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Dental Homes for Nursing Home
and Geriatric Patients”
Patricia Skur, DDS
Assistant Professor
Baylor College of Dentistry
Changing Risks for Society
Larger proportion of society that is older
More people in need of long-term care
After 2020, exceptional slow labor force growth,
including people who could provide long-term care
How many elderly are there?
35 million now, doubling to 70 million by
How many elderly are there?
35 million now, doubling to 70 million by
Places Where Long-Term Care is Provided
• At Home by family
• At Home by skilled and less skilled personal
• At day care centers
• In a variety of senior housing alternatives
• In assisted living facilities
• In nursing homes
Options for Individuals to Finance
Long-Term Care
Retirement saving and assets
• Move into a continuing care retirement
Community (CCRC) or life-care community
• Purchase long-term care insurance
Current LTC System
Little planning, especially on the part of individuals
Health insurance does not integrate social services
Medicare does not cover most long-term care needs
Medicaid, by default, has become the primary source of financing
• Medicaid eligibility varies by state
• Medicaid home and community-based waiver services vary from county
to county
Availability of services varies dramatically by region
Neither private long-term care insurance nor Medicaid cover the full
array of long-term care needs
Hard to know what to do or where to go for help (including
Everyone wants to remain at home, but assistance from Medicaid is
much more likely from a nursing facility
Living Arrangement of the Long Term Care
Age 65 and Older
In a Nursing
In the
2001 Financing
Of Long Term Care
Oral Health and Access Challenges
Why is oral health care particularly important?
Because oral diseases:
• Are cumulative and more complex over a lifetime
• Have an increasing impact on the quality of life
• Have an increasing impact on general health
Oral Health and Access Challenges
Why do the elderly need special care?
Many have experienced extensive oral disease
Medical problems complicate their care
Diagnosis and care planning are complex
The elderly should receive special consideration
in terms of their oral health care needs since
1) May have unique problems accessing the health
care delivery system
2) Experience different patterns and prevalence rates
of oral diseases and
3) May have characteristics that affect the amount
and types of dental treatment and the method by
which it is performed
Older adults are maintaining their natural teeth
into their later years and epidemiologic trends
suggest the increasing need for dental services
by older adults.
Yet dental utilization rates are lower for older
adults than for younger age groups and barriers
to care include the cost of dental care, the lack of
perceived need for care, transportation problems,
and fear.
The Panoply of Oral Structures, Functions,
A&P and Environmental Factors
• Socio-dental Scale: chewing, talking, smiling,
laughing, pain, appearance
• General Oral Health Assessment Index: chewing,
eating, social contacts, appearance, selfconsciousness
• Dental Impact Profile: Confidence, happiness,
social life, relationships
• Oral Health Quality of Life Inventory: nutrition,
breath odor, self-rated oral health, overall quality of
• Oral Impacts in Daily Performance: performance in
eating, speaking, oral hygiene, sleep, emotion
Oral Health and Access Challenges
Characterizing the elderly based on access to
dental care:
• Independent elderly
• Frail elderly
• Functionally Dependent elderly
Oral Health and Dental Access Barriers
Older adults face dental access barriers
due to physical limitations and functional
Oral Health and Access Challenges
What is the split based on access?
Independent Older
Frail Older Adults
Dependentor Home
Care Adults
Living in Nursing Homes
What are the “Frail Elderly” like?
The Majority are Female:
By age 65 there are approx 141 females for every
100 males
By age 85 there are approx 237 females for every
100 males
Many are Homebound:
Dependency in physical abilities
May be cognitively impaired
Often economically disadvantaged
What are dependent elderly like?
