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Thai, Shuman, and Davidson investigated the adequacy of the MDS to identify oral health problems. MDS data from Minnesota nursing homes and records of subsequent dental care were compared. Of 466 residents, nurses identified 3.2 percent with oral debris; 3.0 percent with broken, loose, or carious teeth; and only 4 (0.9 percent) with gum inflammation/soft tissue problems. In contrast, subsequent utilization measured in dental visits per year and gross dental charges per year bore no relationship to the MDS findings. The authors concluded that the nurse’s assessments identified few oral health problems and that the problems identified did not translate into dental treatment.49 A study by Blank, Arvidson-Bufano, and Yellowitz50 found that more experienced nurses were able to identify broken or carious teeth nearly 85 percent of the time among nursing home residents. However, regardless of the nurse’s experience level, they were less able to identify soft tissue lesions.50 Taken together, the potential for misidentification and underreporting of oral health problems is difficult to ignore. While only about half of all Americans have any type of dental coverage, most with this employment benefit lose it upon retirement and subsequently decrease their utilization of dental care. As a result, most older adults lack dental insurance and must pay for dental care as an out-of-pocket expense.51,52 This phenomenon unfortunately occurs at a time of increased oral health needs and, with declining function into old age, oral health needs often are further relegated due to other pressing health care needs as well as a reduced ability to pay for services out of pocket.
Further eroding dental access for seniors is the fact that many states’ Medicaid programs do not provide dental coverage for adults. Even in states with adult dental benefits, dental services vital for the frail elderly are frequently not covered. For these Medicaid recipients, dental coverage represents an empty promise because access is limited by extremely low levels of participation by dentists who cite low fees, complex administrative policies, and a host of other reasons for not participating. Numerous states have recently made significant changes in their Medicaid dental programs to increase dental provider participation. Although the American Dental Association has recommended that fees be set at the 75th percentile in order to increase participation, there is a pressing need to also simplify administration, eliminate treatment delays, and, in general, reduce provider disincentives within the program. Health care costs for the elderly have been rising over time, and are higher for older cohorts. Adults 85 years of age and older have significantly higher health care costs than those who are in the 65 to 84 age bracket. This phenomenon, where various diseases and health care costs are pushed farther and farther into old age is sometimes called the “compression of morbidity.” Institutionalization not only changes access to a routine source of dental care, but also reduces the out-of-pocket resources available to pay for services. Dental services for older adults are largely an out-of pocket expense (79 percent), with only 10 percent covered by private insurance.53 Unfortunately, public programs do not fill the gap. Medicare does not cover routine dental services, and Medicaid does not offer dental benefits for adults in many states.
Medicare beneficiaries that went towards dental care in 1992 and 1996.
Lack of Understanding of the Importance of Oral Health
Lack of knowledge and low expectations about oral health and its value influence care-seeking behavior and can result in care being deferred or neglected entirely. Among the elderly living independently, the most commonly cited reason for not seeking dental care is a lack of perceived need. Seeking help for a dental problem is less likely when there is a belief that tooth loss is inevitable or oral problems are part of the aging process. For the institutionalized elderly, often the decision whether or not to receive care is determined by others. Warren, Hand, and Kambhu investigated the role of nursing home residents’ family members in the utilization of dental services for nursing home residents. “Utilization of dental services” was defined as consent for the completion of a comprehensive dental examination. Overall, the next of kin or guardian decision-makers accepted treatment for 64.2 percent of the residents. Resident characteristics that increased the likelihood of accepting an oral examination included being female, being ambulatory, having natural remaining teeth, and having a higher level of education. Other factors that influenced the decision were next-of-kin characteristics: perceived need, age, and relationship of resident to next of kin (relative vs. nonrelative).