Emerging Models of Dental Practice Aim at Addressing Needs of the Aged

The number of senior citizens, categorized as those who are aged 65 and older, is expected to double to more than 98 million by 2060, when they will represent nearly one-quarter of the US population.¹ Considering that about 180 million residents of the United States do not visit the dentist yearly,² it can be estimated that roughly 27 million seniors do not access dental services annually. If this trend continues, approximately 43 million seniors will go without care by 2060.

Fortunately, disease rates for senior citizens as measured by edentulism and incidence of untreated decay have decreased over time. Among seniors, edentulism rates declined over the past 20 years by about 40% and currently stand at about 18%.³ Untreated decay rates for this group declined by a similar margin over the same time period and are currently about 17%.³ The overall rates mask large disparities in disease incidence between the poor and non-poor, and the most recent analyses show that over time, the disparities in disease rates by income have substantially widened. Currently one-third of seniors living in poverty have untreated decay, and 36% are edentulous; this is more than four times the rates of both conditions among seniors with annual household incomes at or above $47,000.³ It is concerning that nearly 40% of seniors did not visit a dentist in 2014.⁴ Utilization rates are marked by similar income disparities. In sum, the nation is seeing a rapidly growing population of people who are living longer and keeping their teeth. Many seniors are going without care, and the poorest elderly—those with the largest burden of dental disease—are least likely to seek care.

These data raise questions about the adequacy of the nation’s dental care delivery system to meet the growing needs of an expanding senior population. Assuming there is a Medicare dental benefit in the future, one has to wonder whether the oral health workforce will have the capacity to care for the additional millions of newly insured who will seek care. The question of whether the dental care delivery system in the United States, which is now almost entirely office-based, will be prepared to care for a quickly growing elderly population that will face increasing mobility challenges is legitimate. The US Census Bureau projects that by 2030 the nation will be home to about 9 million people aged 85 and older.⁵ Will the delivery system be positioned to maximize opportunities to meet seniors’ dental needs when they access medical care by educating medical providers to conduct oral health screenings and referrals and/or co-locating dental providers with medical providers?

This article will describe some emerging oral health workforce models, as well as interprofessional team approaches that may help provide access to this growing population of seniors.

Emerging Oral Health Workforce Models

While research shows that cost is the primary barrier keeping people of all ages from seeking dental care,⁶ the adequacy of the dental care delivery system for seniors with and without insurance is a major concern. Our dental care delivery system comprises a maldistribution of dentists that leaves 53 million people in the United States living in areas with dentist shortages.⁷ Without a dentist to provide treatment, a Medicare dental benefit will not solve the access problem for many seniors in these areas. The millions of senior citizens who have Medicaid as their source of dental insurance face an additional problem: about two-thirds of dentists do not accept public insurance.8 Public clinics serving patients on Medicaid and the uninsured fall far short of meeting the need for care.

Increasingly, states are considering authorizing midlevel dental providers, often called dental therapists, as a cost-effective strategy to expand the dental workforce while making it more culturally diverse. States are also encouraging the deployment of these midlevel providers to nursing homes and other community settings to make access more convenient, and for a growing number of homebound and institutionalized elderly, possible.

Akin to physician assistants in medicine, dental therapists are oral health practitioners who work under the supervision of a dentist to provide routine preventive and restorative care, including preparing and filling cavities and performing nonsurgical extractions—restorative procedures that traditionally only dentists have been allowed to perform. Dentists hire and supervise dental therapists to offer routine care to more patients, grow their practices, offer evening and weekend care, and deliver services in a variety of off-site locations. The scope of practice of a dental therapist is about one-quarter of that of a general dentist. National guidelines for dental therapist training programs issued by the American Dental Association’s Commission on Dental Accreditation call for students to develop competencies in caring for elderly patients, including those with cognitive impairment, complex medical problems, and significant physical limitations.⁹

In the United States, dental therapists currently practice in Minnesota and parts of Alaska and have been authorized in Vermont, Maine, and, specifically for Native Americans, Washington state. They are serving two Native American tribes in Oregon under state pilot authority and are being considered in about a dozen state houses.¹⁰ Alaska’s training program integrates care for elderly patients into a number of its didactic and clinical classes such as diagnosis and treatment planning and behavioral management. In Minnesota, dental therapy students complete rotations at nursing homes.