Some live in nursing homes:
• Tend to be over 75 with the average around 85
• Often widowed
• Mainly white, non-Hispanic
• Functionally dependent
• Dependent on Medicaid
Barriers to Oral Health for Residents of
Alternative Long Term Care (ALTC) and
Nursing Home (NH) Facilities
ALTC (%)
1) Willingness of general dentist to treat
residents at your facility
2) Willingness of general dentist to treat
at private office
3) Financial concerns of resident or family
4) Transporting resident to dentist or hygienist
5) Availability of suitable dental treatment space 32
6) Availability of suitable treatment equipment
7) Time constraints on facility
There is a widespread oral health problems
among nursing home residents, including:
• Poor oral hygiene
• High levels of dental needs
• Low rates of dental care utilization
Geriatric Patients
Root Caries
 Soft irregular shaped
Confined to the root
Undermines enamel at
Initiates on the root
Starts only if root is
Class V Restorations
• Within nursing homes a number of barriers
prevent access to professional care or prevent
residents from receiving daily oral hygiene
• While the level of dependence of nursing home
residents varies from patient to patient, most
residents require some assistance to complete
oral hygiene regimes
Some of the challenges providing dental
services in nursing homes are:
Communication with family members or representatives
Patients are medically complex
Medicaid (regional nurse) has (had) the authority to approve
or disapprove dental treatment
Lack of facilities at nursing homes
5) lack of adequate equipment
6) lack of training of the nursing homes staff
Lack of oral education of the staff and most patients
Little or none training of the undergraduate students
Additional barriers include
– the functional and medical status of the
– transportation and accessibility difficulties
– financial considerations
– lack of education
– and fear
Brown Dental Health Management,INC.
Steps for treating Nursing Facility Residents
1) Receive a referral from the Social Worker of Director
of the Facility
2) Make dental chart for the resident:
a) Face sheet or health information sheet
b) Medications list
c) Verify resident is either private pay or has
Nursing Home Medicaid
d) If the residents is Nursing Home Medicaid,
they have an applied income that must verified
with the bookkeeper or the TDHS case worker
2) Cont.
e) “1263 B- Certification of no medical
contraindication- dental” form must be completed
by the social Worker, signed by the patient or the
responsible party, and the patient’s practitioner.
• “ Routine Dental Treatment” is all that is
required on the 1263 B form under dental
services. No approval is required. The only
treatment that can be performed will be on the “
Routine Dental List” provided by Medicaid.
• If other dental services are recommended,
these procedures would be sent to the Medicaid
RN for prior approval.
3) when the chart is complete, it goes into the dentist
box to schedule the exam. Exam is completed and if
the resident has teeth, an x-ray is ordered.
– x-ray team schedules a visit, if the resident
requires sedation, the practitioner is contacted
before the treatment plan.
– x-rays are placed in the dentist’s box for a
treatment plan to be completed
– If the resident has teeth, the dentist will order
prophy at this time and will be completed before
the treatment plan.
3) cont.
– Once the treatment plan is written, it is faxed and
mailed to the responsible party and/or the Social
Worker for the resident to sign off for treatment.
– Once treatment consent is signed, the dentist is
given the chart with the consent and schedules the
visit to begin treatment.
– Once treatment is completed, the Medicaid
insurance claim is ran and the original 1263B and
the signed treatment consent is sent to Medicaid to
be funded through the resident Medicaid Applied
Income (which is their rent).
3) cont.
– Medicaid is to make an adjustment to the applied
income and the dental bill is to be paid from the
responsible party who pays the resident’s rent.
They would lower the amount they pay the nursing
facility in rent and pay for their dental services.
– If the resident is private pay, we have a private
consent instead of the Medicaid 1263B, otherwise
we make up the dental chart the same way, the
process is the same
Other mobile dental companies in the area”
Mobil Dental
Life cycle
Dr. Leddett
Why aren’t graduating dental students more
willing to treat geriatric patients?
Lack of experience and fear when treating geriatric problems
Lack of financial incentives
Transportation and access problems to the dental office
Special problems that exist in providing dentistry to
homebound and institutionalized patients
Negative attitudes toward the elderly’s need for dental care and
their low perception and motivation for oral health care
The poor oral status of the elderly, resulting in an edentulous
state or teeth compromised by periodontal disease
Difficulties dealing with debilitation and life threatening illnesses
The problem of informed consent and of family members or
residential facility staff member with negative attitudes
It is of utmost importance for dental professional to be
well trained, understanding and compassionate, and
to be aware of the special needs of the mature
The dental profession should seed interdisciplinary
team training to better address these needs
Education in the elderly care, however, must be
supplemented with practical experience in the
treatment of seniors, in various locations and using
appropriate dental equipment
Education in geriatric dentistry include not only
the practical clinical aspects of treating the
elderly, but the social, environmental,
psychological, behavioral and financial aspects
as well