June 1, 2000
by Vivien Lee, B.Sc. (OT), M.Sc.(Audiology), DDS
ABSTRACT: In 1994, the Dental Clinic was created at the Queensway Carleton Hospital (QCH), through the generous donation of Dr. M Lorne E. Macalchlan , a long-term care patient. The fund was earmarked for use in regards to elderly patients at the institution. The hospital itself is a 201-bed facility located in Nepean, Ontario, Canada and serves the population of west-end Ottawa-Carleton and the surrounding valley.
In 1998, based on the health care restructuring committee’s recommendations, the chronic care programme and the patients involved were transferred out of the hospital. The trust fund’s mandate was revisited and as a result, the dental programme was opened to the outside community in June 1998. Success of the programme is attributed to the support of the hospital and the professional commitment of all participants involved. Marketing of the programme is continuous and the results have been very impressive. As well, the links forged between the hospital and the community have proven to be very beneficial.
With Statistics Canada proclaiming that by the year 2021, one in five Canadians will be over the age of 65 and as the world’s elderly population continues to increase at an incredible rate, the ensuing impact on the dental profession both in terms of management and delivery of care will be felt spontaneously with the changes in our basic health care system.1-5
Most of the prominent industrialized countries have already recognized that the requirements of the elderly worldwide must be addressed immediately, so much so that the United Nations declared 1999 “The International Year of the Older Persons.” In regards to the old adage about the only things that are certain in life being death and taxes, well, we can add to this list the process of aging.
Many dentists have already made concentrated efforts to target this ever increasing market by announcing that their offices are now senior friendly and provide wheel chair accessibility or offer discounts, dentures, etc. However this type of marketing applies only to that segment of the population who are independent, healthy and mobile. Unfortunately, an ever increasing portion of the elderly who have complex health problems and who are not mobile reside in nursing homes which are also referred to as Long Term Care facilities.
One cannot ignore the fact that in the last five years in the Ottawa Carleton Region alone, there have been at least six new retirement homes and an equal number of nursing homes that have been constructed, with plans for more of the same within the next five to 10 years.
It is common knowledge that the elderly are the greatest consumers of medical services but not of dental services. Holm-Pedersen (1999) found that there is a direct correlation between the level of mobility and the level of dental services required.6
Currently, for many of the less mobile patients who reside in nursing homes, a visit to the dental office means that a coordinated effort between support workers with regards to special transportation arrangements, organizing medical data and a host of other services is required. This is a very inefficient use of precious time and health care funds, which could be better applied to other sectors.
There may also be a traumatic effect on some of the patients who are already very disoriented or are too weak to make the arduous journey.3 Treatment is always on an emergency basis.
One of the solutions to this ensuing problem would be to increase the number of dental professionals who would make “house calls” to the various institutions on a monthly or quarterly basis. Unfortunately, unlike the number of physicians who specialize in geriatrics and who are already providing this service, the number of dentists who are willing to travel has been less than stellar.4
The reasons for this lack of enthusiasm are many–uncooperative patients, time-consuming, less than ideal working conditions, and the stigma of being a dentist to the aged and not to the “stars.”
At a recent gathering at the 1st International Conference on Geriatric Dentistry held in Montreal, dental professionals worldwide concurred that dental outreach programmes as well as nursing home dental care services are either non-existent or operate on a very limited scale in Canada, the U.S. and Europe.
As health care professionals, it is our duty to provide comfort and aid to that segment of the population who in the past have enriched our lives with their efforts and experiences.
After an intensive 14-month study regarding oral health care for the aged, the findings have been summarized in this paper which will provide crucial data and an insight into the requirements and prognosis of this ever-expanding market, and how we should be responding to this area in the decades to come.
From the period of April 1998 to June 1999, the oral status of 713 residents in 14 retirement and nursing homes have been compiled and summarized below. This project also entailed providing ongoing oral treatment and educational services to the Long Term Care facilities.
The mobile patients were examined in designated rooms.
Non mobile and bedridden patients were treated and evaluated in their beds.
The age of the residents ranged from 57 to 107 years old with 247 or 35% of them being more than 90 years of age and the median being 84. Seven of the residents were over 100, the oldest with teeth being 103. Of all the 713 residents, 81% were women.
Most could not recall their last visit to a dental professional — in fact one 92 year old female reported that in the previous weeks, her parents, who have long been deceased, had brought her to see a dentist.
The residents were evaluated for dentate/edentulous, the number of teeth present, the condition of the dentition, type of prosthesis if any, oral hygiene status, oral pathology and the treatment required.
296 (41.5%) were completely edentulous. Of these, 234 wore both an upper and lower denture. Most reported that it was their original set while 62 residents did not wear any dentures.
471 (58.5%) were dentate with teeth in at least one arch.
From these dentate elderly, there was an average of 6.6 teeth in the maxillary arch and 8.2 teeth in the mandibular arch.
Dentate individuals had an average of 14 teeth.
446 teeth (7.2%) of dentition were fractured. The presence of cavities could not be accurately determined as most dentitions were coated by food debris, plaque and calculus.
47% of all 713 examined had extremely poor oral hygiene. Because of the heavy existence of debris, plaque, calculus, edematous and gingival erythema, the examiner could not always visualize accurately the surfaces of restored teeth.
95 (13.3%) exhibited some oral manifestation of pathology. The most commonly observed lesions were: broken/fractured dentition, edema and gingival erythema, denture stomatitis, candidiasis, denture induced hyperplasia, gingival/ mucosal growths, abscesses, fistulas, and gingival inflammation. Less frequent but present were: tumors and oral cancer.
110 residents ( 15.4%) had some type of fixed prosthesis.
