Tooth loss and dental caries in community-dwelling older adults in northern Manhattan

Abstract

Objective

To examine tooth loss and dental caries by sociodemographic characteristics from community-based oral health examinations conducted by dentists in northern Manhattan.

Background

The ElderSmile programme of the Columbia University College of Dental Medicine serves older adults with varying functional capacities across settings. This report is focused on relatively mobile, socially engaged participants who live in the impoverished communities of Harlem and Washington Heights/Inwood in northern Manhattan, New York City.

Materials and Methods

Self-reported sociodemographic characteristics and health and health care information were provided by community-dwelling ElderSmile participants aged 65 years and older who took part in community-based oral health education and completed a screening questionnaire. Oral health examinations were conducted by trained dentists in partnering prevention centres among ElderSmile participants who agreed to be clinically screened (90.8%).

Results

The dental caries experience of ElderSmile participants varied significantly by sociodemographic predictors and smoking history. After adjustment in a multivariable logistic regression model, older age, non-Hispanic Black and Hispanic race/ethnicity, and a history of current or former smoking were important predictors of edentulism.

Conclusion

Provision of oral health screenings in community-based settings may result in opportunities to intervene before oral disease is severe, leading to improved oral health for older adults.

Introduction

While vaunted improvements in the health of the US population have occurred over the last century, the persistence of health disparities between segments of society, notably those defined by race/ethnicity and socioeconomic factors such as education and income, indicates that such improvements have been uneven¹. Among the enduring health disparities are those concerned with oral health; social disparities in tooth loss, dental caries, and periodontal disease have consistently been documented both nationally and regionally^2-9. Overall, findings indicate that racial/ethnic minorities, impoverished populations, and groups with lower educational attainment suffer worse oral health outcomes than non-Hispanic Whites, wealthier populations, and groups with higher educational attainment^10-11.

Throughout the life course, teeth remain at risk for the two most prevalent oral diseases: dental caries and periodontal disease, which are cumulative¹². Older adults are at increased risk for root caries because of both increased gingival recession that exposes root surfaces and increased use of medications that produce xerostomia. Approximately 50% of persons aged 75 years and older have root caries affecting at least one tooth, and approximately 25% of older adults have loss of tooth-supporting structures because of advanced periodontal disease¹⁰. Without early prevention and control interventions, these progressive conditions can demand extensive treatment to curb infection and restore function¹³.

Given the vast expansion in the population of US older adults and the challenges of providing supportive care to growing numbers of people, coordinated efforts and continued support from academic research are needed to better ensure more satisfying later years. In particular, minimising the impact of diseases and conditions now prevalent in older adults and improving their quality of life through better oral health as part of overall health and well-being has been championed as part of the healthy ageing agenda¹⁴. The ElderSmile programme of the Columbia University College of Dental Medicine (CDM) has adopted an interdisciplinary approach to meet these challenges, which represents a flexible model for the future¹⁵. Here we present the clinical findings regarding tooth loss and dental caries obtained from community-based oral health examinations conducted by dentists in northern Manhattan, New York as part of the ElderSmile programme of the CDM.

Material and Methods

Study sites and populations

The ElderSmile clinical programme currently consists of 27 prevention centres, which are located at senior centres and other locations in which older adults gather in the Harlem and Washington Heights/Inwood communities of northern Manhattan, New York City¹⁵. The foremost reason that the CDM elected to focus on creating a network of prevention centres was to access a population of older adults that was not centrally interested in obtaining oral health care for painful conditions, in order to intervene before disease is severe. Given ongoing partnership with the prevention centres over time, both older adults who received services and centre directors, who value the programme, help recruit additional participants for subsequent oral health screenings. The prevention centres host a combination of services, including: (1) general presentations and discussions in both English and Spanish of oral health promotion in later life (e.g., potential oral health problems, how to choose oral health care products, and access to oral health care, including transportation issues); (2) demonstrations of brushing and flossing techniques and care of prosthetic devices; and (3) oral cancer and oral health examinations for older adults who elect to participate. Services are provided by two faculty dentists and dental students of the CDM, who were trained by the project director.

