Dr. J.M. Symington, BDS, MSc, PhD, FDSRCS and Mr. O.R. Perry, MSc
THE GROWING NUMBER OF OLDER PATIENTS
Part 1 of this series on Canada’s aging dental population, observed how, if trends continue, the number of dental visits will grow at less than the population rate and the number and type of dental services will change. By 2021, there will be eight million Canadians age 55 and older without dental insurance–representing about 1 in 4 Canadians. More than one third of these retirees will have root caries and will need associated restorative and periodontal services.
GROWING LEVELS OF DENTAL CARIES
Part 2 of this series, noted that older Canadians have significantly more caries. Borrowing from Swedish research, it is expected that Canadians reaching their 80th year, the second fastest growing part of the Canadian population in the medium term, will have three to four times the level of tooth decay than those aged 60 to 69 years, the fastest growing group in the Canadian population. This growth in caries could be stimulated by xerostomia resulting from widespread use of multiple medications for systemic conditions such as hypertension, inflammation and depression.
This scenario of rising dental caries in an older, uninsured Canada departs significantly from the past 40 years in Canadian dentistry where caries levels steadily declined because of water fluoridation and growing involvement with professional dental care supported by employer-based dental benefits.
REASONS FOR VISITING OR AVOIDING THE DENTIST
Given these prospects for changing levels of both dental disease and dental insurance in an aging Canada, it is instructive to examine why Canadians currently seek dental care, and also why they avoid it.
Two surveys on reasons for visiting the Canadian dentist were conducted in the 1990s. The first survey in the early 1990s examined the motives for people aged 50 years and over for not visiting the dentist.1 Two main reasons were cited: 51.5 percent of respondents indicated “nothing was wrong”, while 25.2 percent said that dental care was “too expensive.” The second survey of all Canadians of all ages, taken in the late 1990s, corroborated the first survey. The primary reason for not seeking dental care was that it was considered unnecessary, and the second reason for the older Canadians (primarily those without dental insurance) was the cost of these services (Fig. 1).
By contrast, Canadians visit the dentist for a larger number of reasons, most of which are associated with prevention of dental disease, not its treatment. Cleanings, fluoride and maintenance are the main reasons for seeking dental care and these activities are supported by other motivations such as “make sure everything is OK”, and “to take care of teeth, gums and dentures” (Fig. 2).
These surveys pose some strategic implications in an aging Canada.
The cost and cost-effectiveness of dental services will become an increasingly important factor in dental attendance. Dental insurance becomes less common with age, but dental problems become more common and complex. The aging “baby boomer” will seek those dental services, which can best resolve this emerging paradox in Canadian dental care. Those services which deliver on both effectiveness and affordability could well be “winners” in the eyes of the older dental patient, and in turn, the dental office.
Dental prevention services could grow increasingly important for Canadian dental offices. The older patient clearly expects these services and as the Ontario survey found, he/she wants “to make sure everything is OK.” The aging “baby boom” generation in particular, has high expectations for continued oral health. As noted in a recent survey of newly retiring Americans:
“Their attention to retirement reflects the fact that a hallmark trait of the Baby Boom generation is self-reliance. Perhaps this generation learned after several years of recession, downsizing, and the scaling back of employee benefits that they need to take care of themselves in order to prosper.”2
However, prevention of dental disease in an older mouth where saliva may be limited, roots exposed and restorative margins are deteriorating, has both a different context and clinical requirement, than in a child’s mouth.
Dental prevention emerged in younger Canada where the six-month recall prophylaxis and topical fluoride were appropriate and entirely reimbursable. For the older, often medically-complex Canadian dental patient, the scientific validity and economic value of this approach may well be questioned by more discriminating older patients.
Predictably, there will be a demand for new prevention regimens geared to more complex clinical requirements, evidence-based outcomes and circumstances involving user-pay.
In short, a main conclusion we draw from the profound aging of Canada’s population, is that dental prevention services as we have come to know them in Canadian dental offices, will likewise change dramatically to meet the new clinical and cost imperatives of the Canadian dental patient.
NEW DENTAL PREVENTION SERVICES
The tools for preventing dental diseases are also changing profoundly and quickly–partly in response to emerging needs and partly because of growing scientific understanding and pharmaceutical research in these chronic diseases.
Canadian dental offices now have at least two new therapeutic products which deal with the bacterial infections and host response behind periodontal disease. In the U.S., within four years of their introduction, almost one-in-four dentists is using these new therapeutic tools to manage gum disease. This represents a dramatic shift in treatment approach.
In terms of caries prevention in older adults, we believe the development of a temporary chlorhexidine coating for at-risk older adults, reported by Banting’s group, is important to the aging Canadian population.3 This coating has been tested for its effectiveness in reducing caries increment in patients using multiple medications for other ailments, including hypertension, arthritis and depression. As a consequence of this medication profile, the patients in the study suffered from xerostomia.