Alaska started using dental therapists in 2004 to work in remote Native Alaskan villages, where dentists made rounds just a few times a year. A problem that persists not just in Alaska but anywhere is that health providers often want to live and practice only in metropolitan areas. Health officials serving Native Alaskan tribes addressed this dilemma by recruiting Native Alaskans from rural communities, training them, and returning them to their communities where they have existing social and familial support systems and choose to live.

In Minnesota, private practices use dental therapists to serve more patients on Medicaid. Nationally, with average Medicaid payments for adult dental care at about 41% of commercial fees, dentists report low payment as the primary reason for not treating patients on Medicaid or other public insurance.¹¹ Dental therapists command lower salaries than dentists do (one Minnesota public clinic reports a salary differential of $30 per hour),¹² and thus their utilization can lower the cost of delivering care for a practice and make it more feasible to accept Medicaid’s discounted payment rates.

Minnesota nonprofit clinics and Federally Qualified Health Centers are using dental therapists as an efficient way to increase their capacity to serve more patients on Medicaid and offer free or sliding-fee care to more low-income uninsured patients. Recently, a nonprofit dental operation in Minnesota, Apple Tree Dental (appletreedental.org), demonstrated the cost-effective use of a dental therapist in meeting the dental needs of a nursin g home population. Results from a recent case study found that more than 70% of the gross production generated from on-site care was within the scope and ability of a dental therapist to perform, and the nonprofit organization saved more than $50,000 a year by deploying a dental therapist instead of a dentist to a veterans’ home to provide needed care.¹³ Nearly 60% of the procedures performed by the dental therapist on-site were restorative, suggesting that restorative care is a significant need for this population and that such care can be delivered on-site with a lower-cost provider.¹³

Dental hygienists are also increasingly delivering preventive care to seniors in non-office–based community locations, such as nursing homes. Currently, most states allow dental hygienists to provide off-site care without a dentist present. This more liberal scope of practice arrangement, often called “affiliated practice” or “public health dental hygiene,” nearly always requires some type of contractual agreement with a supervising dentist specifying which procedures may be performed without first having to ask the supervising dentist for permission. Many states have expanded the range of procedures, locations, and care that hygienists can initiate without permission so that care can be provided for populations that would otherwise most likely not receive preventive dental services.

The virtual dental home (VDH) is a new delivery system model for preventive care that is gaining attention as a means for reaching the elderly in long-term care settings and senior centers. This model uses telehealth technology to link dental hygienists working in community locations with dentists in dental offices and clinics. Dental hygienists conduct examinations and collect diagnostic information that they send to their supervising dentist electronically through a cloud-based record system. In California, where the VDH is operating and the state practice act allows hygienists to place interim therapeutic restorations (ITRs), hygienists identify teeth that could benefit from ITRs and are virtually advised by the dentist as to whether to proceed or not. Patients in need of more advanced restorative care are referred to dental offices.¹⁴ In addition to California, VDH has been authorized in Colorado; these two states have approved Medicaid reimbursement for dentist consults conducted electronically.

Interprofessional Models Linking Oral and Systemic Health for Older Adults

Historically, dental professionals and dental care have not been viewed as an integral component of interprofessional team models and the primary care medical home. One reason for this is that most of the curricula preparing non-dental health professionals have a dearth of oral health content and clinical experiences that integrate oral health. Approximately 70% of medical schools include only 4 hours of oral health content and clinical experiences, while an estimated 10% have no oral health content at all.¹⁵ Historically, nurse practitioners (NPs), nurse midwives (NMs), and physician assistants (PAs) also have not had defined oral health content nor a set of oral health clinical competencies.^16,17 Training to integrate interprofessional oral health competencies may have the greatest impact on standardizing clinical practice uptake when it is integrated in the education of family practice, pediatric, obstetrician-gynecologist, and endocrinology residents and fellows.

