Oral Health and Older Adults

1. Oral Health and Older Adults W4A Advisory Councils and State Council on Aging October 16th, 2008

2. Seniors are at increased risk for oral disease • Poor oral health throughout life – worsens with time • New disease due to: • Breakdown of previous restorations • New health condition which affects the mouth (including dry mouth) • Gum recession leaves tooth roots vulnerable to decay • Physical/mental conditions make home care challenging – must rely upon caregiver • Lack access to preventive care • Expectation to need dentures (seems to be fading) • Competing financial priorities – lower value on oral health

3. Magnitude of the Problem • Nationwide, seniors’ oral health is improving: • Untreated decay is down 30% • Untreated root caries is down 36% • Edentulism (toothlessness) is down 20% • However, too many seniors still experience oral disease: • 1 in 5 currently have decay • 1 in 4 have severe periodontal disease (gum disease) • Jumps to 1 in 3 among low-income

4. Gum Disease Increases with Age

5. Racial/Ethnic Disparities

6. Income Disparities

7. Difficulties Accessing Care • Medicare doesn’t cover dental • 75% of seniors in WA are dentally uninsured • Only ~20% on Medicaid access care • Seniors are age group most likely to have had no dental visit in 5 years (BRFSS) • Causes missed opportunities for prevention • Many seniors put off paying for care until problem is significant

8. Oral Health - Overall Health Connection “You cannot be healthy without oral health.” Surgeon General’s Report on Oral Health ~May 2000

9. Periodontal Disease – Medical Link • Diabetes: • Diabetes increases risk for gum disease • People with diabetes and severe gum disease are more likely to have problems with glycemic control • Treating gum disease may improve glycemic control and prevent costly diabetic complications • Heart Attack/Stroke • Pnemonia

10. Gum Problems - Photos 4. Gingivitis 5. Periodontal Disease

11. Dry Mouth (xerostomia) • Estimated that 25% of seniors have dry mouth • Saliva is protective: • cleanses the mouth; • neutralizes acid; • kills bacteria and other germs • remineralizes teeth (fluoride and calcium) • Causes: • Health conditions (diabetes, Sjögren’s Syndrome) • Cancer treatments • Medications • 7 out of 10 most commonly prescribed medications • Antidepressants, antipsychotics, antihistamines, decongestants, antihypertensives, diruetics, antiparkinsonian drugs

12. Dry Mouth Incidence • Risk increases with the number of medications taken. Nederfors, et. al, 1997

13. Dry Mouth – Side Effects & Photos 11. Root Decay Tongue 12. Cracks on Corners of Lips 14. Possible Fungal Infection 13. Dry, Painful Tongue

14. Dry Mouth Prevention and Remedies • Saliva substitutes (Biotene, Orajel, etc…) • Increase water intake • Increase fluoride • Avoid alcohol (including in mouthwash), tobacco, sugary drinks • Xylitol: • Plant-derived sugar alcohol. • Sugar alcohols - reduce tooth decay interferes with the production of acids. • Xylitol the most effective sugar alcohol at reducing tooth decay.

15. Washington Dental Service Foundation • Non-Profit Corporate Foundation • Mission: to eliminate oral disease for all • Values: • All people should have an equal opportunity to be healthy. • We strive to end racial, ethnic and income disparities as barriers to oral health. • We make a positive impact on people’s lives by influencing environments that affect oral health over the long-term. • We are creative, innovative, adaptive and take calculated risks. • We are outcomes-driven. • We value teamwork, integrity, trust, diversity and shared purpose in our work internally and externally.

16. The Theory of Change for Eliminating Oral Disease Conditions for Success Determinants of Oral Health WDSF Mission Access to Quality Healthcare People access oral health care including preventive and restorative services • Policy/decision-makers buy-in to the importance of oral health and establish policies that support: • Prevention of oral disease • Access to services • Good oral health behaviors Adequate pool of providers, which contains the appropriate balance of disciplines (including medical professionals), offers oral health services efficiently in easily–accessible and geographically distributed settings. Physical Environment The physical environment promotes good oral health: WA residents drink fluoridated water, healthy snacks are available in schools and work places Public values the importance of oral health; understands the mechanics and link to overall health; demands services and is motivated to conduct good oral health behaviors and nutrition habits Eliminating oral disease in order to improve overall health Social Environment Social norms define behaviors and policies that promote oral health as an essential element of overall health as the accepted and expected standard Science-based best practices for prevention and treatment are understood and implemented by health professionals. Science continually advances in the understanding of the biology of oral disease. Personal Behavior People regularly and effectively practice oral self-care and avoid practices that increase their risk for oral disease Financial system provides incentives for and eliminates barriers to serving the underserved; all patients have coverage for care. Culturally competent and diverse workforce increases the comfort and quality of care for all populations and participates in efforts to improve oral health at the community level Biology People routinely assess and manage their risk for oral disease based on their individual biology Community systems and services facilitate access to care for everyone in their local community

