Health Promotion and Aging
     "Oral Health"

       Helen C. Gift, Ph.D.
Epidemiology and Oral Disease Prevention Program
    National Lnstitute of Dental Research
       National Institutes of Health

1. BACKGROUND

There is a growing interest in the oral health needs of older persons, particularly as the size of the
population age 65 and older increases and as the composition of th
increase in population is occurring in the oldest-old-age 85 and over B t age group changes. The largest
                                   -a group for which little is known

regarding oral health.

Historically, older adults have had fewer financial and social resources than have other age groups, but
evidence suggests that the picture is changing. For example, in 1984, 91 percent of older adults received
Social Security benefits; 24 9 ercent received income from private pensions, and 68 percent received
income from private assets.  These represent considerable improvements over the past two decades.
Furthermore, it is projected that improvements in the socioeconomic status of older individuals will
continue over the next several decades.  This does not mean, however, that all older Americans will be
financially able to secure the necessary benefits from health care. Even considering these improvements,
general health and medical expenditures are sizable.  While older Americans represent nearly 12 percent
of the population, they account 2fy 27 percent of all health expenditures and purchase 25 percent of all
medications sold in this country.

In the most comprehensive, published data-the National Medical Care Expenditure Study (NMCES)-it
was reported that three percent of the per capita health expenditure for those 65 and older went for
dental care in 1977. Modest increases were observed in mean dental expenditure per older person between
1970 and 1977-from $31 to $40 (1977 dollars)5  Traditionally, dental care for older persons has been an
out-of-pocket expense. In 1981, nineteen percent of tkose ages 65-74 had some dental insurance, while 10
percent of those age 75 and older had some coverage.  @elf-reported dental insurance is often at a high-
er level for this age group.) In spite of major successes in dental research, treatment and prevention over
the past several decades, oral diseases of all kinds remain among the most costly health prob  ms
prevalent in the United States, adding up to a national bill of $22.7 billion for dental services in 1986. 3p

Older Americans traditionally have accounted for large proportions of less advantaged categories and are
more likely to be without major support systems, judged by sociodemographic and access measures. For
example, there are high proportions who 1) live alone and are widowed, 2) have few ye  r
are below the poverty level, 4) are not in the labor force, or 5) live in non-urban areas. f 8 g\eiJy~ytion, 3)

         >

Improvements in oral health status and dentally-related. behaviors of the older age group have been
observed over the past several decades.  Continued improvements in oral health status, oral hygiene
practices and dental service utilizatipy ~5 e projected as upcoming cohorts continue to become better
~~e~s~sdrPlo~!l e ffluent and dentate,    yet, the older individual will continue to be at risk for oral
         There is no research evidence to suggest that tooth loss or specific oral diseases are a
necessary concomitant of the aging process, nor do al
in terms of oral health or dentally-related behaviors. {persons over age 65 fall into one descriptive group
                             Rather, it appears that there is a great deal of
heterogeneity in the older population.15 k&a ise, there is no evidence that older persons are, by
definition, in poor general or oral health.     The combination of genetic predisposition, lifestyle and
socioeconomic environment, exposure to fluorides, oral hygiene at home and dental-visit behaviors
             lifetime, contribute to the state of oral health, or lack thereof, in later

Maintaining quality of life through retention of the dentition requires the prevention and/or treatment of
oral diseases beginning at younger ages and continuing throughout the lifetime. Preventive activities for

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all ages include professional and self-care.  Professional preventive activities include examination of the
dentition, supporting structures and muscosal tissue for decay, attrition, abrasion, periodontitis,
recession, oral cancers and evidence of oral symptoms of systemic diseases, as well as oral hygiene
education and regimens such as prophylaxis and fluoride applications. Appropriate restorative tBatment
of observed conditions is accepted as preventing further destruction of oral structures.    The
prescription for maintaining optimal oral health through self-care is the same for the older person as it is
for the younger one: daily toothbrushing with a fluoride toothpaste, use of a fluoride and/or antimicrobial
rinses, interdental cleaning, dental visits at least once a year and observation of a balanced diet and food
intake pattern.  Some oral conditions may be prevented or retarded by a change in behaviors including
stopping ~"4"  of tobacco, improving toothbrushing technique or abandoning inappropriate chewing
behaviors.   Other oral conditions and appropriate treatments may be controlled through careful
monitoring of systemic conditions and medications.

The overall quality of life of any  individ    articularly an older one, can be enhanced through oral
diseases prevention and health promotion. Y'b'a~ The health of the oral cavity--teeth, oral soft tissues,
underlying bone, neural apparatus, immune system and glandular mechanisms-is critical to chewing, tast-
ing, swallowing and speech, as well as adaptation to dentures if they are worn. Health of the oral cavity
also contributes to nutrition, facial esthetics and protection from systemic infection and injury.

Most older Americans are relatively healthy and functionally independent. They can be expected to cont-
inue to follow habitual patterns of oral hygiene behavior and use of dental services. Still, an estimated 40
percent of older Americans are 4s ejected to constitute a special-needs category based on complex health
problems and functional status.    These include:  emotional and physical stresses associated with the
aging process; physical an  mental disabilities resulting from chronic diseases and physical and financial
barriers to access to care. 86

IL ORAL HEALTH STATUS-OUTCOMES OF ORAL HEALTH PROMOTION

A. Data Sources

Descriptions of the oral health and related behaviors of older Americans are available from a number of
national and local sources. National data are the most readily available, but rziany of these studies placed
an upper limit on age in the sample.  Furthermore, those studies which do include older individuals
typically have not focused on this age group, thus the ability to analyze the data may be iimited by the
number of older individuals in the subsample.  The weakness in all surveys conducted to date is the near
absence of a comprehensive data set on older individuals--including attitudes, knowledge, behaviors,
environmental/structural conditions, as well as clinically-determined oral health status.

The major surveys which include both interview and clinical examination data on older Americans are the
National Health and Nutrition Examination Survey (NHANES I), Hispanic Health and Nutrition
Examination Survey (HHANES), and A St d
with depaid Dental Care: 1981    # sff Dental Health Related and Process Outcomes Associated
                  (HRSA).    A National Institute of Dental Research (NIDR) study-
National Suivey of Oral Health in U.S. Employed Adults and Seniors: 1985~86-contains complete clin' al
but minimal self-reported data on a sample of 5686 older Americans who attended 208 Senior Centers. 8

Most other national studies do not include clinical examination and are based on data collected by
interview, including information on dentally-related behaviors, attitudes and knowledge. An example is
the National Health Interview Survey (NHIS) conducted by the National Center for Health Statistics.
Dental health questions have not been a routine part of the core questionnaire since 1981, but issues
related to dental health have been included regularly in supplements. Other examples are the 1980 NCHS
Personal and Preventive Practices Survey; NHANES I Epidemiologic Followup Study; the National Medical
Care Expenditure Survey, 1977; the National Medical Care Utilization and Expenditure Survey (NMCUES),
1980; and Center for Health Administration Studies and National Opinion
Medical Expenditures and Use of Health Services: 1953,1958,1963,1964,1970. p$?e$bch Center Surveys of

Descriptions provided in this manuscript are based on reported correlations between selected measures of
predisposing and enabling factors, perceived r,eed and oral health variables which, most often, have not

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been analyzed in combination as part of any predictive model.  Emphasis has been placed on national
probability samples and verified data over convenience samples or self-reported data. In some cases,
reports may appear inconsistent, as recent analyses are providing more in-depth understanding of issues
than was available when earlier research was published; for example, separation of the dentate and
edentulous groups in the analysis of dental expenditures, visits and oral hygiene behaviors.

B. Oral Health Status

1. Fdentulousness (Absence of Teeth)

Traditionally, the primary measure of oral health status of older populations has been the extent of eden-
tulousness. It appears now that each succeeding gener t'o
                       li
more individuals are retaining their teeth as they age.  fghas improved compared to older cohorts and
                              Based on NHIS data, in 1958, 67 percent of
persons over age 74 reported being edentulous. The proportion of edentulous persons in this age category
has decreased over the years to 60 percent in 1971 and 45 percent in 1983. Decreases also have been seen
in populations as they reach the age group 65-74, with 55 percent being edent 98 us in 1958, 45 percent in
1971 and 34 percent in 1983. Declines were seen among both females and males.  Edentulousness is rn$&e
prevalent among older persons below the poverty level and among those with fewer years of education.