437 (61.6%) wore some type of removable prosthesis. Of these, 44% were ill fitting and required modifications and adjustments.
84 (11.8%) were quite uncooperative – refusing to open their mouths, opening inadequately, opening for insufficient length of time or displaying aggressive and physically abusive behaviour. These residents were typically afflicted with severe dementia.
ANALYSIS & DISCUSSIONS
As our findings indicate, more than half (58.5%) of all those studied retain their teeth for a much lengthier period of time than was originally thought. This correlates to the findings of Walls 1999, that the National Survey Statistics 1998 in the UK found greater than 50% of individuals aged 65 and over had their own dentition.5 As well, due to an ever increasing life expectancy rate, the majority of denture wearers will gravitate towards keeping their original dentures which will require more adjustments.
Since our study shows that more t
han 50% of residents are already retaining on average 14 of their natural teeth, we predict that there will be an increase in oral, dental and peridontal pathology, in particular for the aging “baby boomers” who will have invested in complex dental treatments to maintain their dentition.
Not only does poor oral health place a person at medical risk, it diminishes the quality of life. When one refers to the quality of life, it is not only to the ability to chew and enjoy the nutritional values of certain foods but also to the possible dysfunction of the oral apparatus which may result in manifestation of secondary diseases.
The current lack of emphasis on oral care is mainly due to a shortage of trained personnel, education and understanding among support staff as well as health care professionals. Support staff and health care givers must realize that dental disease is not inevitable or a normal process of aging. We expect to see an increase in potentially serious consequences and health complications as a result.
A notable misconception among caregivers is that oral care and regular oral evaluation applies only to those who are dentate. The perception is a denture wearer no longer requires any future attention because it is presumed that a denture will last a lifetime. However, changes in the supporting tissues and bone due to the aging process will require maintenance and adjustments of the denture. As well, debris, staining, ill fitting and lost dentures are very common occurrences.
Currently oral care often falls outside the sphere of nursing care. Long Term Care facilities concentrate mainly on the cosmetic appearances of their residents with emphasis on hair, make up, etc. Little attention is devoted to the oral cavity, resulting in higher rates of bad breath, unsightly teeth and debris coated prostheses.
In an attempt to balance this, there is a notable presence of antimicrobial alcohol mouth rinses in the bathrooms and many of the “tuckshops” offer a range of inadequate oral hygiene and cleaning aids.
Because many of the elderly already take a lengthy list of medications which result in xerostomia, the additional use of these mouthwashes will only aggravate their conditions as well as detenarate (unbalance) the microflora of the oral cavity.
In deciding the type of treatment that will be offered to a resident, the following points must always be considered: existing medical conditions, medications, prognosis, current age, life expectancy, behavioural changes, economic factors and the extent of family involvement. Recognizing the oral needs of the elderly in Long Term Care facilities without providing treatment and staff education is futile.
Our programme also entails providing treatment and ongoing hygiene maintenance and consultations. When oral care was brought to the resident, treatment was well received and there was a huge reduction in stress and anxiety for all the parties involved. The result was that consultations and utilization of dental services increased.
Any dentist venturing into this field will find the challenges exciting, as traditional treatment methods in the office may no longer be the norm but new innovations will carry the day. Mobile dentistry, weekly rounds of Long Term Care facilities, team meetings, close consultations with physicians, care givers, administrators and patients’ families will all be part of the new work environment.
However, if the dental professional continues to ignore this market, we will see other sectors of the oral health care services being more than happy to provide a limited service.2,3,4,5
Legislative changes from both the provincial and federal governments will also be necessary if all residents in every Long Term Care facility are to have access to this important health benefit. Every resident in a Long Term Care facility must have an oral health admission evaluation with guidelines stipulating a certain standard of oral care maintenance.
Ideally, a basic “dental treatment room” would be incorporated in every Long Term Care facility. Currently QCH operates satellite dental treatment rooms in four Long Term Care facilities and is in planning stages for five more. To date, QCH has contracts with 23 Long Term Care facilities to provide dental services and there are many more on the waiting list.
The response thus far from the patients’ families, the patients themselves, administration as well as staff, has been very positive and appreciative. This in itself has been a very rewarding experience.
Special thanks to:
Dr. J. Russell – Director of Geriatric Medicine at QCH for the advocacy of dental services at QCH and a strong believer in the important relationship between medicine and dentistry.
Sue Burnell-Jones, R.N. and Marketing Director at QCH for her enthusiasm, encouragement and support of the programme and her initiative in helping to research and submit this paper.
r. Lee also practices at the Ottawa-Carleton Regional Health department and serves as a consultant at The Sisters of Charity of Ottawa, a hospital dedicated primarily to the elderly, chronic and terminally ill patients and persons with disabilities.
Oral Health welcomes this original article.
1.Clarfield AM. The old-old: are they getting healthier? Geriatrics & Aging 1999; 2:1,28.
2.Matear D. Why do we need education in geriatric dentistry. J Can Dent Assoc 1998; 64:736-8.
3.Burry A. Public health dentistry:2000 to 2020. J Can Dent Assoc 1999; 65:163-6.
4.Morreale J. The forgotten discipline of dentistry. J Can Dent Assoc 64:195-9.
5.Walls A. Oral health and nutrition in the elderly. 1st International Joint Conference On Geriatric Dentistry Oct 1-3, 1999.
6.Holm-Pedersen P. Impact of functional disability on oral health. 1st International Joint Conference On Geriatric Dentistry Oct 1-3, 1999.
Currently, the QCH dental outreach programme provides dental services to the less mobile elderly in 22 nursing and retirement homes in the community.