An aging population – have we got an Oral Health Policy?

Noel Woods¹, Helen Whelton², Tara Crowley², Ian Stephenson², and Mary Ormbsy³

Introduction

With life expectancy in Ireland at its highest level ever and population projections predicting significant increases in the total number of older people, much of the recent national health policy documents has targeted ‘care packages’ for older people including specific commitments in our national social partnership agreement Toward 2016, to improve health outcomes for older people. The emphasis of recent health policy is directed toward prevention, health promotion and self responsibility coupled with a determination by the government to reduce institutional and hospital-based care. Whilst the Health Services Executive (HSE) provides a wide range of services for people growing older in Ireland, the National Health Promotion Strategy 2000-2005 (2000) did not contain a single reference to the oral health of the elderly although it is recognised by the World Health Organisation (WHO) that oral health is integral to general health, highlighting that poor oral health can influence general health and quality of life by impacting on their ability to chew their food, their diet and nutrition. This article on oral health policy for an aging population is relevant in a journal on public policy as it seeks to redress this imbalance by putting forward policy recommendations to raise awareness of oral health amongst the elderly and their carers, and to highlight the need for greater integration between the dental and medical profession.

In the Republic of Ireland, The Department of Health and Children has the statutory role in the formulation and evaluation of policies and the strategic planning of health services. This is carried out in conjunction with the HSE which is the largest organisation in the State, employing over 130,000 people, with a budget of €14.7 billion in 2008.The establishment of the HSE, as part of the provisions of the Health Act, 2004, represented the beginning of the largest programme of change ever undertaken in the Irish public service. Prior to its establishment, services were delivered through a complex structure of ten regional Health Boards, the Eastern Regional Health Authority and a number of other different agencies and organisations.  The HSE replaced all of these organisations. It is now the single body responsible for ensuring that everybody can access cost effective and consistently high quality health (including oral health) and social services.

Over the past decade the context in which Ireland’s complex mix of public and private health care operates has changed radically, as the numbers purchasing health insurance have soared and the nature of the insurance market has changed in response to EU regulations. This has widened the divide between those with and without health insurance, and called into question the public-private structure on which Ireland has relied for many years. Almost half the Irish population now pays for private health insurance, one of the highest levels of coverage in the OECD. This is despite the fact that hospital care is what private health insurance mostly covers, and everyone has entitlement to public hospital care from the state. The insured can avail of private health care, but much of this private care is actually delivered in public hospitals. The resulting two-tier system is now widely regarded as problematic from an equity perspective, but there are also serious efficiency issues arising from the incentive structures embedded in this particularly close intertwining of public and private.

The Irish dental system is a public/private mix consisting of three separate schemes of dental delivery: the Dental Treatment Services Scheme (DTSS) for medical card holders who are entitled to free dental care, the Dental Treatment Benefit Scheme (DTBS) for insured workers who have partial coverage, and private patients who pay full-fees for their dental services.

By April 2008, the population in Ireland reached 4.42 million, which is the highest recorded since 1861. Life expectancy in Ireland is also at its highest level ever, at 76.8 years for men and 81.6 years for women. The Census 2006 recorded 467,926 individuals aged 65 years and older – 55.7 per cent were female, and 44.3 per cent were male, who are referred to here as ‘older people’. Using 80 as the dividing age, 24 per cent of older people are ‘old’ older people (80+). Population projections by the Central Statistics Office predict significant increases in the total number of older people to over 1.1 million by 2036. The number of those aged 80 and over is set to rise even more dramatically to a projected 323,000 in 2036. (CSO, 2004). The present and future generations of older people can also expect to live for considerably longer than their predecessors. Combined with changes in the pattern of oral disease through the life course, these predicted demographic changes will pose new challenges for oral health services which need to be examined and addressed (Whelton et al., 2008).

The World Health Organisation (WHO) defines health as a ‘complete state of physical, mental and social well-being and not merely the absence of infirmity...a resource for everyday life...’. In keeping with this concept of general health, oral health is achieved when the teeth and oral environment are not only healthy but also fulfil the criteria of being comfortable and functional (food can be chewed without pain and teeth are not sensitive to different stimuli such as cold), socially acceptable (mouth does not give rise to bad breath, teeth and gums do not cause embarrassment), and free from sources of infection which may affect general health (Whelton et al., 2008).