The comparison population for this study is adults aged 65 years and older who received a dental examination in the National Health and Nutrition Examination Survey (NHANES) 1999-2004. In these US national surveys, dental examinations were conducted in the mobile examination centre by trained dentists who were periodically calibrated by the reference dental examiner¹⁶. Similar procedures were followed for the ElderSmile dental examinations. In brief, ElderSmile examiners used a non-magnifying mirror and a pen light to assess for tooth loss and dental caries. The examining protocol was based upon the Radike criteria¹⁷ with minor modifications, as per the NHANES protocol.

Older adults are enrolled in the ElderSmile programme after participating in the oral health promotion activities and being examined by one of the ElderSmile dentists. After the screening dentist reviews the results of the oral health examination with each patient, the patient has the option of being referred to an ElderSmile community-based treatment centre (if there is no dental home) or to her or his own dentist¹⁵. The project coordinator functions as a case manager to better ensure that indicated follow-up is received by the patients, which is currently at 88%.

Study design and measures

The present study is cross-sectional in design and is centrally concerned with baseline data collected during community-based screenings of adults aged 65 years and older who agreed to participate in the ElderSmile programme. Self-reported sociodemographic characteristics and health and health care information were provided by ElderSmile participants who took part in community-based oral health education and completed a screening questionnaire. Oral health screenings were conducted by dentists in partnering prevention centres among ElderSmile participants who agreed to be clinically examined.

The primary outcome measure of interest is the presence or absence of teeth as assessed by an ElderSmile dentist based upon a complete dentition of 28 teeth. Third molars were excluded from the analysis as they are often missing because of reasons other than dental caries or other oral diseases. Secondary outcomes of the study were dental caries. The following conditions were measured and calculated based upon the clinical examinations of ElderSmile participants: (1) DMFT—number of decayed, missing, and filled permanent teeth; (2) DT—number of decayed permanent teeth as assessed by gross lesions clearly visible to the unaided eye (radiographs were not used); (3) MT—number of permanent teeth missing due to caries¹⁸; and (4) FT—number of filled permanent teeth. Finally, edentulism is defined as having no natural permanent teeth in the mouth¹⁶. No radiographs or probing were involved, which may lead to an underestimation of dental caries but not missing teeth.

Covariates included in the analyses included age group (65-74 years and 75 years and older), gender (men and women), race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic), education level (less than high school, high school, more than high school), and smoking history (current smoker, former smoker, and never smoker). These covariates were selected and the categories formed to be consistent with those employed in NHANES 1999-2004 to aid in comparisons between these US national surveys and the ElderSmile programme data.

Statistical analyses

Means and standard deviations were computed for continuous variables and counts and percentages were computed for categorical variables. In addition to descriptive statistics, mean differences across different levels of each characteristic were computed using a two-sample t-test (for two levels) or a one-way analysis of variance (for more than two levels) for continuous variables, and a chi-squared test for categorical variables. Bivariable and multivariable logistic regression analyses were conducted with edentulism as the outcome variable, and age, gender, race/ethnicity, education level, and smoking history as the predictor variables. All analyses were conducted in SAS version 9.1¹⁹.

Results

From August, 2006 through March, 2009, a total of 729 older adults aged 65 years or older participated in oral health promotion presentations and discussions and completed a self-reported oral health survey. Of these 729 older adults, 662 (90.8%) were clinically examined by dentists.

Sociodemographic characteristics

As shown in Table 1, two-thirds of the ElderSmile participants were women (65.9%). Although there were fewer participants in the oldest age groups, there was nonetheless representation throughout the age range of 65-69 years to 95 years and older in the ElderSmile programme. Two of every five participants (39.0%) stated that their primary language was Spanish and self-identified as Hispanic (37.4%); another two of every five participants self-identified as non-Hispanic Black. More than half (53.4%) were born outside of the mainland United States, largely in Puerto Rico (18.8%) and the Dominican Republic (14.8%). About a third (32.5%) had earned less than a high school education. While the study is based upon participants in a community-based service delivery programme and is not population-based, the sample is representative of older adults who frequent senior centres in northern Manhattan.

