Running head: Reducing Barriers to Dental Care for Geriatric Patients 1

Reducing Barriers to Dental Care for Geriatric Patients

Michele Andrus and Leslie Coleman

Lamar Institute of Technology

Reducing Barriers to Dental Care for Geriatric Patients 2

Abstract

People are keeping their teeth longer now than ever before because of the knowledge and education

available on oral hygiene. The geriatric population is growing rapidly in the United States.

Between 2014 and 2060 the geriatric population is expected to more than double (Colby and

Ortman, 2015). Currently there are several barriers to dental services that need to be addressed to

be ready to serve these people. The barriers that will be discussed are the general decline in

geriatric health, money and insurance limitations, and transportation issues. Education,

collaborative groups of multi-disciplinary dental professionals, and changes or remodeling of

current facilities are a few ideas that will be explored as solutions to the barriers. Lastly, the

benefits of removing barriers, which include improving quality of life for geriatric patients and

increasing dental offices income, will be discussed.

Keywords: Geriatric, dental care, dental office, barriers to geriatric care

Reducing Barriers to Dental Care for Geriatric Patients 3

Reducing Barriers to Dental Care for Geriatric Patients

The Baby Boomer generation, individuals born between 1946 and 1964, has

started hitting their senior years. By 2030, this entire generation will be over 65. The 65 and

older population is expected to increase from 15% to 24% between 2014 and 2060 (Colby and

Ortman, 2015). This will be bringing a large influx of older patients into the healthcare system.

Since dentistry is a part of healthcare, there is a need to start preparing to treat an increased

number of senior patients. There are currently several barriers in the way for our older population

including declining health, insurance coverage, and transportation. In preparation for the increase

in senior patients there are many things that can be done such as educating and training, not only

the dental health professionals, but all healthcare professionals on the importance of good oral

healthcare. Dentists and dental specialists can work together in making practices that offer

several services in one location. Also with these changes, there are a lot of ways to improve

current dental facilities with a little remodeling. Adding a dental operatory in assisted living

homes or even nursing homes is another option. Lastly, the benefits of these changes will be

lucrative for dental professionals while also improving the overall health for the geriatric

population. Reducing barriers to dental care for the geriatric patient will benefit the practicing

clinician by giving them job satisfaction along with improved ability to work on patients in an

enjoyable workplace. The benefits extend to everyone involved, from patient to care provider.

The barriers to oral health that exist for older adults include affordability, accessibility,

availability, and acceptability. While there are similar barriers for geriatric adults living in our

community and those that live in residential assisted living homes, we will also address the

differences and significant challenges of providing oral care in the unique setting of assisted

living. When considering affordability, we will explore the change from private insurance to
Reducing Barriers to Dental Care for Geriatric Patients 4

Medicaid coverage as well as out of pocket cost for both groups of geriatric patients. We will

discuss the availability of offices and mobile dental professionals that meet geriatric adults

expanding needs especially considering the increased risk of systemic disease involvement. The

accessibility of these offices will be explored with a focus on patients who have limited mobility

and those that may rely on family or public transportation to and from an office. We will also

consider the patients acceptability of treatment. The largest barrier to oral health care that

geriatric adults face also affects all Americans regardless of age. Oral health is treated as a

separate type of medicine, when it should be encompassed in every patients primary care. The

first surgeon general workshop to include topics on oral health occurred in 1988, change has

been happening at a snail pace since then. The implementation of ideas from workshops and

studies on oral health has been largely limited by the lack of coverage for dental visits by

Medicaid and Medicare. Encompassing oral health into overall health is crucial because a

direct relationship exists between older adults who suffer from severe periodontal disease and

cardiovascular disease, respiratory disease and poor diabetic control (Montini, 2014).