Several significant initiatives are reversing this trend, particularly in relation to geriatric oral health. The launch of Smiles for Life: A National Oral Health Curriculum (smilesforlifeoralhealth.org) represented an important interprofessional tipping point for engaging non-dental clinicians in considering oral health and its relation to overall health as an integral component of their practice. Tooth Wisdom (toothwisdom.org), developed by Oral Health America, has an older adult consumer focus and emphasizes the importance of oral health to overall health, finding dental care services, and paying for care.

In 2014, the US Health Resources and Services Administration (HRSA) convened an expert panel to develop interprofessional oral health competencies to promote the integration of oral health in primary care across the lifespan, culminating in the “HRSA Report, Integration of Oral Health and Primary Care Practice.”¹⁸ Dissemination of the article “Putting the Mouth Back in the Head: HEENT to HEENOT” challenged health professionals to include the intraoral and extraoral cavity when taking a health history, performing a physical examination, determining risk, implementing a management plan, and documenting clinical findings, including collaboration with and referral to the dentist.¹⁹ Distribution of “Oral Health: An Essential Component of Primary Care,” a white paper from Qualis Health, and its implementation framework (Figure 1) reinforced the importance of the HEENOT approach (ie, the traditional head, ears, eyes, nose, and throat [HEENT] examination with the addition of the teeth, gums, mucosa, tongue, and palate examination [HEENOT] for assessment, diagnosis, and treatment of oral-systemic health) by providing an interprofessional workflow redesign model for integrating oral health, including collaboration with and referral to dental professionals as an essential part of whole-person care, in primary care practices.²⁰ Finally, a new document, “Shared Principles of Primary Care,” developed by the Patient-Centered Primary Care Collaborative, includes for the first time oral health as an essential component of comprehensive primary care.²¹

Strategies for Integrating Oral Health Into the Health Professional Curriculum

Evidence of the effectiveness of using oral-systemic health as an exemplar to operationalize the Interprofessional Education Collaborative (IPEC) competencies has provided a catalyst for the development of curricular interprofessional education innovations.²² Haber et al recently provided evidence supporting the effectiveness of an interprofessional clinical simulation and case study experience at New York University using oral-systemic health as the clinical population health exemplar, on nurse practitioner, midwifery, dental, and medical students’ self-reported attainment of interprofessional competencies.²³ Students learned from, with, and about each other using a team-based approach to teach each other oral, cardiac, and respiratory assessment for a standardized older adult patient with symptoms of diabetes and periodontal disease. Findings revealed that students’ self-reported interprofessional competencies improved significantly from pre- to post-test (P < .001) for all three student types. This clinical experience is now a standard component of the curriculum for all three academic programs. The findings of similar initiatives nationwide validate the effectiveness of this approach to using oral-systemic health to operationalize interprofessional competencies.^24-26

A national study of all PA program directors documented that 78% of responding programs (n = 125) had integrated oral health into their curriculum. A follow-up study on a stratified sample of 2014 PA graduates (N = 2,500) from all currently accredited PA programs (N = 166) found that 75% of PAs who responded to the survey received some education in oral health during their education. After controlling for PA specialty and primary employer, PAs who received education in oral health and disease were approximately 2.79 times more likely (95% CI = 1.39 to 5.59, P = .0038) to provide oral health services in their clinical practice, compared with those who did not receive any education in oral health competencies.^27,28

