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Inside Dentistry

June 2007, Volume 3, Issue 6
Published by AEGIS Communications


The Race to Retirement

Fred Balzac

How the Aging Boomers Will Impact Dentistry

In 2011, the first wave of the mammoth cohort of Americans born from 1946 through 1964 will reach official retirement age.

The “Baby Boom” generation has been a significant agent of change in American life throughout its lifespan, soaking up resources and causing a repeated cycle of expansion and contraction at every step along the way. Now much speculation centers on how this vaunted “pig in a python” will affect an already overstressed healthcare system, as Boomers continue to turn 65 in a rising tide of gray through at least the early 2020s and survive longer into old age than any previous generation.

In terms of oral health and the impact on dentistry, the prospect of an aging patient population appears to be a double-edged sword. On the one hand, some observers say, the Baby Boomers constitute a health-conscious and financially well-off generation that will continue to demand dental services and be able to pay for them for many years. The rate of older adults losing their teeth has been dropping steadily in the United States since the 1950s, and this trend is likely to accelerate in the future. With the increased number of seniors retaining more of their teeth, the optimists predict, there will be a greater demand for esthetic dentistry as well as standard care—and all the products and services required to meet those needs. Dentists will be busier—and their practices more lucrative—than ever.

On the other hand, more pessimistic observers caution, be careful what you wish for. The decline in the rate of edentulism means an increased risk for dental caries and periodontal disease—and all the chronic comorbidities associated with them and with aging. The upside of the Boomer lifestyle notwithstanding, the graying of the population also means more people surviving well into their 80s and 90s and experiencing the downside of very old age: an increased risk for such diseases as cancer, stroke, and Alzheimer’s, and a greater likelihood of ending up in a nursing home or other long-term care facility.

The burgeoning of the indigent/ dependent elderly population raises serious questions about access to care and how to pay for it. Most seniors are unable to retain private dental insurance for very long, assuming they were fortunate enough to have it in the first place. Medicaid covers only a small percentage of the nation’s elderly. Medicare has never covered dental work and, given the current climate in Washington, it is unlikely that Medicare will be extended to cover it in the foreseeable future.

Cost and reimbursement issues aside, there are concerns over the ability of the dental profession itself to handle all this new—and, in some respects, more challenging—business from older adults. As Baby Boomers retire, so will Baby Boomer dentists, and it remains unclear whether a sufficient number of dentists can be trained and recruited from the younger generations to fill the vacuum that will be left by this horde of retirees.

Some big questions linger. Are we entering a “golden age” for dentistry, where innovations in procedures and technology, fueled by the growing demand for products and services, will enable fewer practitioners to handle a greater number of patients? Or will this “oldie onslaught” overburden the system to the extent that it will make the remaining dentists wish they had closed up shop and gone fishing?

The answers depend largely on whom you talk to. But the consensus seems to be that it will take a concerted effort from all sectors of the oral healthcare system—including professional associations, industry, public health, and dental schools—to meet this impending challenge.

A HETEROGENEOUS AND OFTEN COMPROMISED POPULATION

One individual who has been at the forefront of raising awareness about the impact of the aging patient population has been Ira B. Lamster, DDS, MMSc, dean of the College of Dental Medicine at Columbia University. In May 2004, Lamster published an editorial in the American Journal of Public Health titled, “Oral Health Services for Older Adults: A Looming Crisis.”1 It was intended as a national call to action for a more geriatric-oriented approach to dentistry.

Looking broadly at statistics and trends such as those relating to tooth retention and extraction, Lamster recognized that the rapidly dropping rate of edentulism would have serious ramifications for the country. “That was point one—people were keeping their teeth. What we also know is that periodontal diseases and root caries become more severe in the elderly, to say nothing of the problem of polypharmacy and xerostomia.

“All of that really suggests that we’re going to have a needs crisis. The part of the population 65 or older is going to need many more services. And then you compound the problem by noting that Medicare provides no dental benefits. So you have a great deal of need and no way to pay for it.”

Lamster acknowledges that many Baby Boomers have resources and probably will be able to pay for some dental services once retired, although not necessarily all of the complex, expensive care associated with rebuilding the mouth. “But you also have a whole host of other people who we may not be talking about as much—those who are members of immigrant groups or recent arrivals to this country, people who don’t have significant resources,” he warns. “Then you have, of course, individuals who are in long-term care facilities, and people who are home-bound elderly.... So it is a heterogeneous population.”