First, we must consider the cost of dental treatment. While many aging adults have been

in the routine of seeking preventative care, they have been accustomed to this type of treatment

being covered by their insurance. While Medicaid offers comprehensive dental coverage in less

than half of the states, once an older adult begins their Medicare coverage they are often left

paying for comprehensive, routine and preventative care out of their own pocket because

Medicare generally only covers dental emergency treatment. Once a person reaches 64 years of

age, has been rewarded Social Security disability benefits for 24 months, or is in end stage renal

failure only then do they become eligible for Medicare. This leaves elderly adults with the option

of paying for their dental care out of pocket or having a supplemental dental insurance plan
Reducing Barriers to Dental Care for Geriatric Patients 5

through companies such as Aflac. While Medicaid covers the health needs of adults over 65

years, it does not include a comprehensive dental benefit. (Montini, 2014). Medicare doesn't

cover most dental care, dental procedures, or supplies, like cleanings, fillings, tooth extractions,

dentures, dental plates, or other dental devices. Medicare Part A (Hospital Insurance) will pay for

certain dental services that you get when you're in a hospital. Part A can pay if you need to have

emergency or complicated dental procedures, even though the dental care isn't covered

(Medicare.gov, 2017).

Knowing that there are barriers and what those barriers are is a good start to fixing the

problem of reducing the barriers for geriatric patients so they can receive dental care. The next

step is to look at some different solutions to each barrier. Geriatric patients face different

financial problems than other age groups such as being on a fixed income and access to

insurance. Dental insurance for the elderly is seen as more of a privilege than a right. More than

half of working older adults report having dental insurance, while only about 38% of retired

older adults do (Calvo, Chavez, and Jones, 2016). When someone retires from their job there is

generally not a continue of coverage on dental insurance. There are a few different ways retired

older adults can get dental insurance. They can purchase private dental insurance out of pocket

or, for qualified geriatric patients, some states offer Medicaid dental benefits (Calvo, Chavez,

and Jones, 2016). Of the older adults with dental insurance, approximately four out of five have

a private dental insurance plan (Lee et al., 2014). Being on fixed incomes makes paying for

private dental insurance difficult and usually it gets pushed aside when budgeting.

Without dental coverage on Medicare, most geriatric patients go without dental insurance

because of their fixed incomes. The 2010 Affordable Care Act (ACA) was introduced to help

Americans without health insurance get health insurance, but nowhere in the ACA was there any
Reducing Barriers to Dental Care for Geriatric Patients 6

dental coverage for adults (Shuman and Owen, 2016). There needs to be new laws made that will

include dental coverage in Medicare. There was a study on insurance claims that shows patients

with diabetes would save an average of over $1,500 on medical expenses per person over a

period of two years if they received dental treatment. At that amount, Medicare could save over

$6 billion annually (Nasseh, Vujicic, and Glick, 2016). This money could be easily directed to

Medicare dental coverage. Another way to help the older adult population with finances is to

make sure the healthcare providers are tracking health insurance and retirement dates for

established patients. When a patient is within a year or two of retirement, someone can talk to the

patient about what the patients options are. Healthcare providers can make sure their patients get

a cleaning and a full exam to deal with any problems that need to be addressed before the dental

coverage expires. This provides the patient with some time to look into other options for dental

coverage before needing to be seen again. This may seem like a very simple step, or even a

common-sense step, to some providers but it is important and shouldnt be overlooked.

The second barrier that the older population face is their overall personal health. As

people age, it is common to see more health issues. Oral disease is associated with

cardiovascular disease, diabetes, and other systemic problems. Making sure oral care is being

given will help to manage diabetes and help overall health which will ultimately save money

(Saunders, 2016). In order to take care of different health problems in older adults there are a lot

of different medications prescribed. One of the most common side effects of any medication is

dry mouth. Dry mouth not only contributes to caries and periodontal disease but may also

interfere with speech, taste, chewing and swallowing, bad breath, and even social activities

(Chen and Kistler, 2015). A team of mouth care advocates for older people has recently come

across a patient who had such a dry mouth that her tablets became stuck to the inside of her
Reducing Barriers to Dental Care for Geriatric Patients 7

cheek and slowly dissolved there, causing discomfort to her mouth and the loss of benefit of the

medication. There have also been examples of tablets being lodged underneath poorly fitting

dentures, resulting in patients not consuming medications as prescribed (Humphreys, 2016).

