Download Report on Seniors` Oral Health

British
Columbia
Dental
Association
Report on Seniors’ Oral Health
November 2008
REPORT ON SENIORS' ORAL HEALTH
Report Authors
Batoul Shariati, UBC Faculty of Dentistry
Michael MacEntee, UBC Faculty of Dentistry
Chris Wyatt, UBC Faculty of Dentistry
Jocelyn Johnston, Executive Director, BC Dental Association
Susan Boyd, Manager, Communications, BC Dental Association
Approved by the BC Dental Association's Geriatric Dentistry Committee
Copyright 2008
British Columbia Dental Association
400 – 1765 West 8th Avenue
Vancouver, BC V6J 5C6
Acknowledgements
This report was prepared by the British Columbia Dental Association's Geriatric Dentistry
Committee working with the University of British Columbia's Faculty of Dentistry. The Geriatric
Dentistry Committee would like to thank the BC Ministry of Health for support in funding the
report.
BC Dental Association
Report on Seniors' Oral Health
TABLE OF CONTENTS
1. EXECUTIVE SUMMARY .................................................................................................. 1
2. INTRODUCTION ......................................................................................................... 4
3. THE AGING POPULATION ............................................................................................. 5
4. CHALLENGES FOR SENIORS IN MAINTAINING ORAL HEALTH ................................................. 6
Income and Dental Coverage...................................................................................... 6
Overall Health .......................................................................................................... 6
Medication .............................................................................................................. 6
Frailty and Independence........................................................................................... 7
5. ORAL HEALTH'S IMPORTANCE TO GENERAL HEALTH AND OVERALL WELL-BEING ....................... 8
Disease Diagnosis and Early Detection ......................................................................... 8
Diet ........................................................................................................................ 8
Overall Quality of Life ................................................................................................ 8
6. ORAL DISEASE .......................................................................................................... 9
Tooth Decay (Caries)................................................................................................. 9
Poor Oral Hygiene, Gingivitis and Periodontal Diseases ................................................... 9
Tooth Loss ............................................................................................................... 9
Dentures, Mucosal Inflammation & Infection ................................................................. 9
Oral Cancer............................................................................................................ 10
7. ORAL HEALTH CARE REGULATIONS ............................................................................... 11
8. ACCESS/BARRIERS TO ORAL HEALTHCARE ..................................................................... 13
Challenges for Seniors ............................................................................................. 13
Challenges for Dental Professionals ........................................................................... 14
Challenges for Long-Term Care Facilities .................................................................... 15
9. EXISTING MODLES OF CARE IN LONG-TERM CARE FACILITIES ............................................. 16
Individual Models.................................................................................................... 16
Interdisciplinary Models ........................................................................................... 17
10. PRIVATE AND PROVINCIAL DENTAL COVERAGE .............................................................. 18
LTC Dental Coverage Pilot ........................................................................................ 19
Dental Coverage for British Columbians...................................................................... 19
11. ORAL HEALTH PROMOTION ...................................................................................... 21
Professional Awareness............................................................................................
Public Awareness ....................................................................................................
Oral Cancer Screennig .............................................................................................
Oral Health Assessment ...........................................................................................
Dental Program Assessment .....................................................................................
21
21
21
22
22
12. RECOMMENDATIONS ................................................................................................ 23
13. REFERENCES ......................................................................................................... 25
BC Dental Association
Report on Seniors' Oral Health
LIST OF FIGURES
FIGURE 1 BRITISH COLUMBIA POPULATION PYRAMID – 1971, 2001, 2031 .......................................... 5
FIGURE 2 NUMBERS OF OLDER PEOPLE IN BRITISH COLUMBIA BY SELECT AGE GROUPS .............................. 5
LIST OF CHARTS
CHART 1 SCOPE OF DENTAL HELATH CARE PROFESSIONALS IN BRITISH COLUMBIA .................................. 12
BC Dental Association
Report on Seniors' Oral Health
1. EXECUTIVE SUMMARY
Now more than ever, with baby boomers heading towards retirement and rising life expectancy,
there is increased attention to fulfilling the health needs of the growing senior population. Oral
health, an important part of health in general, is a fundamental part of this planning due to
evidence that neglect of teeth and mouth might be closely linked to other diseases such as
diabetes and heart disease, and almost certainly contributes to pneumonia. In fact, regular
dental visits can help to screen for other serious diseases including oral cancer, while good oral
health is invaluable to quality of life and healthy social relationships.
Unfortunately, gaps in mouth care are being seen in the senior population and are likely to rise
in coming years among the more vulnerable groups, in particular among those with restricted
incomes. While over the past 20 years, there has been a significant increase in the number of
people keeping their natural teeth well into old age, factors often associated with aging, such as
increased use of prescription and over-the counter medications, poor general health and other
barriers to care are negatively impacting oral health. In general, neglect of oral health can have
major physical and social impacts that add more strain to our health care system, especially
when it leads to increased use of emergency services.
To address this concern, the British Columbia Dental Association's (BCDA) Geriatric Dentistry
Committee in partnership with UBC Faculty of Dentistry has reviewed current care practices and
issues around oral health care for seniors in British Columbia. In doing so, the Committee has
made several recommendations to address the problem, particularly around funding and steps
needed to engage key stakeholders around access to care.
Seniors, as they become frail, are very susceptible to oral diseases such as caries (tooth
decay), periodontal (gum) diseases, tooth loss, mucosal inflammation and infection. Associated
with other health disorders, untreated diseases of the teeth and mouth are a growing concern.
Regular professional monitoring can reduce the likelihood of neglect and serve as an effective
strategy for identifying and treating other serious conditions, such as tooth decay and oral
cancer. Effective prevention through daily oral hygiene and a healthy diet and lifestyle can
further support good oral health. However, seniors face a number of obstacles to maintaining
oral health, including limited finances and dental insurance coverage, along with impaired
physical and cognitive status.
Upon retirement, seniors may begin to modify behaviour based on changes in finances and loss
of dental coverage, thus opting to reduce professional visits and seek treatment only when it
becomes an absolute necessity. This is particularly evident among seniors with low incomes. As
physical and cognitive difficulties increase, seniors become more reliant on family and other
care-givers, even for basic mouth care such as daily tooth brushing. Consistent support and
personal care can be difficult to arrange as frailty increases, communications deteriorate, pain
goes unnoticed, diet declines and the senior can no longer make personal decisions. In short,
the risk of oral neglect and disease increases directly as a person’s physical and cognitive
abilities deteriorate. As a consequence, the need for additional professional care and support
becomes increasingly important with advancing age.
Challenges for dental professionals and other care staff to facilitate the growing demands of the
older population also contribute to gaps in dental services. In the early senior years, the
biggest challenge usually revolves around finances, but access to care becomes the dominant
issue with increasing frailty. Without special training, many dental practitioners find it difficult
to manage the complicated and time-consuming needs of this vulnerable population. This is
particularly evident in long-term care (LTC) facilities where there are many conflicting priorities,
inadequate resources, neglect of basic mouth care, and all too frequently, a widespread lack of
understanding of the significance of oral health on general health and well-being.
