Dentistry and Medicine Collaborate on Health Care for Older Adults
A symposium for creating dialogue between medicine and dentistry.
On October 16, 2009, a classic fall day in New York City, an energetic group looked out from the 40 th floor of the World Trade Center building #7, home of the New York Academy of Sciences.
A symposium titled, “Collaborative Health Care for Older Adults” once again brought together leaders in dentistry and medicine for a second in a series jointly sponsored by Columbia University College of Dental Medicine, Columbia University College of Physicians and Surgeons, Oral Health America , and the New York Academy of Sciences. Importantly, this second symposium served as a catalyst for medical and dental healthcare professionals to collaborate on the health of the elderly.
Dr. David Albert described the symposia focus on oral health and the significant role it plays in the overall health of the population. The recognized link between oral and systemic health among older adults has grown stronger in recent years; however, physicians and dentists are rarely provided with an opportunity to discuss the implications of the oral–systemic connection that will only become larger as the older population grows older.
Beth Truett, president and CEO of Oral Health America (OHA), explained OHA's role in this landmark conference. “Oral Health America is the nation's leading independent organization dedicated to eliminating oral disease through access, education, and advocacy for all Americans, but especially those most vulnerable. As we begin the symposium, just remember there are over 35 million senior citizens over 65 and expected to grow to 48 million by 2015, and yet there are almost no policy plans to change the healthcare system in a way that will truly meet the needs of older adults.”
A keynote address on “Health and Aging—Opportunities for Medical/Dental Collaboration” laid the day's groundwork. Dr. Marie Bernard presented a review some of the demographics of aging with particular reference to oral health. A summary of research that has been funded by the National Institute on Aging and the National Institute of Dental and Craniofacial Research of relevance to the medical and dental health of the aging population was presented. “We have an aging epidemic,” stated Dr. Bernard. “In fact, currently, the most rapidly growing segments of the population are octogenarians and centenarians.” Although in the last wave of data collection there was nearly a 20% reduction in the percentage of adults 60 and older who had lost all of their teeth, issues with regards to root caries and related to smoking habits have emerged. And of particular interest to the dental community is that the mortality of oral cancer is absolutely skewed to older ages. “I, as a geriatrician, wonder about how much of that is contributed by, again, multiple morbidities in older individuals, how much of it is contributed by, again, lack of dental coverage in many cases and, therefore, no one looking in the mouth.” She concluded her remarks to emphasize that there is an opportunity for the education of healthcare professionals and the public with regards to oral health in the elderly.
Dr. Joshua Z. Wiley informed the group that stroke is the leading cause of disability in adults in the United States and the third leading cause of death, and is disproportionately a disease of individuals of lower socio-economic status, African Americans, the elderly, and women in the older age groups. Dr. Moise Desvarieux of Columbia University has been leading a study of oral and periodontal infections and vascular disease (INVEST study). The hypothesis here and based on other findings from other individuals is that chronic infection and inflammation predisposes a person to vascular disease. Periodontal disease may accelerate the progression of atherosclerosis, and, therefore, the development of stroke, myocardial infarction, or vascular deaths can be demonstrated. In some notable findings from the INVEST study, tooth loss, which is used as a marker of past periodontal disease, was associated with a greater prevalence of carotid plaque, particularly if more than 10 teeth were missing in multivariable models.
Dr. Wiley concluded that whether or not a causative association or just sort of a disassociation of general ill health is being observed is still yet to be determined. However, the emergence of periodontal infections as a potential risk factor for CVD is leading to a convergence in oral and medical care that can only benefit the patients and public health.
Dr. Richard Mayeux focused on Alzheimer's disease (AD) as the most frequent cause of dementia in western societies. The current rates of 5 million people in the United States and possibly 20 to 30 million worldwide are expected to quadruple by the year 2040. Alzheimer's disease risk is augmented among individuals with cardiovascular and cerebrovascular disease and their antecedents. The concerted effort to identify the genetic basis of the common, late-onset form of AD underway will, no doubt, clarify the role of environmental and other health factors on risk and have profound influences on the treatment of this disease.
Dr. M. Carrington Reid spoke on the topic of pain. “Advancing age is associated with progressive impairments in multiple domains…pain is a highly prevalent symptom across multiple chronic conditions and in itself is significant and an underrepresented cause of disability and, as importantly, suffering, in later life. Pain is associated with fragility, advancing age, and minority status, it has a high impact on life, and is highly morbid with immune dysfunctions. Arthritis and arthritis-related diseases are the most common causes of pain in older populations; however, painful neuropathies associated with diabetes and herpes zoster also occur commonly and can be equally disabling.”
Dr. Daniel Malamud told the gathering that, “Older adults is an ideal group to consider oral diagnostics, they have very complex medical situations and they are often in nursing homes where there's a lack of trained personnel and they are having multiple blood draws.”
It is now widely accepted that most molecules present in blood can also be detected by sampling the oral cavity. These molecules include ions, antigens, antibodies, nucleic acids, steroid hormones, tumor makers, inflammatory mediators, and many drugs. Dr. Malamud reported that his studies have focused on using oral sampling for detecting or tracking systemic diseases, particularly infectious diseases, while others have identified salivary markers for asthma and chronic obstructive pulmonary disease, cardiovascular disease, and cancer. The focus on the ability of these tests for the geriatric population is based on the ease of acquiring saliva, that there are markers present with high accuracy.
