Contributor

Prof J. Vanobbergen

Country – Institution

Ghent University, Belgium

Title

Changing treatment needs in oral health care in elderly patients

Summary

Nobody doubts the fact that we are an ageing population. The proportion of older people continues to grow worldwide, especially in developed countries. While the developed countries see older adults with longer life expectancies at age 65, developing countries, on the other hand, often have a far lower percentage of older adults, because of both lower life expectancies at age 65 and higher birth rates.

By 2050, it is expected that 30% of Europeans will be older than 60 years. Whereas the very old people constitute 3% of the European population today, most of the EU member states will have at least 10% of their population aged 80 years or older by 2050.

Present-day older adults are different compared to the generation of elderly living around 20 years ago. They are perhaps best characterized by their diversity. At least it is important to notice that heterogeneity is probably greater among people 65 and older than among people of any other ageing grouping. There is a diversity in health status, in education, in wealth, in cultural background, in awareness and expectations about oral health. There is even a diversity in age with ‘young elderly' versus ‘old elderly' (85 years and older). This group of young elderly represents the first to have benefited from widespread preventive programs and fluoridation programs and will be the first generation getting old while having experienced considerably less tooth loss than the previous generation. Perhaps more significant than all other characteristics, is their educational attainment, the majority of this cohort had at least secondary school education. As dental patients, these groups will have a wider range of needs and expectations and will request a wider variety of services compared to their predecessors.  Another important aspect related to their diversity is the functionally dependency. Rather than a chronological definition, a functional definition based upon an older individual's ability to seek services, seems more appropriate. This leads to a definition of three distinct groups: the functionally independent older adult, the frail older adult and the functionally dependent older adult.

All these diverse groups with their respective characteristics will have different needs and different expectations concerning oral health.

As a result of the observed worldwide trend toward less edentulism over the past few years, the actual and new generation of elderly will be faced with a variety of dental and oral problems. Coronal dental caries and root surface caries will be more prominent in the ageing population. Incidence data in recent literature shows that people 65 and older have more caries than children under 14 years of age. The risk of caries continues and might even increase in old age with the abundant use of medication that disturb saliva, and the increased consumption of cariogenic and erosive food. Caries is likely to remain a significant public health problem, especially in these older age groups.

Recent epidemiological studies show that oral hygiene is poor in older age groups and high levels of dental plaque are associated with high prevalence rates and severity of periodontal disease.

Age-specific rates for cancer of the oral cavity increase progressively with age, most cases occurring in the groups above 60 years.

The interrelationship between oral health and general health is particularly pronounced among older people. Poor oral health will increase the risks to general health and, similarly, systemic diseases and the adverse effect of their treatments can lead to increased risk of oral diseases.

An important aspect is the difference found in older age groups  between objective clinical diagnosed needs and perceived needs. Elderly people's perception of their need for oral health care services remains poor, they tended not to see oral health care as important. However, recent studies indicate that attitudes toward dentistry are changing. A more positive perception of dental care and dental awareness will be evident in the near future because the next generation of elderly people will be more educated than previous generations. Their oral health goals will include: keeping their teeth, keeping their teeth healthy and keeping their teeth pretty.

The current cohort of elderly people varies also widely in its use of dental services, from regular preventive users to non-users who report that they have not been to a dentist in more than twenty years. A lot of barriers have been reported to oral health care among older people in industrialized countries: impaired mobility, financial hardship, lack of dental care tradition, negative attitudes toward oral health and oral health care, fear, availability of appropriate services, availability of dental insurance, systemic and functional health, ...

A look at the strategies and approaches in improving the delivery of oral health care in older people,  based on how our patients, in particular these older age groups, have changed will be supported by the WHO Global Oral Health Program.  A key element in any clinical intervention will be preventive care. We believe strongly that prevention is not just for children. The ongoing ageing population will provide dentistry the opportunity to apply the actual preventive technology and markedly improve oral health of older adults. Oral hygiene will be the basis of any preventive treatment plan and this preventive plan will be integrated into any health plan agreed upon between the dentist and the patient, meeting the emancipatory need of the patient (a balance between the objective and subjective need taking into account medical, social, ethical and environmental factors). A preventive protocol will include a risk assessment model where risk factors are identified , instructions are given to the patients in their risk level and professional and personal care interventions are provided to lower the risk. Oral health education for elderly people will improve their self-care skills.

The curative and restorative care should be available, affordable, acceptable and accessible.

Beside the clinical approach, community based health promotion and oral disease prevention will considerably contribute to the improvement of the oral health status of both functionally dependent and independent elderly. Oral health care programs for residents in nursing homes providing oral examinations, dental treatment, oral prophylaxis and instructions for both nursing staff and residents will result in better oral and general health. Recent studies demonstrated that tooth brushing by nurses and caregivers combined with professional oral care by dentists and dental hygienists were associated with decreased pneumonia, febrile days and improved daily living activities, cognitive functions and quality of live.

Policy strategies will include two important items: a public health approach based on the common risk approach to integrate interventions for oral health among older adults into general health programs; a necessary reorientation of oral health care services toward prevention and the delivery of appropriate care meeting the diversified needs of the large and heterogeneous older population group.  This include a modification in oral health care systems with free comprehensive dental care for specific age groups, opening to domiciliary care and third party payment systems.

As a consequence training and education in geriatric dentistry will be oriented not only toward the bio-medical and clinical aspects of care, but also toward the sociological and behavioral factors of ageing and care. It is also essential to increase the involvement of other health professionals and caregivers in oral health education and promotion including preventive care.

Finally, both, basic research and health systems research should be encouraged. Process and outcome evaluation will be integrated using  dental clinical indicators, behavioral indicators and socio-dental indicators (feelings of well-being, Quality of Life). The extreme paucity of research on oral health promotion and population-directed oral disease prevention for older people should be overcome and compensated for by future research projects.