In addition to the socioeconomic concerns, there are medical concerns to be factored into the equation, according to Louis Rose, DDS, MD, of the University of Pennsylvania School of Dental Medicine. He is concerned with such problems of aging as the association between oral disease and systemic disorders, including diabetes, stroke, and cardiovascular disease. “As you get older you become more susceptible to different kinds of medical problems,” he says. “The immune system is not as able to fight off diseases, and older people become more susceptible to periodontal disease.”

The multiple drug prescriptions that many elderly patients take—often including antihypertensives, anticoagulants, and nonsteroidal anti-inflammatory drugs—can also complicate dental care. Rose observes that some patients may be on eight or nine different medications prescribed by different doctors. “One doctor may not know what the other is prescribing,” he says. “Sometimes there is no good way of communicating with general practitioners and specialists. This poses problems for a dentist. Often physicians have no idea how important an oral infection is.... They think a dentist is drilling, filling, and billing. We [dentists] have to educate physicians.”

Linda C. Niessen, DMD, Vice President and Chief Clinical Officer of DENTSPLY International, agrees. “Improving oral health care for older Americans will require dentistry to move beyond dental professionals. The complex medical needs of this population and the oral-systemic linkages will demand that dental professionals take a leadership role in educating our colleagues in medicine, nursing and pharmacy on oral health diseases and conditions common in older adults.”

As an illustration, Rose points to the problem of osteonecrosis stemming from the use of bisphosphonates. Bisphosphonates, which were originally indicated for osteoporosis, are now frequently being given to patients with malignancies to prevent metastases, particularly in such forms as breast, bone, and prostate cancer.

“Patients are not necessarily citing bisphosphonates when reporting other drugs, so I have to ask specifically,” Rose says. “With IV [intravenous] bisphosphonates, if you pull a tooth it may not heal and the bone can become necrotic. There has been virtually no research on it.... There is no approved way to treat it, and all the current approaches are empirical.”

He cites the recent case of a patient who had recurrent breast cancer, was put on chemotherapy and a bisphosphonate, and developed a large abscess. Rose felt the tooth had to come out, but her oncologist insisted that he leave the tooth alone. Rose put the patient on antibiotics, and the area of the abscess started to respond. The lesson this case drove home for him was the critical necessity for dentists to consult with their patients’ physicians—especially when there are serious medical conditions to consider. “Periodontists have a lot of patients for whom they want to do implants,” he says. “But if they’re elderly and compromised, you’re not going to do it—older patients simply may not heal as well.”

In Rose’s view, as people get older, their dentist’s approach to treatment will need to change depending on the health of the patient. “Today you have to take a good medical history,” he urges his fellow practitioners. “Don’t just ask 10 questions—the history has to be updated all the time.”

A SAFETY NET STRETCHED THIN

Both Rose and Lamster look to the dental schools to help fill the gap in caring for older patients. But the dental schools, despite a slew of innovative programs, are stretched thin in many cases. Carole Anderson, RN, PhD, is interim dean of the College of Dentistry at Ohio State University. She highlights her school’s focus on geriatric dentistry as evidence of the expanding mission of dental colleges and other academic institutions to care for elderly patients: a course in geriatric dentistry, a geriatric clinic, and a geriatric outreach program involving mobile units going into about 14 nursing homes. Dental students do the work in the mobile units under the supervision of a faculty member, Abdel R. Mohammad, DDS, MS, MPH, who is the author of a textbook on geriatric dentistry. In fact, the outreach program won an award in 2006 from the American Dental Association (ADA), Anderson reports.

“We’re doing pretty well, but I think we need to continue to do it and more, as more and more of the patients are elderly,” she says.

One thing that worries her is the continued ability of dental schools to help meet the demands made of the oral healthcare system as the increased elderly population retains more and more of their teeth. “There clearly will be more demand,” Anderson says. “The other very, very critical area is the aging of dental faculty and the difficulty of getting dentists to go into academic dentistry. We’re right now in a real shortage of dental faculty. The salaries have not been able to keep up with private practice salaries. It has a huge implication for preparing future dentists. If we don’t have the faculty, we’re not going to be preparing the dentists. As the demand goes up, we’re not going to be supplying enough dentists for the system,” she warns.

Reimbursement issues and overall healthcare funding remain serious concerns. The fact that Medicare does not cover oral healthcare—which is associated with general health, as spelled out in the groundbreaking publication of Oral Health in America: A Report of the Surgeon General in 2000—is a real shortcoming of the policy, according to Anderson. “Dental schools and dental clinics can be safety nets for dental patients, but we can’t do it with education dollars—we have to do it with healthcare dollars,” she says. “Right now, that’s not a real viable option. So I think there absolutely is a role for government. There is a role for the public health plans, because dental schools aren’t able to pick up the slack to take care of the oral healthcare needs of a population that doesn’t have access to private insurance.”