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Report on Seniors' Oral Health
Adult Care Regulations in British Columbia through the Community Care and Assisted Living Act
have allowed for steps to be made towards recognizing the importance of oral health in old age.
However, the regulations fail to recognize the necessity of a health care team involving several
dental and medical professionals. In addition, it seems that many dependent seniors may be
subject to inadequate mouth care due to current regulations that hinder their direct access to
some dental professionals, such as certified dental assistants in residential care.
While there are challenges facing all age groups of the senior population, finance is a consistent
barrier impacting access to professional care. Based on current information, it is estimated that
as little as $24 million annually can help to deliver a basic care plan for low-income seniors, and
provide an important step towards alleviating one of the many challenges facing seniors.
Increasing this amount by $2.5 million to $26.5 million will extend coverage to all of the
residents in long-term care facilities in British Columbia.
Clearly, there are a variety of issues affecting seniors' oral health. There are many immediate
remedies available; however, this is an issue that requires further professional research and
education along with increased public awareness and support.
The Committee's recommendations towards solving these issues are as follows:
Professional Collaboration
1.
Form a Seniors' Oral Health Secretariat to bring together dentists, dental hygienists,
denturists and certified dental assistants in order to collaborate on the delivery of seniors'
oral health care.
Delivery of Oral Health Care
2.
Review current models of care and provide recommendations to create a multidisciplinary
approach to care. Innovative models are needed to address dental care in the community
and comprehensive interdisciplinary care, taking into account age and frailty of patient as
well as location (community, hospital, urban, rural). Attention must also be given to the
three aging phases (recently retired, transitional, frail elderly) and their specific needs.
3.
Review and create standardized charting systems to facilitate care within LTC facilities.
4.
Define “Oral Health Assessment”, “Dental Examination”, and “Reassessment” for seniors
with special needs. Establishing what is required and who can deliver (dentist, physician,
dental hygienist, certified dental assistant (CDA), denturist, residential care aide & nurse).
5.
Lobby the provincial government to establish dental coverage for low-income seniors, with
separate coverage for all residents in LTC facilities.
6.
Lobby government to establish standards for dental equipment and space requirements in
LTC facilities to meet residents' oral health care needs.
Daily Mouth Care in LTC Facilities
Create a position statement outlining a standard for “daily mouth care” with respect to
7.
what needs to be performed and who can provide care.
8.
Lobby the provincial government to review current regulations for oral care in LTC
facilities and support expanded education for staff to meet the residents' daily oral
hygiene needs.
9.
Provide standards of care for “seniors' daily oral hygiene” in LTC facilities to interested
dentists, other provincial dental associations, dental schools, and other professions.
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Education
10. Encourage the UBC Faculty of Dentistry to create a professional program in geriatrics with
an emphasis on “seniors with special needs” for dentists. This dental geriatric program
may be a Certificate, Diploma, and/or Degree.
11.
Lobby continuing education providers such as UBC & local dental societies to increase
course availability on geriatrics. Encourage them to develop online continuing education
courses through the BCDA to reach members in remote communities. The annual BCDA
conference (Pacific Dental Conference) should dedicate at least three hours to geriatrics.
12.
Work with community colleges to establish minimum education standards on seniors' oral
hygiene. Create online daily hygiene course to support education of residential care
aides/nurses.
Research
13. Lobby the Canadian Institute of Health Research's (CIHR) Institute of Aging to increase
funds for projects and graduate student research related to dental geriatrics. Encourage
research on areas related to seniors’ oral health such as:









Reviewing the transition from retirement to long-term care with respect to
disability and declining oral health
Developing strategies to provide appropriate care for elders who are at risk of
oral diseases
Establishing and assessing reasonable and sustainable levels of oral health for
seniors with special needs
Identifying the effects of inappropriate oral health on frailty and general health of
seniors especially in disadvantaged groups
Creating standards and best practices in oral heath care of seniors
Developing valid clinical and psychometric tools to assess oral health status and
propensity for care by non-dental personnel
Demonstrating economic implications of oral health neglect in seniors with special
needs
Creating effective guidelines for assessing the maintenance of oral health in LTC
facilities
Assessing oral health needs of independent seniors
Strategic Planning
14. Lobby and open communications with seniors and special needs advocacy groups to
support the BCDA with respect to the aging British Columbian population.
15.
Continue BCDA public education programs to focus on awareness and prevention of dental
disease for seniors. Oral Health Month activities, office brochures, media outreach, tip
sheets, website content, should be considered.
16.
Communicate common messages and issues concerning geriatric dentistry to other dental
professions (dental hygiene, denturists, and dental assistants).
17.
The BCDA Geriatric Dentistry Committee should implement, monitor, and report on the
recommendations.
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BC Dental Association
Report on Seniors' Oral Health
2. INTRODUCTION
In general, British Columbians enjoy good oral health and today can be expected to maintain
their teeth throughout a lifetime due to successful preventative strategies, restorative
procedures and access to care. Meeting the changing dental care needs and accessibility to care
for the older population has not kept pace and gaps in maintaining good oral health are being
seen in various segments of the senior population. This is especially true of frail seniors or
those with special needs, who may be home-bound, or in residential care, and among those
with low incomes. Moreover, recent estimates suggest that this disparity in health care is likely
to increase in the near future due to the growing senior population and extended life
expectancy.
While British Columbians are enjoying longer and healthier lives, increased age will inevitably
bring a higher incidence of oral disease, such as dental caries (tooth decay), periodontal (gum)
disease and oral cancer, and increase the risk of losing natural teeth. This has a negative
impact on comfort and quality of life and threatens general health.
The report reviews the oral health needs of British Columbia's senior population outlining
growth trends, barriers to care and current models of care. It concludes with recommendations
to improve seniors' oral health.
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Report on Seniors' Oral Health
3. THE AGING POPULATION
British Columbia is experiencing a growth in its senior population which will continue at an
accelerated rate as the baby-boomers enter the ranks of seniors. Furthermore, the general
health of the population has improved and as a result, life expectancy is increasing.
In 2006, the percentage of the population in BC over the age of 65 was 15%, a marked
increase of 13% from 2001. Current estimates indicate that the older population will more than
double in number over the next 25 years (Figure 1).
Figure 1: British Columbia
Population Pyramid – 1971, 2001,
2031
Source: Demographic Characteristics of British
Columbia's Senior Population: An Environmental
Scan, Ministry of Labour and Citizens' Services,
2005
Perhaps even more significant, is the
increase in the number of people over
80, which increased by 24% between
2001 - 2006 and now represents about
4% of the population (BC STATS
Business Indicators, 2007). In 1997,
men lived on average 76 years, and
women 81 years, with expectations that
life-expectancy will rise to 81 years and
86
years
for
men
and
women
respectively by 2041 (Canada’s Aging Population, 2002). Today, the average 65 year-old can
expect at least two more decades of life (Aging Well in British Columbia, 2006).
While the population of seniors is growing, varying rates of growth are occurring among
different age groups (Figure 2), each having divergent oral health care needs. Essentially, there
will continue to be larger numbers of frail elderly people who will need special care and
attention to maintain a dignified quality of life (Grundy, 1997).