Table 1.

Sociodemographic characteristics of older adults aged 65 years and older who participated in community-based oral health education and completed a screening questionnaire (N=729): The ElderSmile Programme, New York, NY, August, 2006 to March, 2009

Characteristic (n1)	Number	%
Gender (n=728)
Men	250	34.3
Women	478	65.7
Age in years (n=729)
65-69	172	23.6
70-74	177	24.3
75-79	167	22.9
80-84	116	15.9
85-89	72	9.9
90-94	21	2.9
95+	4	0.6
Primary language (n=728)
English	414	56.9
Spanish	284	39.0
Other	30	4.2
Race/ ethnicity (n=639)
Non-Hispanic White	108	16.9
Non-Hispanic Black	264	41.3
Non-Hispanic Other	28	4.4
Hispanic	239	37.4
Place of birth (n=724)
Mainland United States	337	46.6
Dominican Republic	107	14.8
Puerto Rico	136	18.8
Other	143	19.9
Education (n=701)
Less than high school	228	32.5
High school	269	38.4
More than high school	204	29.1
Totals	729	100.0

¹Sample sizes (hence denominators used to compare percentages) may vary across characteristics because of missing values.

Health and health care information

About one in 10 (10.3%) ElderSmile participants reported that they currently smoke cigarettes or cigars and nearly a third (32.2%) reported that they were former smokers (see Table 2). The overwhelming majority of participants reported having medical insurance (94.4%) and visiting a medical doctor within the last year (80.9%). In contrast, less than half of participants reported having dental insurance (46.7%) and visiting a dentist within the last year (45.6%). Finally, 60.5% rated the condition of their teeth or mouth as fair (31.8%) or poor (28.7%).

Table 2.

Health and health care information of older adults aged 65 years and older who participated in community-based oral health education and completed a screening questionnaire (N=729): The ElderSmile Programme, New York, NY, August, 2006 to March, 2009

Characteristic (n1)	Number	%
Smoking history2 (n=624)
Current smoker	64	10.3
Former smoker	201	32.2
Never smoked	359	57.5
Has medical/ health insurance (n=717)
Yes	677	94.4
No	40	5.6
Last visit to a medical doctor (n=707)
Less than 1 year	572	80.9
1-3 years	58	8.2
More than 3 years	41	5.8
Never	36	5.1
Has dental insurance (n=694)
Yes	324	46.7
No	370	53.3
Last visit to a dentist (n=695)
Less than 1 year	317	45.6
1-3 years	212	30.5
More than 3 years	150	21.6
Never	16	2.3
Self-rated condition of teeth or mouth (n=645)
Excellent	18	2.8
Very good	151	23.4
Good	86	13.3
Fair	205	31.8
Poor	185	28.7
Total	729	100.0

¹Sample sizes (hence denominators used to compare percentages) may vary across characteristics because of missing values.

²ElderSmile participants in the former smoker and never smoked categories were determined by dividing the subset of older adults who reported that they do not currently smoke cigarettes or cigars into those who reported that they ever smoked cigarettes or cigars (former smokers) and those who reported that they did not ever smoke cigarettes or cigars (never smokers).

Of the aforementioned access to care measures (having medical insurance, visiting a medical doctor within the last year, having dental insurance, and visiting a dentist within the last year), significant differences by race/ethnicity and educational level were found for dental insurance coverage (Hispanics were more likely to be covered than other racial/ethnic groups) and time since last dental visit (those with more than a high school education were less likely to have visited a dentist in the past year than those with less education). In addition, self-rated condition of the teeth or mouth was examined by race/ethnicity and education level, and non-Hispanic Blacks and those with more than a high school education were more likely to report poor self-rated oral health than other groups (data and analyses are available upon request from the authors).

