With the rapidly increasing number of older adults in the U.S., dentists must question if we are adequately prepared to accommodate these older adults within our practices. Increasing comorbidities and frailty associated with aging for many older adults make it complex for proper delivery of dental care. In addition, the implications of oral health affecting systemic health make proper and easy access to dental care for older adults even more crucial. Many have investigated this topic from a patient-related perspective.
However, it is the goal of this blog to explore what types of barriers dental professionals experience in treating older adults, not patients. It is my hope that we can become aware and properly respond, individually and as a group, to eliminate or reduce these barriers.
Bots-VantSpijker and coworkers carried out a systematic review of seven suitable articles to identify barriers to delivering oral health care to older people in the care homes experienced by dentists.
This review identified four barriers: (1) the lack of adequate equipment in a care home, (2) No area for treatment available, (3) lack of adequate reimbursement for working in a care home, and (4) inadequate training and experience in delivering oral health care to older care home residents.
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Then the same authors subsequently published another very interesting study in which they surveyed 595 dentists in private practice in the Netherlands to find out the types of barriers dentists experience in treating community-dwelling older adults aged 75 and older. A total of 15 questions were asked and the opinions and responses of participating dentists can be seen in the table below.
Source: Bots-VantSpijker PCet al. Opinions of dentists on the barriers in providing oral health care to community-dwelling frail older people: a questionnaire survey. Gerodontology 2016 Jun;33(2):271
Many interesting opinions can be noticed here. 42% of participants were unwilling to visit homebound older people for a periodic oral examination. The authors express that this may be due to a lack of dental equipment and the feeling of being unprepared for this sort of task. This certainly is a complex issue without any quick and easy solutions. If our profession is unwilling to address this issue, public policymakers may eventually propose alternative solutions such as the utilization of mid-level providers such as dental therapists.
It is refreshing to surf the internet and find that there are quite a few mobile dental services available nowadays although even these services may not be available in most areas in the U.S.
59% considered that the reimbursement of oral care to frail older people is poor. Increasing reimbursement rates may not be easily achievable by dentists unless the government or insurance industry takes the initiative which may be uncertain or even unlikely. Furthermore, we as a profession have yet to unify our voices in advocating for Medicare coverage of basic dental services.
In the meantime, dentists in private care may need to look for innovative ways to develop elective (not covered by insurance plans) but highly desirable dental services for older adults to compensate for low reimbursement for basic services reimbursed by a third party if any.
Only about half of the participants felt that they have sufficient knowledge of the adverse effects of medications used by older people and that they are capable of providing care to cognitively impaired frail older people. I believe this is where we need to step up as a profession to increase the quality and quantity of geriatric dental education for undergraduate dental students as well as actively practicing dentists. It is urgent that more practical continuing education in various geriatric dental topics should be available to busy dental professionals.
Most notably, 66% of participants reported that there are limited opportunities to refer frail older people with complex oral healthcare problems to a colleague with specific knowledge and skills. Yes, we are talking about specialists in geriatric dentistry that do not exist in the U.S. as we speak. What will happen in this arena remains to be seen. However, in the meantime, I believe that there should be considerably more postgraduate-level geriatric dental programs available in order to meet this specific demand for skillful geriatric dentists regardless of specialty recognition. These highly skilled geriatric dentists can easily market their availability in the community, and I believe they will be welcomed with open arms by their colleagues.
Herman Ostrow School of Dentistry of the University of Southern California offers two different postgraduate level geriatric dentistry training programs (1 year Certificate and 3 year Master’s Degree) that are flexibly designed for actively practicing dentists to fit within their schedule and lifestyle. Considering how inadequately prepared the dental profession is for the influx of the rapidly growing number of older adults, further studies and research in geriatric dentistry are much needed to support practicing dentists to treat older adults more appropriately and safely with confidence. A huge task indeed.
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References:
- Bots-VantSpijker PC, et al. Barriers of delivering oral health care to older people experienced by dentists: a systematic literature review. Community Dent Oral Epidemiol. 2014 April;42(2):113-21. Doi: 10.1111/cdoe.12068
- Bots-VantSpijker PC, et al. Opinions of dentists on the barriers in providing oral health care to community-dwelling frail older people: a questionnaire survey. Gerodontology 2016 Jun;33(2)268-74. Doi: 10.1111/ger.12155