Figure 2: Numbers of Older People
in British Columbia by Select Age
Groups
Source: Demographic Characteristics of British
Columbia's Senior Population: An Environmental
Scan, Ministry of Labour and Citizens' Services,
2005
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4. CHALLENGES FOR SENIORS IN MAINTAINING ORAL HEALTH
There are a number of challenges that aging adults face that can impact their oral health
and/or influence their ability to maintain a high standard of prevention and professional care
throughout the senior years. These are outlined below and include available income and dental
insurance coverage, emerging health conditions, impact from medications, deterioration of
teeth, and increased frailty with loss of independence.
Income and Dental Coverage
For the most part, seniors rely on a fixed budget with less discretionary income than younger
adults which can affect their choice and/or ability to access professional dental care. As can be
expected, this issue is critical for low-income seniors who need to stretch limited finances
further. Indeed, nearly one in ten (8%) British Columbians over 65 in 2004 were living below
the poverty line, and many more had restricted incomes (Aging Well in British Columbia, 2006).
Rising life expectancy has also created a need to extend retirement funds further and consider
care needs over an extended period of time.
Today, with dental coverage being one of the top benefits provided by employers, at 56.1%
(Workplace and Employee Survey Compendium, 2005), British Columbians have benefited from
extensive treatment and limited personal expenditure on obtaining professional care. However,
upon retirement the transition to planning for future care supported through personal dental
coverage is limited. In 2003, less than one-quarter (22%) of women aged 75, compared to
69% of women aged 25-54 had dental coverage. Again, income level is likely to influence
coverage for seniors, with individuals with the highest level of income more likely to have
coverage (A Portrait of Seniors in Canada, 2006).
Consequently, due to financial constraints and lack of dental coverage, many seniors who have
dental problems elect to visit a dentist only when the problem becomes painfully acute rather
than attend a dentist on a regular basis to help prevent oral diseases. This can result in a
higher cost and impact on the senior and/or the health care system, in particular if emergency
treatment is required.
Overall Health
While today's seniors are staying healthier for longer, age is often associated with chronic
impairments and disabilities that affect quality of life. For example: cardiovascular, neurological
and musculoskeletal disorders, Alzheimer’s and other dementias, along with respiratory
diseases are the usual precipitators of increased frailty. All of these conditions can seriously
complicate dental treatment, and, in turn, oral disorders can have a very significant impact on
both morbidity and mortality in old age.
As with general health, aging can also impact oral health through deterioration of the teeth due
to wear and the affects of chronic disease. Xerostomia (dry mouth) can also begin to manifest
among older adults as a side effect of many medications, which can contribute to dental decay.
In fact, in one Canadian study of older adults (50 and over) it was found that one-fifth reported
oral dryness and it was the most common of 22 oral symptoms and complaints (Locker, 1993).
Medication
Most seniors in Canada regularly use a number of over-the-counter medications in addition to
several prescribed drugs (Baqir et al. 2000). Many contain sugar and have xerostomic side
effects, two factors which can impact oral health. The result can be devastating to natural teeth
as tooth decay (caries) progresses rampantly in the acidic environment produced by the
mixture of oral bacteria and sugar in a dry mouth (Guggenheimer et al. 2003).
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In addition to the adverse potential of serious drug interactions, many of the medications
prescribed for chronic diseases, such as depression, insomnia and high blood pressure, disturb
the quality and quantity of saliva (Baqir et al. 2000). This is particularly evident for residents of
long-term care (LTC) facilities who consume an average of seven prescribed drugs daily
(Broderick, 1997).
Frailty and Independence
Frailty and loss of independence generally increases over the age of 80, often with a need for
extra home-support or, more drastically, a move to a residential care facility. At this stage,
seniors usually need some help with basic oral hygiene and other preventive dental care.
Currently, about 5% of British Columbians over 65 live in residential care and most of these are
older than 80 (Aging Well in British Columbia, 2006). This amounted to 31,000 seniors in
residential care for at least part of 2004-05. Consequently, it is evident that as the population
ages and life expectancy rises, serious consideration must be given to the need for ongoing oral
health care over an extended period of time (MacEntee et al. 1997).
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5. ORAL HEALTH'S IMPORTANCE TO GENERAL HEALTH AND OVERALL WELL-BEING
Oral health care plays a vital role in general health and well-being. There is incontrovertible
evidence that healthy teeth enhance appearance, social interactions, nutrition, enjoyment of
food, and can prolong life, whereas diseased, broken or missing teeth can greatly disturb an
individuals’ general health and well-being (Locker et al. 2002; MacEntee, 2007).
Disease Diagnosis and Early Detection
As the primary gateway to the body, the mouth senses and responds to the psychosocial
environments both inside and outside the body. Oral organisms have been linked to infections
of the endocardium, meninges, mediastinum, vertebrae, hepatobiliary system, and prosthetic
joints (Shay, 2002). The dentist is often the first to see and diagnose warning signs for serious
diseases, such as diabetes, cancer, cardiovascular disease and drug dependencies.
However, the most threatening consequences of poor oral hygiene in elderly people with
dysphagia (difficulty swallowing) are the direct aspiration of bacteria from the mouth to the
lungs causing pneumonia (Wǻrdh et al. 2004; Terpenning, 2005). This realization prompted
Terpenning (2005) to suggest that “the expense of aspiration pneumonia as a nursing home
complication makes dental hygiene a potentially cost-saving intervention."
Diet
Individuals with strong oral health benefit from eating a wider range of foods than those with
pain, discomfort or tooth loss, positively contributing to overall health. The risk of malnutrition
triples when the mouth is unhealthy whereas a healthy mouth facilitates good eating habits by
enhancing our ability to enjoy a wider variety of foods (Sheiham et al. 2002).
Unfortunately, various factors such as finances and poor health can result in inadequate food
choices that can negatively impact oral health. For instance, seniors with low incomes may
choose processed over fresh foods due to restricted finances or may receive support from the
local food banks, thus limiting choice. Such scenarios can result in food options that are often
higher in sugar. Additionally, when increased frailty curbs the appetite of seniors in care, many
facilities will offer sugar-laden foods, such as muffins and sweet drinks, which in addition to
sweetened medications can compound oral health issues. Again, the consequence can be
devastating to natural teeth by greatly increasing the risk of decay that can inflict major
damage to natural teeth in very short order, and without noticeable signs or symptoms until
the decay is advanced.
Overall Quality of Life
Pain, discomfort and appearance are just some of the effects poor oral health can have on
quality of life. Individuals suffering from tooth loss, decay or halitosis (bad breath) may begin
to withdraw from social interaction due to increased self consciousness, discomfort or
embarrassment. Additionally, since eating is often a part of social interaction and may cause
increasing discomfort, individuals may opt out of such social interactions. One study of older
adults found that the presence of teeth enhances their appearance, ability to eat, enjoyment of
food and that teeth also had a positive effect on comfort, confidence, speech, enjoyment and
longevity (MacEntee et al. 1997; Strauss and Hunt, 1993). If oral health is not restored and
continues to decline, individuals may begin to withdraw and become isolated which can impact
life satisfaction.