DMFT Index

As highlighted in bold in Table 3, the dental caries experience of ElderSmile participants varied importantly by certain sociodemographic predictors and especially by smoking history. Indeed, the mean DMFT, mean DT, and mean MT were decidedly higher and the mean FT was decidedly lower for current smokers than for former smokers (whose caries experience was intermediate for all measures) and never smokers (whose caries experience was best for all measures). In effect, those participants who were current smokers lost on average five more teeth than participants who never smoked. As expected in an older adult population, missing teeth (MT)—an indicator of past severe disease--was the major contributor to DMFT with important differences in mean MT found across all sociodemographic characteristics examined. In particular, higher mean MT values were found among participants 75 years and older (vs. 65 to 74 years), women (vs. men), non-Hispanic Blacks and Hispanics (vs. Whites), and those with less than high school or high school as their highest educational level achieved (vs. more than high school). Other findings of note include that men were at higher risk of current disease than women (e.g., exhibited higher mean DT levels), although there were no important differences found by gender in filled teeth (e.g., mean FT levels were similar at 5.2 for men and 5.0 for women) in this population.

Table 3.

Means and standard errors (SE) of Decayed Filled Missing Teeth (DMFT), Decayed Teeth (DT), Missing Teeth (MT), and Filled Teeth (FT) by age, gender, race/ ethnicity, education level and smoking history of older adults aged 65 years and older (N = 662¹) who participated in community-based oral health examinations conducted by dentists: The ElderSmile Programme, New York, NY, August, 2006 to March, 2009

Characteristic	Mean DMFT (SE)	p-value3	Mean DT (SE)	p-value3	Mean MT (SE)	p-value3	Mean FT (SE)	p-value3
Age in years
65-74	20.6 (0.3)	0.19	0.9 (0.1)	0.66	14.2 (0.5)	0.05	5.5 (0.3)	0.04
75+	21.2 (0.3)		1.0 (0.1)		15.6 (0.5)		4.7 (0.3)
Gender
Men	20.5 (0.4)	0.14	1.4 (0.2)	<0.01	13.9 (0.6)	0.04	5.2 (0.4)	0.66
Women	21.2 (0.3)		0.7 (0.1)		15.4 (0.5)		5.0 (0.3)
Race/ ethnicity
Non-Hispanic White	20.4 (0.5)	0.09	1.2 (0.3)	0.13	8.9 (0.9)	<0.01	10.4 (0.7)	<0.01
Non-Hispanic Black	21.2 (0.4)		1.0 (0.1)		16.4 (0.6)		3.9 (0.3)
Non-Hispanic Other	18.4 (1.2)		1.3 (0.4)		10.4 (1.5)		6.8 (0.8)
Hispanic	21.1 (0.4)		0.7 (0.1)		16.1 (0.6)		4.2 (0.3)
Education level
Less than high school	21.7 (0.5)	0.02	1.0 (0.2)	0.89	17.4 (0.7)	<0.01	3.4 (0.3)	<0.01
High school	21.0 (0.4)		0.9 (0.1)		15.5 (0.6)		4.6 (0.3)
More than high school	20.0 (0.4)		0.9 (0.1)		11.4 (0.7)		7.7 (0.4)
Smoking history2
Current smoker	23.0 (0.7)	<0.01	1.8 (0.5)	<0.01	18.2 (1.2)	<0.01	3.0 (0.6)	<0.01
Former smoker	22.0 (0.4)		1.0 (0.2)		15.8 (0.7)		5.2 (0.5)
Never smoked	20.0 (0.3)		0.7 (0.1)		13.5 (0.5)		5.7 (0.3)
Total	20.9 (0.2)		0.9 (0.1)		14.9 (0.4)		5.1 (0.2)

¹Sample sizes (hence denominators used to compare percentages) may vary across characteristics because of missing values.

²ElderSmile participants in the former smoker and never smoked categories were determined by dividing the subset of older adults who reported that they do not currently smoke cigarettes or cigars into those who reported that they ever smoked cigarettes or cigars (former smokers) and those who reported that they did not ever smoke cigarettes or cigars (never smokers).

³p-values correspond to testing whether the mean DMFT, DT, MT, and FT is the same across different levels of each characteristic (age, gender, etc.) Mean differences between groups were computed using a chi-squared test.