Dr. David J. Zegarelli reviewed the two major diseases of oral mucosa in his presentation, oral lichen planus and candidiasis, diseases of the oral mucosa having a predilection for older adults. These entities can occur singly and in combination with one another. Lichen planus has six clinical forms and is seen with increased frequency in patients having oral squamous cell carcinoma. Oral candidiasis is an opportunistic superficial mucosal infection. Presenting symptoms often include the patient stating that the mouth “burns” or is “sensitive.”
There were also presentations dedicated to policy implications and inter-professional relationships. In “Building the Health Care Workforce for an Aging America,” Carol Raphael, MPA, reminded the audience that building a healthcare workforce means to enhance geriatric competence throughout all disciplines, increase the recruitment and retention of geriatric specialists, and improve the way care is delivered by spreading evidence-based models, redefining traditional job roles, and leveraging technology as an enabler. With about
7,100 geriatricians in United States , while the real need is 36,000, the problem is that the field of geriatric specialization is not attractive to either new medical or dental residents. Available fellowships are not filled. New certification in geriatric medicine has gone down. Geriatric medicine has the lowest earnings. With this landscape, there are no geriatric medicine subspecialties. Ms. Raphael recommended increased recruitment and retention of geriatric physicians and dentists, and training for all residents in older adult care. Licensure and certification should include competence in geriatric medicine.
Dr. Kenneth Brummel-Smith specifically addressed expanding geriatric education in medical training. All medical students, and almost all residents, need to incorporate more geriatrics. This training must include not only common diseases and syndromes seen in older persons, but also key geriatric principles, such as reduction of polypharmacy, improving care transitions, and interdisciplinary, palliative, and end-of-life care.
While more schools have departments of geriatrics, and almost 100% of medical schools report some dedicated coursework, only 23% have a required rotation (while 100% require a pediatric rotation), and less than 50% integrate geriatrics into other clerkships. Dentistry is ahead of medicine because it is competency based. The other important aspect is this training has to include collaborative and team-based training and that's where the connection to dentistry comes in.
Dr. Douglas Berkley, focusing on the geriatric dental education and training in the United States ,
noted the alarming parallels to geriatric medicine, reports on the failure of dentistry from the Institute of Medicine, the US Surgeon General, and the American Dental Association that all confirm that the dental workforce is not adequately prepared to address the complex oral health needs of older adults. He advocated the development of a variety of strategies to transform training of oral healthcare providers, such as incorporation of geriatric issues in national and regional licensure examinations; increasing the amount of experiential training in geriatrics during the first and second years of dental school curricula; expanding the diversity of clinical training experiences to include the very-old patient; identifying the most effective strategies for teaching geriatrics in each learning environment, employing geriatric-specific competency measures to improve dental education outcomes; and developing Web-based resources to form a “clearinghouse” of information to help advance ongoing learning about the issues affecting older adults.
Dr. Cynthia M. Boyd pointed to the importance of multiple coexisting conditions, or multimorbidity, to the health and healthcare of older adults. Currently, evidence-based medicine is often focused on a single condition at a time. This framework proves challenging for older adults with multimorbidity. This issue is relevant to the oral health of older adults, which can contribute to the outcome of other conditions and vice versa.
Full proceedings from the symposium will be published in the Annals of the New York Academy of Sciences . Additional coverage, including audio and PowerPoint presentations, is available in the eBriefings section of the Academy's Web site. Visit www.nyas.org for more information.
Kathy Granger, PhD, Senior Project Manager, The New York Academy of Sciences
Beth Truett, BSc, MDiv, President and CEO, Oral Health America
David Albert, DDS, MPH, Associate Professor of Clinical Dentistry and Clinical Health Policy and Management Director, Section of Social and Behavioral Sciences, Columbia University College of Dental Medicine, New York, New York
Ira Lamster, DDS, MMSc, Dean and Professor of Dental Medicine, Columbia University College of Dental Medicine, New York , New York
Evelyn C. Granieri, MD, Assistant Professor of Clinical Medicine, Chief, Division of Geriatric Medicine and Aging, Columbia University , Collage of Physicians and Surgeons, New York , New York
Panos N. Papapanou, DDS, PhD, Professor of Dental Medicine, Chair, Section of Oral and Diagnostic Sciences, Columbia University College of Dental Medicine, New York, New York
Marie Bernard, MD , Deputy Director, National Institutes on Aging/National Institutes of Health, Bethesda , Maryland.
Joshua Z. Wiley, MD, MS, Assistant Professor, Department of Neurology, Columbia University Medical Center , New York , New York.
Richard Mayeux, MD, MSc, Professor of Neurology, Columbia University Medical Center, Sergievsky Center/Taub Institute, New York , New York.
M. Carrington Reid, MD PhD, Associate Professor of Medicine, Weill Cornell Medical College , New York , New York
Daniel Malamud, PhD, Professor Basic Science and Craniofacial Biology, New York University College of Dentistry and New York University College of Medicine, New York, New York
David J. Zegarelli, DDS, Professor Dental Medicine, Director Oral Pathology, Columbia University College of Dental Medicine, New York, New York
Carol Raphael, MPA , President and CEO, The Visiting Nurse Service of New York , New York
Kenneth Brummel-Smith, MD, Chair, Department of Geriatrics, The Florida State University College of Medicine, Tallahassee, Florida
Douglas Berkley, DMD, MPH, MS, Professor of Applied Dentistry, University Colorado School of Dental Medicine, Denver , Colorado
Cynthia M. Boyd, MD, MPH, Assistant Professor, Department of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine and Bloomberg School of Public Health, Baltimore, Maryland