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6. ORAL DISEASE
Seniors are susceptible to a number of very prevalent oral diseases that can be prevented or
minimized through proper care and professional monitoring including:
Tooth Decay (Caries)
Dental caries continues as a very prevalent and destructive disease among seniors. The
increased challenges associated with maintaining oral health combined with the success of early
preventative strategies can lead to higher incidence of caries throughout the senior years. New
caries in coronal and root surfaces develop at a higher rate in older adults than in younger
populations (Saunders et al. 2005). In a three year study of adults aged 50, the incidence of
coronal caries was 57% and the mean net decayed or filled coronal surfaces (DFS) increment
was 1.9 (Hawkins et al. 1997).
Of particular concern is the incidence of Late Elder Caries (LEC) among the older, more
vulnerable senior population. Caries is rampant in a significant proportion of frail elders in much
the same way as it is active among vulnerable populations of children (MacEntee, 1994).
Prevention and management of caries in a frail population remains a public health and an
individual professional challenge. A recent clinical trial at UBC has shown that the rate of
carious attack can be reduced very significantly in this population by using a daily over-thecounter fluoride mouth rinse (Wyatt and MacEntee 2004). The cost and effectiveness of dental
restorative treatment remains an unresolved challenge for LEC.
Poor Oral Hygiene, Gingivitis and Periodontal Diseases
The bacteria that accumulate around teeth when oral hygiene is neglected can rapidly lead to
gingivitis and can exacerbate the course of periodontal disease. Affecting the tissues that
support and anchor the teeth, periodontal disease is highly preventable through positive oral
hygiene habits. There also exists a strong possibility that the risk of diabetes mellitus,
osteoporosis, and cardiovascular disorders, including stroke, is significantly elevated by
periodontitis (Locker et al. 2000; Persson et al. 2005).
Probably the most significant and harmful contribution that caries and periodontal disease can
have on older seniors, particularly in residential or LTC facilities is the contribution to aspiration
pneumonia.
Tooth Loss
The pattern of tooth loss is changing rapidly in older populations. Where previously most
elderly people could expect to replace all of their natural teeth with dentures, today most
Canadians retain their natural teeth for a lifetime. The 2006 British Columbia Dental Association
(BCDA) Adult Dental Health Survey shows clearly that since 1986 there has been a very
substantial decrease (approximately 40%) in the average number of missing teeth within the
66-85 age group. As noted, caries continues to take its toll as the leading cause of tooth loss in
all age groups; nonetheless, the impact is not nearly as high as it was 20 years ago.
Dentures, Mucosal Inflammation & Infection
Removable dentures remain a common solution to replace missing teeth since not everyone can
afford bridges spanning natural teeth or oral implants. Unfortunately, dentures are not always
easily managed by people who have xerostomia (dry mouth), dyskinesia or dementia. Sadly, over
half of the edentulous (without teeth) residents in Vancouver LTC facilities some years ago did not
wear their dentures, while many of the dentures worn were seriously defective; and there is no
reason to believe that the situation has improved much in recent years. Typically, the
consequence of this predicament is malnutrition, psychological distress and social isolation (Fiske
et al. 1998).
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BC Dental Association
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Acute and chronic changes to the mucosal lining of the mouth due to continuous denture use are
quite prevalent. Poor oral and denture hygiene can also result in fungal infection. As a social
concern, halitosis (bad breath) from poor oral and denture hygiene detracts from self-esteem and
induces social isolation (MacEntee, 2005).
Oral Cancer
The burden of suffering from oral cancer is enormous. Oral cancer was diagnosed in 3,200 people
in Canada and responsible for 1,100 deaths in 2007 (Laronde et al. 2008). Current estimates
indicate that one in 346 women diagnosed with oral cancer and one in 216 men die of oral
cancer annually in BC (British Columbia Cancer Agency, 2008). Survival rates in BC and the
rest of Canada have improved slightly from about 50% in the mid-1970s to about 60% in
recent years, which is due in part to early diagnosis and more effective treatments (Locker et
al. 2000; Sutcliffe, 2008).
The propensity of oral cancer is higher among the senior population, in fact, adults as young as
40 years should speak to a dentist about oral cancer and maintain regular screenings. Regular
dental check-ups offer one of the most efficient ways to screen for oral cancer, especially for
older people and for those who smoke tobacco and drink alcohol (MacEntee et al. 2004). If
caught early, oral cancer has an 80 – 90% survival rate (British Columbia Cancer Agency,
2005).
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BC Dental Association
Report on Seniors' Oral Health
7. ORAL HEALTH CARE REGULATIONS
Minimal standards of oral health care in LTC facilities have been established provincially. The
“Community Care and Assisted Living Act - Adult Care Regulations, B.C. 1997” recognizes
specifically the importance of oral health and its impact on quality of life and general health
(Government of British Columbia Order in Council #1105, 1997).
According to the BC regulations, an administrator of a licensed residential care facility must:
1. encourage each resident to obtain an examination by a dental health care professional1 at
least once every year; and
2. ensure that a resident is assisted in:
a. maintaining daily oral health;
b. obtaining professional dental services as required; and
c. following a recommendation or order for dental treatment made by a dental health care
professional, providing care to the resident.
This regulation provides flexibility for administrators and staff in each facility to encourage a
resident towards an appropriate level of examination based on the resident’s desires, needs and
financial resources (Community Care and Assisted Living Act - Adult Care Regulations, B.C.,
1998). The regulations do not specify that a dentist must perform the annual clinical examination;
however, the policy recognizes that only dentists may provide dental services related to the
examination, diagnosis and management of all conditions of teeth and their supporting hard and
soft tissues. However, hygienists (including residential care hygienists who can work
independently of a dentist in a LTC facility), denturists and certified dental assistants employed by
the provincial government can provide oral health care within their scope of practice (Chart 1).
Although these regulations are a positive acknowledgement of a need for care, the oral health
care offered in most facilities is little more than an emergency service, probably because of the
multitude of conflicting health care priorities and shortage of staff in most residential care
facilities around the province (MacEntee et al. 1999).
1
A 'dental health care professional' can be a dentist, dental hygienist and denturist.
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Chart 1 - Scope of practice of dental health care professionals in British Columbia
Profession
(Regulatory Act)
Dentists
(Dentists Act)2
Certified Dental Assistants (CDA)
(Dentists Act)2
Dental Hygienists
(Health Professions Act)
Scope








Residential Care Hygienists
(Health Professions Act)


Denturists
(Health Professions Act)



Diagnose and treat all conditions in the oral-facial
complex;
Prescribe medication for oral concerns;
Order diagnostic radiographs and tests.
Assist dentists under the direct supervision of a
dentist;
Provided a limited range of preventive dental services.
Assess the status of teeth and adjacent tissues;
Provide preventive and therapeutic dental hygiene care
for teeth and adjacent tissues when a patient has been
examined by a dentist within the previous 365 days;
Administer local anesthesia under the direct
supervision of a dentist.
Practice independently of a dentist within residential
care facilities approved by the College of Dental
Hygienists of British Columbia;
Administer local anesthetic if authorized by a dentist or
physician if a person qualified to act in a medical
emergency is immediately available.