Edentulism

To better understand levels of and predictors of edentulism in the ElderSmile participants, we first compared results obtained in this community-based sample to those obtained in a nationally representative sample, namely, NHANES 1999-2004 (Table 4). While overall levels of edentulism of adults aged 65 years and older were lower in the ElderSmile sample (19.5%) than in the US national sample (27.3%), the results by sociodemographic characteristics and smoking history were showed similar trends in the two populations.

Table 4.

Edentulism¹ by age, gender, race/ ethnicity, education level and smoking history of older adults aged 65 years and older who participated in community-based oral health examinations conducted by dentists (N=662): The ElderSmile Programme, New York, NY, August, 2006 to March, 2009 and seniors 65 years and older in the United States, National Health and Nutrition Examination, 1999-2004²

Characteristic	% Edentulism in ElderSmile3	% Edentulism in NHANES3
Age (years)
65-74	17.0	23.9
75+	21.8	31.0
Gender
Men	19.4	24.4
Women	19.6	29.3
Race/ ethnicity
Non-Hispanic White	8.7	26.1
Non-Hispanic Black	21.8	32.8
Hispanic4	24.3	23.9
Education level
Less than high school	27.9	43.3
High school	19.2	28.3
More than high school	11.5	13.6
Smoking history5
Current smoker	30.0	49.7
Former smoker	22.1	28.7
Never smoked	14.8	21.7
Total	19.5	27.3

¹No natural permanent teeth.

²Source: Table 68 in Dye BA, Tan S, Smith V, et al. Trends in oral health status: United States, 1988–1994 and 1999–2004. Hyattsville, Maryland: National Center for Health Statistics, 2007: 1-92. (Vital and health statistics; series 11; no. 248.)

³Sample sizes (hence denominators used to compare percentages) may vary across characteristics because of missing values.

⁴Mexican American for NHANES.

⁵ElderSmile participants in the former smoker and never smoked categories were determined by dividing the subset of older adults who reported that they do not currently smoke cigarettes or cigars into those who reported that they ever smoked cigarettes or cigars (former smokers) and those who reported that they did not ever smoke cigarettes or cigars (never smokers).

Finally, we examined findings regarding edentulism within the ElderSmile sample using bivariable and multivariable logistic regression (Table 5). Even after adjustment for the other predictors in the model, older age, non-Hispanic Black and Hispanic race/ethnicity, and a history of current or former smoking were important predictors of edentulism; more than a high school education level was protective against edentulism, but was not statistically significant in the multivariable model.

Table 5.

Unadjusted and adjusted¹ Odds Ratio (OR) and 95% Confidence Intervals (CI) of edentulism² with covariates of age, gender, race/ ethnicity, education level and smoking history of older adults aged 65 years and older who participated in community-based oral health examinations conducted by dentists (N=662): The ElderSmile Programme, New York, NY, August, 2006 to March, 2009

Characteristic	Unadjusted OR (95% CI)	Adjusted OR (95% CI)
Age (years)	1.03 (1.00, 1.06)	1.04 (1.01, 1.08)
Gender
Men	1.00	1.00
Women	1.05 (0.66, 1.68)	1.11 (0.68, 1.81)
Race/ ethnicity
Non-Hispanic White	1.00	1.00
Non-Hispanic Black	2.64 (1.19, 5.86)	2.42 (1.06, 5.56)
Non-Hispanic Other	0.49 (0.06, 4.11)	0.62 (0.07, 5.40)
Hispanic	3.14 (1.42, 6.94)	3.06 (1.28, 7.30)
Education level
Less than high school	1.00	1.00
High school	0.67 (0.41, 1.11)	0.77 (0.45, 1.33)
More than high school	0.37 (0.21, 0.67)	0.57 (0.29, 1.10)
Smoking history3
Current smoker	2.53 (1.32, 4.83)	3.00 (1.50, 6.02)
Former smoker	1.59 (0.97, 2.58)	1.81 (1.09, 3.02)
Never smoked	1.00	1.00

¹Multivariable logistic regression adjusting for age, gender, race/ ethnicity, education level, and smoking history.