One fourth (27%) of those ages 65 and older who attended senior centers in 1985-86 had 20 teeth or more,
while 17 percent had 1-12 teeth.  The average number of teeth decrea
average being 18.1 at age 65 and 15.1 for the age category age 80 and over. j%d steadily with age, with the

Presence of teeth appears to be related to socioeconomic status and race. Among the Baltimore
Longitudinal Study panel members, a primarily healthy, middle-socioeconomic, well-educated, volunteer,
older, study group-the averag?plder person has 70 percent of natural dentition (20 of 28 teeth&and only
4 percent wear full dentures.  Data from a North Carolina study, encompassing 15 yeas? indicate a
decrease in mean number of missing teeth in succeeding cohorts of whites, but not in blacks.

The functional adequacy of dentition is further reflected in the measured treatment needs for prosthetic
services: in the 65 and older age group in 1981, 8 percent needed bridge unit(s); 19 percent needed partial
denture(s); 9 percent needed full denture(sL6  Based on self-report in 1983, approximately one-fourth of
~~~on~~~,s~~~~~~~~~~eeded new dentures.  This proportion increased to over one-third among those

2. Caries

Caries in older adults is exhibited mostly as recurrent caries surrounding failing restorations, cervical
caries associated with plaque accumulation at the gingival margin, root caries Y-f? ciated with gingival
recession or as a side effect of medical conditions or pharmaceutical challenges.  Research in$jcates
that a small portion of individuals account for most of the restorative treatment needs for caries.

In 1985-86, older adults attending Senior Centers had an a
faces.  About 92 percent of these surfaces being
increase in the prevalence of root s Yaf
                         r aces caries. ii YP rage of 20 decayed or filled coronal tooth sur-
                   1 . 35 Additionally, as individuals age, there is an
                                Well over one-half (63%) of the indivi
                                   Ill uals
over age 65 have root surface caries.  Only about one-half (54%) of these root surfaces are filled.

Prevention of root caries is particularly important, since there is insufficient knowledge of optimal ther-
apeutic approaches for root caries, making restoration difficult.  While fluoride traditionally has been
associated with prevention of decay in children, a recent study in Canada showed that the occurrence of
root decay in adults with lifelong histories o 1493 tjoridated water consumption was approximately 60
percent less than it was in nonfluoridated areas.

3. Periodontal Diseases

Periodontal disease is a frequent self-reported chronic condition in persons ag
hypertension, hearing loss, heart conditions, vision impairments and diabetes.

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                older persons including gingivitis, periodontitis, gingival recession and
             1985-86, over one half (53%) of older adults attending Senior Centers had
               or more, 23 percent had supragingival calculus and 66 percent had
subgingival and supragingival calculus-prevalence rates greater than younger adults. Appl$ximately 22
percent of older individuals have loss of attachment of 4 mm or greater at one or more site.

The prevalence of periodontal diseases appears to increase with age." l3 36 The higher prevalence and,
severity of periodontal diseases among older persons may not
rather, may reflect the accumulation of disease over time. 5E suit from enhanced susceptibility, but
                                   If periodontitis is defined as mild

pocketing, there may not be greater proportions of older adults with disease.  With the increasing
numbers of adults in this age group, however, this remains a considerable disease issue. The number of
teeth lost due to periodontal diseases is not f~ 1y ,
                              o n but the number of teeth which need to be extracted
from periodontal disease increases with age.    Whether periodontal diseases are episodic or steadily
progressive is still undecided, but evidence suggests that those persons who have retained their teeth to
old age have a type of periodontitis that, at any given site, usually progresses slowly.

4. Oral Cancer

The prevalence of oral cancer is greater among men tha
                       ch women and increases with age, with the great
majority of cases occurring in people over t          ln 1987, 29,800 new cases of oral cancer were
discovered and 9400 deaths were estimated. $5 age of 40.
                        In a series of screenings conducted between 1957 and 1972
among older white adults in Minnesota, IO percent had at least one oral lesion unusual e
recorded. Leukoplakia had a prevalence of 29.1/1000 and oral cancer a prevalence of .9/1000. YY$Jap~
gressive impact of smoking, drinking and use of smokeless tobacco on the condition of teeth and develop-
ment of soft tissues lesions-specifically oral cancer-is more apparent in older individuals.  Use of
     roducts and alcohol, both individually and in combination, is associated with denture-rel  ed
     Also, lower educational levels and infrequent dental visits are associated with oral lesions. $3

5. Other oral conditions

Other oral conditions are reported more often in older than younger adults. These include oral motor
function and sensori-motor problems, such as difficulties in chewing, tasting or swallowing, oral effects
of systemic diseases, acute and chronic pain, among others.

No real evidence exists that a generalized deterioration in oral motor function or performance occurs
with aging, but selected oral conditions-alteration of lip posture, masticatory muscle function,
increasing dysfunction of the tongue and suspensory musculature-appear to be related to aging.
Functional problems which might result from these conditions include labial spill of saliva, inability to
prepare food for swallowing, altered speech, dysphagia, traumatic bite injury, increased mouth
breathing. Very serious dysftf ctions in oral motor function can lead to fatal choking, laryngeal food
&netrat-lon and regurgitation.

Certain diseases of the salivary glatis are more common in older adults, specifically local inflammatory
diseases and Sjogren's syndrome.    Acute suppurative sialadenitis, as well as chronic recurrent
sialadenitis, is more common in elderly, seriously ill, debilitated patients. The prevalence of Sjogren's
syndrome-lymphoepithelial lesions-is second only to rheumatoid arthritis among the connective tissue
diseases and a typical onset is age 40-60. In addition, there i& some indication that submandibular saliva
and possibly minor gland secretions may be affected by aging.

Evidence suggests that there is a decline in bone mass so that by age 70, the total is only about 60
percent of the peak. These changes can be observed in the oral cavity, can be exacerbate
disease processes and can contribute to functional problems, such as poorly fitting dentures. If ?"qEertain

Some oral conditions have become stereotypic of agingaiminution of stimulated parotid fluid output,
structural changes in epithelium, atrophic change in oral mucosa, and generalized decreases in taste
acuity and perception--but research has led increasingly to a lack of consensuc on these conditions.
Evidence suggests that other factors, such as polypharmacy, inadequate nutrition, or systemic diseases,

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may be the precursors of these conditions and not age, per se. l4 41 42 43 Other age-reIated change- `1
taste and oral sensation, e.g. touch, temperature, and pressure sensibility, have been observ,d b,t :. I
well described or documented.

111. AREAS OF PARTICULAR CONCERN

A. Concomitant Medical Conditions, Pharmacological Challenges and Oral Conditions

1. Nature of Problem

There are approximately 120 physical or mental diseases which manifest symptoms in the oral cavity or
affect ab `ty to perform dentally-related behaviors.
with age."                     The prevalence of most of these conditions increase
       For example:

o Slower movements, less agility, impaired vision and hearing, urinary dysfunction, vascular
insufficiency, among other things, may affect the ability to follow recomm
and may make it impossible for an older individual to visit a dental office; zidations for self-care

o The oral symptoms which result from hypofunctional or nonfunctional salivary glands are unpleasant
and painful and affect vital functions such as speech, taste, chewing and swallowing. Xerostomia
is highly associated with prescribed radiation or medications. It ma~~~e~n~i~r~~~~~~~~~ibility
infections-both oral and systemic-and have an impact on nutrition
to caries and periodontal diseases;

o Cancer in the head, neck and oral cavity increases with age;

o Aging diabetic patients are vulnerable to oral i nfi ections and impaired healing which may lead to
periodontal diseases and related oral problems;

o Psychoses, affective disorders and sleep disturbances may affect the patient's willingness or
ability to perform appropriate  r
health, speaking or swallowing?' 1 hygiene or seeking of dental services, thus affecting oral

o Neurological problems, including stroke and Parkinson's disease, can adversely affect oral
functions. Dementing conditions such as Alzheimer's disease increase with age. Traditional
education, training or compliance methods might be
                     5tf effective in changing any inappropriate
dental health beliefs or behaviors for such patients.

o Chronic and acute pain can adversely affect oral functions and the provision of dental care.

Oral health Status also can affect general health status. Examples include the impact of missing teeth,
inadequate restorations or poorly fitting dentures on food intake which ultimately might affect
nutrition. Mso, .untreated o# infections can result in serious systemic complications, especially in
immunocompromised patients.

Medications for age-related systemic conditions--e.g. congestive heart failure, diabetes, depression, sleep