With costs being what they are and the limited ability of government, dental schools, and other institutions to help, much of the burden of caring for the elderly currently falls on private practitioners—and it may continue to do so for the foreseeable future. Jack Ribacoff, DDS, has been practicing for the past 15 years in Sunrise, Florida, a municipality within Fort Lauderdale, where people 65 and older already constitute about 50% of his patient population. With retirees constantly moving into his neighborhood, that percentage is likely to only increase.

In Ribacoff’s experience, the number one issue regarding the elderly has to do with the large number of medications many patients are on and the resulting medical complications that can affect how he treats them. Blood thinners such as warfarin can increase the danger of bleeding during a dental procedure such as an extraction, and xerostomia is another frequent complication of multiple medications, he notes.

Ribacoff finds himself trying to do more to save his older patients’ teeth and says that more patients are considering the option of implants, compared to years past. Monetary considerations, however, play a key role, especially given the increased cost of fixed bridge work and implants, the fixed incomes of many patients, and such external factors as hurricanes and other unforeseen events. Because his patients spend a lot of their income on medications, they often cannot afford optimal dental treatment. Ribacoff does quite a bit of removal prosthetics, dentures, and partials as less expensive alternatives to implants or permanent fixed bridgework.

Although many of his older patients are paying out of pocket, he estimates that close to half have some type of limited insurance—for example, via a reduced fee schedule or preferred provider organization. “Fewer and fewer are coming in without some kind of discounted fee plan or trying to get some kind of insurance,” he says. “A lot of them, if they are retirees, will have some kind of retirement insurance that may not cover very much, but they want to try and use that to maximize any kind of benefits they can get.” He adds that a lot of his older patients ask about Medicare, erroneously assuming that it covers dental work.

Asked whether he saw the coming retirement of the Baby Boomers as a burden for private practitioners, Ribacoff responds that he sees it as just a demographic trend. “People are much more aware of their health and focus on doing more things to maintain a healthy lifestyle,” he maintains. “I have some patients who are in their 80s and are very active and proactive about their health and willing to do whatever is necessary [to prolong their lives]. I think it’s really a function of people being more educated and aware of much more now.”

Adds Niessen, “the Baby Boomers’ improved oral health and retention of their natural teeth reflects the fact that they were the first generation to benefit from widespread community water fluoridation and fluoride in the toothpaste. As they reach their golden years, they may find that these preventive services may be just as important in maintaining their natural dentition as they were in their early years, but for different reasons. As older adults, they need preventive services to counteract the effect of multiple medical conditions that compromise their oral hygiene ability or multiple medications that decrease the protective benefits of adequate salivary flow.

“For the Baby Boomers, 60 is the new 40 and 80 is the new 60,”she continues. “Older adults value preventive services because it tells them that their dental professionals believe in their future and want a healthy future for them, no matter how long it is. For some patients, that future could be 3 months, 3 years, or 3 decades.”

A BEAUTIFULLY BORING OPPORTUNITY FOR INVESTMENT

Despite the evident problems associated with the aging population, some observers remain confident that the dental profession will rise to the challenge and that the opportunities for technological innovation and private-sector growth will outweigh the inability of some older patients to pay for services. There is also now at least a glimmer of a signal indicating that government and the public sector is taking the oral healthcare needs of the country very seriously and that help may be on the way for the most disadvantaged members of the population.

Of course, optimism for the future is riding largely on the backs of the Baby Boomers, and prospects for a positive impact on dentistry will be even greater as the latter part of the cohort reaches retirement age, predicts L. Jackson Brown, DDS, PhD, associate executive director of the ADA. He differentiates between the “front edge” of the generation—those born between 1946 and the early 1950s—whose members are currently retiring early or will retire in the next several years, and the wave of retirees that will follow until about 2030.

“As Baby Boomers retire, the proportion of the elderly in the population will increase, as younger cohorts are smaller,” he says. “Retired Baby Boomers will have more money, will be more ambulatory, and may work longer than previous generations of retirees. For the most part, Boomers will be healthier and will have more teeth. Now what about at the back end? The last year of the generation is usually cited as 1964, so Boomers will be turning 65 from about 2010 to 2030. During that time, a lot of elderly will be seeing dentists. They’ll have a lot of teeth, and many of their teeth will be attacked by caries. Of the cohort born between 1946 and 1964, however, the amount of caries will actually decline. We’ve seen a difference between people born before World War II and those born after. We are currently seeing decreases in caries, due to such things as use of fluoride in the drinking water, improved dental care, and better personal oral habits.”

