Oral Health and Aging

Oral diseases and conditions that are associated with aging concomitantly result in an increased need for preventive, restorative, and periodontal dental care. This is particularly true of seniors aged 65 years and older who are economically disadvantaged, who are members of racial/ethnic minority groups, and who are institutionalized, disabled, or homebound.

Nearly 19% of seniors no longer have any natural teeth. Loss of teeth increases with age and varies by race/ethnicity.¹ According to 2011–2012 data reported by the National Center for Health Statistics, adults aged 75 years and older (26%) were twice as likely to be edentulous as those aged 65 to 74 years (13%). Non-Hispanic Blacks (29%) were significantly more likely to be edentulous compared with Hispanics (15%) and non-Hispanic Whites (17%). A Massachusetts survey revealed that 34% of seniors in nursing homes have urgent and major dental health needs.²

Tooth loss has multiple impacts on health and well-being. Seniors who have lost all or most of their teeth often end up avoiding fresh fruits and vegetables—basic elements of a healthy diet. Relying on soft foods that are easily chewable results in a decline in nutrition and health. In addition to pain and difficulty speaking, toothlessness often leads to embarrassment and a loss of self-esteem contributing to loneliness and social isolation.

More than half (53%) of seniors have moderate or severe periodontal disease. There is increasing evidence of the association of periodontal disease with chronic conditions including diabetes, heart disease, and stroke. Oral health conditions among seniors with chronic conditions are often exacerbated by use of medications. About 400 commonly used medications can cause dry mouth, which heightens the risk of oral disease.³

DENTAL INSURANCE COVERAGE

About one half of seniors do not go to the dentist.⁴ More than one in five Medicare beneficiaries have not visited a dentist in five years.⁵ Cost is the major reason why seniors do not seek or utilize dental care. Approximately 70% of older Americans lack dental insurance. The remainder are covered through employer-sponsored plans, Medicaid, or self-purchased supplemental insurance.

For its 55 million beneficiaries, traditional Medicare does not cover routine dental care. Medicare Part A (hospital insurance) covers very limited “medically necessary” benefits related to certain dental services provided during a hospital stay. Medicare Advantage plans that do offer dental coverage provide minimal benefits. According to the Medicare Rights Center, most beneficiaries do not realize that dental services are not covered and express concern about how to access and afford needed dental services. Under Medicaid, states have the option of providing adult dental coverage. As a consequence, four states do not offer a dental benefit and 15 states offer emergency-only coverage.⁶ Access is further hampered because 80% of dentists do not accept Medicaid because of low reimbursement rates.

Upon retirement, seniors often lose their dental insurance. Only two percent of retirees retain dental coverage.⁷ With supplemental dental insurance, the coverage cap on claims generally ranges from $1000 to $1500 per year and has not increased in 30 years.

SYSTEM BARRIERS TO CARE

Many seniors incur high out-of-pocket dental expenses. For example, the average cost of an implant is $4000 or more if bone graft and anesthesia are needed. For the large segment of seniors who live on fixed incomes, this is unaffordable. Seniors below 150% of the federal poverty level are three times as likely to report unmet dental needs compared with those with incomes over 300% of the federal poverty level.

Complicating this situation are overall and regional shortages of dental practitioners willing to treat seniors. More than 60% of states have substantial provider shortages and racial/ethnic diversity of providers is lacking. Only six percent of dentists are racial/ethnic minorities.⁷

ADDRESSING THE NEEDS

To address the oral health needs of seniors, a multiyear, multipronged approach is needed. This includes tackling two cultural norms: First, we must challenge the concept that oral health care is optional rather than an integral part of health care. Second, we cannot yield to the ageist view that accepts less-than-optimal oral health or asserts that seniors should be resigned to losing their teeth and living with oral disease.

A successful approach encompasses the following components:

1. A vigorous education campaign that will get this issue on the public’s radar screen. The campaign must demonstrate why society should care about this issue and how it would benefit if these issues were addressed.

2. A broad and potent coalition that builds broad support particularly among credible groups with no financial stake in the outcome. It should include national stakeholders, collaborators, and champions in executive and legislative branches.

3. A set of financially and politically feasible options that includes a set of essential benefits and supports quality care and value-based outcomes with the additional goal of reducing costs. A recent study by Avalere (2016) for the Pacific Dental Services Foundation estimated the cost and savings of a new Medicare Part B benefit covering the initial and ongoing treatment of periodontal disease for beneficiaries with diabetes, coronary artery disease, or stroke. It concluded that this new benefit would generate a net savings for Medicare of $63.5 billion from 2016 to 2025.

4. At the same time, it may be advisable to work with private-sector insurers and providers establishing risk-based coordinating entities such as accountable care organizations. These organizations would have more flexibility in benefit design and in applying the results of retrospective claims research demonstrating the link among oral health, periodontal disease treatment, and medical costs in practice environments.

5. New models of delivery are needed to treat the increasing population of older adults who are retaining more of their teeth and have multiple chronic conditions that require multiple medications. In addition, new delivery models are needed to address the needs of the homebound and long-term-care populations in nursing homes and assisted living sites. Mobile technology, tele-dentistry, adoption of oral health teams, and integration with geriatric and primary care offer opportunities for significant improvements in care delivery models.

CONCLUSIONS

The population of older adults is growing and is increasingly diverse. Dental practice and dental systems can and should be transformed to ensure the oral health of all seniors. Focusing on the oral health of seniors benefits not only those who are seniors today, but also seniors in the future.