In this controlled study, the chlorhexidine coating reduced total caries increment by 24.5 percent (p = 0.03) over one year, and root caries increment by 40.5 percent (p = 0.02) over the same period compared to placebo. This level of caries reduction meets and, at the root surface, surpasses the recorded effectiveness of fluoride in reducing caries in children.4 Moreover, this clinical success has been seen in a different study which used a different chlorhexidine coating on the root surfaces of elderly frail patients with root caries.5
THE ADOPTION OF NEW PREVENTION SERVICES
As the Canadian population ages over the medium term, and new demands for new (largely uninsured) dental services are placed on the Canadian dental professional, some dental offices will adapt more quickly than others. Studies on the adoption of new techniques and services in the dental professions are rare.
For those who have studied this phenomenon, the focus has been on the role of professional knowledge and dental insurance in influencing a change in service or a use of a new product. For example, Fiset and Grembowski, and more recently Del Aguila et al have reported that the content of dental insurance plans are critical to the use of new dental treatments, and in particular, new preventive approaches.6
In the aging Canada, however, it is foreseeable that the role of dental insurance in influencing dental care delivery and content, will wane. In its place as a major force of change in Canadian dentistry, we believe, will be the informed dental patient. The aging baby boomer has become eager to participate not only in the diagnosis of his/her condition, but to go further to uncover the cause of the disease and its treatment.
The Internet has facilitated the pursuit of this inherent interest, and pharmaceutical advertisers have responded to it. The Canadian baby boome
rs have supported the brand new group of lifestyle pharmaceuticals (e.g. Viagra, Rogaine), which primarily deal with the effects of aging. This same generation could also respond to new forms of dental prevention if and when they learn about them.
In the case of dental caries, the patient has a comparatively simple task of understanding the symptoms, the cause and the treatments available. The concept that dental decay, for example, is an asymptomatic, low-grade bacterial infection could be of great interest to those older Canadians who are (beginning) to suffer from root caries.
Likewise, topical treatments of this infection could also be provocative to the aging Canadian dental patient.
CONCLUSIONS
In this series of three articles, we have touched on some of the structural change to Canadian dentistry imparted by an aging Canada. Canadian dental professionals could be extraordinarily challenged by these changes; their domestic population is amongst the most rapidly aging in the western world (Table 1).
To a large extent, Canadian dental practices have been founded on the needs and reimbursed procedures for a younger population, which characterized the past thirty years. However, these mainstay dental customers, the “younger population”, are not increasing in numbers. By contrast, the fastest growing part of the Canadian population, those over age 50, for the first time is starting to experience caries coincident with other chronic diseases, as well as the realities of user-pay in the dental office.
In the past, these aging Canadians were influential in demanding dental insurance from their employers. As they retire, we expect this generation will continue to demand the dental professional respond to their new clinical needs and their abilities to pay for dental care.
Dr. J.M. Symington, BDS, MSc, PhD FDSRCS (England)
Mr. O.R. Perry, MSc
REFERENCES
1.D. Locker and B. Payne, Oral Health Status and Use of Dental Services among Ontarians Aged 50 Years and Over, Community Dental Health Services Research Unit, Health Measurement and Epidemiology Report #1, 1993
2.Baby Boomers Envision Their Retirement: An AARP Segmentation Analysis –Executive Summary Part III, at http://research.aarp.org
3.D. Banting et al, “The effectiveness of 10 percent chlorhexidine varnish treatment on dental caries incidence with dry mouth”, Gerodontology, v. 17, #2, 2001.
4.As reported by V. Marinho et al, “Fluoride mouthrinses for preventing dental caries in children and adolescents (Cochrane Review)”, The Cochrane Library, Issue 3, 2003, and V. Marinho et al, “Fluoride gels for preventing dental caries in children and adolescents (Cochrane Review)”, The Cochrane Library, Issue 2, 2003, and H. van Rijkom et al, “A meta-analysis of clinical studies on the caries-inhibiting effect of fluoride gel treatment”, Caries Research, v.32, 1998, pp. 83-92.
5.S. Brailsford et al, “The effects of the combination of chlorhexidine/thymol- and fluoride-containing varnishes on the severity of root caries lesions in frail institutionalized elderly people”, Journal of Dentistry, v.30, 2002, pp. 319 – 324.
6.L. Fiset and D. Grembowski, “Adoption of innovative caries-control services in dental practice: A survey of Washington dentists”, Journal of the American Dental Association, v.128, March 1997, pp.337 – 345 and M. Del Aguila et al, “Patterns of oral care in a Washington state dental service population”, Journal of the American Dental Association, v.133, March 2002, pp. 343 – 351.