17. WDSF Role Identify and drive strategic changes in systems to improve oral health

18. WDSF Initiatives • Seniors’ Dental Access Pilot Project • Caregiver Curriculum • Media Campaign

19. Seniors Dental Access Pilot • Goal: Improve oral and overall health of seniors through increased access to preventive and restorative dental care in medical and dental settings. • Medicaid-insured adults age 55 and up • 3-Year Pilot project • July 09 – June 2010: systems, training, provider recruitment • July 2010 – June 2012: Medicaid payments

20. Pilot Sites San Juan Whatcom Pend Oreille Okanogan Ferry Skagit Stevens Island Clallam Snohomish Chelan Jefferson Douglas Spokane Kitsap Lincoln King Grays Harbor Mason Grant Kittitas Adams Whitman Thurston Pierce Pacific Lewis Franklin Garfield Wahkiakum Walla Walla Columbia Cowlitz Yakima Benton Skamania Asotin Klickitat Clark Clark County- Clark County Health Department Southeast Region- Southeast WA Aging and LTC

21. Partners University of Washington School of Dentistry ELDERCARE ALLIANCE WASHINGTON SENIOR CITIZENS’ LOBBY

22. How it will work • Based on Access to Baby and Child Dentistry model • Links with other chronic disease management programs • WDSF funds local coordinating agencies to conduct patient outreach and provider recruitment • UW School of Dentistry offers training events for dental and medical providers • Medicaid provides enhanced rates to dentists and payments to physicians for oral health services • Track utilization rates and study improvements in health for patients with diabetes

23. Key Metrics • Dental utilization rates - are more seniors accessing care in dental setting? • Preventive oral health services - does improved network lead to more preventive screening and services in medical and dental settings? • Attracting participating providers - are more dental and medical providers serving Medicaid-insured seniors? • Medical and dental costs – will increased dental care for this population that is at risk for chronic diseases reduce medical costs associated with those diseases?

24. Caregiver Training • Curriculum developed in 2004,pilot-tested by PRN, certified by DSHS to qualify for 10 hour c.e. rolled-out to caregiver training agencies • Goal is to engage caregivers in oral health and teach skills for improving oral health of clients/family members • 6 modules: tooth decay, gum disease, oral cancer, dentures, nutrition, dry mouth

25. Caregivers Can Improve Oral Health! • Prompt, assist, or perform the oral health care. • Monitor client’s mouth for changes. • Educate client about oral health information. • Refer problems to supervisor or case manager.

26. Tooth Decay - Process Germs + Refined Carbohydrates = Acid Acid Attacks + Tooth = Decay Untreated Decay  Infection, Abscess, Loss of Tooth

27. Activity: Check Your Mouth • Look at your gums, teeth, and tongue • What do you see? • Normal? • Not normal?

28. Evaluation • Conducted in 2007 – 96 participants • Key Question: Does training impact how caregivers provide oral health care to clients/loved ones? • Qualitative design: • 14 focus groups – • 6 trained, 6 untrained, 2 mixed • 11 IPs, 3 agency • 2 Russian • 17 phone interviews • Survey • King, Pierce, Lewis, Yakima Counties

29. Partners • Professional Registry of Nursing • AAAs: • LMT AAA • Pierce County AAA • King County Aging and Disability Services • Southeast Washington Aging and LTC • ResCare HomeCare (formerly Armstrong) • Elite International

30. Key Findings • Trained caregivers are more active participants in their clients’ oral health care (60% vs. 20%) • Trained caregivers are more likely to: • Look in the mouth – screen for problems • Help clients access dental care • Prompt or assist with brushing • Prompt or assist with cleaning dentures • Encourage wearing dentures • Recommend dry mouth remedies

31. Key Findings continued • Trained caregivers are more confident in ability to care for client’s teeth and mouth • Trained caregivers mentioned improvements to their own oral health care following the training: • Eating healthier • Brushing right after meals • Flossing more regularly • Making a dentist appointment • Using gum with xylitol

32. Challenges • Caregivers experience the following challenges in providing oral health care for their clients: • Client resistance • Conflict of roles with family members • Client dementia • Access to dental care for clients

33. Implications/Recommendations • Need tips and support for overcoming client resistance • Need additional content on providing oral health care for clients with dementia • Oral health needs a greater role in care plans – currently falls in personal hygiene section, not health • Develop programs to improve access to dental care for this population • Engage medical community

34. Media Campaign • Television and radio spots • Summer 2007: greater Puget Sound area • Fall/Winter2007 and early 2008: Major WA markets • Op-Ed pieces • Tacoma News Tribune • Spokane Spokesman Review • Seattle PI • Tacoma News Tribune

35. Resources • Geriatric Dental Group – Federal Way (253-839-1300) • Community Clinics • Local Health Jurisdictions/Oral Health Coalitions • WSDA Senior Discount Program – through I and R • Preventive services by hygienists in senior centers • Dental societies – community access programs

36. Vision… • Public and leaders understand the link between oral health and overall health • Medical providers screen and provide preventive services • Pharmacists counsel on dry mouth • Oral health services available in community-based settings • Medicare includes dental benefit Anything else????????