Given these improvements in dental care, Brown thinks the profession will not feel much of an impact at the front end of the retirement boom. “But as the generation continues to retire, dentists will be seeing elderly patients with a lot of teeth, in need of a lot of fillings,” he says. “The Boomers will need a lot of care, and they probably will continue to be better off financially than elderly generations that came before them.”

It is that prospect of a well-heeled and comparatively healthy cohort of older adults that has financial markets upbeat about the future of dentistry. Jeffrey D. Johnson is a senior research analyst at R.W. Baird & Company. “What investors love about dentistry is that it’s beautifully boring,” he observes. “It’s a way to invest in healthcare without having a lot of the headaches that come with healthcare from a reimbursement standpoint.” Because of this stability, dental companies tend to be afforded a “higher valuation” than other companies in terms of what investors are willing to pay.

In Johnson’s view, the graying of the population is a net plus, thanks largely to the proportion represented by the Baby Boomers. “As disposable income levels go up, you get more and more esthetic dental procedures,” he says, adding that such procedures as tooth-whitening techniques and veneers are growing well above the market as a whole.

Another hot area of dental care is the implant market, which is currently experiencing about 20% growth while attracting more orthopedic-product manufacturers. By comparison, the dental field overall has grown, on average, between 4% and 6% annually, according to Johnson.

Johnson summarizes investors’ general attitude toward dentistry, including some surprising findings: One is that there is less concern among investors regarding the inability of some older adults to pay for dental care. “Historically, there hasn’t been significant dental insurance,” he says, estimating that little more than 50% of workers are covered. “On the elderly side, insurance has never been a big part of dental care. What investors like is they don’t have exposure to that reimbursement risk.”

Another surprise is the view of the number of dentists that will be needed to handle the coming retirement boom. “You are seeing a declining number of dentists in the United States,” Johnson confirms. “We’ve had some dental schools close over the years, and we’re not graduating as many dentists today as those who are retiring.... [But] from an investment standpoint, that’s pure opportunity.”

He cites innovations in technology as factors that will enable dentists to take care of more patients. “That’s another reason why growth is at the upper end. Dentists need to become more efficient and are willing to spend to make their practice more efficient because they can see more patients.”

SPECIAL CARE DENTISTRY TO THE RESCUE

In the view of Ronald L. Rupp, DMD, senior manager of professional relations for GlaxoSmithKline (GSK), it will take a coordinated effort by industry, the dental profession, and other partners to effectively deal with the impact of the aging population, and he points to a number of programs GSK has initiated or is participating in to help address the issue (See The Role of Industry on page 50). The day he spoke to Inside Dentistry for this article happened to be national “Give Kids a Smile Day,” a program aimed at improving access to care for children in underserved populations that currently represents a partnership between several companies and the ADA.

“Everybody recognizes—whether it’s GSK, a professional association, or another advocacy group—the future in terms of the country, the population, rests around that aging population,” Rupp emphasizes. “Whether it comes from the standpoint of providing good care through our member constituency of the ADA, whether it comes as the charge to lead the cause by the ADA [itself], or if it is driven by collaborative alliances with industry, we all know that it’s here and that it’s here to stay.” GSK and the ADA have announced their “Oral Longevity” partnership aimed at enabling and promoting oral health for the fast growing aging US population.

If such partners as industry, academia, and the profession are adequately energized, as some observers have noted, the last remaining components of the aging-population conundrum may be the lack of dental insurance and the need for more public funding. There are indications that the federal government is waking up to the problem. In September 2003, the Special Committee on Aging of the US Senate held a forum chaired by now-retired Sen. John Breaux (D-La) titled, “Ageism in Health Care: Are Our Nation’s Seniors Receiving Proper Oral Health Care?” Among those testifying at the forum were the US Surgeon General, representatives of the ADA, and practitioners involved in providing care to the aged, blind, and disabled (ABD).

One proposed solution coming out of that forum is the Special Care Dentistry Act, a bill that would require each state to provide oral healthcare services for the ABD population at a 90/10 federal-to-state split. Nationally, 6.4 million ABD adults make up approximately 28% of the adult Medicaid population yet account for 71% of overall healthcare expenditures as determined by the US Centers for Disease Control and Prevention (CDC), according to Gregory Folse, DDS, a private practitioner in Louisiana who cares for patients in nursing homes and who has remained an advocate for the disadvantaged since testifying before Sen. Breaux’s subcommittee. In terms of oral health, what is driving these costs is active infection. “Of my 1,600 patients in my nursing home practice, 800 have active chronic abscesses and/or severe gum disease,” says Folse, who also serves as co-chair of the Legislative and Policy Committee of the Special Care Dentistry Association. “We are convinced that healthcare expenditures will go down overall once we start to take care of these infected people.”

