Older Americans’ oral health: Improvement is slow

The number of Americans age 65 or older is rising quickly. Unfortunately, the state of their oral health isn’t keeping pace.

In its third “A State of Decay” report on older Americans’ oral health since 2003, Oral Health America evaluated oral health trends in all 50 states and found that 76 percent, or 38 states earned a Composite Score of “Fair” (22 percent) or “Poor” (54 percent). Ten states received a Composite Score of “Good.” Only two states, Minnesota and North Dakota, earned a Composite Score of “Excellent,” with a 100 percent and 96 percent rating, respectively. Evaluation criteria were :

• Edentulism (extraction or loss of all natural teeth).
• Adult Medicaid dental benefits.
• Community water fluoridation.
• Basic screening surveys (public health surveillance of older adult oral health benefits).
• State oral health plans.

Top findings include:

• Tooth loss continues to be a signal of suboptimal oral health. Eight states have a 20 percent or more rate of edentulism, with West Virginia still having an older adult population that is 33.6 percent edentate.
• Although states have increased the rates of communities with fluoridated water since 2010, five states (10 percent) still have 60 percent or more of their residents living in communities unprotected by fluoridated water. Hawaii (89.2 percent) and New Jersey (85.4 percent) have the highest rates of unprotected citizens, representing an unnecessary public peril 70 years after Community Water Fluoridation was introduced and since named a public health best practice, according to Oral Health America.
• Persistent shortage of oral health coverage. Sixteen percent (8 states) cover no dental services through Medicaid, and only four states (8 percent) cover the maximum possible dental services in Medicaid.
• Critical lack of a strategic plan to address the oral health of older adults. Forty-two states lack a State Oral Health Plan that both mentions older adults and includes SMART objectives (Specific, Measurable, Achievable, Realistic and Time scaled). Of the 42 states, 14 lack any type of State Oral Health Plan.
• Inadequate surveillance of the oral health condition of older adults. Twenty-three states have never completed a Basic Screening Survey of older adults and have no plan to do so.

Contributing factors
Older Americans are at risk of adverse oral health for a variety of overlapping reasons, according to the Oral Health America report. The most significant include:

• Income, race, ethnicity, disability and mobility. Oral diseases disproportionately affect low-income individuals, racial and ethnic minority groups, older adults with physical and intellectual disabilities and people who are homebound or institutionalized. OHA cites literature showing that older African-American adults are almost two times more likely than Caucasian adults to have periodontitis (gum disease); lower-income older adults suffer more than twice the rate of periodontitis than more affluent individuals in the same age group (17.49 percent versus 8.62 percent); and Americans who live in poverty are 61 percent more likely to have lost all of their teeth when compared to those in higher socioeconomic groups.
• Declining overall health. Many older adults experience poor oral health associated with multiple morbidities and chronic health conditions. For example, evidence of the association between periodontitis, diabetes, and heart disease has emerged in recent years, along with increased awareness of oral conditions such as xerostomia, also known as dry mouth, associated with prescription drug use, according to the report.
• Inadequate knowledge about oral-systemic health factors. According to Oral Health America’s 2015 Public Opinion Poll, lower income and less educated older adults are more likely to misunderstand oral health’s connection to systemic health. The poll also found they are less likely to know that medication can affect mouth health and that they need to continue visiting the dentist even when they have dentures or missing teeth.
• Emergency rooms treating more patients with dental emergencies. The number of Emergency Room Dental (ED) visits rose from 2.11 million per year in 2010 to 2.18 million in 2012. More than 100 of these dental patients died in the ER, and nearly 85 percent were there for no additional reason. Total charges for ED visits were $1.6 billion, and the average charge per visit was $749. Medicaid accounts for $520 million or about one-third of total ED charges. Even though older adults account for only 4.5 percent of total charges, the average charge among elderly adults was almost twice that as for younger age groups.
• Minimal resources to pay for oral healthcare. Older adults with dental insurance are 2.5 times more likely to visit the dentist on a regular basis. A recent Oral Health America survey by Harris Poll revealed that more than half of people who earn less than $35,000 a year reported that they do not visit the dentist routinely because they lack insurance or cannot afford to visit the dentist.
• Lack of an oral health benefit in Medicare. Oral Health America’s 2015 public opinion survey found that 52 percent of people aged 50 and older—regardless of income or education—either did not know or believed that Medicare covers routine dental healthcare. In fact, less than 1 percent of dental services are covered by Medicare. Older adults are left with the option of paying for dental care out-of-pocket or purchasing a Medicare Advantage Plan, adding another cost burden for people largely living on fixed incomes.

What to do?
Oral Health America proposes six recommendations related to oral health that would contribute to older Americans aging healthily and independently:

1. Advocate for financially viable oral health benefits in publicly funded insurance.
2. Work to implement the oral health screenings provision in the Older Americans Reauthorization Act of 2016. For the first time, the Older Americans Act includes a provision allowing aging networks to use funds they already receive for disease prevention or health promotion activities to provide oral health screenings.
3. Sustain community water fluoridation as an evidence-based public health practice that positively impacts oral health.
4. Support caregivers through passage of the RAISE Family Caregivers Act (S.1719), introduced in Congress in July 2015. The act would require the development of a national strategy to support family caregivers’ health and well-being while caring for others.
5. Include provisions for older adults in every state’s Oral Health Plan.
6. Establish continuous surveillance of older adults’ oral health by requiring states to conduct a basic screening survey.

To view the report, “A State of Decay: Are Older Americans Coming of Age Without Oral Healthcare?” go to http://b.3cdn.net/teeth/492f646d03c892b6aa_l6m6bj3ql.pdf