²No natural permanent teeth.

³ElderSmile participants in the former smoker and never smoked categories were determined by dividing the subset of older adults who reported that they do not currently smoke cigarettes or cigars into those who reported that they ever smoked cigarettes or cigars (former smokers) and those who reported that they did not ever smoke cigarettes or cigars (never smokers).

Discussion

This study contributes to a better understanding of the oral health and health care of community-dwelling older adults who were examined at senior centres and other venues where older adults gather, rather than those who were seeking oral health care per se. A key finding is that the study participants were twice as likely to have health insurance and recent visits over dental insurance and recent visits, pointing to the need for policy reform in order to ensure that older adults receive indicated oral health care services.

Even in socially disadvantaged communities such as Harlem and Washington Heights/Inwood in northern Manhattan, New York City, appreciable variation in levels of tooth loss and dental caries experience was evident among participants in the community-based screenings of the ElderSmile programme. Moreover, while social disparities in edentulism were evident in both the ElderSmile and NHANES 1999-2004 (US national) samples, the overall level of edentulism was lower in the ElderSmile sample (19.5%) than in the US national sample (27.3%). Ahluwalia et al. found an even lower level of edentulism (9.0%) among community-dwelling older adults who regularly utilise dental services in northern Manhattan²⁰. It may be that the social support evidenced by gathering with other adults at senior centres and the affordable clinics available in these communities through the CDM and may aid in ensuring that these segments of the population have more regular dental care than other similarly disadvantaged populations.

Factors operating at the societal, community, interpersonal, and individual levels may support or hinder older adults in realising oral health, including oral health care access and utilisation, which is consistent with social-ecological theories for describing and understanding multilevel interventions^21-23. According to Trickett, “Multilevel community-based culturally situated interventions are those that integrate a multi-layered ecological conception of the community context, a commitment to working in collaboration or partnership with groups and settings in the local community, and an appreciation of how intervention efforts are situated in local culture and context^{22, p. 257}.”

With regard to the segment of older adults in northern Manhattan who participated in the present study, it is possible that their social participation and integration in activities of the senior centres countered societal ideologies such as ageism and racism and enabled them to take advantage of services including health promotion activities and dental care that positively enhanced their oral health outcomes. The complex, multilevel relationships just delineated which determine tooth loss and dental caries in older adults are captured in the Ecological Model of Social Determinants of Oral Health for Older Adults presented as Figure 1, as adapted from a previous conceptual model²⁴.

Figure 1. Ecological Model of Social Determinants of Oral Health for Older Adults.

This ecological model for thinking about pathways whereby social determinants at various scales (societal, community, and interpersonal) influence oral health and related health outcomes for both individuals and populations of older adults is adapted from a conceptual model titled, “Social Determinants of Health and Environmental Health Promotion” that first appeared in Northridge ME, Sclar E, and Biswas P. Sorting out the connections between the built environment and health: a conceptual framework for navigating pathways and planning healthy cities. J Urban Health 2003; 80: 556-568. Note that these factors operate across the life course from pregnancy through older age to affect oral health and related health outcomes (see, e.g., Fisher-Owens SA, Barker JC, Adams S, Chung LH, Gansky SA, Hyde S, Weintraub JA. Giving policy some teeth: routes to reducing disparities in oral health. Health Aff 2008; 27: 404-412).

As depicted in this framework, oral health in older adults is due to the lifelong accumulation of advantageous and disadvantageous experiences at multiple scales, from the micro-scale of the mouth to the societal scale that involves inequalities in the distribution of material wealth and educational attainment. A corollary is that certain factors at the neighbourhood scale (e.g., access to services such as health and dental care), interpersonal scale (e.g., health behaviours such as oral hygiene activities), and individual scale (e.g. related health outcomes such as cognitive impairment) may be particularly important in influencing oral health outcomes for older adults such as tooth loss, dental caries, and periodontal disease, and may be useful targets for intervention. Note that this model is compatible with the life course perspective, as both view oral disease as cumulative^12,25. Systems science holds promise in integrating multiscalar and dynamic processes to understand places to intervene to improve oral health and health care over time and place²⁶.

