Permanent dental offices located within nursing homes, when they exist, generally do not have sufficient equipment to provide primary dental care. Such basic equipment as an X-ray machine and developer are frequently not available. Although a few permanent dental clinics within nursing homes do have adequate equipment, they often do not have the portable equipment necessary to serve bedridden residents. Some bedridden residents cannot be transported or transferred to a dental chair even if it is located within the nursing home. Like the homebound, these residents must have access to portable dental services in order to receive dental care at their bedside. Research into the availability of either permanent dental clinics within nursing homes or portable dental services has been conducted in several states. In a study of Louisiana nursing homes, Garbee, Legett, Lee et al.43 stated: Dental resources in the surveyed nursing homes were almost non-existent. Over 98 percent of the homes surveyed had no dental equipment. There was no regular staff dentist in 93 percent of the homes, and 82 percent had no staff hygienist. Most of the homes (84 percent) called upon non-affiliated private dentists to take care of their patients, on an ad hoc basis, whenever emergencies arose. Some of the homes (34.1 percent) took their residents to outside dental clinics for their dental care. This data suggests that the only nursing home residents who receive more than emergency dental care are those who are sufficiently mobile to be transported to either a private office or clinic. Although 34.1 percent of the nursing homes reported that they transported some of their residents to outside dental clinics, the other 65.9 percent did not.43 It is important to note that transporting residents is generally not undertaken for primary dental care, but rather occurs when problems or emergencies arise. Further, even those nursing home residents who are physically capable of being transported to dental offices must overcome other non-transportation-related barriers to receive the care they need.
Siegal conducted a survey of dentists practicing in New Mexico. He obtained responses from over 70 percent of all the dentists practicing in the state (N=410), making his study the most representative study of its kind available. Only 2.2 percent of the dentists in New Mexico indicated that they owned portable equipment. This contrasts with 32 percent who stated that they made more than one visit to homebound patients during the previous year. How could these dentists be providing dental care to the homebound, in their homes, without portable equipment? Siegal addresses this question as follows: This relatively small number of New Mexico respondents (who own portable equipment), when compared with the larger number who reported making at least one home visit in the previous year, raises questions about the distribution of the equipment and perhaps the nature of the care provided.
Siegal found that 67.8 percent of the dentists had not made a single visit to a homebound patient within the previous 12 months; 27.8 percent of the dentists reported making one to five visits during the same period. Thus, a total of 95.6 percent of the dentists reported making five or fewer visits during the previous 12 months. How many patients could these dentists treat in 1 year? Elderly patients who seek regular dental care average 3.26 visits per year, so each dentist could treat only about two patients. Lack of basic portable equipment such as portable high-and low-speed drills, portable X-ray equipment, and common dental supplies creates a significant barrier to primary dental care. Traditional delivery systems characterized by permanent offices and immobile equipment cannot adequately meet the needs of the long-term care population group.
Lack of Special Equipment for Special Patients
Many patients cannot be treated without special equipment. A Hoyer Lift, for example, is a crane-like device that is used in hospitals and nursing homes to transfer patients to and from beds and wheelchairs. By providing on-site dental care within a nursing home, those patients who need the Hoyer Lift can be treated using the nursing home’s lift. Many homebound patients have these lifts in their homes, but are unable to transport a large Hoyer Lift to or from a dental office. A Hoyer Lift is one example of a special device that enables access to care for a number of long-term care recipients. Many long-term care recipients suffer from Alzheimer’s disease and other types of dementia. These patients are profoundly confused and disoriented and must often be sedated for dental care—even for something as basic as an adequate oral examination or dental cleaning. Because of their age, and the presence of multiple medical problems and medications, sedating these patients must be a cooperative effort between the physician, nursing staff, and dentist. At the nursing home, the medications most appropriate for each patient are available and, if on-site dental care is provided, the nursing staff can administer the sedation and help monitor the patient both before and after dental treatment. Thus, by providing dental care that is integrated into overall care at the nursing home, a very large group of mentally impaired nursing home residents can gain access to primary rather than emergency dental care.