21st century dentistry

C D A J O U R N A L , V O L 4 3 , N 7

Geriatric Dentistry
in the 21st Century:
Environment and Opportunity
Paul Glassman, DDS, MA, MBA

A B S T R A C T The aging of the baby boomers in the 21st century is creating

unprecedented numbers of vulnerable older adults. The increase in people
keeping their teeth and their increasingly complex conditions all point to
more people with more complex needs. Although these demographic shifts are
providing unparalleled challenges for our health care system, they also bring new
opportunities to develop and implement innovative systems for reaching and
maintaining the oral health of older Americans.

AUTHORS

Paul Glassman, DDS,
MA, MBA, is professor
of dental practice, director
of community oral health,
and director of the Pacic
Center for Special Care at
the University of the Pacic,
Arthur A. Dugoni School of
Dentistry in San Francisco.
He is also director of the
California Statewide Task
Force on Oral Health for
People With Disabilities
and Aging Californians. He
served on the Institute of
Medicines (IOM) Committee
on Oral Health Access to
Services that produced the
IOM report called Improving
Access to Oral Health
Care for Vulnerable and
Underserved Populations
and the board of directors of
the DentaQuest Institute.
Conict of Interest Disclosure:
None reported.
I
n the 21st century, unprecedented
numbers of vulnerable older adults
in the baby boom generation and
people with functional limitations
and complex medical conditions
are living in community settings and
care facilities and are needing oral
health care. The well-documented
trend for people to keep their teeth
as they age, the aging of disabled
populations and the increasing
complications of medical treatments
for people in these groups all point to
increased numbers of more complex
individuals needing more complex
oral health care management. These
demographic shifts are providing
unparalleled challenges for our
health care system. However, they
also bring new opportunities to
develop systems and train personnel
adequately to face these challenges.
The growth in the number
and proportion of older adults is
unprecedented in the history of the
United States. Two factors, longer life
spans and aging baby boomers, will
combine to double the population
of Americans aged 65 years or older.
As illustrated in F I G U R E 1 , this group
will increase from 43.1 million in
2012 to 83.78 million in 2050.1
The relative proportion of the baby
boomer population in the total U.S.
population is illustrated in F I G U R E 2 .2
By 2030, older adults will account
for roughly 20 percent of the U.S.
population compared to 13 percent
in 2010 and 9.8 percent in 1970.1,3,4
In addition, the population over the
age of 85 is projected to increase
from 5.8 million or 1.9 percent of the
population in 2012 to 18 million or 4.5
percent of the population in 2050.
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 21st century dentistry
C D A J O U R N A L , V O L 4 3 , N 7

90
80
70
60
The dramatic growth in the 50

Millions
population of older adults is underscored 40
by the realization that since Jan. 1, 2011, 30
and each and every day for the next 20
20 years, roughly 10,000 Americans
10
will celebrate their 65th birthdays.5
0
This baby boomer generation has
2012 2015 2020 2025 2030 2035 2040 2045 2050
exerted widespread influence on many
aspects of society including sales of
80
commercial baby food during the late
1940s, to the construction of thousands
70
of new schools during the 1950s, and
Percent of total population

the boom in housing construction 50

of the 1970s and 1980s. Now, in the
21st century, that influence will be
felt in the unprecedented need for
increased health and social services.2
In addition to the population of older
adults increasing as a percent of the total
population, older adults are becoming
more diverse. The total U.S. population
is undergoing dramatic shifts in racial
and ethnic diversity. It is predicted
that by 2020 non-Hispanic Whites
will no longer comprise more than 50
percent of the population of children
and by 2044 non-Hispanic Whites
will no longer comprise more than 50
percent of the total U.S. population.6
In the population older than age 65,
the Hispanic population is expected to
grow from 7 percent of the total in 2010
to more than 20 percent by 2030.7
Another significant result of the
aging population is the increase in
disability as we grow older. Almost 40
percent of the population, age 65 and
older, has at least one area of significant
functional disability.8 By age 85, more
than 75 percent of the population has at
least one area of significant functional
disability. The most common disabilities
faced by older individuals are limited
mobility followed by limited sensory
function.9 These disabilities, combined
with significant medical conditions,
arthritis being the most common and
390J U LY 2 015
30
20
0
2012 2015
Source: U.S. Census Bureau, 2012 population estimates and 2012 national projections.
FIGURE 1. Growth in the U.S. population over the age of 65 : 2012 to 2050.1
including heart disease and cancer, create
significant challenges in providing dental
care and maintaining oral health.
Probably the most significant change
in characteristics of the aging baby
boomer population compared to previous
generations of older Americans is that
baby boomers have teeth. In 2000, the
U.S. surgeon general reported on a
20-year decline in the percent of people
older than age 65 with no teeth from
45.6 percent of the U.S. population
between 1971 and 1974 to 28.6 percent
between 1988 and 1994.10 In 2012, the
CDC reported a decline in edentulism
in people older than age 60 from 31.08
percent between 1988 and 1994 to
24.93 percent between 1999 and 2002.11
Continuing this trend, the CDC has
reported that the rate of edentulism
2020 2025 2030 2035 2040 2045 2050
among adults older than 65 was 22.9
percent between 2005 and 2008.12 Of
course, the decline in edentulism means
an increase in the number of people
with teeth and the number of teeth
at risk of coronal caries, root caries
and periodontal disease. One estimate
of the number of teeth at risk in the
population of older Americans concluded
that teeth at risk increased from 2.8
billion in 1972 to 4 billion in 1990 and
will increase to 5 billion in 2030.13
Policy, Coverage and Care Among
Older Adults in the 21st Century
Dental care for adults has been
considered optional in federal and
state public programs since at least the
addition of Medicare and Medicaid
to the Social Security Act in 1965.
 C D A J O U R N A L , V O L 4 3 , N 7