disturbances, chronic pain--influence the oral conditions observed, cpytribute to the cause of some oral
conditions, and affect the kinds of treatment which can be provided.   More than 75 percent of a rural
Iowa population age 65 and older took medications that could affect oral health or dental treatment.
About one-half of the older individuals in the Iowa study took drugs which may cause xerostomia, e.g.
antihypertensives, antihistamines, decongestants, diuretics, pain killers and tranquilizers.   Other
commonly used drugs affect blood clotting and cause oral ulcerations or sloughing of soft tissue. About
one-fourth of these older adults took muscle relaxants and medications for anxiety, which can interact
adversely with drugs commonly used in dental surgery for sedation and pain relief. Drugs used commonly
for cardiac conditions by older persons can interact adversely with local anesthetics containing
epinephrine.  Broad spectrum antibiotics, medications for diabetes, systemic corticosteroids, phenytojn
for convulsions, nifedipine used for cardiovascular disease, medications for angina and congestive heart

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failure and antipsychotic medications each may be associated with abnormal healing, predisposition to
infection, overgrowth o &' mgival tissue, inability to tolerate long, stressful appointments and/or abnormal
oral-facial movements.   Also, dental visits create anxiety for many older individuals, a condition which
may be heightened by some drugs.

2. Mechanisms and Interventions Established To Deal With Problem

Health education and promotion efforts have been used to increase the awareness of older adults or care-
takers regarding systemic conditions and medications which relate to oral health. Examples include:,
Radiation, Chemotherapy, and Dental Health, Detection and Prevention of Periodontal Disease in;
Diabetes and NIDR Fact Sheet: Dry Mouth (Xerostomia).

Health care providers can play an active role in early diagnosis of systemic and oral conditions, assisting
the patient and each other in limiting the progressio
dentist, pharmacist and physician is very important. ivYi diseases. Emphasis on the interaction among the

Education for dentists, physicians, nurses and pharmacists, both in basic training and continuing
education, should provide increased attention to medical conditions and pharmacologica challenges
exhibiting symptoms in the oral cavity. Increased emphasis should be given to recording, routine monitor-
ing and clinical application of medical histories, particularly those specific to changes since the most
recent visit. Review of related medical conditions involves recording medications whichthe individual is
taking. This is particularly important for patients who are taking multiple medications."

Dentists should be knowledgeable regarding alternate treatment approaches for compromised patients.
For example, the removal of oral infection and employment of antibiotic therapy is especially critical for
patients undergoing cardiac or joint-replacement surgery.  Where discontinuing medication with negative
oral side effects or substituting less harmful agents is not possible, a protective regimen for the oral
environment can be instituted. This could include sugar-free chewing gum or candy, artificial saliva, con-
trolled-release devices and specific plaque control programs to reduce bacterial burden.

The National Foundation of Dentistry for the Handicapped and the American Society for Geriatric
Dentistry encourage programs which address the needs of older individuals. They encourage dentists to
consider the style of furniture, positioning of the patient, office lighting, staff assistance and other
aspects of practice to improve the ease and comfort of the delivery of services to the older patient.
Hearing and sight limitations have been acknow!edged in some dental disease prevention programs for the
impaired older adult.

The American Denal Association (ADA) is developing hospital protocols for twelve medical/surgical con-
ditions, including head and neck radiation therapy, cardiovascular disorders, cancer chemotherapy and
end-stage renal diseases.   These protocols,  will assist physicians and hospital-based dentists in
understanding oral complications of diseases, why they are important and what to do about them. The
Veterans Administration (VA) has established guidelines for the oral health of medically compromised
patients in long-term care facilities to assist the health care team.

The American Society of Hospital Pharmacists sponsors a project through affiliated state c&ptefs which
distributes materials to educate older consumers on appropriate drug use and compliance.   Similarly,
the American Pharmaceutical Association, in collaboration with state pharmacy associations, has encour-
aged the use of Medication and Self-Medication Awareness Tests and Health Check Test to de  onstrate
to older consumers the importance of having information about medicines and how to use them. i%  "Share
the Health", a National Pharmaceutical Council project provides education and T-8 istance for older adults
regarding medication identification and purpose through "Operation Brown Bag".

3. Apparent Deficiencies

More basic research and health professional education is needed to clarify the linkages among systemic
conditions, medications and oral problems seen in o!der individuals.  More health services research is
needed to develop, evaluate and demonstrate ways to improve: 1) interaction among the dentist,

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physician, pharmacist and patient regarding health care, * 2) clinical applications of information on medical
histories in the practices of dental and medical professionals; and 3) the routine updating of medical his-
tories in the practices of health care providers; 4) oral health care of medically compromised patients in
long-term care facilities.

B. Orientation toward Oral Health and Oral Hygiene

1. Nature of Problem

The importance attached to oral health is a key factor dete IF ining actual oral health status and the
behaviors which influence its attainment among older adults.   A range of attitudinal, behavioral and
socioeconomic factors over a lifetime interact to form that orientation. In turn, these factors affect an
individual's performance of oral hygiene practices, dental visit behaviors, and compliance with
recommended regimens.  Attitudes, knowledge and beliefs appear to have the
dentally-related behaviors among older adults as they do among younger adults. gjrne correlations with
                                                          As current middle-
aged adults become older, it is assumed that they will keep appropriate levels of knowledge and attitudes
thus creating a more informed older sector in the future.

Perceived oral health status, as measured by the self-reported presence of conditions, has be
investigated in several research projects and is often a key explanatory variable for visiting a dentist. 22
In a study of older rural Minnesota residents regarding perceived overall health status and presence of
common health problems, dental (or denture) problems were frequently mentioned conditions along with
vision problems, arthritis, hypertension and obesity.  There were no differences in self-reported dental
problems when the age group 60-74 was compared to that 75 and older.  Other stu ws have shown that
dental problems receive less mention than other chronic conditions of older persons. 4;  ln a 1981 national

survey, only 18 percent of dentate individuals age 65 and older--compared to 28 percent of younger
adults-reported two or more oral problems (e.g. broken tooth, bleeding gums, sensitive to hot and cold,
canker6sores, toothache, sensitive to sweets), while only 10 percent reported problems with chewing and
biting.

In a study of older Massachusetts health care panel study members, perceived need for care was best
explained by perceived oral health status, dentate status and previous dental utilization. Age*ger se, was
not significantly related to perceived need and socioeconomic indicators were not predictive.

Perceived oral health status is not always a reflection of actual clinical conditions.45 47 48 For example,
in a recent study of older patients scheduled for periodontal treatment `4'1p nly 18 percent were aware
before arriving at the dental school that they had periodontal disease.   In another study, it was
estimated that 70 percent of older adults need treat "48 nt, 25-40 percent of older adults perceive that
need, and 20-35 percent of older adults seek treatment.

Lack af perceived need has been a primary reason for not seeking dental care. 8 24 53 55 62 63 64 Addi-
tionally, a low re Al tive priority usually is assigned to dental care in comparison to other health and func-
tional activities.   Survey research indicates that the combination of perceived need and attitudes
toward oral healqk gp d e  is y as considerable predictive power in explaining the use of dental services
by older adults.   6Q gi & 6l$  For example, in a sample of older individuals in senior centers in the
Seattle area, those who attributed greater importance to oral health, believed they needed dental
had more teeth, and had more positive dentally-related beliefs, were more likely to seek dental care. we7

Older Americans seem to be resigned to accepting their oral health status, yet express positive attitudes
regarding oral health. Fifty seven percent of adults ages 65 to 74 believe nothing can be done to change
oral health, while 70 percent of those age 75 and older believe this.  Only 32 percent of older adults
strongly agree that some people have good teeth and other have bad teeth no matter what they do, while
9 percent strongly agree that people lose their teeth anyway. The majority of dentate older individuals
never expect to lose all of their teeth. It appears that if individuals reaches age 65 and if they have not
lost their teeth already, they do not expect to.
fied with the way their teeth look.6      Interestingly, 80 percent of dentate older adults are satis-