There are complex oral health issues that older adults experience that accelerate end of life

decline and cause serious systemic complications. Some of these issues are poor oral hygiene,

dental pain, dental infection, tooth loss, oral soft tissue pathology, and poor fitting dentures

(Chen and Kistler, 2015). There is no room for argument that oral health is an important integral,

not elective, component of aging healthily and successfully (Chvez, Calvo, and Jones, 2016).

One option to help coordinate geriatric medical health with their oral health is to create team

approach care. This means educating all healthcare professionals, even ones not in the dental

field, on the importance of oral care. It also means having the dental professionals pay more

attention to a patients overall health rather than just their oral health. Improved communication

between dental providers and medical providers will help with earlier detection for diseases and

systemic issues. Working as a team will also help dental providers with any ethical issues that

may come up, such as questioning if a patient with dementia is mentally capable of decision

making, when the medical provider will be better informed (Shuman and Owen, 2016). A way to

accomplish the better communication is to have multidisciplinary clinics available. These clinics

will also increase patient compliance. There is a significant lack of facilities that aim to treat a

geriatric individual as a whole. These interdisciplinary practices should be developed and

developed soon.

Although often challenging to implement, a collaborative, patient-centered

interdisciplinary practice setting can provide high-quality services for elders and their care-

givers (Yellowitz, 2016). One example is the Gary and Mary West Foundation. It started as a
Reducing Barriers to Dental Care for Geriatric Patients 8

senior center with medical facilities with the purpose of helping older population in California

get the medical help they needed for as cheap as possible and give them a place to socialize. A

2014 survey of over 300 seniors found that dental care was their greatest unmet need (Becerra

and Nguyen, 2016). When this was discovered, the foundation decided to add dental care to the

center as well as the medical and social care. Each senior is given a patient care coordinator that

helps to make sure they are getting all the help they need. There is a screening done by a dental

hygienist for patients that need dental care. The hygienist is responsible for prioritizing the

seniors need for treatment and then making sure appointments are made. This has worked out so

well that they have opened a second center in Washington D.C. to continue helping older

patients and gathering research to help support more places like this for the future (Becerra and

Nguyen, 2016).

Another way to help geriatric patients would be bringing together multiple providers for

dental care into one place. It is not common for a dental office to include more than one

specialty. Once a patient is referred from a general dentist to a periodontist, endodontist or oral

surgeon, they need directions to the new office location and an appointment for a different day.

Transportation is another barrier that the elderly population faces and having to go to different

locations only adds to this problem. An office that includes multiple dental specialties at the

same place can resolve the transportation issue immediately. Being able to navigate the dental

office with ease and be at comfort within the operatory is important to the older patient. When

choosing a location and building a new office, making hallways and operatories large enough for

wheelchairs and walkers can easily be worked into the plans. With some remodeling, existing

dental offices can achieve the same outcomes. Making every operatory larger may not be an

option but just making one operatory larger would make a difference. Simple changes in the
Reducing Barriers to Dental Care for Geriatric Patients 9

waiting room like better lighting and comfortable, easy to get in and out of, chairs can make a

huge difference. Aging generally comes with declining eyesight so not just adding better

lighting, but also adding information, brochures, and patient education materials with larger print

will help to explain different problems and solutions. No matter what the change, simple or even

easy, any change will help to break down barriers between geriatric patients and dental care.

The barriers to oral care affecting geriatric adults living in residential assisted care or

long-term care facilities are not as easy to resolve. Geriatric adults who live in residential

assisted care facilities are usually dependent on others to meet their oral health care needs.

