1. Theodore T. Suh, MD, PhD, MHS, AGSFTheodore T. Suh, MD, PhD, MHS, AGSF
Associate Clin. Professor, University of Michigan Medical SchoolAssociate Clin. Professor, University of Michigan Medical School
Geriatrics Faculty, Ann Arbor VA GRECCGeriatrics Faculty, Ann Arbor VA GRECC
55thth
Annual Clinical Geriatrics Interprofessional SymposiumAnnual Clinical Geriatrics Interprofessional Symposium
San Diego, CA/ Goodyear, AZ/ Rancho Mirage, CA/ Long Beach, CASan Diego, CA/ Goodyear, AZ/ Rancho Mirage, CA/ Long Beach, CA
April 13, 2019April 13, 2019
1

2. 2

3. ObjectivesObjectives
To review common oral health issues among older
adults.
To identify barriers to oral health care among older
adults.
To discuss how oral health impacts general health in the
geriatric population.
Discuss tips for senior caregivers regarding oral health.
Review oral health care in the PACE model.
3

4. Dental Care in U.S. Older AdultsDental Care in U.S. Older Adults
Only about 2% of older Americans have dental
insurance.
Vast majority of older Americans go without dental care.
The older the person, the more likely they need
dental care for a variety of reasons.
Over 30% of older adults have untreated cavities.
Almost 25% of adults between ages 65 and 74 have
periodontal disease.
Nearly 30% of older adults lose their teeth.
4
From: http://www.seniorliving.org

5. 5
https://astrobites.org

6. Oral Health Barriers for SeniorsOral Health Barriers for Seniors
Most lose dental coverage with retirement.
Medicare doesn’t cover most dental work.
Santa Fe Group: wrote a White Paper making the
case for dental benefit under Medicare Part B.
Medicaid coverage varies by state and is
limited.
Most cannot afford out-of-pocket dental expenses.
Inadequate nutrition/ hydration contribute to dry
mouth and tooth loss.
6

7. Oral Health Barriers for SeniorsOral Health Barriers for Seniors
Dry mouth as side effect of many medications that
seniors often take can lead to cavities & gum
disease.
Osteoporosis & its undertreatment are contributing
to tooth loss in older adults.
Darcey J et al., Br Dent J, 2013
Bougioukli S et al., J Bone Miner Metab, 2019.
Lack of transportation for regular dental visits is a
barrier to dental care.
Lack of access/ poor dental care for those living in
many nursing homes. 7

8. 8
www.debtwave.org

9. Dental Care: Medicare & MedicaidDental Care: Medicare & Medicaid
Routine dental care that seniors need most
(checkups, cleanings and fillings) are not covered
by Medicare.
The only dental care covered by Medicare:
Dental services that are an integral part of a covered
procedure (e.g. jaw reconstruction following accidental
injury)
Extractions done in preparation for radiation therapy for
cancer involving the jaw including head & neck cancer
Oral exams prior to kidney transplant or heart valve
replacement
9

10. Dental Care: Medicare & MedicaidDental Care: Medicare & Medicaid
Medicare NEVER pays for dentures.
Medicaid: a joint federal and state program that
provides medical coverage for low-income
Americans:
Only provides comprehensive dental care in some states
and in certain cases.
Most states do offer emergency dental care.
10

11. Oral Health Impacts on General HealthOral Health Impacts on General Health
Poor oral health can lead to serious health issues
including:
Aspiration pneumonia
Coronary artery disease
Cerebrovascular disease
Protein malnutrition
Periodontitis can worsen diabetic control.
Poorly-controlled diabetics are at risk for oral
candidiasis
 Lamster IB et al., JADA, 2008.
11

12. Oral Health Mirrors General HealthOral Health Mirrors General Health
Tooth loss may be a sign of osteoporosis.
Periodontitis and oral candidiasis can be signs of
poorly-controlled diabetes.
Oral sores may be a sign of oral cancer.
Changes in the tongue can be a sign of nutritional
deficiencies.
Beefy red tongue with vit B12 deficiency.
Fissures in the tongue with vit A deficiency.
Tongue ulceration can be seen with scurvy.
12

13. Oral Microbiome Critical toOral Microbiome Critical to
Understanding Health & DiseaseUnderstanding Health & Disease
13From: www.global-engage.com

14. Oral DysbiosisOral Dysbiosis
Definition: microbial shift that causes disease when
there is a decrease in the number of beneficial
symbionts and increase in the number of in the
number of pathogens.
During this period, the oral health of the host
deteriorates until a state of clinical disease occurs.
14
Nath SG & Raveendran R, J Ind Soc Periodontol, 2013.