                    As expected, most older individuals believe t a
care is often too high; but, most indicate that cost of care is not a barrier for them, 8 i @e cost of dental

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Information regarding appropriate dentally-related behaviors may never have been learned or may change
over time.  Today's older people are more likely not to have been exposed to a preventive orientation
early in life and/or may remember outdated information.  Their early exposure to dentistry may have
predated the acceptance of self-efficacy measures for oral health status.  Older adults today have
received a large amount of conflicting health information over a lifetime. Misinforma&n and confusion
often discourages older persons from changing behaviors or seeking preventive services.

The cognitive skills of older individuals as reflected by attention and recall may be somewhat diminished
compared to younger individuals.  This may require special attention to methods of communication,
including  message structuring, repetition and reinforcement, shorter
limitations,  active participation and multiple modes of presentation. ?f ssion length, information
                                           Research projects are
demonstrating that established attitudes and beliefs can be altered or used to the advantage of oral
health.  For example, the generalized belief that people can take responsibility for their own health has
been shown to be associated with reduction in plaque levels. Conversely, older persons who look to others
for control and believe that dental prophylaxis &, important are more likely to avail themselves of
diagnostic, preventive and therapeutic dental care.

Orientation toward oral health is evident also in attitudes, knowledge and behaviors known to affect oral
health status.  Approximately three-fourths of older adults believe smoking increases risk of cancers in
the throat-a lower proportion than in younger adults. Slightly over a third of older adults believe&avy
drinking increases risks of mouth arid throat cancers, a higher percentage than adults of other ages.

Health professionals may hold inappropriate beliefs which compound the problems faced by the older indi-
vidual. For example, beliefs that older persons cannot learn, will forget quickly what il@.tEhtl that it is
too late for them anyway may interfere with effective practitioner-patient interaction.    Smce phys-
icians have more contact with older adults than dentists, their attitudes toward oral health issues are
important to monitor and change as appropriate.

Social and psychological risks are not easily quantified, yet need serious consideration in understanding
the promotion of oral health. Significant improvements in oral health may be achieved only when the gap
               need and perceived need-as reflected in numerous attitudinal variables--is

2. Mechanisms and Interventions Established to Deal With Problem

Not only should dental practitioners understand normal and pathological aging, they also should have
excellent interpersonal skills.  Dental practice provides an opportunity to educate and change the
attitudes of the patient through examination and communication.  For example, when the dentist or
dental hygienist cleans teeth, self-care can be discussed.  Additionally, when dentists and other health
0";;; ,","Pl,`gai screen for oral cancer, they can educate patients on the relation of tobacco, alcohol and
        Precancerous lesions and conditions'predisposing to cancer that can be detected and

treated early result in less mutilation and increased survival rates.

Cognitive behavioral methods that emphasize a strategy of changing an individual's inaccurate beliefs are
believed to be effective in oral health promotion.  Educational and oral health promotion sessions can be
conducted in private practice, but probably can reach more people, at lower cost, if provided in other
settings, especially where older persons gather.  It has been demonstrated that some preventive dental
and educational sessions, in which motivation to %% hieve oral health is significantly enhanced with regular
feedback, can be conducted by paraprofessionals.

Oral health promotion to improve attitudes and change behaviors can relate to and build on the current
lifestyle of the older individual. For example, research demonstrates that older people watch more telev-
ie5;on~;;l~;~~~; ;;ews~~~rs regularly. In addition, their use of other media can be targeted and used
              Non-dental organizations that already have access to older adults can facili-
tate changes in oral health attitudes and behaviors.  The American Association of Retired Persons
(AARP) and the American Red Cross work together to keep members informed regarding health

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::.toy;; topics through -resource manuals,  slide/tape programs and articles in publications.

activities. &, these organizations have established demonstration projects to encourage health promotion

Educational materiaIs to improve orientation toward oral conditions and appropriate self-care and
professionally-provided services are available from several sources. Some of these are specific to older
adults-emphasizing problems which are more prevalent in later years or prepared with the older person
in mind, e.g. the use of large print.  Others addressing general adult problems also are useful to older
persons.  The Federal gover ment , state public health departments, professional associations, and
universities are active in producing oral health education audiovisual and print materials to be used with
individuals or in community or institutional settings.  Examples include `Keeping Your Smile in Later
Years" (ADA brochure), radio spots on special care for older persons and "Prescription for Periodontal
Health" (NIDR film).

m May, 1987, as part of the Congressionally proclaimed "Older American Month", the ADA established a
National Senior Smile Week. The theme was "A Healthy Smile Can Last a Lifetime" and the purpose of
the campaign was to heighten awareness on the part of the general public of the importance of dental
care and the availability of dental services for the older adult. The kit, provided to state and local dental
societies, included a planning guide, program ideas, a slide and script for television, a cassette for radio
and sample advertising copy, as well as posters and other visual aids.  The effort was designed to
encourage media, special community activities and dental practice programs.   Communities were
encouraged to work with pharmacists, hospitals, health fairs and nutritional counseling services. The pro-
gram also encouraged the involvement of more dentists in the provision of appropriate care for older
aduIts. This program will continue on an annual basis.

The American Dents1 Hygienists Association (ADHA) has developed a national campaign-"A Beautiful
Smile is AgelesstL-to increase older adults' access to oral health information and services. The nationai
organization developed a `program &ifr for use in promoting oral health care that has been adopted by 349
local chapters of the organization.

3. Apparent Deficiencies

The 1980s have shown an increase in efforts to improve attitudes and knowledge of oral health for older
adults, yet the efforts have not been widespread, sustained or evaluated. Many have been demonstration
projects at the local level.  More directed efforts are needed to encourage: 1) positive attitudes
regarding the oral health of older persons on the part of both the health practitioners and the public; 2)
educational materials for older dentate individuals; 3) education on lifestyle including the oral
implications of tobacco use, alcohol consumption and polypharmacy.

C, Oral Hygiene Behaviors

1. Nature of Problem

Appropriate toothbrushing with fluoride toothpaste, interdental cleaning and rinsing with fluorides or
antimicrobial products are useful methods to keep the oral cavity clean to prevent caries and periodontal
diseases.  In addition to preventing further oral disease, appropriate oral hygiene behaviors can result in
improved physiological and psychological wellbeing. Plaque retention is a major problem in older adults,
exacerbated by existing restorations, rough root surface topology, and inability to brush correctly.

Diminished manual dexterity, in addition to more severe functional limitations associated with serious
conditions frequently seen in older persons--such
abilities to use a toothbrush and interdental devices. 2f s stroke, arthritis, Parkinson's disease-decrease
                            Also, the motivation to prevent diseases and learn
~g$yIi?l ques may be less than for a younger adult, and for some people, self-care may not be physically
      .

Most (70%) dentate older Americans believe that brushing is the most iv ortant preventive measure for
dental problems.  This is reflected in their dentally-related behaviors.  The great majority (88%) of

B-V


deptate older adults report brushing at least once a day-front and back of teeth and over one fourth
(27%) of older dentate individuals report flossing at least four lmes a week. Frequent snacking h
reported by less than one third (30%) of adults, age 65 and older. 8'  Wh'l

over two-thirds of dentate older adults report using a fluoride dentifrice. 620 less than for younger adults,

2. Mechanisms and interventions Established to Deal With Problem

Availability of appropriate oral hygiene aids, instruction on how to use them and continuation of lifetime
oral hygiene activities address this issue. These may be accomplished through maintenance of activities
from younger ages or established through special training sessions.

Physical limitations of certain older adults may require oral hygiene measures such as fluoride and
antimicrobial rinses.  Also, toothbrushes and other oral hygiene aids are being developed with better`grips
and other specifications to improve ability to clean the entire oral cavity.

