Could it be said that a wave of poor oral health outcomes is heading toward older Americans, or are these outcomes already here? And why?
I think it would be fair to say that as more people age, they will not have access to the dental care they are used to – unless they have the financial means to be able to afford it. This is the crux of the problem. Because if you can’t access care regularly, you’re more likely to have poor oral health for the rest of your life.
What is the structural problem of insurance for the elderly? Why don’t they have dental coverage as part of Medicare?
Medicare does not provide a dental benefit. So if you think about Medicare now, there are four parts: Medicare A, B, C, and D. Part A is mostly for hospital care. Part B is for outpatient medical care. Part C Advantage are plans offered by private companies where people can buy dental insurance. But Medicare recipients do not automatically receive a dental benefit as part of Medicare. So this is a problem.
And that’s why more than half of people over the age of 65 don’t have any dental insurance, which is the largest demographic in the United States without dental insurance. Our dental insurance structure is generally based on employment status – the primary policyholder is employed somewhere and their employer insures them.
Is it incumbent on policymakers to expand dental coverage within Medicare? Is this the main way to solve this problem?
Well, yes. As a country, we really have two paths here. We can find a way to make it work within the existing private third party insurance structure, or we offer dental coverage through public insurance. So we need to expand coverage either by using private or public entities.
And the best way to do it through the public entity would be Medicare. That’s because everyone, every single American 65 and older, gets Medicare. They are used to it and understand how it works. So providing a benefit through Medicare makes the most logical sense if we were to provide dental coverage through a public structure.
In the private sector, it will be a patchwork. You will have many insurance companies involved, and then it will come down to financing. How will you finance this?
If we don’t make progress, we will have millions more older Americans with poor oral health and poor health outcomes. And it will cost our society on the other side of Medicare — spending more and more money taking care of chronic conditions that can be exacerbated by poor oral health.
What are some of the most common oral health issues for people as they age?
The elderly, like the young and children, are susceptible to dental caries. So you still have the risk of tooth decay. But older people are also more likely to experience decay on the root surfaces of their teeth rather than the crown portion of their teeth. This is because as we age we lose some bone around our teeth and the gums begin to recede.
Older adults also have a higher prevalence of periodontal disease. So you will have bone loss with periodontal disease and you will have more exposed tooth root surface. The root surfaces of the teeth are not as strong as the “crown” surfaces of the tooth enamel making the elderly more susceptible to tooth decay in the exposed parts of their tooth roots.
Also, the prevalence of oropharyngeal cancer is highest in older adults. Pharyngeal cancer usually occurs in the upper part of the soft palate, in the pharynx. And the death rate for all pharyngeal cancer is higher in older adults. So if you think about the big three dental diseases – caries, especially root caries, periodontal disease and pharyngeal cancer – the prevalence of all of these is higher in older people.
With any of these oral conditions, accessory problems are likely. What are the ancillary conditions that then end up affecting overall health?
Right, and that’s what the study led by Natalia Chalmers, DDS, MHSc, PhD and Steffany Chamut, DDS, MPH, was all about. Because they were looking at people in nursing homes, they saw people with tooth loss, who needed dentures and had problems with their dentures or with eating and oral pain. So pain from either existing natural teeth or pain from ill-fitting dentures affects a person’s ability to eat healthily. And the older we get, the more important it is for adults to have adequate nutrition.
Inadequate nutrition can not only affect a person from a biological perspective; it also affects their quality of life because we have so many customs, celebrations and other events that revolve around food. So if you can’t enjoy food from a cultural perspective, your quality of life is diminished.
What disparities have been noted between ethnic and racial groups when it comes to older adults and dental care?
We see disparities in older adults by race and ethnicity, particularly with non-Hispanic blacks. And it depends on which result we are looking at. The disparities vary depending on whether it is caries, periodontal disease, or tooth loss, severe tooth loss. Because one very important thing we think about is how many natural teeth are left. We know that if you have about 20 to 21 natural teeth left, your quality of life is much better.
When you have less than 20, it is a significant indicator of a higher probability of some negative health outcomes. Complete tooth loss is also an important marker for chronic health problems. We know that when people don’t have enough teeth, they are more likely to have more problems with self-care, for example with activities of daily living. They are less likely to be able to live independently and the risk of falls and disability may increase. So there is a link between functional status and oral health.
But I would say that when you want to think about the disparities in older adults, the biggest disparity in whatever poor oral health outcome you’re looking at, the biggest disparity is between those who live in poverty and those who live in 200% or more. of the federal poverty line. So income, and especially living in poverty, is an important driver of poor oral health.
And we know that oral health and general health are strongly linked.
The understanding of this connection has grown largely in the last 20 years, hasn’t it?
Yes, it started with the first Surgeon General’s report on Oral Health in America in 2000. In the most recent Oral Health in America report (released in 2022), the amount of new information gained over the previous two decades was significantly increases actually strengthens our understanding of the connection. The really important thing is that you cannot have overall health and wellness without oral health. So you must have oral health to enjoy health and have a high quality of life.
