Podcast Bites into the Realities and Challenges of Oral Health in Older Adults

October 3, 2019
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“I fear that this focus on older adult oral health may come as a surprise to medical providers and even geriatricians in the trenches of care,” said Wayne Saltsman, MD, PhD, CMD, at the start of the September 16 AMDA On-The-Go podcast. He then led a conversation with his guest, Karin Andrenyi-Arsenault, DMD, MPH, clinical director of the Geriatric Center Program at the Tufts School of Dental Medicine, that took on the challenges of oral care in older adults and empowered practitioners to take the lead on this issue.

“Since the Surgeon General’s report in 2000 referring to oral health in elders as a silent epidemic, there has been a growing focus on this issue,” Dr. Andrenyi-Arsenault said. “We have a better understanding of oral disease and its impact on physical and psychological well-being. This shouldn’t just be considered a dental problem but a health problem.”

Unfortunately, as Dr. Andrenyi-Arsenault observed, access to oral care remains a problem for some populations. She suggested, “Oral health for older adults needs to be an integral part of programs such as Medicare and Medicaid; and there needs to be a greater emphasis on allied dental professionals. We also need a more qualified dental workforce with skilled expertise to work with older adults.”

Times have changed when it comes to oral health and older adults, Dr. Andrenyi-Arsenault said. “In the past, dentistry for older people was about extractions and dentures. But people are no longer living with the expectation that they will lose all of their natural teeth.” This is especially true, she noted, among educated people and those with financial resources.

One challenge, she observed, is that people often lose their dental insurance when they retire. Paying out of pocket for dental care can be difficult, or even impossible, for many older Americans. At the same time, as older people become frail and need more assistance with activities of daily living such as teeth brushing and flossing, oral health becomes more challenging. Complex medical conditions such as hypertension, diabetes, heart disease, and Alzheimer’s disease also increase their vulnerability.

Polypharmacy presents an additional challenge. As Dr. Andrenyi-Arsenault explained, medications work differently in older adults; and these individuals may experience increased sensitivity to drugs used in dentistry such as local anesthesia; in addition, various prescription drugs have dry mouth as a side effect.

Providing oral care in older adults becomes more time-consuming and challenging when they have sensory and cognitive impairments. When people with Alzheimer’s or other dementias have dental problems, Dr. Andrenyi-Arsenault noted, issues around decision-making and informed capacity arise. She said, “It’s very important to establish dental care programs as soon as a person is diagnosed with dementia.” In early stages, most care can be provided; and all potential sources of pain, infection, etc. should be addressed as soon as possible. People should be encouraged to handle their own dental care for as long as possible and get the training and tools to do so. In later stages of dementia, care is more preventive and maintenance-oriented than restorative.

Nonetheless, despite the challenges, it is essential to address oral health in older adults. As Dr. Andrenyi-Arsenault said, “Studies show compelling evidence of the link between oral disease and general health. Dental health is a reflection of systemic conditions of older people.” There also are studies, she added, suggesting the number of natural teeth are a predictor of longevity; while loss of teeth can signal a risk for early mortality. This link isn’t surprising, she said, but it’s often overlooked because “we have such a siloed system.”

As older adults become more dependent on others for care, their oral health often rapidly declines. Dr. Andrenyi-Arsenault observed, “Long-term care residents have unmet dental needs ranging from 80 to 96%, and they have three times the rate of tooth decay compared to their community-dwelling counterparts.” They also have higher levels of candida and staph leading to problems such as infections and aspiration pneumonia.

Fortunately, Dr. Andrenyi-Arsenault said, “There is a much greater awareness in the medical profession and among all professionals that there is a strong connection between oral health and overall health. We need to work toward a more collaborative approach to care.” This is not without challenges, she noted. Specifically, more interdisciplinary training is needed, as well as communication and trust between professions.

There are other challenges that need to be addressed, such as who will pay for care, who will arrange dental appointments and transportation, and how to provide staff with time and knowledge to provide oral care. Dr. Andrenyi-Arsenault said, “CNAs are swamped with other tasks, and turnover is high. Brushing teeth often falls to the bottom of the to-do list.” This is a growing issue, as more people are coming into facilities with more natural teeth and poor oral health.

Moving forward, said Dr. Andrenyi-Arsenault, it is important for dental professionals to become part of the interprofessional team. They can add a valuable prospective that is necessary to provide comprehensive care.

Click here to listen to the full podcast and hear more of Dr. Andrenyi-Arsenault’s insights. Check out a full list of archived episodes you can listen to any time. CME is available for these programs.