The VA has developed an oral hygiene in-service manual which has been used since 1985. It is provided to
nursing unit administrators and is designed for periodic updating.  Additionally, hands-on in-service
training is offered.

Researchers at the University of Washington have demonstrated, using several different groups of older
individuals, that oral hygie 31 e can be improved and maintained through behavior management based on
contingency reinforcement.   Research suggests that older persons benefit most from a combin
program of regular oral examinations by a dentist and interactive educational sessions for home care. 59
An interactive educational approach with a self-management focus can improve oral health by increasing
the individual's personal responsibility for health, perception of general health and self-esteem. A focus
on 1) prevention of further disease, 2) control of iatrogenic disease, 3) prescribed regimens for medical
conditions, 4) maximizatio3p f oral functions, such as mastication and speech, has been successful in
these educational sessions.   Trained paraprofessionals and peers have been used to instruct older
individuals using such behavioral techniques.  A combination of traditional educational booklets,
videotapes, modeling, one-on-one interaction with the instructor, self-monitoring, reporting and refining
of home-care behaviors and repetitive interventions have resulted in better plaque scores over time as
well as improvements in25dental behaviors, perceived overall health, morale and beliefs about the
importance of oral health.

Demonstration projects with older persons are in place in several major communities, for example, an
`Elders Take Charge' program in Denver.  Such programs need to be identified and oral health education
and training should be incorporated into these general health efforts.

Commercial manufacturing can encourage oral hygiene behaviors through advertising of products.

3. $pparent Deficiencies

The importance of oral hygiene for all ages needs to be emphasized more by dental and medical personnel
and the media. Other forums which have ready access to older people, e.g., retirement homes, consumer
advocacy groups, Visiting Nurses Association, could be encouraged to promote oral hygiene.

For those people for whom self-care is not possible, caretakers who provide necessary oral health
regimens are essential.  The lack of acceptance by caretakers of this responsibility is a glaring
deficiency.

D. Professionally-Provided Dental Care

1. Nature of Problem

Use of dental services has increased over the past two decades among older adults.50 51 The percent of
                   lder visiting a dentist during the past year increased from 21 percent in 1964
               The 1983 data show that older people have an average of 1.5 visits to the

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dentist during the past yef[, in contrast to 2.0 visits for those age 45-64.
never been to the dentist   and                Less than one percent ha85
                38 percent have received no dental services in the past five years.
Only 31 percent of older adults, 75 years of age and older, have been to the dentist during the past year.
Older white individuals ar  about twice as likely to have gone to a dentist during the past year than black
individuals (40% VS. 19%) f0  As i sd he case among younger adults, having a dental visit during the past
year js directly related to income.

It appears that the dental visit pattern of the dentate older person is very $T#aq;tg2the younger adult,
while it is the edentulous older adult who is less likely to visit the dentist.         Over one-half of
dentate older Americans reported visiting the dentis\Sdurmg- the past 12 months in 1983, compared to
approximately IO percent of edentulous older adults.  Slmrlar data af& reported from the 1986 NIDR
National Survey of Oral Health in the U.S. Employed Adults and Seniors.   At the other extreme, in 1986
two-thirds of edentulous older adults reported that it had been three years or longer since they we t to a
dentist, while only 19-20 percent of the younger adults or dentate older adults had this visit    32
                                                 pattern.

Reasons for visiting a dentist are similar for younger adults and dentate o de
                          6 16 !!!I ults, with `prevention and
checkup' being the primary reason followed by `something being wrong'.    Edentulous oldfb el#g
cite `something wrong' or `prosthodontic care' as the reason for their most recent dental visit.
Some evidence suggests that level of education influences the reason for visit more than does the number
of visits e-r
   er se. As with younger adults, older a$u@ are more likely to give no need (dentate) or no teeth
(edentulous as reasons for not visiting a dentist.

Most older individuals report having reasonable access to a dentist, yet, access to care is not easy for
some older adults, particularly frail and medically compromised individuals.  Access problems may
include actual availability of dentists, perceived barriers to medical care, immobility, i % at ion, problems
with meeting expenses, functional impairments or the need for assistance in daily living.

The evidence of the extent to which finances and isolation are problems is inconsistent. For example, the
best predictors of the use of dental services in a study of older individuals in Massachusetts were
presence of teeth and perceived need for care.  Once these people reached age 75, dentate status a
perceived need outweighed education and liquid assets in differentiating a dental user from nonuser. `4i!
Income and other socioeconomic variables appear to be associated with the priority and relative value
attached to oral health.  These priorities and preferences (relative values) develop from many
sociocultural influences which occur over a lifetime and are not overcome by provision of money, per se.

Expenditures for dental services as well as utilization of dental services and oral hygiene behaviors among
older persons traditionally are reported to be less than for younger adults. Absence of visits and lower
levels of oral hygiene behaviors have been shown to be related to social and economic factors--such as
lower level of education, rural residence, and inability to pay-which are characteristics common among
older ad&s.  Some research has demonstrated that Medicaid, reduced-fee and free care have not
increased use of dental services in a          t  ay; yet little was done in analysis to differentiate
dentate and edentulous older persons. lY6TiF!P&% n

g-oT;, g&get6 `itB t dental visits and expenditures among dentate older adults are similar to
                           .

              Historically, the large percent of older adults who were edentulous appears
to be associated with the lower expenditure and visit level. With an increasing number of dentate older
adults, the issue of finances may need special consideration. With the need for complex restorations and
the lack of insurance, the influence of cost of care among the older person may be considerable.

Having a regular source of care is highly correlated with the use of preventive health services. In fact,
having a regular source of care may predict the use of preventive dental serv'c
                                6 74 far better than do
perceived need, enabling or predisposing characteristics of older individuals.    While preventive
services are generally less expensive than are restorative services,  the absence of insurance or
prepayment for most older individuals or the failure of may4 reimbursement systems to acknowledge pre-
ventive services may create a barrier for their regular use.

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2. Mechanisms and Interventions Established to Deal With Problem

Improvements in financial capabilities, such as availability of dental insurance and reduced-fee program5
address this problem for older adults. The ADA is working actively to encourage the coverage of dental
care in Medicare and is encouraging corporations and insurance companies to extend dental benefits to
retired and older Americans.

National and local efforts established to improve access for older adults who have financial, disability, 01
geographical barriers to dental care address this issue.  For example, during the late 1970's, the ADA and
its constituent and component societies began a directed effort to improve the use of appropriate dental
services by addressing the issues of convenience and available  r
                           E ources in Prevention and Control of
Dental Disease Through Improved Access to Comprehensive Care.   Through this program, over 119 state
and local dental societies provide a toll-free number for referrals to local dentists. Seventy percent of
the programs offer a full range of dental services, nine percent denture services only. Over 70 percent of-
the programs are directed toward older adults and over 80 percent are reduced fee py5grams. Transport-
ation or portable equipment are available through 10 percent of the access programs.   In 1988, the ADA
plans to encourage the component and constituent societies to re-emphasize the access programs,
Additionally, the ADA contributes funds to help sustain the activities of the National Foundation of
Dentistry for the Handicapped and endorses the dental degree program--Disabled Dental Services-
promoted by the Association of Geriatric Dentistry.

Through the ADHAs nationwide geriatric outreach project--"A Beautiful Smile is Ageless"--nygienists-
work on a voluntary basis in oral health care programs.  The programs provide dental screening and on-
site visits to long-term care facilities, senior group settings and individual homes.

Improving access to residents of nursing homes has been an objective of other projects.  As part of their
teaching programs, some dental schools work with nursing homes. Many provide slide/tape materials tom
assist nurses in looking for oral health problems in patients, health education materials for patients and