Ford and colleagues describe a pilot professional training program in which University of Alabama at Birmingham (UAB) medical, nursing, optometry, physician assistant, and dental students collaborate to learn how to perform baseline screenings that identify when a patient should be referred to another discipline.²⁹ Students are assigned to interdisciplinary teams that provide holistic screenings at monthly events organized by community partners in elementary schools and childcare centers. The representatives of each discipline teach their assessment to their team members, who then practice screenings outside of their usual professional domain.²⁹

The University of Iowa, which specializes in geriatric dentistry, operates a mobile dental clinic staffed by dental students that serves 10 nursing homes throughout the state of Iowa. A new joint initiative by the university’s Colleges of Dentistry and Nursing and School of Social Work added NP and social worker students to the team, shifting the focus from oral health to overall health. This approach addresses the reality that frail older adults often have multiple chronic conditions, including oral health conditions, that have a reciprocal effect on their overall health.³⁰

Strategies for Integrating Oral Health Into Interprofessional Clinical Practice

The Walker Dental Clinic at the University of Minnesota School of Dentistry provides training for dental and other health profession students on geriatric care, including medicine, nursing, pharmacy, physical therapy, chiropractic, and pastoral care. The clinic collaborates with the university’s Center on Aging and the Minnesota Area Geriatric Center to support interprofessional training activities at the Walker Dental Clinic.³¹

In another example of the integration of oral health into interprofessional clinical practice, the UAB School of Dentistry and the Fairhaven Retirement Community have partnered under the leadership of Lillian Mitchell, Director of Geriatric Dentistry at UAB, to create the Fairhaven Oral Health Center, the only dental clinic located in a nursing home and retirement community in the state of Alabama. The clinic has a learning center to train caregivers and medical and dental professionals to understand the components of good oral and overall health so they can provide collaborative, high-quality whole-person care to the residents.³²

The UAB Geriatric Education Center sponsors the Inter­professional Clinical Experience program, in which multiple disciplines (eg, pharmacy, nutrition, social work, dentistry, nursing, medicine, and geriatrics) meet weekly to interview patients and develop their care plans.³³ Jablonski and colleagues developed and implemented an innovative program to train clinicians to model specific strategies to reduce mouth-care resistive behaviors in community-dwelling or nursing home residents with dementia and have partnered with the Alzheimer’s Association to disseminate the model to family and professional caregivers.^33,34

The Oral Health Nursing Education and Practice program and the American College of Physicians partnered to develop a set of oral health literacy products, Oral Health Patient Facts (ohnep.org/news/oral-health-patient-facts), to be used in primary care offices. Designed to promote understanding about the links between oral health and overall health, these evidence-based fact sheets are available in English and Spanish with a sixth-grade reading level. Key population health issues like oral health and diabetes, oral health and human papillomavirus (HPV), oral health and older adults, and personal oral health are addressed in a consumer friendly format.

Conclusion

The United States faces a crisis of access to quality oral healthcare for a growing number of senior citizens. Increased utilization of emerging workforce models such as dental therapists and less restrictive access to dental hygienists can improve the situation. In addition, calling on other health professional colleagues in new interprofessional practice models could also contribute to increased access to oral health services for seniors, which ultimately should lead to improved oral and overall health.

About the Authors

Frank Catalanotto, DMD
Professor
Department of Community Dentistry and Behavioral Science
University of Florida College of Dentistry
Gainesville, Florida

Jane Koppelman, MPA
Research Director
Pew’s Dental Campaign
Pew Charitable Trusts
Washington, DC

Judith Haber, PhD, APRN, FAAN
Ursula Springer Leadership Professor in Nursing and Executive Director
Oral Health Nursing Education and Practice Program
New York University Rory Meyers College of Nursing
New York, New York

Queries to the author regarding this course may be submitted to authorqueries@aegiscomm.com.