The Special Care Dentistry Act has been reintroduced in the US House of Representatives this year, and Folse and his colleagues in the Special Care Dentistry Association are also working on getting the bill before the US Senate. While Folse is excited by the bill’s chances for passage, he admits that it’s going to take time for the indigent population to gain adequate access to care. “We’re going to have to gear up a significant part of our profession to take care of the pent-up needs of these needy and vulnerable patients,” he explains.

CONCLUSION

Until adequate access is made available, the neediest segments of the dental-patient population will have to rely on current public health programs, such as those involving the CDC, as well as programs coming out of such joint efforts as those of industry and the ADA. Ultimately, however, the burden for dealing with the aging population will remain largely on the shoulders of private practitioners.

Lawrence S. Lizzack, DMD, practices in Fair Lawn, New Jersey, where the percentage of his patient population 65 years or older is at least 20% and growing. He cites many of the same concerns with older patients as others have noted, including widespread use of medications for comorbid conditions and increased periodontal disease. He has witnessed a decline in the need for full dentures and a rise in implants among his patients. As a 1972 dental school graduate, Lizzack says he did not receive any kind of special training there for geriatric care other than doing a lot of denture work.

“It’s kind of interesting that we are doing fewer dentures,” he says, reflecting on the current situation. “You’d think it would be just the opposite. We must be doing something pretty good with our preventive dentistry.”

That, for good or ill, is the crux of dentistry and the aging population. More patients with more teeth will descend upon the dental profession. They bring with them a daunting challenge as well as a shining opportunity, for their presence will require a commensurate response from practitioners, educators, industry, and legislators. Having shaped the face of America for a half-century and more, it is clear the Baby Boomers have no intention of going gentle—or toothless—into the night.

References
1. Lamster IB. Oral health care services for older adults: a looming crisis. Am J Public Health. 2004;94(5):699-702.

The Inside Look From...
Issue after issue, the feature presentations in Inside Dentistry deliver coverage of relevant topics specifically affecting the dental profession, as well as oral healthcare in general. The publishers and staff could not bring the underlying concerns surrounding these timely topics to the forefront without the insights shared by our knowledgeable and well-respected interviewees. For their collective generosity of time and perspectives, we extend our sincere gratitude.

Academia
Carole Anderson, RN, PhD
Interim Dean
College of Dentistry
Ohio State University
Anderson.32@osu.edu

Ira B. Lamster, DDS, MMSc
Dean of the School of Dental and Oral Surgery
Columbia University
Ibl1@columbia.edu

Louis Rose, DDS, MD
Clinical Professor of Periodontics
University of Pennsylvania School of Dental Medicine
lfrddsmd@verizon.net

Associations
L. Jackson Brown, DDS, PhD
Associate Executive Director
American Dental Association
petersonf@ada.org

Fred Freedman
Director of Marketing
Dental Trade Alliance
fredfreedman@dentaltradealliance.org

Barbara F. Gooch, DMD, MPH
Division of Oral Health
Centers for Disease Control and Prevention
bgooch@cdc.gov

Industry
Ronald A. Bulard
Chairman of the Board
Imtec Corporation
bulard@imtec.com

Tony Package
Senior Product Manager
Vident
tpackage@vident.com

Ronald L. Rupp, DMD
Senior Manager of Professional Relations
GlaxoSmithKline
Ronald.L.Rupp@gsk.com

Linda C. Niessen, DMD
Vice President, Chief Clinical Officer
DENTSPLY International
lniessen@dentsply.com

Private Practice
Gregory J. Folse, DDS
Lafayette, Louisiana
gfolsedds@aol.com

Lawrence S. Lizzack, DMD
Fair Lawn, New Jersey
Lizzack5@aol.com

Jack Ribacoff, DDS
Sunrise, Florida
aribacoff@yahoo.com

Research
Jeffrey D. Johnson
Senior Research Analyst
R.W. Baird & Company
jdjohnson@rwbaird.com

Anna Robbertz, MBA
Vice President
Boston Healthcare
aarobbertz@bostonhealthcare.com

 

CDC on Public Health Strategies

In lieu of greater government spending on oral healthcare, public health strategies and programs such as those fostered by the Centers for Disease Control and Prevention (CDC) remain the first line of defense for maintaining and improving the oral health of communities—especially those that are economically disadvantaged. The CDC’s activities in this realm fall into four main categories: monitoring oral health; identifying effective prevention strategies; translating those strategies into effective programs, typically at the state or community level; and conducting research.