preventive treatment prescriptions along with a recall program for residents.

Some dentists throughout the United States have begun to provide care to homebound an&
institutionalized older Americans.  Using vans furnished with portable dental equipment, dentists carr
screen a large number of older individuals and provide appropriate care to those who need it. These
dentists, working with nursing home administrations, coopera t ingl s ith caretakers and attending to
records, are making the provision of services in institutions a reality.

3. Apparent Deficiencies

Except for the VA, most of the programs mentioned above have been developed on a local and voluntary
basis, resulting in inconsistent availability of care for many older adults.  More directed efforts are
neede,d to assure adequate oral health care for indigent, institutionalized and homebound older adults.
Few programs exist in combination with non-dental organizations, e.g. Visiting Nursing Association. Con-
tinued effotts are needed to encourage payment assistance, e.g. dental insurance or Medicare for retired
adults, as well as reduced-fee programs or improved medicaid for dental services for those unable to pay.

Much of the dental care system, as it exists today, is passive-individuals must seek out care.  Some
efforts have been made to accommodate the service delivery system to the needs of the older adults, but-
more consistent attention needs to be given to reaching out and meeting needs where they exist-
community, senior centers, nursing homes or individual residences.

E. Oral Health of the Edentulous

1. Nature of the Problem

Edentulousness, while decreasing in the overall older population, is highly associated with level of
education. Beyond this, its prevalence among older people reflects a predominant form of dental practice
and patient expectation that existed when these people were younger.  To continue the decrease in-

B - 12


edentuloUnesS, individuals must perceive the value of retaining their teeth. Also, dentists, as well as
other health care prOfeSSiOnalS, must encourage and reinforce the value of retention of teeth.
Appropriate oral health care changes after an individual receives dentUres.6 24 Self-care usually involves
cleaning dentures to prevent bad breath and oral infections as well as to preserve healthy tissues for
denture Support- Regular visits to the dentist are important for instruction on appropriate home care,
detection of soft tissue lesions, refityfg of dentures to accommodate changing bone structure and
repairing ill-fitting or broken dentures.  Although approximately 3 million denture wearers experience
denture retention problems because of alveolar ridge deterioration, dental visits after receipt 0f6c&tures
are low, on average. Most denture wearers believe that they need never again g0 to the dentist.

2, Mechanisms and Interventions Established to Deal with Problem

Professionally-developed educational tools as well as mass media have been used to encourage denture
wearers to maintain adequate oral hygiene and to visit the dentist regularly. The ADA Access Program
encourages denture wearers to visit the dentist regularly at reduced fees.

3. Apparent Deficiencies

Even with a decreasing proportion of edentulousness in the older population, the number of denture
wearers will remain substantial and increased efForts to improve the oral health of these individuals are
needed. Efforts to educate denture wearers must counter a strongly held traditional belief that routine
dental care is not needed.

F. Professional Training for Research, Teaching and Patient Care

1. Nature of Problem

Evidence suggests that dental, medical, pharmacy, and gerontology professionals have ac<i&ss to informa-
tion in their own specific areas of concern, but they know little about each other's areas.   At tention to
oral health symptoms of systemic diseases and basic principles of oral disease prevention are
underemphasized in schools of medicine, nursing and pharmacy.  Oral health care as is relates to overall
medical conditions is not consistently integrated into the learning experience in schools of dentistry,
dental hygiene and dental assisting.

Diagnosis and management of oral diseases in older adults have received minimal emphasis in training
dental professionals.  The older adult may require special management because of potentially
complicating medical conditions; the high prevalence of gingival recession, microbial plaque, gingival
inflammation; reduced periodontal support and fewer teeth.  Educational needs for denti3ts are many but
greater gmphases are needed on general internal medicine, morbidity patterns, pharmacology,
psychological and social conditions and developmental @.sabilities as they relate to the oral health of
older adults. The aim should be placed on prevention of further disease and maintainance of current oral
health status.  Training should emphasize provision of treatment using this acquired knowledge.
Traditionally, the training of dental professionals has been in dental schools, separate from the remainder
of provision of health care. Not only has this created a care system separate from health care, it has
emphas' ed
school."  care for the well, ambulatory elderly-those who can voluntarily come to the dental
    Not only have dental students not been taught about dental implications of medically, mentally
or socially compromised individuals, they received no clinical decision-making experience with at-risk
patients. This has created a cohort of practitioners who are ill-informed regarding geriatric dentistry.

Up until 1979 only 12 percent of the nation's dental schools indicated that they offered courses in
geriatric dentistry in their curricula.  In 1984, 60 percent of the dental schools had a course in geriatric
dentistry.  Nearly all dental and dental hygiene schools have begun to develop curricula, clinic and
research opportunities in geriatric dentistry. Of the more than 20 topics taught, most schools devote less
than one hour to each.  Only `modification of dental techniqygs', `oral manifestations of systemic
diseases', and `prosthetic management' receive more than 4 &urs.   Less than one percent of continuing
education courses are directly related to geriatric dentistry.

B - 13


There is a critical need for trained professionals in research and clinic $2 care. In 1986, there were 20 to
25 dentists with special training in oral health care for the older adult.  Beyond the insufficient number
of dental professionals trained for the clinical care and informational needs of the older population, it has
been suggested that some dentists have inappropriate attit i!&f4 48
                                                          re arding older individuals and many
general practitioners may be unwilling to treat older patients.

2. Mechanisms and Interventions Established to Deal With Problem

Geriatric dentistry curricular guidelines were developed by the American Association of Dental School
(AADS) in 1982 and are being reviewed and revised in 1987. These guidelines set forth educational goals
and behavioral objectives and outline a core content that includes essential elements and elective
experiential learning objectives. A special committee is developing guidelines for postdoctoral geriatric'
fellowships.  The ADHA, with the support of Health Services and Resources Administration (HRSA),
developed a Geriatrics Curriculum for Dental Hygiene Education in which cognitive and behavioral
objectives were defined, and four learning modules developed.  The AADS Section on Dental Hygiene
Education is developing geriatric curricula guidelines.

Dental schools are expanding advanced geriatric training opportunities with post-graduate programs for
training consultants and coordinators in geriatric dentistry, two-year M.S. program in geriatric dentistry,
among others. Currently, there are 270 general practice residency programs, with about 1,000 first-year
pdsftions.  While older patients are not a primary objective of most of these programs, management of
patients with complicating conditions is emphasized.

The VA offers a Geriatric Fellowship, providing dentists with opportunities to work with many older
patients and other health care providers.  Five fellows per year since 1982 have been trained, most of
these staying with the VA. The VA has stimulated an elective geriatric dentistry rotation in VA medical
centers (VAMC) for junior and senior dental students, as well as general practice residents in several
locations.  Such rotations expose the undergraduate dental student to the full continuum of care in an
interdisplinary setting available through the VA health care system.

HRSA funds regional Geriatric Education Centers which encourage multidisciplinary training of health
professionals in geriatrics.  Located in universities, these centers serve as resources and provide short
term faculty training, curriculum development, in-service and continuing education programs, and
assistance to practicing professionals. Twenty-four of the 31 centers have a dental component.

Title VI of P.L. 99-660 adds new authority to train physicians and dentists who plan to teach geriatric
medicine or geriatric dentistry.  The options include one-year retraining programs in geriatrics to
professionals who are faculty members and one-two year fellowship programs to provide training in
clinical tesearch and teaching skills for professionals who have completed graduate education programs.
An AADS committee developed program considerations in responding to this new authority.

The Administration on Aging (AoA) has recently funded ten oral health promotion grants which address
the issues of the older adult through continuing education for health professionals, extension of oral
hygiene services through health professionals, improved strategies and interventions for the homebound,
dissemination of educational and promotional materials, improved networking and cooperation among
existing community and health agencies.  The AADS, the recipient of one of these grants, is using the
funds to encourage implementation of newly revised geriatric curricula guidelines.