Assess and carry out non-surgical intraoral procedures3
to make, repair, reline, replace or furnish complete
dentures;
Make or furnish partial dentures and overdentures on
prescription from a dentist;
Reline, replace teeth, or repair partial dentures and
overdentures.
2
The Dentists Act will be repealed and the regulation of dentists and certified dental assistants will fall
under the Health Professions Act in 2009.
3
Denturists cannot cut, grind, scale, clean, restore, alter or polish natural teeth, crowns or implants.
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8. ACCESS/BARRIERS TO ORAL HEALTH CARE
Seniors' access to oral health care is a multi-faceted issue with challenges for all involved,
including seniors and their care-givers, professionals and LTC facilities.
Challenges for Seniors
As seniors age, their oral and overall health will deteriorate, though naturally the rate of change
and the nature of the problems varies with each individual and age group. Following years of
exposure, it is natural for one's dentition to begin to deteriorate which can be accelerated due
to growing neglect.
For newly retired seniors, oral health is relatively good as the majority have enjoyed ongoing
dental care throughout their lives. However, there is a tendency for seniors to begin to attend
the dentist less often. A recent Canadian study found that the percentage of those aged 65 to
74 consulting a dentist over a 12 month period in 2003 was 48%, a decrease of 10% from
those aged 55 to 64 and almost 20% from those aged 25 to 54 (A Portrait of Seniors in
Canada, 2006). This can be attributed to several factors:
a. Often linked to employment, access to dental coverage or benefits is reduced or
eliminated upon retirement.
b. Limited personal investment is made for dental coverage.
c. Cost becomes a barrier due to restricted finances.
d. Patients' attitudes change placing less importance on oral health and the need for
continuing care. In the worst case scenario, patients will seek treatment only for the
relief of pain and infection.
As they continue to age, seniors face additional challenges as general health wanes. This
problem is even more severe among homebound seniors in which 60 to 90% have reported a
need for dental services, but only 26% reported visiting a dentist at least once every two years,
and 12 to 16% had not visited a dentist in over five years (Marvin, 2001).
This growing decline in care can be influenced by the following:
a. Mobility declines with certain conditions, making it difficult for the patient to visit the
dental office without assistance; this issue can be compounded for seniors in rural areas
where access is limited.
b. Daily oral hygiene practices can diminish due to physical and/or cognitive capacity and
again, the individual may begin to require additional support.
c. Some medical conditions can complicate dental treatment, in some cases requiring
consultation with the patient's physician, additional medication, the need for dental
specialists or even access to a hospital for treatment under general anaesthesia.
d. Oral health care can decline rapidly due to ongoing deterioration, increased consumption
of medications and changing diet creating a greater need to meet daily care and access
professional care.
The greatest challenge is for frail seniors who are completely reliant on others for all aspects of
their care:
a. Dental care options are limited.
b. Financial resources are extremely limited.
c. Consent is required which can delay treatment. Additionally, faced with a variety of
health issues and due to lack of awareness of its ongoing importance towards general
well-being, those with power of attorney may not prioritize dental care.
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d. Daily mouth care is provided by a care aide who may not have the time or recognize the
importance of daily cleanings. This could result in escalating problems due to
complicated treatment such as implants and bridges.
e. Patients, especially with dementia, cannot articulate their problems and often pose a
patient management problem.
f. Transportation may be challenging, making access to dental care through a dental office
difficult.
Challenges for Dental Professionals
For the most part, the dental office provides the ideal multidisciplinary setting for treatment.
However, wheelchair bound seniors and those with increased frailty can often create challenges
for the dental team in an office setting including:
a. Access to a suitable treatment room may be limited. While many zoning by-laws will
require offices to have wheelchair access there are many cases where office and/or
treatment rooms may not be wheelchair friendly.
b. Patient transfer may be difficult due to the nature of some disabilities. Patients may be
more reliant on staff to facilitate transfer to the dental chair, a process which can often
be facilitated by a lift in a facility. This may require additional training for staff members.
c. For the reasons mentioned above, appointment times may be unpredictable often
resulting in disruptions to office schedules and patient appointments. Additionally,
physical and cognitive impairments may require dental professionals to take extended
time with a patient to review medications and ensure comfort.
d. The dental office may have limited information on patient medical history.
e. Although patients may be able to receive an examination, further treatment, if required,
may involve consent, requiring additional visits and time to coordinate.
Care within the facility will pose its own set of challenges to dental professionals including:
a. Reliance on residential staff for patient scheduling to effectively deliver patients to
dental team in order to meet all appointments within a set timeframe.
b. Dental professionals need to work with the facility to fit within the hospital system.
c. Coordinating billing through facility and family members.
d. Remuneration - although many facilities have contractual agreements with dental
personnel, the salary does not motivate dental personnel to make domiciliary calls to
the residents of the facilities.
e. Unpredictability of the patient schedules and consent can often lead to cancelled
appointments and delays making care at a facility unreliable for dental professionals.
f. There are no standardized charting procedures.
g. High residential turnover requires continued visitations to ensure all patients receive
appropriate screening.
h. Lack of adequate space to conduct appointments is a constraint. In some cases, a room
is set aside for the dental professional whereas other times care may take place at the
bedside or in a wheelchair.
i. Most LTC facilities will not have the equipment required to meet a diverse range of
patient needs. This results in the need for further care to be coordinated and conducted
off-site.
Due to lack of comfort in dealing with the multitude of issues, the increased demand on time
and resources for basic dental health care without the appropriate compensation for service,
many professionals are reluctant to treat this vulnerable patient group. This is particularly
evident in LTC facilities where there are greater challenges in dealing with patient families,
administrators and inadequate resources. This further compounds the problem particularly in
remote areas where limited access exists.
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Challenges for Long-Term Care Facilities
According to a report on oral health care for seniors prepared in 1999 for the provincial
ministers responsible for seniors (Innovations in best-practice models of continuing care for
seniors, 1999), respondents from LTC facilities across Canada have identified their greatest
difficulties and challenges facing oral health care program development and delivery as:
1. Resource limitations, identified as one of the major challenges by more than half of the
respondents
2. High public expectations
3. Geographical factors with difficulty implementing programs in rural and remote areas
4. Lack of public awareness regarding continuing care
5. Increased complexity of needs requiring programs to be more complex and usually more
costly
6. Resistance to change; and
7. Political environment and provincial control of programs and services that influence
budgetary commitments to sustain program initiatives.
Additional factors contributing to the poor oral health status of LTC residents are financial
constraints, apathy of the residents and staff, uncooperative administrators, and inadequate
clinical equipment (Thorne et al. 2001).
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9. EXISTING MODELS OF CARE IN LONG-TERM CARE FACILITIES
There are a variety of care models that have been implemented throughout the province to
address the growing concern around seniors' oral health. The majority of these programs have
focused on reaching seniors in LTC facilities due to the acute needs of this population.
Models of care can be broken into individual and interdisciplinary approaches to care.
Individual Models
Dentists
There are a number of dentists in British Columbia that serve patients in LTC facilities. Dentists
may visit a facility each week or once a month, working with a hygienist or certified dental
assistant (CDA). Depending on the nature of the treatment, further care may need to be
coordinated off-site.