Age 2012
100+
90 Male Female
80 dental coverage for children, adult dental
70 benefits are optional in this expansion.
60 Only 2 percent of the population
Baby Boom Population
50 older than 65 are uninsured for medical
care.8 However, and in sharp contrast
40
to medical coverage, estimates of dental
30 coverage among older adults range
20 from 14.5 percent among all those aged
10 65 and older to 28.4 percent of 65- to
0 74-year-olds and 16.5 percent of those
3M 2M 1M 0 1M 2M 3M aged 75 and older. It is known that
M= Millions the availability of dental insurance is
a significant predictor of utilization
Age 2050 resulting in those with coverage being
100+ Male Female 2.5 times more likely to get care.
Baby Boom Population
When only private dental insurance is
90
considered, adults aged 65 and older are
80
least likely to be covered, with rates as
70 low as 10 percent.18 The lack of dental
60 benefits is a major contributor to poor
50 oral health in older Americans.19
40
In 1965, the same year that Medicare
and Medicaid were established, Congress
30
passed the Older Americans Act. Today
20 the OAA is considered to be the major
10 vehicle for the organization and delivery
0 of social and nutrition services to this
3M 2M 1M 0 1M 2M 3M group and their caregivers.20 The Older
M= Millions American Act is due to be reauthorized
this year. The bill introduced to do
FIGURE 2 . U.S. population by age and sex, 2012 and 2050.2 this includes a small provision that
allows the aging network to use funds
designated for disease prevention
Although Medicare covers almost all benefits in 2009 and restored a subset and health promotion to conduct
other health services, routine dental of these benefits in 2014.16 The cycle oral health screenings but does not
care is not covered.14 Medicaid requires of removing and restoring benefits otherwise address oral health care.21
states to provide dental benefits to has been one of several deterrents to It is clear from this long history
children, but adult coverage is optional.15 dentists providing dental care to low- where dental services are considered an
Some states, including California, have income adults covered by this program. optional benefit in private and public
provided adult dental benefits under In 2010, the Affordable Care Act health programs that this will continue
the state Medicaid system. However, (ACA) was signed by President Obama. to be an impediment to improving
in many states, including California, The ACAs triple aim is to improve the oral health of older Americans
these benefits were removed or severely the health of the population, enhance until oral health advocates convince
curtailed in the 2007-2009 recession. patient experience in receiving care policymakers otherwise. This author
Now, a few states have restored some (including quality, access and reliability) has suggested a national campaign
adult dental Medicaid benefits. California and reduce, or at least control, the cost based on the idea that The Mouth Is
removed all but emergency adult dental of care.17 While the ACA will expand Not an Optional Part of the Body.
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 21st century dentistry
Dental Care for Older Adults in the
Era of Accountability
One promising development for
older adults is the increasing attention
being paid to accountability of health
care systems. A 2012 report titled Oral
Health Quality Improvement in the Era of
Accountability described the rapid
movement toward measuring outcomes
of health care systems and structuring
incentives based on the ability to improve
those outcomes.22 The general health
care system is far along this path and it is
beginning to accelerate in the oral health
care system as well. Many groups are
working on developing measures or
beginning to use measures in the delivery
of oral health services.23 One effort in
the general health care system to focus
on outcomes-based incentives is the
development of accountable care
organizations (ACOs) in the ACA.24
A report from the American Dental
Associations Health Policy Institute
described the development of ACOs as
an opportunity to bridge the gap between
oral and general health care, improve
coordination of care, help reduce overall
health care costs and to re-examine the
role of oral care providers within the
health care team.25 Although the initial
efforts might be aimed at pediatric dental
services, it is becoming apparent that
improving oral health of older adults can
improve the performance of ACOs. In
fact, as illustrated in FIGURE 3 , health
care expenses for adults age 65 and older
($10,082) average 2.5 times higher than
expenses for those younger than age 65
($3,931).26 As awareness of the
importance and contribution of oral
health to general health and health
care expenses continues to increase, it is
likely that ACOs will see the value of
including oral health services as a means
of improving health and controlling
expenses in the older adult population.
392J U LY 2 015
<65 years
15,000
12,500 mean
10,000
Dollars
7,500
5,000 3,931 4,014
2,500 1,015 1,218
0
All persons Any
<65 years private
*Persons age 65+ without Medicare are not included in this gure.
Note: Estimates are for the U.S. civilian noninstitutionalized population.
Source: Center for Financing, Access and Cost Trends, AHRQ Household Component of the Medical
Expenditure Panel Survey, 2009.
FIGURE 3 . National health care expenses for individuals 65+ and those <65.26
New Delivery System Models:
Reaching the Older Dependent
Population
As indicated earlier, almost 40 percent
of the population age 65 and older has
at least one area of significant functional
disability, and by age 85, it increases to
more than 75 percent. The significant
proportion of the older adult population
with limited mobility and limited sensory
function combined with lack of dental
coverage results in low utilization of
dental services. Only 42 percent of the
population age 65 and older are reported
to have an annual dental visit and the
percent with functional limitations can be
expected to be much lower.27 The result
is that dependent older adults has been
identified in the 2000 report of the U.S.
surgeon general and the 2011 Institute of
Medicine and National Research Council
of the National Academies of Science
reports, Advancing Oral Health in America
and Improving Access to Oral Health Care
for Vulnerable and Underserved Populations,
as among the groups with the poorest
oral health in the U.S. population.10,28,29
A promising strategy for reaching
these dependent older adults is a model
of care called the virtual dental home
(VDH).30,31 The VDH is a community-
based oral health delivery system in
which people receive preventive and
C D A J O U R N A L , V O L 4 3 , N 7
*65+ years 14,480
median
10,082 9,832
9,427
7,207
4,690 4,542 4,615
3,898
2,132
671 483
Public Uninsured All persons Medicare Medicare/ Medicare/
only 65+ years only private other public
early intervention therapeutic services
in community settings where they live
or receive educational, social or general
health services. It utilizes telehealth
technology to link practitioners in the
community with dentists in offices and
clinics. A six-year demonstration project
showed that registered dental hygienists
in alternative practice (RDHAPs),
registered dental hygienists (RDHs)
working in public health programs and
registered dental assistants (RDAs) can
work in a team lead by geographically
distant dentists and can keep many
people healthy in community settings
by providing education, triage, case
management, preventive procedures and
early intervention therapeutic services.
When more complex dental treatment is
needed, the VDH connects patients with
dentists in the area. This system promotes
collaboration between dentists in dental
offices and clinics and these community-
based allied dental personnel. This project
redefines the use of the term dental
home to include the entire geographically
distributed, collaborative, telehealth-
facilitated system of care. The VDH
provides all the ingredients of the health
home, keeps dentists at the head of the
distributed team, and most important, it
brings much-needed services to individuals
who might otherwise receive no care.