15. Autoimmunity & Oral MicrobiomeAutoimmunity & Oral Microbiome
Sjogren’s syndrome
Dysregulated immune response to normal oral
microbiome may trigger pathogenesis
 Tsigalou C et al., Front Immunol, 2018.
 Van der Meulen TA et al., J Autoimmun, 2019.
Crohn’s disease
Reduced bacterial diversity
Decrease in firmicutes & increase in Proteobacteria may
trigger pathogenesis
 Gevers D et al., Cell Host Microb, 2018.
15

16. Autoimmunity & Oral MicrobiomeAutoimmunity & Oral Microbiome
Rheumatoid arthritis
Altered oral microbiome identified in RA patients
P. gingivitis strongly linked to pathogenesis
 Chen B et al., Sci Rep, 2018
 Avikar S et al., 2017 ACR Meeting Abs
Systemic lupus erythematosus
Autoantibodies against oral microbial products may
influence pathogenesis
 Van der Meulen TA et al., J Autoimmun, 2019
 Silverman GJ, Nat Rev Rheum, 2019.
16

17. Oral Microbiome & Human EvolutionOral Microbiome & Human Evolution
Oral microbiome may have influenced human evolution
through effects on immune development, fertility and
even lifespan.
Grandmothering hypothesis: extended family confers fitness
advantage (Davenport ER et al., BMC Biol, 2017)
17

18. 18

19. Lifestyle and Oral HealthLifestyle and Oral Health
Many aspects of lifestyle can negatively affect oral
health including:
Poor diet/ nutrition
Poor oral hygiene
Tobacco use (all forms)
E-cigarettes
 Kim SE et al., PLOS One, 2018; Sundar IK et al., Oncotarget, 2016
Alcohol use
Poor living conditions also contribute to poor oral
health worldwide.
19
Petersen PE et al., Bulletin of the WHO, 2005.

20. Oral Health Tips for Senior CaregiversOral Health Tips for Senior Caregivers
Prevention is the key!
Daily brushing and flossing
Who does this for those with dementia or physical
disabilities?
Avoid gaps in dental care among older adults!
Too many people are requiring tooth extractions and
dentures after years of benign oral neglect.
Increase public awareness of dental services
available for low-income seniors.
Dental partnership with primary care physicians
20

21. Free/ Low Cost DentalFree/ Low Cost Dental
Options for SeniorsOptions for Seniors
www.toothwisdom.org
Website run by Oral Health America (OHA)
Eldercare Locator
Website run by Department of Health & Human Services
To speak with an information specialist: 800-677-1116
2-1-1 Information & Referral Search
Sponsored by United Way
PACE (more to follow!)
Health Resources and Services Administration
(HRSA)
21

22. Free/ Low Cost DentalFree/ Low Cost Dental
Options for SeniorsOptions for Seniors
The Dental Lifeline Network
Was the Nat’l Foundation of Dentistry for the Handicapped
Call 888-471-6334.
Dentistry From The Heart (DFTH)
Volunteer dentists and hygienists
http://www.dentistryfromtheheart.org
www.freemedicalcamps.com
Locator for free or low cost dental care in all 50 states
 National Association of Free & Charitable Clinics
Non-profit at http://www.nafcclinics.org
22

23. Oral Health Tips for Dementia PatientsOral Health Tips for Dementia Patients
Look for indications of oral discomfort.
Oral sores, bleeding gums, broken teeth, grimacing
while eating
Provide short, simple instructions.
Break directions into steps.
Use a “watch me” technique.
If patient agitated, try again later.
Keep the teeth and mouth clean
Includes gums, tongue & roof of mouth.
23
www.alz.org
www.michigan.gov/documents/mdch