In 1998, the National Council on Ageing and Older People (NCAOP) in association with the Department of Health and Children (DoHC) launched Adding Years to Life and Life to Years: A Health Promotion Strategy for Older People (NCAOP, 1998) to mark the start of their Healthy Ageing Programme. This health promotion strategy was based on the premise that health promotion for older people can improve longevity and benefit health and quality of life, even among those already affected by illness and impairment. The strategy highlighted five key areas - building a healthy public policy; creating supportive environments; strengthening community action; developing personal skills and reorienting health services - as its framework for policy and action. For dental and oral disorders, the goal set by the strategy was ‘to reduce the morbidity associated with dental and oral disorders in older people’ (ibid). The action plans recommended to attain this goal were: education in relation to dental care and oral hygiene for older people; the loss of natural teeth should not be regarded as inevitable; and encouraging older people to visit the dentist on a regular basis.

Globally, poor oral health amongst older people has been particularly evident in high levels of tooth loss (Ettinger and Mulligan, 1999), even though the WHO set the retention of more than 20 natural teeth as a goal for oral health, in 1982. Oral health problems due to missing teeth can cause older people to have difficulty eating, and can force them to adjust the quality, balance and consistency of their diet (Vargas et al., 2001). Maintaining a natural, functional dentition of more than twenty teeth into old age plays an important role in having a healthy diet, a satisfactory nutritional status, and an acceptable body mass index (Marcenes, et al., 2003).Tooth loss and chewing capacity substantially compromised oral health among older adults, particularly the oldest-old and disadvantaged groups (Slade et al., 1997).Such dietary restrictions can compromise nutritional status over time and place older people at health risk (Chauncey, et al., 1984).

Oral health also impacts on life quality. The development of ‘standards of care across the system and emphasise quality of life outcomes’ was a key recommendation advocated by the National Economic and Social Forum in its report Care for Older People (NESF, 2005).Though the relationship between oral health and life quality is not straightforward, recent research has highlighted that the emotional and psycho-social consequences of oral disorders can be as serious as other health disorders (Allen, 2003).The National Survey of Adult Oral Health 2000-02 revealed that compared to younger adults surveyed, older people aged 65+ had the lowest oral-health related quality of life score (Whelton et al., 2007a).

The national survey also established that a minority of individuals now produce a majority of the disease with the elderly clearly having the greatest need for dental care. The finding of high levels of unmet need for dental care amongst the elderly is supported by Woods (2007) who also found below average utilisation of dental services amongst the elderly, pointing to the existence of barriers to dental care as 85 per cent of older people aged 65+ are eligible for free dental care via the Dental Treatment Services Scheme (DTSS) (Whelton et al., 2007b).

The oral health profile of the tomorrow's older people is dependent on the oral health of today's young. Water fluoridation of public water supplies was introduced in Ireland in 1964. An estimated 73 per cent of the population in Ireland are serviced by fluoridated public water. Fluoridated toothpastes entered the Irish market in the early 1970s. Both of these measures have resulted in improved levels of oral health in Ireland, especially among children and younger adults with exposure to water fluoridation since birth (DoHC, 2002). Over time, oral health has improved for all age groups. When the current generation of under 40's who grew up with water fluoridation reach their mid-60's, there will be a dramatic improvement in the oral health profile of older people. We can anticipate a growing population of increasingly dentate older people possessing a greater number of teeth. It is reasonable to predict that as less teeth are extracted the demand for dental services to repair, restore and protect teeth among older people will increase and that the nature of dental services required will change. The aim of this article is to highlight the impact of an aging population on the oral health of the elderly and to recommend policy measures to address the oral health inequities experienced by older people.