A growing body of literature points to changes over time and the diversity of the older adult population with regard to their oral health and health care experiences. In a previous study conducted among US older adults attending senior centres using data from the National Survey of Oral Health in US Employed Adults and Seniors:1985-1986, Marcus et al. found that those with the least education or income and those who lived in New England or the Northeast had the fewest number of teeth²⁷. In the Florida Dental Care Study, 19% of those screened by telephone were found to be edentulous, but the subjects were younger (45 years and older) than those in the present study (65 years and older) ²⁸. At the US state level, there is marked variation in the percentage of older adults who are edentulous: 13% in California and Hawaii compared to 42% in Kentucky and West Virginia²⁹.

Samson and colleagues compared the oral health status among institutionalised older adults in Norway living in the same five nursing homes over a period of 16 years³⁰. They concluded that as more people retain their teeth throughout the life course and the prevalence of oral diseases increases among institutionalised older adults, their objective need for dental care is greater in contemporary than in the earlier time periods. Loesche and colleagues examined the oral health of four groups of older adults across the following settings: (1) lived in a residential retirement home or in the community; (2) sought dental care at a Veterans Affairs (VA) Dental Outpatient Clinic; (3) resided in a VA long-term care facility; and (4) recently admitted to a VA acute care ward with a diagnosis of cerebral vascular disease or other neurologic problem³¹. Findings were that independent living older adults had better oral health than dependent living older adults and healthy persons had excellent oral health whereas the sickest persons were either edentulous or had many missing teeth. Another study of 650 long-term care residents of six VA nursing home care units found moderate levels of untreated dental caries and periodontal disease and significant tooth loss which increased with age³². The authors identified a need for preventive therapy, restorative dentistry, conservative periodontal therapy, and prosthodontic care for these residents.

The oral health status of particular underserved communities of older adults has been reported, including that of rural residents³³, Brazilian adults³⁴, and Canadian Inuits³⁵. While barriers and facilitators to oral health care for older adults have been identified^36-38, the reasons various groups of older adults seek or do not seek oral health care at different stages of their lives are complex. For instance, a census survey designed for a Canadian municipal home for the aged found that among the dentate population, dental insurance was associated with higher oral health status, but its effect on the edentulous population depended upon age and the pattern of visiting the dentist³⁹. Our findings are consistent with the results of these and other investigators who have analysed the importance of dental caries, socioeconomic status, and smoking history into very old age⁴⁰.

Strengths and limitations

Among the strengths of this study is that it is part of the larger ElderSmile programme at the CDM. This context permitted the leveraging of resources in the form of faculty and students to assist in the dental screenings and health promotion activities, and better ensured high cooperation rates for the involved community partners, given ongoing relationships between the CDM and the administrators and staff at the involved prevention sites. Among the limitations are that the assessments reported here were restricted by the field nature of the study. Further, older adults who were home-bound or institutionalised were not included in the study. Finally, it is an assumption of the index that MT represents teeth missing due to caries only, and does not take into account periodontal disease and trauma¹⁸.

Conclusion

The major oral health outcomes in older adults (tooth loss, dental caries, and periodontal disease) usually progress slowly, are chronic in nature, and cannot be fully understood in terms of the reductionist concept of well-defined disease entities⁴¹. In concert with the community engagement perspective, a flexible approach has been adopted by the ElderSmile programme of the CDM that involves oral health evaluation at partnering sites, referral for treatment where indicated to community providers, and case management services in order to meet the oral health and health care needs of different segments of the population¹⁵. Findings from the baseline assessments conducted at the prevention centres demonstrated that the dental caries experience of ElderSmile participants varied significantly by sociodemographic predictors and smoking history. Challenges remain in linking and enhancing the use of health promotion and disease prevention education and services by older adults and their providers, and in integrating oral health and health care into other health promotion and service programmes across the life course.

Human participant protection

Appropriate Columbia University institutional review board and Health Insurance Portability and Accountability Act safeguards were followed.