According to the results of a 2006 BC Census Survey conducted by the BCDA, 8% of
practitioners surveyed were treating LTC patients. Of these, 45.2% provided palliative care
(limited treatment), 30.3% provided comprehensive treatment and 24.5% provided emergency
treatment (BCDA internal report, unpublished). The majority of respondents saw patients in
their own office and provided care in conjunction with a CDA, care aide or dental hygienist.
Due to the challenges outlined previously, there are a limited number of dentists serving this
growing population. Steps have been taken to alleviate some of the impacts on the profession,
such as incorporating a separate fee structure for LTC practitioners in the BCDA Annual Fee
Guide to account for the extra time involved in working with this group. However, according to
the 2006 BC Census Survey, only 19.9% of current practitioners were using this guide (BCDA
internal report, unpublished).
Additionally, the Dentistry Canada Fund (DCF) has created the BC Public Outreach Fund which
is designed to support dentists and CDAs who provide care in BC LTC facilities. This fund
provides a "grant" that can be used to off-set licensure costs. To those that qualify, the BCDA
and the Canadian Dental Association similarly provide grants which together with the DCF's
grant will essentially cover the cost of licensure.
Certified Dental Assistants
CDAs presently serve LTC facilities as part of the dental team. Often, they are a valuable
resource to support basic preventive measures, working with staff and patients. CDAs provide
education and care in the LTC environment under supervision of a public health dentist.
Additionally, they support the administration of LTC programs coordinating with facility staff
and a patient’s family. It is expected that as the bylaw moves under the Health Professions Act
this will include flexibility for further involvement of CDAs in the LTC environment.
Residential Care Hygienists
In line with provincial regulations, a number of LTC facilities throughout the province have
engaged the services of a residential care hygienist to support the facility in executing oral
health care initiatives. The scope of services may include: screening residents upon admission,
creating an oral care assessment, and educating facility staff on good oral health. Once
assessments are conducted, the residential care dental hygienist may engage families for
consent for further treatment on-site such as scaling/denture cleaning or arrange for an
appointment with a visiting or off-site dentist.
Hygienists often work closely with dentists to provide restorative and other treatment as noted
above. Again, challenges such as limited funds and reliance on support from other dental care
professionals can become barriers to prevent dental hygienists from operating in more facilities.
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Denturists
There are a few denturists providing mobile services within BC that serve LTC facilities and
make home visits. The primary service provided is to make dentures, which can be done onsite. Denturists will engage a dentist should the patient need partials, or require any further
dental care. The service is limited within BC, primarily conducted in the lower mainland, making
it more difficult for seniors in rural communities.
Interdisciplinary Models
University of British Columbia Geriatric Dentistry Program (GDP)
Created in 2002, the University of British Columbia Geriatric Dentistry Program (GDP) was
formed to address the needs of elders in LTC facilities (Wyatt et al. 2006). Through the
program, every resident receives a clinical exam upon admission by means of a structured
protocol, and are then offered a comprehensive treatment service as needed. Residents also
receive support and are offered assistance with daily mouth care as required. Moreover,
through the program, each facility has access to an oral health-related educational program for
the residents and staff. The program involves a multidisciplinary approach involving dentists,
dental hygienists, and CDAs. Today, the program serves the oral health care needs of over
2,500 frail elders in 18 LTC facilities. A thorough analysis of program development,
implementation, and outcomes revealed that the GDP has achieved its goal of providing access
to oral health services for enrolled facilities (Wyatt et al. 2006). Funding for this program
comes from Vancouver Coastal Health Region, Fraser Valley Health Region, LTC facilities, Tzu
Chi Foundation, and patient dental care.
Northern Health Region –Prince George Geriatric Outreach Dental Program
Since 1997, a program funded by the Northern Health Region has been providing dental
services to the six LTC facilities in Prince George. Currently, one of the six facilities only
receives emergency coverage, while the others are allocated a set number of visits per year.
Within a minimal annual budget ($17,610 in 2007/2008), the program provides a service
option through a dental team to the 325 residents in facilities. This collaborative approach
involves four dentists, a residential care hygienist and a CDA.
The dentist conducts a number of scheduled visits per year to each facility. In 2007/2008, the
participating dentists provided nearly 100 hours of care conducting initial and recall exams and
services including: fillings, extractions, denture adjustments/relines, and other treatments as
required. During the year, seven dental emergency visits were also required.
The residential care hygienist regularly attends the facility to provide care for residents along
with attending care conferences and education for facilities on preventative care when able. In
2007/2008 the hygienist provided 110 hours of care with services consisting of developing daily
oral care plans, individual consults, clinical dental hygiene sessions and debridements. The
hygienist also participates in a yearly total care review on patients to support the promotion of
oral care and help to identify residents most in need of treatment. Nurses at the facilities help
to support the team throughout the year by identifying who needs to be seen.
The CDA plays a significant role in the coordination of the program ensuring that the dental
team has the equipment available, that it is sterilized and that visits have been scheduled with
the facility. During the year, the CDA allocated over 130 hours to support the program. The
CDA helps to ensure a smooth running program whereby a dentist can show up at the
scheduled time and get straight to work.
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10. PRIVATE AND PROVINCIAL DENTAL COVERAGE
As noted earlier, over the years, aging dentitions often require increasing dental services to
maintain good oral health. Ongoing daily home care and professional preventive and restorative
treatment become critical in achieving this. As noted before, finances are a commonly cited
barrier to care in all seniors age groups.
This is evidenced by the relative frequency of dental visits by age – in 2003, 45.5% of seniors
had visited a dentist during past 12 months compared to 66.4% of aged 25-54 years (A Portrait
of Seniors in Canada, 2006).
Dental benefits or coverage can reduce or even eliminate the cost; however, coverage is
positively correlated with income - either as a benefit through employment or by having the
financial means to purchase a dental plan.
Federal coverage is available though broader plans such as the Non-Insured Health Benefits
Plan which covers First Nations. Similarly, Veterans Affairs provide dental coverage as part of
its benefit plan for retired military personnel.
In BC, the only government coverage for basic dentistry is through the Ministry of Housing and
Social Development. It is available for those seniors who were Ministry clients prior to turning
65 and with a disability and is limited to $1,000 over a two-year period. Coverage is not
available for those who become disabled after the age of 65.
Medically necessary dental care is covered under the Medical Services Plan, but limited to
extractions, infections and oral surgical services that require a hospital setting due to the need
for general anaesthesia or the patient's medical conditions. Patients admitted to hospital that
require dental care not covered under the plan are responsible for the cost.
Most provinces offer similar coverage through their medical and income assistance plans.
Specific coverage for older adults available in three provinces: The Yukon, the Northwest
Territories, and Alberta (Leake, 2000).
The Yukon provides dental services to eligible seniors, those over 65, as part of its “Pharmacare
and Extended Health Care Benefits” program. Treatment is provided by private dental offices
and coverage is up to $1,400 per two-year period (Quiñonez CR et al. no date).
In the Northwest Territories, dental services are covered for those over 60 who are non-native
or Métis. The “Extended Health Benefits (EHB) Seniors Dental Plan” covers up to $1000
annually and is provided by dentists' and denturists' offices and community clinics (Quiñonez
CR et al. no date).