24. Oral Health Tips for Dementia PatientsOral Health Tips for Dementia Patients
Try different types of toothbrushes.
Soft bristle children’s toothbrush may work better.
Floss regularly.
Dental picks may be easier to use.
Be aware of potential mouth pain.
During mealtimes, read facial expressions.
For patients with dentures, dentures should be
removed and brushed clean after each meal.
24
www.alz.org
www.michigan.gov/documents/mdch

25. Oral Health Tips for Healthy SeniorsOral Health Tips for Healthy Seniors
Increase fluoridation.
Use a fluoride toothpaste.
Avoid tobacco.
Chewing tobacco can lead to tooth decay because of
sugar in most products.
Increase oral hydration!
Drink plenty of fluids, chew sugarfree gum & limit
alcohol.
Use an antibacterial mouthwash.
 Along with brushing & flossing, reduce plaque buildup.
25
www.colgate.com

26. 26
From: https://leansixsigma.community

27. Oral Health Culture ChangeOral Health Culture Change
“Mouth Care Without a Battle”
Person-centered approach to quality mouth care for
persons with cognitive and physical impairment.
Developed by an interdisciplinary team of clinician
researchers based on literature review, consultation with
experts, environmental scan of existing programs, and
testing in nursing homes.
Based on the success of “Bathing Without a Battle.”
Beneficial to build the evidence base for culture change
by attending to care processes and outcomes benefiting
all residents, ability to implement culture change, and
costs of implementation.
27
Zimmerman S. et al., Gerontologist, 2014.

28. Oral Health Educational InitiativesOral Health Educational Initiatives
Development of oral health resources for patients:
28
www.nidcr.nih.gov

29. Oral Health Educational InitiativesOral Health Educational Initiatives
Development of oral health resources for allied
health professionals:
U of M Mini-Cube project
 Theodore Suh, MD, PhD
 Livia Tenuta, DDS, PhD
 Lona Mody, MD, MS
29

30. 30

31. Dental Care in the PACE ModelDental Care in the PACE Model
Dental care has been part of the PACE Model from
its inception.
Noted in the PACE Protocol from April 1995, prior to the
CMS demonstration period.
Unfortunately, no benchmarking values are available
that are specific for Dentistry within PACE.
 Anecdotally, Dentistry is the most prevalent of the
specialist encounters across all PACE programs.
31
ID Measure Average
Peer Group
Results
25th
%ile of
Peer Group
Median of
Peer Group
75th
%ile of
Peer Group
256 Specialist
Visits (PMPM)
0.90 0.55 0.72 1.09
Data courtesy of Alan Gay, National PACE Association

32. Dental Care in the PACE ModelDental Care in the PACE Model
Most PACE programs have policies regarding
approval of dentures.
Remember, PACE is managed care!
Dentures require approval by the interdisciplinary
team, based on an evaluation tool that focuses on
need, participant wishes, nutritional status and ability
to maintain dentures.
Huron Valley PACE does not replace dentures lost or
damaged due to neglect in less than a 3 year
timeframe.
New PACE participants must wait 30 days before a
request for dentures is approved. 32

33. Dental Care in the PACE ModelDental Care in the PACE Model
“The dental status of many of our participants who have teeth (many do
not) is poor. It is common to have retain roots, teeth broken off at the
gum line, or dental caries. Tooth extraction is not uncommon. I
cannot account for a single individual who developed an abscess,
pneumonia, hospitalization, or level 2 event who did receive regular
dental care. On the other hand, I can cite one specific case of a
participant who has consistently refused dental care, and did develop a
significant abscess requiring hospitalization.”
Peter A. DeGolia, MD
Medical Director, McGregor PACE
Cleveland, Ohio
33From: NPA PACE Medical Directors List Serve

34. Dental Care in the PACE ModelDental Care in the PACE Model
“It is clear that there are multiple outcomes from psychosocial to
clinical that arise from appropriate dental care. This appropriate care
involves individual assessment - elderly without teeth may not always
prefer the use of dentures. We have multiple cases of dental abscesses
arising from severe caries - creating pain and failure to thrive - followed
by C. difficile from the antibiotics that we gave! ”
Elisabeth Broderick, MD
Medical Director, Elder Service Plan of the North Shore/ PACE
Lynn, Massachusetts
34From: NPA PACE Medical Directors List Serve

35. QUESTIONS?QUESTIONS?
35
From: https://wordpress.com

36. 36