Study clubs and continuing education opportunities are developing across the nation. For example, the
ADA has offered clinical symposia in preparing dentists to treat the aging populatior+,7 Also, dental
students in universities have developed geriatric study clubs, networks and newsletters.   The VA and
local dental societies have formed study clubs to encourage interaction.

B - 14


a3. Apparent Deficiencies

It is estimated that 40 percent of older adults fall into the special needs-patient group and that about 50
percent of these will seek dental care. Based on an assumption that a dentist with specialized training in
geriatric dentistry can serve approximately 1000 older patients, there will be a need for 7,500 trained
dental practitioners by the year 2000, and 10,000 by 2020. Even with t 3% projection, this special group of
dentists will account for only about 5 percent of all practicing dentists.

There is a near absence of models to effect interdisciplinary education or to encourage the interaction
among health care professionals. There is a need for routinely available training opportunities for health
professionals with ambulatory as well as frail older adults for general medical and oral conditions..
Continuing education courses in geriatric dentistry need to be encouraged, specifically for those dentists
who serve large number of older patients.

G. Biomedical and Health Systems Research Basis for Planning and implementing Health Promotion

1. Nature of Problem

An adequate research base is critical for planning oral health promotion for older persons. There are still
considerable gaps in knowledge regarding the severity, rate of progression, and likelihood of occurrence
of oral diseases and disorders, as well as the nature of oral flora and host defense mechanisms in aging.
More research is needed on how generalized or specific changes in oral diseases affect and are affected
by overall health status, the oral implications of medication side effects and drug-induced oral diseases;
improving pain control; improving infection control; the impact of professional health promotion (dental
school or continuing education) on improving the oral health of older adults; evaluation of patient
management techniques required to plan multiprofessional care.

2. Mechanisms and Interventions Established to Deal With the Problem

The National Institutes of Health (NIH), specifically NIDR and the National Institute on Aging (NIA), as
part of broader research missions, have several ongoing programs which could improve knowledge
regarding the oral health of the older population. Of special note are NlAs ten 5-year geriatric dentistry
academic awards and Teaching Nursing Home Award.

The VA conducts research specific to the veteran population as well as general health problems which are
prevalent among veterans. ln addition to general clinical research opportunities, the VA considers ways
of improving effectiveness and efficiency of its health delivery, which has implications for institutional
as well as outpatient care. The VA has several opportunities which specifically encourage research on oral
health of older adults:  Dentist Geriatric Fellow Programs (a 2-year geriatric fellowship); Dental
EducaJion Centers; Career Development Programs; the Geriatric Research, Education and Clinical
Centers; interdisciplinary Team Training in Geriatrics; and the Office of Academic Affairs.

Several important Federal intramural research efforts are concentrated in ongoing longitudinal studies:
The VA at the Boston Outpatient Clinic and the NIA at the Gerontology Research Center in Baltimore.
Both the Boston VA Normative Aging Study and the NIA Baltimore Longitudinal Study provide an
opportunity to study normal oral physiology as it ages.  These studies of volunteer groups who have
frequent and comprehensive dental care, a high concern for dentition and a positive lifestyle enable the
researchers to observe normal agi 35 in the oral cavity relatively free of complications that disease or
complex treatment may introduce.  Research on periodontal diseases and aging is being conducted by
the University of New York at Buffalo and the University of Texas at San Antonio under contract with
NIDR.

The NIA, NIDR and VA collaborated in the development of A Research Agenda On Oral Health in the
Elderly to encourage more biomedical and behavioral research in relation to oral health in aging. Thi:
Agenda, which was published in 1986, identified research needsand established the basis for an implemen
tation plan which is leading to program announcements, symposia, workshops, or other ways of informing-

B - 15


the research community of opportunities.  The Research Agenda efgourages grant requests fro4
individuals as well as proposals for collaborative and interagency studies.

As part of an ongoing Implementation Plan, A Catalog of Resources summarizing existing resources ad
funding mechanisms available at the three agencies has been developed. Also, the three agencies (NID 1
NIA, VA) issued a Request for Application (RFA) in October, 1987 inviting applications for the support o "r
research centers on oral health in aging.  Applicants are to propose multidisciplinary studies on oraj
health with older Americans and must represent a consortium that includes a VA and one or more non-V4
institution. In addition to conducting research, successful applicants are asked to apply for a researcfi
training grant during the first year of their grant award. The development of research centers, which cad
emphasize the aging process should provide critical knowledge on which to base any proposed oral health
promotion activities for older Americans.

3. Apparent Deficiencies

The basis for all oral health promotion programs or training opportunities to improve the oral health of
older adults requires fundamental knowledge of the nature of the principal diseases and their progression,
as well as how to prevent them or diminish their impact.  Equally important, clinical and social and
behavioral sciences research must go forward to supply essential information on epidemiology, risk
factors and other sociodemographic data as well as assure that the results of research are transferred
readily to appropriate application.

IV. Summary and Conclusions

A relatively high level of oral health can be achieved for most older adults through the promotion of
appropriate self-care and regular dental visits. An emphasis on prevention from early childhood through
middle to old age-fluoridation of community water supplies, the use of fluoride applications and mouth
rinses, dental sealants, appropriate oral hygiene behaviors and routine dental visits-will promote oral
health of older adults. A better understanding of the natural history of caries, periodontal diseases and
other oral diseases, particularly as they relate to general systemic conditions, also should be a major
focus for oral health promotion for older adults.  While current epidemiological data provide some
guidelines, considerably more basic, clinical and epidemiological research is needed to enhance
opportunities for improving oral health for all of the nation's older adults.

Older individuals can have the same oral diseases as do younger individuals, yet the range of risk factors-
          `c, biological, physical and mental-is broader, resulting in different prevalence
;$,",`i,"yp:, ey;;~;?~;~?S  Some portion of older adults will experience complicated oral conditions
requiring intensive and sophisticated care.  As with other special care populations, many of these
individuals will have multiple medical problems with associated drug therapy, both of which may seriously
affect oral health and related treatment.

While improvements in oral health of older persons are impressive, major needs still exist which can be
met through health promotion efforts:  1) developing information targeted to older people-especially
homebound, minorities and those in remote areas; 2) developing and implementing techniques and
strategies for teaching older people ways to prevent disease and promote oral health; 3) improving
training and continuing education of medical, pharmacy, nursing, health planning and dental professionals;
4) increasing the availability of assessment, prevention, and promotion services, including the use of
nondental settings, e.g. alter the service delivery organization to accomodate older persons special access
situations; 5) continuing efforts to reduce the financial burden of oral health care for older persons.

Oral health promotion includes efforts at the individual, health professional, community and
environmental levels. Programs need to be directed toward the public--at the individual and community
levels-as well as the health care professionals to improve knowledge, attitudes and behaviors. While oral
disease prevention is critical, cognitive, attitudinal and behavioral dentally-related outcomes can and
should be taken into consideration as values that can improve overall health and the quality of life of the
older individual.

B - 16


V. REFERENCES

1. Census of the United States population, 1980. Washington, D.C.: Bureau of the Census.

2. mcome of the population 55 and over, 1984. Office of Research, Statistics and
International Policy, Social Security Administration, December, 1985.

3. Kiyak HA. Utilization of dental services by the elderly. Gerondontology 1984; 3(1):17-25.

4. Gibson RM, Fisher CR. Age differences in health care spending: fiscal year 1977.
Social Security Bulletin 1979; 42:3-16.

5. Kasper JA, Rossiter LF, Wilson R. A summary of expenditures and sources of payment
for personal health services from the National Medical Care Expenditure Survey.
NCHSR Data Preview 24; US Department of Health and Human Services, 1987.

6. National study of dental health outcomes related to prepayment: 1981. Rockville,
Maryland: Health Resources and Services Administration, 1987. (unpublished data)

7. National income and product account. Bureau of Economic.AnaIysis, Department of Commerce, 1986.