In Alberta, low-income seniors are eligible for up to $5,000 every five years through the Dental
Assistance for Seniors Program.
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LTC Dental Coverage Pilot
Most dental plans are designed to cover treatment care with little or no distinction made about
where the treatment is provided. In the case of LTC, the challenges in providing treatment are
markedly different. The dental needs of a LTC patient often involves 'palliative' which is
intended to keep the patient pain- and infection-free. Dental practitioners are also faced with
considerable challenges in treating patients, from dementia to lack of equipment.
In 2006, the UBC Geriatric Dentistry Program working with the BCDA and Three Links Care
Centre developed and implemented a dental insurance pilot project designed to eliminate the
financial barriers to basic dental care in LTC facilities. Based on a budget estimate of $54,000,
the program allowed for residents to access two oral assessments, two dental hygiene visits,
basic restorations, extractions, and chair-side denture reline during the project. The estimate
was based on an assumption that 90 residents/beds would participate at an individual/bed cost
of $600 per year. Funding was provided by the BC Ministry of Health; the Ministry of Housing
and Social Development; Vancouver Coastal Health Authority, Dentistry Canada Fund and the
Three Links Care Society.
The project funded $27,765 worth of basic dental care over a one year period which was
calculated using the BCDA's LTC fee guide which accounts for the higher cost associated with
delivery of care in residential facilities. Due to lower than expected participation rates, the
remaining funds were used to continue providing care to registered residents of the home. The
actual cost of basic dental care for participating residents was $566.63 per resident.
Along with cost of coverage, the project provided valuable insights into need for care (77% of
those participating requiring treatment) and other factors impacting treatment; language
barriers, lack of adequate on-site treatment facilities and the need for family consent, to name
a few.
Dental Coverage for British Columbians
Infrequent dental visits are most likely among working persons with low incomes (A Profile of
Seniors in British Columbia, 2004). Similarly, low-income seniors are less likely to maintain
regular visits with the dentist. As noted previously income level influences the likelihood that an
individual will invest in health coverage. As such, low-income seniors are at risk of developing
poor oral health, which can be exasperated as they continue to age.
According to recent data provided by the Ministry of Housing and Social Development, and
based on anticipated program uptake, it is estimated that a low-income senior dental plan for
British Columbia would be around $24 million (internal document, unpublished). This would
support basic dental care, dentures and access to emergency services. On average the cost per
senior to fulfill these services is: $328.66 for basic care; $311.71 for emergency care; and
$585.07 for denture services. Coverage would be available for seniors eligible for the federal
government's "Old Age Security Program".
If coverage was provided to only residential or LTC residents, the cost would be approximately
$6 million, based on recent cost and utilization data. In 2007, 82% of 1,775 residents of 13 LTC
facilities consented to care under the UBC Geriatric Dentistry Program (GDP). Of these, 1,021
(70%) required dental treatment. The total cost of all dental treatment provided and paid by
residents was $507.60. If extrapolated across the number of residents in BC, 28,371, the total
cost to the province to provide access to care would be $6,037,851.42 or $212.82 per bed.
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A case can be made for a 2-tiered dental plan for seniors that differentiates between seniors
and frail seniors. While most seniors covered would be treated in dental offices at rates
equivalent to other patients, those in LTC homes would be eligible for palliative care-type
services at higher fees which would adequately compensate practitioners for the loss in
productivity in providing care in LTC. Taking into account the overlap to account for low-income
seniors in care, if coverage was extended to both low-income seniors groups (including all
residents in LTC facilities), the total annual cost is estimated to be $26.5 million.
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11. ORAL HEALTH PROMOTION
Professional Awareness
The UBC Geriatric Dentistry Program offers all dental care professionals interested in LTC the
opportunity to visit and see the residential oral care program in action.
The BCDA engages its members year-round on issues impacting seniors’ oral health through its
newsletter, Connections. Topics related to geriatric dentistry are included on the annual agenda
of the Pacific Dental Conference. This issue is also featured through a number of Dental
Component Societies and study clubs throughout the province.
The UBC Elders Program produced “Mouth care for persons in residential care” a manual
designed to provide basic information to help caregivers maintain the oral health of their
residents. Copies were distributed to dentists providing care in LTC facilities, administrators,
public health and program heads of care aide schools.
Public Awareness
A number of dental professional associations, including BCDA, Certified Dental Assistants of BC
(CDABC) and British Columbia Dental Hygienists' Association (BCDHA), work to raise awareness
of the issues affecting seniors’ oral health to health professionals and the general public. The
participation in seniors’ fairs, media outreach and public service campaigns are some tools used
to communicate with the public.
Every April, the BCDA celebrates Oral Health Month. The theme of the 2007 campaign was
Seniors’ Oral Health. Tactics, such as TV advertising and media outreach helped to spread the
message of the importance of continued focus on oral health for aging parents. As part of Oral
Health Month, dental services are offered to low-income residents throughout the province
through Community Dental Day. In 2006, the campaign supported targeted treatment for lowincome seniors.
Oral Cancer Screening
As previously discussed, oral cancer, similar to many other malignancies may be diagnosed in
earlier stage by regular dental visits. Seventy per cent of British Columbians with oral cancer
who had regular dental visits were diagnosed at an early stage (stage I or II cancers) in
comparison to 40% of those who did not have regular dental visits (Musa, 2008).
Recently, the BC Cancer Agency and the College of Dental Surgeons of British Columbia
developed guidelines for early detection of oral cancer in BC. The BC oral cancer screening
program targets adults over the age of 40, creating awareness on the importance behind early
detection. The rational behind these strategies is that the incidence at age 40 is 10–20 times
than at age 20 and the number of screening examinations to detect one case will be lower in
older people. These guidelines support annual oral cancer screenings by dentists (Williams et
al. 2008).
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Oral Health Assessment
Several oral health assessment instruments have been developed to monitor seniors' oral
health, especially for LTC residents. These include: “Brief Oral Health Status Examination”
(Kayser-Jones et al. 1995), “Index of Activities of Daily Oral Hygiene” (Bauer, 2001), and the
“Index of Clinical Oral Disorder in Elders “(MacEntee et al. 1999). Also, the Resident
Assessment Instrument (RAI) is used widely in Canadian nursing homes to screen and assess
the level of care needed, and the Minimum Data Set (MDS) is the basic data collection
instrument within the RAI (Morris et al. 1990).
While these tools are available issues still exist as to who should use the instrument as a
screening tool. Estimates of treatment needs conducted by a dentist or dental hygienist will
differ from non-dental personnel because of their educational backgrounds and due to the lack
of a standardized approach to the examinations (Kayser-Jones et al. 1996; Lin et al. 1999). The
instruments all need further evaluation to confirm their accuracy as predictors of oral health
and treatment needs.