Data and Methods

The data is based on detailed clinical oral examinations carried out in the NSAOH 2000-02, in the Republic of Ireland between October 2000 and June 2002, on a nationally representative sample of 714 adults aged 65 and older (average age 71.2), using commonly used parameters of dental health (per cent edentulous, number of natural teeth, wearing of dentures) and of dental disease (dental caries, periodontal disease, other oral conditions).The survey included an assessment of the current and projected future specific oral health needs of older people and identified the risk factors associated with unmet treatment need.The survey consisted of a clinical oral examination, a detailed questionnaire to establish behaviour patterns and attitudes and focus group discussions to establish broader health and quality of life issues. A profile was established of the elderly in terms of levels of tooth loss, current patterns of service use, exposure to fluoridated water supplies, socioeconomic status, barriers to care, etc.

The clinical examination for a survey differs from a regular dental check-up in that caries is recorded at the dentinal level of involvement and recorded at a fixed stage of development, not on an absolute presence or absence basis. Teeth are examined wet, whereas in a regular dental check-up the teeth are dried to aid diagnosis. Diagnostic aids were not used in the survey. Because the epidemiological assessment of tooth surface condition does not equate with a clinical diagnostic examination, the examining dentist records separately their opinion of treatment need, based on clinical experience, and on the visual condition of the tooth. Even though individual variations was expected amongst the clinicians, it is practicable to suggest that the combined scores of the clinicians reasonably reflect subjects’ treatment-needs, as perceived by a group of practicing dentists.

Results

Sixty five per cent of the older people surveyed in 2000-02 held medical cards. Blanket eligibility to a medical card for all persons aged 70 and older, regardless of income, was introduced on 1st July 2001 while the survey was in progress. Seventy per cent of those aged 70+ examined during the NSAOH 2000-02 prior to this date held medical cards that were means-tested or issued on the grounds of undue financial hardship owing to medical or other exceptional circumstances. Of those aged 70+ examined after this date, 96 per cent held medical cards, an indication of the widespread uptake following the introduction of blanket eligibility to a medical card. However, under the Health Act 2008, automatic entitlement to a medical card for persons aged 70 or over ceased on December 31st 2008. It is estimated that 85 per cent of older people aged 65+ held medical cards in 2003 and, hence, had access to the DTSS. However, in 2003 only 14 per cent of medical card holders aged 65+ used the DTSS (Whelton et al., 2007b).

The clinical examination from NSAOH 2000/02 established that 41 per cent of all older people had no natural teeth and were completely dependent on dentures for the basic function of eating; the average older person possessed 8 (out of a full complement of 32) natural teeth; 79 per cent of all older people had a clinical need for dental treatment. Unmet dental treatment need was largely accounted for by extractions, bridges, crowns and root canal treatment. Denture-related treatment is required by 56 per cent, with older people with natural teeth (dentate) having a greater requirement for fillings and extractions and a much greater need for all dental services than all older people (dentate and edentulous) on average. Periodontal treatment (gum disease) was required by 24 per cent of the elderly. Gum disease affects those with some natural teeth (dentate). Among older people with natural teeth, 50 per cent required complex periodontal treatment (e.g., root planing or surgical intervention).

A detailed comparison of treatment need (as predicted by the NSAOH 2000-02) and the treatment actually provided by the DTSS (as estimated from the DTSS payments database) during the survey period revealed that:

• Older adults aged 65+ had significantly higher unmet treatment needs than younger adults aged 16-24 and 35-44;
• Unmet dental treatment need amongst those aged 65 and over was largely accounted for by extractions and other treatments not covered by the DTSS (e.g., bridges, crowns, root canal treatment);
• Older people with natural teeth (dentate) had, on average, a greater requirement for fillings and extractions and a much greater need for all dental services than all older people (dentate and edentulous).

A key finding for the younger age groups was that once an individual accesses the DTSS, their need for dental treatment largely tends to be met. This did not hold true, however, for older adults. Older adults who were regular DTSS users had significant unmet needs. A large portion of these unmet needs were for advanced restorative treatment not covered by the DTSS.