With respect to monitoring oral health, one area where significant change has occurred is tooth loss. The US Department of Health and Human Services “Healthy People 2010” objective for total tooth loss is to reduce the percentage of American adults ages 65 to 74 who have lost all their teeth to 20% by the year 2010. So far, the indicators are favorable and it appears that an increasing number of older adults will be keeping their teeth in the future, says Barbara F. Gooch, DMD, MPH, of the CDC.

“In 2003 we looked at the percentage of adults retaining most of their teeth—that is, who had reported that they had lost no more than five teeth as a result of caries or periodontal disease,” she explains. “We found, in most of the states, most of the older adults reported that they had most of their teeth, which really was a large change in how we had viewed the oral health status of this population. As some of us remember, many of our grandparents did not have their own teeth.”

In the 1950s, more than 50% of adults 65 to 74 years had lost all of their teeth. By the late 1980s, that number had fallen to about 30%, according to Gooch. “In 2004, the most recent national data reported total tooth loss in this age group at about 24%,” she says. “So we have made great progress on complete tooth loss, and of course that reflects all of the advances in prevention, such as community water fluoridation and daily use of fluoride toothpaste, advances in dental technology, and expectations in older adults that they can now retain most of their natural teeth.”

Although progress in tooth loss is also reflected in other areas of oral health, such as dental caries and periodontal disease, Gooch indicates that one should still expect to see disparities in terms of income and education, and that racial and ethnic minorities are likely to be overrepresented in certain disease categories. Such disparities constitute an important reason why strategies aimed at prevention remain crucial to maintaining oral health in the general population, whether they are programs involving fluoridation, community partnerships aimed at “triaging” seniors by ensuring they receive dental services, or approaches to reduce alcohol consumption and cigarette smoking. Tobacco and excessive alcohol are two major contributors to poor dental health, together accounting for up to 90% of oral and pharyngeal cancers while cigarette smoking remains a major risk factor for periodontal disease.

“Clinical care services are extremely important, especially for older adults who may have current and even a backlog of treatment needs,” Gooch emphasizes. “Here at the CDC one of our key strategies is to lift the burden of disease. We can’t eliminate disease—we certainly can’t eliminate disease in older adults—but we can reduce the burden of disease on a population level through application of effective prevention strategies.”

 

The Role of Industry

To hear Ronald L. Rupp, DMD, tell it, despite the obvious hurdles associated with the impact of the aging population, the future is bright for the profession of dentistry, and industry can serve as a catalyst for the action needed to ensure such a future. For example, GlaxoSmithKline (GSK) has developed and marketed an innovative over-the-counter mouthwash and mouth spray (Oasis®) aimed at helping dental patients manage their dry mouth. “These instances of xerostomia in the population are increasing in a wide range of ages, largely due to the increased use of systemic medications for a variety of illnesses managing a variety of conditions,” says Rupp, senior manager of professional relations at GSK. “It is a good illustration of the commitment to innovation that one can expect from industry in response to the needs of the aging population.”

In Rupp’s view, the role of industry rests on a tripod: one leg is the research that has validated and brought credibility to what the industry is currently doing; the second involves education, making certain that the issues are being addressed and incorporated into the educational arena; and the third is the dental profession itself.

By forming partnerships with organized dentistry, working in turn with educators and researchers, industry can achieve aims, in Rupp’s words, “aligned with GSK’s global mission ‘to improve the quality of human life by enabling people to do more, feel better, and live longer.’ If at the end of the day, our patients all live a better life, their quality of life is improved with what we do—whether it be through better treatment, better products, or innovative products for their care—isn’t that what we should all be about?”

At GSK, efforts to advance the oral healthcare that the company believes is needed in this country begin with good, sound research. Several years ago, GSK, working with counterparts at the American Dental Association (ADA), engaged a consulting company, Boston Healthcare Associates, Inc, to conduct a comprehensive assessment of the oral healthcare landscape. The findings, which were published in an article titled, “A Qualitative Assessment of Dental Care Access and Utilization Among the Older Adult Population in the United States,”1 yielded some valuable insights into barriers preventing access to care, attitudes of “stakeholders” across the spectrum of dental care, and the rationale for stratifying the older patient population based on lifestyle rather than age.

Their innovative approach to methodology led the researchers to focus on the group they termed the “semi-dependent” elderly, explains lead author Anna A. Robbertz, MBA, vice president of Boston Healthcare. “We moved away from it as being driven solely by age because we found that you could have a retired individual who was a very healthy 50-year-old and you could have a retired individual who was 85 years old,” she said. “While retired adults may be having some income problems, their access and affordability [issues] weren’t as significant as the semi-dependents.”