Dental care providers within an assisted care facility is not common practice due to financial

constraints. Whether a facility is government or privately funded, money left in the budget to

allow for a regular staff of dental care professionals, or even those who would come in with

mobile equipment, is slim to none. Along with money issues, most of the staff in long-term care

facilities are not trained on how to handle patients that require extra help with their oral care.

While most of the staff believe oral health care is an important component of overall health, oral

care is usually put on the back burner (Hearn and Slack-Smith, 2016). With education for current

and upcoming dental providers there needs to be an emphasis on helping in long-term care and

assisted living facilities. This education will hopefully lead more providers into geriatric

dentistry since there is already a demand for them, which will only continue to grow with the

aging population. With more dental providers available, there will be better connection between

dental providers and the medical staff at long-term care facilities (Hearn and Slack-Smith, 2016).

There is mobile equipment made that can be bought online or through different dental supply

companies which aids in going room to room so patients can be worked on in the comfort of

their beds. Of course, this would limit what procedures dental providers have the ability to do,
Reducing Barriers to Dental Care for Geriatric Patients 10

but it will be a start to improving the patients oral care. Another way to improve oral care in

long-term care settings would be to have a dental operatory or two in the facility. This would be

more expensive but would give the dental professionals more options for different treatments and

procedures. When building new facilities in the future, which is guaranteed with the 65 and older

population increasing, dental operatories being added into the building design will help save

money so there is no remodeling necessary later. Adding dental providers into geriatric dentistry

and giving them an equipped room will more than pay itself back in the improvement of oral

care in the patients.

Change is not an easy thing to accept for anyone, anytime, or anywhere. However,

change is a part of life whether people like it or not. Some of the changes addressed to be able to

overcome barriers for the growing geriatric patients may seem difficult or even impossible but

the changes are needed and will be for the better. The geriatric patient will experience overall

better health systemically and orally. The quality of their lives will be much higher without

worrying about tooth pain, dry mouth, or pain when chewing or swallowing. Ultimately,

improving access to dental care for the elderly could prolong their life. Having to put out the

initial cost to make improvements or build new offices will pay itself back and more because

dental providers will be able to treat a part of the population that is almost doubling in size over

the next 30 years. The geriatric population will benefit most from breaking down these barriers

but they will not be the only ones. Dental providers will be better prepared with education,

equipment, and space to be able to give older patients the best care possible. By giving the best

care possible, dental providers will be happier and more satisfied with their jobs and patients will

be more comfortable and able to relax which will help with any fear or anxiety the patient may

already have.
Reducing Barriers to Dental Care for Geriatric Patients 11

The World Health Organization (WHO) defines oral health as being free from oral

and throat cancer, oral infection and sores, periodontal disease, tooth decay, tooth loss and other

diseases and disorders that limit an individuals capacity in biting, chewing, smiling, speaking

and psychosocial wellbeing (WHO, 2016). It is most desirable to see oral care for all

Americans, but especially geriatric patients, as a more inclusive care. Providers should be

treating the whole patient with the knowledge that the mouth is the window to overall health.

The barriers geriatric patients face today include affordability, accessibility, availability, and

acceptability. Some options given were to educate the patient about their expected insurance

coverage changes, rework Medicare funding, adding a dental operatory to long-term care

facilities, and develop interdisciplinary or multi-dental specialty offices with comfortable

designs. The current condition of most dental offices is not at an excellent standard when it

comes to treating the geriatric patient. While many geriatric patients continue to see their family

dentist, it becomes difficult to navigate offices not designed with their comfort in mind and is

inconvenient to have to travel to other offices for referral work. The largest deficit in geriatric

oral care is found in long-term care facilities, it will take much time and effort by many

professionals to reconcile this deficit. As these barriers are knocked down, oral care for geriatric

patients will move more towards the definition outlined by the WHO.
Reducing Barriers to Dental Care for Geriatric Patients 12

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