Dental Program Assessment
There is little or no information available on the long-term consequences of oral health care
programs for frail elders (Mojon et al. 1998; Vigild et al.1998; Yoneyama et al. 2002; Wyatt et
al. 2006). However, to provide evidence on the quality of oral health related services in LTC
facilities and to promote the ongoing oral healthcare, assessment is required. In general, some
models of health disparities are developed to explain the huge number of variables influencing
health disorders and provision of care, but they offer no guidance on how to evaluate a
particular program of care (Patrick et al. 2006). As a result, a major challenge occurs when the
policy makers look for effective strategies to implement and assess the outcome of the dental
program in LTC facilities (Pruksapong et al. 2007).
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12. RECOMMENDATIONS
A holistic approach is required to improve the oral health of seniors. Professional associations,
regulatory bodies, administrative staff, researchers, dental professionals, health professionals,
seniors and their relatives should be engaged in this issue to contribute in its promotion.
Professional Collaboration
1. Form a Seniors' Oral Health Secretariat to bring together dentists, dental hygienists,
denturists and certified dental assistants in order to collaborate on the delivery of seniors'
oral health care.
Delivery of Oral Health Care
2. Review current models of care and provide recommendations to create a multidisciplinary
approach to care. Innovative models are needed to address dental care in the community
and comprehensive interdisciplinary care, taking into account age and frailty of patient as
well as location (community, hospital, urban, rural). Attention must also be given to the
three aging phases (recently retired, transitional, frail elderly) and their specific needs.
3. Review and create standardized charting systems to facilitate care within LTC facilities.
4. Define “Oral Health Assessment”, “Dental Examination”, and “Reassessment” for seniors
with special needs. Establishing what is required and who can deliver (dentist, physician,
dental hygienist, certified dental assistant (CDA), denturist, residential care aide & nurse).
5. Lobby the provincial government to establish dental coverage for low-income seniors, with
separate coverage for all residents in LTC facilities.
6. Lobby government to establish standards for dental equipment and space requirements in
LTC facilities to meet residents' oral health care needs.
Daily Mouth Care in LTC Facilities
7. Create a position statement outlining a standard for “daily mouth care” with respect to what
needs to be performed and who can provide care.
8. Lobby the provincial government to review current regulations for oral care in LTC facilities
and support expanded education for staff to meet the residents' daily oral hygiene needs.
9. Provide standards of care for “seniors' daily oral hygiene” in LTC facilities to interested
dentists, other provincial dental associations, dental schools, and other professions.
Education
10. Encourage the UBC Faculty of Dentistry to create a professional program in geriatrics with
an emphasis on “seniors with special needs” for dentists. This dental geriatric program may
be a Certificate, Diploma, and/or Degree.
11. Lobby continuing education providers such as UBC & local dental societies to increase
course availability on geriatrics. Encourage them to develop online continuing education
courses through the BCDA to reach members in remote communities. The annual BCDA
conference (Pacific Dental Conference) should dedicate at least three hours to geriatrics.
12. Work with community colleges to establish minimum education standards on seniors' oral
hygiene. Create online daily hygiene course to support education of residential care
aides/nurses.
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Research
13. Lobby the Canadian Institute of Health Research's (CIHR) Institute of Aging to increase
funds for projects and graduate student research related to dental geriatrics. Encourage
research on areas related to seniors’ oral health such as:









Reviewing the transition from retirement to long-term care with respect to disability
and declining oral health
Developing strategies to provide appropriate care for elders who are at risk of oral
diseases
Establishing and assessing reasonable and sustainable levels of oral health for
seniors with special needs
Identifying the effects of inappropriate oral health on frailty and general health of
seniors especially in disadvantaged groups
Creating standards and best practices in oral heath care of seniors
Developing valid clinical and psychometric tools to assess oral health status and
propensity for care by non-dental personnel
Demonstrating economic implications of oral health neglect in seniors with special
needs
Creating effective guidelines for assessing the maintenance of oral health in LTC
facilities
Assessing oral health needs of independent seniors
Strategic Planning
14. Lobby and open communications with seniors and special needs advocacy groups to support
the BCDA with respect to the aging British Columbian population
15. Continue BCDA public education programs to focus on awareness and prevention of dental
disease for seniors. Oral Health Month activities, office brochures, media outreach, tip
sheets, website content, should be considered.
16. Communicate common messages and issues concerning geriatric dentistry to other dental
professions (dental hygiene, denturists, and dental assistants).
17. The BCDA Geriatric Dentistry Committee should implement, monitor, and report on the
recommendations.
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13. REFERENCES
1. A Portrait of Seniors in Canada. 2006. http://www.statcan.ca/english/freepub/89-519XIE/89-519-XIE2006001.pdf (Accessed November 2008)
2. Aging Well in British Columbia. Report of the Premier’s Council on Aging and Senior’s
issues. November 2006.
http://www.cserv.gov.bc.ca/seniors/council/docs/Aging_Well_in_BC.pdf (Accessed June
2008)
3. Baqir W, Maguire A. Consumption of Prescribed and Over-the-counter Medicines with
Prolonged Oral Clearance Used by the Elderly in the Northern Region of England, with
Special Regard to Generic Prescribing, dose form and sugars content. Public Health.
2000;114:367-73
4. Bauer JG (2001) The index of ADOH: Concept of measuring oral self-care functioning in
the elderly. Spec Care Dent 2001;21:63-7.
5. BC STATS Business Indicators, July 2007.
http://www.bcstats.gov.bc.ca/pubs/bcbi/bcbi0707.pdf (Accessed Aug 2008)
6. British Columbia Cancer Agency.
http://www.bccancer.bc.ca/ABCCA/NewsCentre/stats.htm#oral (Accessed April 2008)
7. British Columbia Cancer Agency. Survival Statistics 2005.
http://www.bccancer.bc.ca/NR/rdonlyres/D8291ED8-FAEE-4692-A2565320928187F2/29082/Survival_Statistics_2006.pdf (Accessed November 2008)
8. British Columbia Dental Association. The 2006 British Columbia Dental Association Adult
Dental Health Survey. 2006.
9. Broderick E. Prescribing patterns for nursing home residents in the US. The reality and
the vision. Drugs & Aging. 1997;11(4):255-60.
10. Canada’s Aging Population. Health Canada & Interdepartmental Committee on Aging and
Seniors Issues. 2002. http://dsp-psd.pwgsc.gc.ca/Collection/H39-608-2002E.pdf
(Accessed July 2008)
11. Demographic Characteristics of British Columbia's Senior Population: An Environmental
Scan, Ministry of Labour and Citizens' Services, August 2005; 3-4.
http://www.bcstats.gov.bc.ca/DATA/pop/pop/SeniorsDemographics.pdf (Accessed
November 2008)
12. Fiske J, Davis DM, Frances C, Gelbier S. The emotional effects of tooth loss in
edentulous people. Brit Dent J 1998;184(2):90-93.
13. Government of British Columbia Order in Council #1105. Victoria, B.C.: Appended and
ordered October 1st, 1997 to amend Section 9 of the Adult Care Legislation, 1997.
14. Government of British Columbia. Community Care and Assisted Living Act – Adult Care
Regulations. Community Care Facilities Programs: Policies and Procedures. Victoria, BC:
Queens Printer. 1998.
15. Grundy E. Demographics and gerontology: Mortality trends among the oldest old. Aging
& Society 1997;17:713-25.
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