Attitudes towards Dental Care

Older people’s attitudes towards dental care are largely forged by their past experiences

The present generation of older people grew up during a period when extraction was the common practice and dentists were feared, when the cost of dental treatment was prohibitive for many, when dental visits were mainly necessitated by pain and visits for check-ups were not common. Hence, members of this age group have developed less favourable dental attitudes and have lower oral health expectations than those prevalent among the younger age cohorts (Whelton, et al., 2007a).When questioned on their frequency of dental visits within recent years, 22 per cent of older people with natural teeth and 71 per cent with no natural teeth replied they never visit the dentist, and only 44 per cent of them attend the dentist regularly (every 2 years or more).Only 38 per cent of those with teeth attend the dentist for routine check-ups; just 2 per cent of those who have lost all their teeth go to the dentist for an oral health check-up. The majority of older people with teeth only go to the dentist when they are in pain and have a problem or when they feel they need treatment. Those with no teeth tend to not visit the dentist at all, unless they are in need of new dentures or experience pain.

The prevailing opinion among older people, especially those with no teeth, is that they have no need to visit a dentist. When non-regular dental attendees were asked why they did not visit a dentist regularly, “no need” was cited by 88 per cent of those with no teeth compared to 53 per cent of those with natural teeth and. It is a common misconception that if you have no teeth you don’t need a dental check-up. Oral lesions were found in 30 per cent of older people examined. Many of the conditions recorded could benefit from clinical treatment. Regular dental visits would also enable opportunistic screening and early detection of oral cancer.

When asked how often they thought they should visit a dentist, 75 per cent of those with teeth felt that they should make a dental visit at least every 12 months, but only 29 per cent of them did so. This large discrepancy between opinion and actual practice is a strong indication that other barriers to care, over and above lack of awareness, are in play for older people with teeth.

Older people with no teeth appear to be less well informed regarding the need for dental visits – 25 per cent did not know how often they should visit the dentist, 16 per cent replied “never” and another 25 per cent replied “when in pain/problem”. For older people with no teeth, not being informed of the importance of oral health care is in itself a major barrier to utilisation of services.

Differences in oral health awareness between those with teeth and those with no teeth is related to how recently they had their last contact with the dentist. Just 49 per cent of those with teeth had been to the dentist within the previous year, while 70 per cent of those with no teeth had not visited a dentist in over 3 years. Evidence from the focus groups reveal that many of those with no teeth had not made a dental visit since they received their original set of dentures. The focus group discussions with older people supported the findings of the NSAOH 2000-02 (see Table 2):

The discussions and individual interviews were guided by a semi-structured schedule of discussion topics, broader health and quality-of-life issues towards a focus on teeth and dentures and access to oral health services. Table 2 shows the main issues raised by the participants and interviewees within each topic and section, and the number of focus groups and of interviewees expressing these issues.

Many focus group participants were happy with the quality of treatment and aftercare they received on the medical card. However, in half of the focus groups, older people voiced the sentiment that medical card patients received inferior quality of dentures and treatment to that provided to paying patients, the inference being that the medical card does not buy the same quality of care that private patients receive. This sentiment may not be entirely unfounded. During interviews with dentists, a number intimated that it was difficult for them to provide the same level of care to medical card patients at present DTSS fee rates as they provided to paying patients. A common view among dentists was that the DTSS fee levels were not commensurate with the time and effort involved in providing treatment to older patients, who can be difficult to treat and whose treatments can be difficult. Over 70 per cent of dentists surveyed ranked the inadequacy of DTSS fee levels as one of the three most important barriers they encountered in providing treatment to older people.

The cost of dental treatment was cited by 5 per cent of older people with teeth and by 13 per cent of those with no teeth in the national survey as their major reason for not going to the dentist regularly. Not being able to afford dental services was an issue raised by participants in seven of the twelve focus groups. Among the dentists surveyed, more than two-thirds reported that they ‘often’ and ‘sometimes’ provide probono treatment to older people for which they are not paid.

Though older people may say they see no need to visit a dentist or that they are not able to pay for dental treatment, other underlying reasons often exist that act in combination to effectively deny them access to dental care. Barriers to dental care raised by older people during the focus group discussions included:

• difficulty getting to the dentist caused by their reduced mobility;
• cost of transport to the dentist (taxi fare) being prohibitive, particularly if they lived in rural areas and had a distance to travel to the dentist;
• requiring a companion to accompany them to the dentist;
• difficulty obtaining suitable and timely dental appointments;
• being on prescribed medications (e.g. anticoagulant medication);
• hearing and/or speaking difficulties which hamper communication with the dentist;
• fear of the dentist;
• not having a dentist or difficulty in finding a dentist who would treat them.