Furthermore, the study’s authors thought that the semi-dependent group would provide the best focus for a joint initiative between industry and the dental profession, Rupp notes. “That’s why the semi-dependent group was raised up in the research and, ultimately, conclusions were drawn based on that research,” he says. “If we could make a significant impact with the semi-dependent group—at least coming out of the gate with a partnership like this, where no one else has been yet—if we can improve and raise the awareness of oral health for that segment, then ultimately as [people] move into that frail elderly situation, they will come into it even better.”

To date, the findings from this study have led to several innovative programs funded by GSK and the ADA. Initially, a request for proposals was issued through the ADA Foundation to dental associations, dental schools, and other groups for grants of up to $50,000. Each grant would cover one year of research leading to the development of an “innovative, scalable, reproducible” community-based or statewide program addressing the needs of semi-dependent elders. Six programs were selected, developed by the following groups: the New York State Dental Foundation, Ohio Dental Association, American Red Cross, Spokane Regional Health District, Medical College of Georgia School of Dentistry, and Donated Dental Services Program through the National Association of Dentistry for the Handicapped. Following the research and implementation periods, the directors of each program reported their findings in the summer of 2006.

The program that had a significant impact, according to Rupp, was the one developed by the Ohio Dental Association called Smiles For Seniors, an educational campaign to raise the awareness of the oral health issue among the aging population and those involved with them. “They created a DVD program, an educational program that was distributed nationwide to different groups and, in particular, the Alliance of ADA Senior Smiles program (a program delivering oral care information and products to home bound seniors through community advocacy groups), to talk not only to the patient population but also to caregivers and nurses and the dental and medical professions about the issues around oral health and its importance for aging,” Rupp explains. “And that spurred them.”

The next commitment that GSK made to the ADA Foundation was a $1 million grant funding a 3-year program to extend this approach. “That is coming to fruition in this coming year as the ADA plans to develop a 45-minute-long, interactive Oral Health DVD program, with multiple channels you can follow,” Rupp reports. “Modeled after the Ohio [program], this will take it to a new level.” This new program is scheduled to be launched at the ADA Annual Session in September and then distributed nationwide. For the aging population, the fastest growing segment in the US, for caregivers, and for healthcare professionals, this educational resource will serve to raise up the importance of oral health to systemic health.

Across the industry from pharmaceutical companies, dental manufacturers also appear to be gearing up for the population shift. “The aging population represents an opportunity for manufacturers to provide new products and services,” says Fred Freedman, director of marketing of the Dental Trade Alliance. He envisions a larger demand for dentures as well as implants and indicates that there are many new products and procedures in the pipeline aimed at the increase in older patients.

Tony Package, a senior product manager at Vident, agrees. “What we’re going to see is an extension of the ‘esthetic revolution,’” he says. As Package sees it, Baby Boomers were responsible for adding esthetics to form and function as the standards of care for dental work. They have grown up in what he terms “a cycle of dental care”—from basic maintenance and cleaning through orthodontics, minor repairs and direct restorations, and finally full crown restorations and dentures—that has been hallmarked by its emphasis on esthetic dentistry. They have access to more information about oral health and oral healthcare, and more discretionary income than previous generations to bring esthetic value to the last phase of this cycle. “These retiring Baby Boomers will want esthetic dentures,” he says, and the industry is already trending in that direction. “There is a phenomenon going on that’s been growing since 2000. There is a total growth in the market for dental wearers, and because of the esthetic aspect, there is a demand for higher-end dentures in terms of esthetics.”

Echoing Freedman and Package’s comments from the implant arena is Ronald A. Bulard, DDS, chairman of the board of Imtec Corporation and a board-certified implantologist. “The aging population represents a boom for the dental implant market, certainly,” he says. “The mini dental implant affords these patients with an economic alternative to the more expensive conventional dental implants. With the small-diameter implant, this aging dental population can go into a dental office and within one hour have their teeth stabilized to where they can have the feel and function of fixed teeth.” Bulard notes that these implants require a minimally invasive surgical procedure with no incision and very little anesthetic, which is especially important in an aging population that may have medical problems. “Many patients that are not candidates for conventional implants are candidates for the mini dental implant,” he says. “These patients can have the implants placed and walk out of a dental office and it will change their lives.”

1. Robbertz AA, Lauf RC Jr, Rupp RL, Alexander DC. A qualitative assessment of dental care access and utilization among the older adult population in the United States. Gen Dent. 2006;54(5):361-365.

 

The Dental School Solution

Among the patchwork of institutions and organizations that currently constitutes the oral healthcare system in the United States, dental schools may prove to be the “last, best hope” for addressing the needs of the older-patient population at large—at least until more dramatic reforms are made to the system.