References

1. Mather M, Jacobson LA, Pollard KM. Aging in the United States. Population Bulletin. 2015;70(2):1-19.

2. Dental care utilization, dental benefits coverage, and cost barriers: Update 2015. American Dental Association Health Policy Institute Webinar. October 2015. http://www.ada.org/en/science-research/health-policy-institute/publications/webinars/update-2015-dental-care-utilization-dental-benefits-coverage-and-cost-barriers. Accessed August 15, 2017.

3. Tomar S. Changes in disparities in dental caries status in the United States. Unpublished data conducted for the Pew Charitable Trusts. January 10, 2017.

4. National Center for Health Statistics. Health, United States, 2015. With Special Feature on Racial and Ethnic Health Disparities. Hyattsville, MD: US Dept of Health and Human Services, Centers for Disease Control and Prevention; May 2016. DHHS Publication No. 2016-1232. Table 78. http://www.cdc.gov/nchs/data/hus/hus15.pdf. Accessed August 15, 2017.

5. Ortman JM, Velkoff VA, Hogan H. An Aging Nation: The Older Population in the United States. US Census Bureau. P25-1140. 2014:1-28. https://www.census.gov/prod/2014pubs/p25-1140.pdf. Accessed August 15, 2017.

6. Yarbrough C, Nasseh K, Vujicic M. Why adults forgo dental care: evidence from a new national survey. Health Policy Institute Research Brief. American Dental Association. November 2014. http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_1114_1.ashx. Accessed August 15, 2017.

7. Health Resources and Services Administration. Shortage Designation: Health Professional Shortage Areas and Medically Underserved Areas/Populations. HRSA website. http://www.hrsa.gov/shortage. Accessed August 15, 2017.

8. American Dental Association. Characteristics of Private Dental Practices: Selected 2013 Results from the Survey of Dental Practice. February 2015. http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIData_SDPC_2013.ashx. Accessed August 15, 2017.

9. Commission on Dental Accreditation. Accreditation Standards for Dental Therapy Education Programs. American Dental Association: Chicago, IL; February 6, 2015. http://www.ada.org/~/media/CODA/Files/dt.pdf. Accessed August 15, 2017.

10. Koppelman J. Oral health workforce for the 21st century. Presented at: Association of Health Care Journalists; April 22, 2017; Orlando, FL.

11. Nasseh K, Vujicic M, Yarbrough C. A ten-year, state-by-state, analysis of Medicaid fee-for-service reimbursement rates for dental care services. Health Policy Institute Research Brief. American Dental Association. October 2014. http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_1014_3.ashx. Accessed August 15, 2017.

12. Wovcha S, Pietig E. Dental Therapy in Minnesota: A Study of Quality and Efficiency Outcomes. Children’s Dental Services. 2015. http://legislature.vermont.gov/assets/Documents/2016/WorkGroups/Senate Health and Welfare/Bills/S.20/Witness Testimony/S.20~Sarah Wovcha~Dental Therapy in Minnesota- A Study of Quality and Efficiency Outcomes~2-11-2015.pdf. Accessed August 15, 2017.

13. Smith B. An advanced dental therapist in long-term care: an Apple Tree Dental case study. Unpublished manuscript developed for the Pew Charitable Trusts. June 2017.

14. Glassman P, Harrington M, Mertz E, Namakia M. The virtual dental home: implications for policy and strategy. J Calif Dent Assoc. 2012;40(7):605-611.

15. Ferullo A, Silk H, Savageau JA. Teaching oral health in U.S. medical schools: results of a national survey. Acad Med. 2011;86(2):226-230.

16. Dolce MC, Haber J, Shelley D. Oral health nursing education and practice program. Nurs Res Pract. 2012;2012:149673.

17. Hooker RS, Berlin LE. Trends in the supply of physician assistants and nurse practitioners in the United States. Health Aff (Millwood). 2002;21(5):174-181.