Older People in Residential Care

An estimated 4 per cent of the older population are in residential care (i.e., HSE extended care units, HSE welfare homes, voluntary homes/hospitals for older people, voluntary welfare homes, and private nursing homes). Among the ‘old’ older people, 11 per cent of those aged 80+ and 16 per cent of those aged 85+ are in residential care.

The Long-Term Stay Statistics for 2005 published by the Department of Health and Children reported a total of 19,320 residents, 94 per cent of whom were older people. Two out of every three residents were 80 years old or older. Seventy two per cent of those in residential care are high or maximum dependency patients (i.e., require assistance for most or all activities of daily self-care), 52 per cent have physical disorders and 36 per cent have mental disorders.

Information on the oral health profile of older people in residential care is very limited. Only three clinical studies with restricted geographical coverage have been carried out since the 1980s. These studies, each one conducted in a different decade, point to a low and static level of oral health among older people in residential care. The proportion of residents with no teeth (per cent edentulous) reported by the separate studies were at the level of toothlessness prevalent among older people in Ireland in 1972 [Lemasney and Murphy, 1984; Daly, 1998; O’Farrell et al., 2005].

A non-clinical nationwide survey of long-term residential units (Whelton, et al., forthcoming) carried out by the Oral Health Services Research Centre on behalf of the Department of Health and Children and the HSE reported that 60 per cent of residents are fully dependent on staff for their daily mouth care needs. The reported barriers encountered by staff in providing such care included:

• patient cooperation;
• time pressure of (other) normal routines (i.e., staff shortages);
• inadequate training or awareness of the importance of daily oral hygiene.

A majority of the units encountered difficulties in getting dentists to provide routine care to residents on a regular basis; dentists mainly provided emergency services for the treatment of patients in pain. 80 per cent of units indicated a need for the provision of dentures/extractions and denture repairs while some 60 per cent reported a need for oral hygiene instruction and scaling and polishing services.

Residential care units harbour a concentration of frail older people, a large proportion of whom have physical or mental disorders that compromise their oral health and impact on their access to dental services. Levels of oral health among residents are at a much lower than prevalent in the general population.

Conclusions/Recommendations

In respect to their oral health, older people remain a disadvantaged and marginalised group (Whelton et al., 2008). Older people have the poorest oral health profile, the highest levels of unmet treatment need and the poorest oral health-related quality of life compared to younger age groups. They generally avoid the dentist unless they have an absolute necessity for treatment (pain/problem) and tend not to be aware of the importance of regular oral check-ups in terms of the potential impacts of oral-ill health on their general health. Finally, older people experience other barriers, in addition to lack of awareness, which impede their access to dental care.

The Department of Health and Children, in collaboration with the HSE must address the oral health inequities experienced by older people particularly as the National Health Promotion Strategy 2000-2005 (2000) did not contain a reference to the oral health of the elderly.

The policy issues that need to be considered for older people include:

• older people’s low uptake of dental services;
• oral health promotion among older people to raise their awareness of oral health and of their DTSS entitlements;
• oral health promotion by other healthcare professionals and carers who are in frequent contact with older people;
• the adequacy of the DTSS in relation to older people’s treatment needs;
• the provision of domiciliary care for those who cannot access clinic-based services;
• integration between the dental profession and medical profession.

Oral Health Promotion:

There are two main reasons for the poor uptake of dental services by older people: Older people, particularly those with no teeth, are generally not aware there is a need to visit the dentist for regular oral health check-ups, and many older people are not aware that the medical card also entitles them to free routine dental care via the DTSS.

It is recommended that a national oral health promotion campaign targeting older people be carried out to raise their awareness of the need for dental visits (even if they have no teeth) and to inform them of their DTSS entitlements. The responsible agencies include the Health Promotion Policy Unit – DoHC, the Dental Health Foundation, and Population Health- HSE.