Despite significant resource needs of their own, dental schools may be resilient enough and flexible enough to innovate—internally as well as externally—while meeting their traditional mission of training new dentists. Situated at the front lines of dental care in most places where they are physically located, dental schools can serve as the linchpin in a re-imagined oral healthcare system, connecting elderly patients to practitioners who are better prepared to provide geriatric care.

That is the vision of observers like Ira B. Lamster, DDS, MMSc, dean of the Columbia University College of Dental Medicine. Although dental schools will not be able to completely fill the gap created by the aging population, Lamster thinks that the schools can be an important part of the solution. “Dental schools in this country are not able to treat millions of patients,” he admits. “If they impart to the trainees the fact that this is an important need, and the trainees go out to practice and do start to treat those millions of patients, then I think you’ll find that the message is getting across effectively.”

At Columbia, Lamster and his colleagues have initiated a program called “ElderSmile™,” which consists of four components: geriatric clinical care services, educational programs, research, and public policy and advocacy. The clinical care program involves three community treatment centers, located outside of the confines of the Columbia University Medical Center, which serve as the hub of an outreach network. The spokes of that network are multiple community-based centers considered “prevention sites.”

These are typically senior centers or other places where older adults gather, Lamster explains. “We go there, provide an oral hygiene message and [distribute] toothbrushes and toothpaste,” he says. “Then we provide an evaluation—do a quick examination of the people who are there. If problems are identified, we can refer them to a treatment center.”

It is too early to tell how successful this approach is, but from what Lamster has seen after visiting more than a dozen of the prevention sites, patients are being effectively seen at the initial encounter and, when necessary, referred to the treatment centers. More importantly, the program is taking root in the community. “We’ve gotten buy-ins from a number of other community health organizations who understand what we are doing as an effective way to approach the problem,” he says. “It’s not going to solve the problem, but it’s an effective way to begin to address the problem.”

Another way to address the problem is via the dental school curriculum. Columbia introduced geriatric education in the pre-doctoral curriculum back in 1983 but, like other dental schools in the United States, does not offer a subspecialty in geriatric care. Establishment of such a specialty has been the source of debate in recent years. Lamster sees merit on both sides of the issue. “Without question, we’re going to need a core group of specialists who understand the medical/dental/public health sides of this question who are dentists,” he says. “On the other hand... every dentist should be able to see and treat these patients, up to a limit. One of the things the dental school is going to be doing is offering continuing education programs for dentists who want to become involved in treating older adults. So general practitioners will need to be able to do more, and we also need to develop a group of specialists.”

Absent other significant developments, such as an expansion of Medicare to cover oral healthcare, Lamster thinks it will fall to the dental schools to play a major role in addressing the dental care needs of older adults. “There are no major hospitals, such as New York-Presbyterian Hospital or Massachusetts General Hospital, to do this,” he declares. “So where do you have a lot of capacity? You have a lot of capacity in dental schools. Schools have 100, 200, 300 dental operatories. They have young providers who are in training who want to do the right thing, who want different patient-care experiences, who want to serve those who have difficulty accessing services. So in many ways, I think dental schools are ideal locations to make this happen. Plus, they’re training the future dentists. If they send this message, young dentists will enter practice with the sense that this is an important part of their professional life.”

 

How the ADA Equals Advocacy

One question that came up repeatedly in the course of researching the impact of the aging population on dentistry involves the critical role of the American Dental Association (ADA) in the ability of the profession to field enough dentists to handle the increase in older patients, especially as Baby Boomer dentists themselves retire. At the ADA, associate executive director L. Jackson Brown, DDS, PhD, says his organization is confident that dentistry would remain a “very attractive” profession—enough so to ensure an adequate number of dentists in the future.

Asked about the concerns expressed by many in the profession as well as academia, including the difficulty of attracting enough faculty members and the need for a greater focus on geriatric dentistry, Brown says that the ADA would be following such concerns “extremely carefully.” While, to his knowledge, the organization does not have a position on creating a new subspecialty of geriatric dentistry, Brown emphasizes that it is important for dentists to understand such issues as systemic diseases that can complicate dental treatment. “The ADA does recognize that the importance of geriatric issues in the treatment of patients is going to increase,” he says.

The organization’s general position, Brown continues, is to work to see the oral health of the American people be as good as it can be. Helping that segment of the population unable to pay for dental services is a critical component of that mission. Does the ADA advocate extending Medicare to cover oral health? “We’d like to see all segments of the American people have appropriate access to oral care,” Brown responds. “There are a number of ways you can approach it. Subsidizing private dental insurance for those who have [or had] insurance to extend it is one approach. Creating the equivalent of a healthcare savings account for dental is another. Our overall focus, rather than taking the position, ‘We like this program or that program,’ is to maintain oral health.”


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