18. Integration of oral health and primary care practice, Executive Summary. US Dept of Health and Human Services, Health Resources and Services Administration. 2014. https://www.hrsa.gov/publichealth/clinical/oralhealth/primarycare/integrationoforalhealth.pdf. Accessed August 15, 2017.

19. Haber J, Hartnett E, Allen K, et al. Putting the mouth back in the head: HEENT to HEENOT. Am J Public Health. 2015;105(3):437-441.

20. Oral Health: An Essential Component of Primary Care. Qualis Health. June 2015. http://www.safetynetmedicalhome.org/sites/default/files/White-Paper-Oral-Health-Primary-Care.pdf. Accessed August 15, 2017.

21. Shared Principles of Primary Care. Patient-Centered Primary Care Collaborative website. https://www.pcpcc.org/about/shared-principles. Accessed August 15, 2017.

22. Interprofessional Education Collaborative. Core Competencies for Interprofessional Collaborative Practice: 2016 Update. American Association of Colleges of Nursing. https://www.mededportal.org/download/322304/data/corecompetenciesforcollaborativepractice.pdf. Accessed August 15, 2017.

23. Haber J, Hartnett E, Allen K, et al. The impact of oral-systemic health on advancing interprofessional education outcomes. J Dent Educ. 2017;81(2):140-148.

24. Scherer YK, Anders PL, Antonson DE, et al. Incorporating standardized patients into an interprofessional oral-systemic health practicum. TJNP J Nurse Pract. 2015;11:e29-e35.

25. Anders PL, Scherer YK, Hatton M, et al. Using standardized patients to teach interprofessional competencies to dental students. J Dent Educ. 2016;80(1):65-72.

26. Calvo JM, Hamud-Ahmed W, Nye H, Hyde S. Integration of a novel interprofessional oral health module into medical student clinical skills curriculum. MedEdPublish. 2016;5(3). https://www.mededpublish.org/manuscripts/549/v1. Accessed August 15, 2017.

27. Langelier M, Surdu S, Gao J, Glicken AD. Determinants of Oral Health Assessment and Screening in Physician Assistant Clinical Practice. Rensselaer, NY: Oral Health Workforce Research Center, Center for Health Workforce Studies, School of Public Health, SUNY Albany; December 2016. http://www.chwsny.org/wp-content/uploads/2017/03/OHWRC_Oral_Health_Assessment_in_PA_Practice_2016.pdf. Accessed August 15, 2017.

28. Langelier MH, Duhl Glicken A, Surdu S. Adoption of oral health curriculum by physician assistant education programs in 2014. J Physician Assist Educ. 2015;26(2):60-69.

29. Ford CR, Foley KT, Ritchie CS, et al. Creation of an interprofessional clinical experience for healthcare professions trainees in a nursing home setting. Medical Teacher. 2013:35(7):544-548.

30. Anderson Davy L. UI College of Dentistry promotes geriatric dental care in the classroom and community. Iowa Now. University of Iowa website. https://now.uiowa.edu/2017/03/ui-college-dentistry-promotes-geriatric-dental-care-classroom-and-community. Accessed August 15, 2017.

31. Regents of the University of Minnesota. Walker Dental Clinic Fact Sheet. 2016. https://ohsoa.dl.umn.edu/sites/g/files/pua3441/f/media/walker_clinic_fact_sheet_accomplishments12-2016.pdf. Accessed August 15, 2017.

32. Meet Lillian from Birmingham, Alabama. Tooth Wisdom. Oral Health America website. http://www.toothwisdom.org/practices/entry/meet-lillian-from-birmingham. Accessed August 15, 2017.

33. Jablonski RA, Kolanowski A, Therrien B, et al. Reducing care-resistant behaviors during oral hygiene in persons with dementia. BMC Oral Health. 2011;11:30.

34. Jablonski RA, Therrien B, Mahoney EK, et al. An intervention to reduce care-resistant behavior in persons with dementia during oral hygiene: a pilot study. Spec Care Dentist. 2011;31(3):77-87.