The six-year demonstration of the VDH
system, directed by the Pacific Center for
Special Care at the University of the Pacific,
Arthur A. Dugoni School of Dentistry
(Pacific), has shown that more than two-
thirds of individuals who do not regularly
receive dental care can be kept healthy in
community sites by the services that can be
provided on site by allied dental personnel.
This is true for the older adult population
as well as younger populations. The success
of the demonstration of this unique model
of care resulted in 2014 legislation that
addressed barriers to spreading of the
system being proposed and supported by
more than 35 advocacy agencies. That
legislation, AB 1174, was signed by the
governor of California in the fall of 2014
and became law on Jan. 1, 2015.32 Pacific
is now working with regulatory agencies
on the implementation of this legislation
and is planning to assist health centers
and dental practices across the state in
expanding their reach into community
sites using telehealth-connected teams.
Conclusion
The aging of the baby boomers in the
21st century is creating unprecedented
numbers of vulnerable older adults, with
functional limitations and complex health
conditions, who are living in community
settings and care facilities and needing
oral health care. The increase in people
keeping their teeth as they age, the aging
of disabled populations and the increasing
complications of medical treatments
for people in these groups all point to
increased numbers of more complex
individuals needing more complex oral
health care management. Although
these demographic shifts are providing
unparalleled challenges for our health care
system, they also bring new opportunities
to develop and implement innovative
systems for reaching and maintaining
the oral health of older Americans.
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THE AUTHOR, Paul Glassman, DDS, MA, MBA, can be reached at
pglassman@pacic.edu.
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