8. Gift HC. Utilization of professional dental services. In: Cohen LK, Bryant PS, eds.
Social Sciences and Dentistry, 11. London: Quintessence Publishing Company, 1984, pp. 202-266.

9. Kovar, MG. Aging in the eighties, in Advance Data From Vital and Health Statistics,
Number 115, National Center for Health Statistics, May 1, 1986.

10. Oral Health of United States Adults: National Findings. National Institute of Dental Research,
United States Department of Health and Human Services, NIH Publication No. 87-2868.1987.

11. Besdine RW. Current issues in health care for the elderly. The Report of the
National Invitational Conference on Issues and Strategies in Geriatric Education: 1985. March 1985.

12. Douglass CW, Gammon MD. Implications of oral disease trends for the treatment needs
of older adults. Gerodontics 1985; 1(2):51-58.

13. Beck JD. The epidemiology of dental diseases in the elderly. Gerondontology 1984; 3(1):5-15.

14. Ba&n BJ. Current research on aging and oral health. Spec Care Dent 1981; l(3): 105-109.

15. Giangrego E. Dentistry and the older adult. J Amer Dent Assoc 1987; 114:298-307.

16. A Research Agenda on Oral Health in the Elderly. Bethesda, Maryland: The National
institute on Aging, The National Institute of Dental Research and The Veterans Administration, 1986.
1'7. Gift HC. The seventh age of man: oral health and the elderly. J Am Co11 Dent 1979; 46(4):204-215.

18. Halpert BP, Zimmerman MK. The health status of the `old-old': a reconsideration. Sot Sci Med
1986; 22(9):893-899.

19. Blau ZS. Socioeconomic variations in dental status and behavior of today's elderly. Spec Care Dent
1982; 2(6):244-247.

20. Ross LN, Beall GT. Health Promotion and Aging: Opportunities for National Organizations.
Washington, DC: The National Council on the Aging, Inc., 1984.

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21. Price SC, Kiyak H. A behavioral approach to improving oral health among the elderly. Spec Care
Dent 1981; 1(6):267-274.

22. A Research Agenda for Health Promotion and Disease Prevention for Children and the EIderly.
Health Services Research 1985; 19(6):part II.

23. Morhart RE, Davis ME, Weiss DG, et al. Dental health status of an aging VA population: implicationd
for a preventive dental health care program. Health Services Research 1986; 6 (part II):933-947.

24. Martin RF. Preventive dental care for older people. Rockville: Health Resources
and Services Administration 1985.

25. Kiyak HA. Oral health promotion for the elderly, in Matarazzo JD, Weiss SM, Hard JA, et al. teds):
Behavioral Health: A Handbook of Health Enhancement and Disease Prevention. New York: J Wiley,
1984. pp. 967-975.

26. Personnel for health needs of the elderly through the year 2000. Draft Report to Congress for the
Secretary, U.S. Department of Health and Human Services, March 1987.

27. Health Statistics and Older Persons: United States, 1986. Analytical and Epidemiological Studies,
Series 3, No. 25, National Center for Health Statistics, 1987. (DHHS Pub# (PHS) 87-1409)

28. Gift HC. Current utilization patterns of oral hygiene practices. In: Lee H, Kleinman D teds): Dental
Plaque Control IMeasures and Oral Hygiene Practices. Oxford, England: IRL Press Limited,
1986, pp. 39-71.

29. Weintraub JA, Burt BA. Oral health status in the US: tooth loss and edentulism. J Dent Educ 1985;
49(6):368-376.

30. Ismail AI, Burt BA, Hendershot GE, Jack S, Corbin SB. Findings from the dental care supplement of

the National Health Interview Survey, 1983. J Amer Dent Assoc 1987; 114:617-621.

31. Baum BJ. Characteristics of participants in the oral physiology component of the Baltimore
Longitudinal Study of Aging. Comm Dent Oral Epid 1981; 9:128-134.

32. Hughes JT, Rozier RG, Ramsey DL. Natural History of Dental Diseases in North Carolina 19
Durham, North Carolina: Carolina Academic Press, pp. 250-254.

76-197

33. Banting DW. Dental caries in the elderly. Gerondontology 1984; 3(1):55-61.

34. Baum BJ. Research on aging and oral health: an assessment of current status and future needs.
Spec Care Dent 1981; 1(4):156-165.

35. Stamm JW, Banting DW. Comparison of root caries prevalence in adults with life-long residence
in fluoridated and nonfluoridated communities. J Dent Res 1980; 59:405.

36. Page RC. Periodontal diseases in the elderly:  a critical evaluation of current information.
Gerodontology 1984; 3(1):63-70.

37. Hand JS, WhitehiIl JM. Oral mucosal lesions in an elderly population. J Amer Dent
Assoc 1986; 112: 73-76.

38. American Cancer Society, 1987.

7.

39. Ebuquot JE. Common oral lesions found during a mass screening examination. J Amer
Dent Assoc 1986; 112:50-57.

B - 18


40. F&urn BJ, Bodner L. Aging and oral motor function: evidence for altered performance
among older persons. J Dent Res 1983; 62(1):2-6.

41. Mandel ID. Oral defenses and disease: salivary gland function. Gerondontology 1984; 3(1):47-54.

42. E&urn BJ. Evaluation of stimulated parotid saliva flow rate in different age groups.
J Dent Res 1981; 60(7):1292-1293.

43. Hill MW. The influence of aging on skin and oral mucosa. Gerondontology 1984; 3(1):35-45.
44. Branch L, Jette A, Evashwick C, Polansky M, Rowe G, Dierhr P. Toward understanding
elders' health service utilization. J Comm Health 1981; 7(Z): 80-92.

45. Marinelli RD, Sreebny LM, Kamen S. Perception of dental needs by the well elderly.
Spec Care Dent 1982; 2(4):161-164.

46. Wilson AA, Branch LG. Factors affecting dental utilization of elders aged 75 years or
older. J Dent Educ 1986; 50&):673-677.

47. Lie T, Mellingen JT. Periodontal awareness, health, and treatment need in dental
school patients. Acta Odontol Seand 1987; 45:179-186.

48. Kandelman D, Lepage Y. Demographic, social and cultural factors influencing the
elderly to seek dental treatment. Int Dent J 1982; 32(4):360-370.

49. Branch LG, Antczak AA, Stason WB. Toward understanding the use of dental services by
the elderly. Spec Care Dent 1986; 6(1):38-41.

50. Jack SS. Use of dental services: United States, 1983, in Advance Data from Vital and
Health Statistics, Number 122, National Center for Health Statistics, August 8,1986.

51. Health United States: 1986. US Department of Health and Human Services, DHHS Pub. No
(OHS) 87-1232,1987.

52. Brown LJ, Brunelle JA, Miller AJ, et al. Oral health of US adults 1985; tooth
mortality, sociodemographic and otherdental health characteristics. Paper presented
at the International Association of Dental Research, 1987.

53. National Health Interview Survey. National Center for Health Statistics, unpublished data, 1986.

54. Bureilu of Economic and Behavioral Sciences. Utilization of Dental Services by the
Elderly Population. Chicago: American Dental Association, 1979.

55. Gift HC. The elderly population: oral health status and demand and utilization of
dental services. J Am Sot Ger Dent 1978; 13(2):9-21.

56. Whittle JG, Sarll DW, Grant AA, Worthington HV. The dental health of the elderly
mentally ill: a preliminary report. Br Dent J 1987; 162:381-383.

57. Levy SM, Baker KA, Semla TP, Kohout FJ. Medications with dental significance: usage in an elderly
population. Paper presented at the International Association for Dental Research, March 1987.

58. Ettinger RL. Evolving curricular developments in the health professions. The Report of the National
Invitational Conference on Issues and Strategies in Geriatric Education: 1985. March 1985.

59. Tryon AF. A model for intergrating geriatrics into the dental school curriculum.
Spec Care Dent 1981; l(3): 114-121.

B - 19


60. Ross LN. Compendium of Health Promotion-Related Initiatives for Older Adults. Washington, DC:
The National Council on the Aging, Inc., 1984.

61. Diehnelt D, Kiyak HA. Predictors of oral health behaviors among elderly Japanese-Americans.
Unpublished manuscript, 1984.

62. Evashwick C, Conrad D, Lee F. Factors related to utilization of dental services by the elderly.
Am J Public Hlth 1982; 72:1129-1135.

63. Knazan Y. Dental health promotion for senior citizens. Paper presented at meetings of the
International Association of Gerontology, July 1985.

64. Kiyak HA, Crinean J, Stockinger S. Older persons' use of dental services compared to
  other health services. Paper presented at meetings of the GSA, November 1985.
65. Kiyak HA. Explaining patterns of dental service utilization among the elderly. J Dent Educ
1986; 50(11):679-687.

66. Kiyak HA, Miller RK. Age differences in oral health behavior and beliefs. J Public Hlth Dent
1982; 42:404-416.

67. Gilmore S, Kiyak HA. Predictors of dental behaviors among the elderly. Spec Care Dent
1985; 5:169-173.

68. Beck J, Cons N, Field H, Walker J. The Iowa Survey of Oral Health: 1980. Iowa City,
Iowa: University of Iowa College of Dentistry and Iowa Dental Association, 1982.

69. Provisional data from the health promotion and disease prevention supplement to the national health
interview survey: United States, January-March, 1985, in Advance Data From Vital and Health
Statistics, Number 113, National Center for Health Statistics, November 15, 1985.

70. Hagebak JE, Hagebak BR. Serving the mental health needs of the elderly. Community Mental Health
J 1980; 16:263-275.

71. Antczak AA, Branch LG. Perceived barriers to the use of dental services by the elderly. Gerodontics
1985; 1:194-198.

72. Doherty N, Segal J. Dental care as an extended Medicare benefit: The Triage Experiment. Technical
Rep:rt, University of Connecticut, 1978.

73. Portnoy R, Yellowitz J. Senior citizens need teeth too. Paper presented at meetings of the
Gerontological Society, November 1977.

`74. Wolinsky FD, Coe RM, Miller DK, et al. Health services utilization among the noninstitutionalized
elderly. J Health Social Behavior 1983; 24(4):325-337.

75. Results of the 1985 Access Program Survey. Chicago: American Dental Association, 1986.

76. Beck JD, Ettinger RL. The development of geriatric curricula in U.S. dental schools, 1979-1984.
J Dent Educ 1987; 51(g): 523-527.

77. Geriatric Dentistry Network Newsletter 1987, l(1).

78. Mecklenburg RE, Martin RF. Oral health objectives for the elderly in the year 2000.
Gerodontics 1986; 2:161-163.

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