The national oral health promotion campaign should be centrally coordinated. Ideally, there should be a designated body with the requisite expertise and resources to map out a well-planned campaign of sustained oral health promotion at all levels – among the older population, among medical and social services professionals who are involved with older people and among policy makers. The use of the mass media (television/radio/newspapers) would be an option for reaching a wide audience. Other possible elements of the campaign could be an oral health awareness week or an oral cancer week to promote opportunistic screening for oral cancer.

Oral health awareness among other medical professionals and carers who are in frequent contact with older people (e.g., GPs, public health nurses) need to be raised, as oral health is an integral component of general health, and they would be best positioned to advise older people on a face-to-face basis to visit the dentist. Hygienists with training in the care of older people could also be deployed to nursing homes, day-care centres and other places with a concentration of older people to provide oral hygiene, preventive services and advice within an oral health promotion programme.

Dental Treatment Services Scheme (DTSS):

The DTSS is the main scheme for providing services to older people. In 2003, older people comprised 41 per cent of the DTSS client base. Because older people constitute its broadest client base, the DTSS should be better tailored to meeting their treatment needs. A large portion of the unmet dental treatment needs of older people surveyed was for items not covered by the DTSS. At issue here is the DTSS budget, as many of the treatments required by older people involve more complex and expensive restorative dentistry.

Based on the survey findings and population growth trends, there will be an increasingly dentate older population with, on average, a greater number of teeth in an increasingly larger (both in absolute numbers and as a proportion of total population) older population and, hence, an increasing demand for complex restorative dental treatments. Looking to the future, oral health promotion and preventive dentistry measures aimed at today’s children should bring about a much-improved oral health profile among the next generation of older people, which hopefully will reduce the demand for complex restorative treatments. Until then, the treatment needs of the present generation of older people need to be met. At issue here are the resources available to the government and the priority given to maintaining an equitable and acceptable level of treatment services to older people.

Dentists ranked DTSS fee levels and range of services as their most important barriers to providing care to older people. They felt that fee levels did not provide adequate compensation for quality services and that restrictions imposed by the DTSS prevented them from providing an adequate level of care to patients. Older people also expressed their perceptions that quality of dentures and services provided through the medical card was inferior to that provided to paying patients.

It is recommended that the DTSS range of services and fee levels be reviewed such that older people are assured an equitable and acceptable level of treatment services. The responsible agency here is the HSE executive.

Domiciliary Services:

Among the barriers to care highlighted by older people was their inability to get to a dental surgery. With age, older people experience mobility difficulties. While some of these difficulties can be overcome (e.g., subsidies for taxis, wheelchair-accessible clinics), there are older people who are not able to access clinic-based services and require domiciliary care. The HSE-salaried service is the main provider of domiciliary services. However, due to manpower constraints, domiciliary care tends to be provided on a reactionary emergency basis rather than on a proactive preventive routine basis. An estimated 4 per cent of the older population is in residential care. The oral health profile of older people in residential care is considerably poorer than that of the general population. Residential care venues provide a concentration of older people who would benefit from domiciliary care.

It is recommended that domiciliary services, particularly for older people in residential care, be given greater priority by the HSE dental service. The responsible agency is the HSE. The range of domiciliary services could include oral health promotion to both residents and carers, among other initiatives. Incentives for the delivery of domiciliary care by private sector dentists could also be considered.

Integration with Medical Services:

The Health Strategy 2001 proposed the setting up of primary care teams involving medical and social services professionals. Dental professionals were seen as part of the wider primary care network, interacting with the primary care teams. Ways to better integrate oral health care into primary care structures should be investigated. There has been little on-the-ground progress with the alignment of dental services and other primary care structures. Dental practices should be encouraged to form alliances with primary care teams or medical practices to facilitate the cross referral of patients from medical to dental care and vice versa and to facilitate the exchange of information on the interactions of dental conditions with medical conditions and vice versa.

It is recommended that linkages between dental professionals and other primary care professionals be promoted within the structure of Primary, Community and Continuing Care (PCCC) public services as well as among private sector professionals.The responsible agencies include the HSE, DoHC, Dental Health Foundation, Irish Dental Association (IDA), and the Irish Medical Organisation (IMO).

References

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