Improving the Standards of Care

The challenges that face patients and their caregivers when assistance is needed both in nursing facilities and at home cannot be met only by providing instruction to caregivers. In order to provide optimal care and the needed system of oral healthcare for this population, multiple strategies must be employed. This is the only way that the ideal standards of oral care at the national, state, and local levels can be realized.

Surveillance of Oral Care Needs

Although it is widely recognized that there are urgent oral health needs in this population, understanding the actual scope of the problem is dependent on adequate surveillance, and there is a paucity of data. One of the reasons that the standard of care is not adequate in nursing homes is that the surveillance of care needs to be improved at the national, state, and local levels. Improved collection of data through oral health surveys in nursing homes is needed at the regional and state levels. The Association of State and Territorial Dental Directors (ASTDD) Basic Screening Survey (BSS) for Older Adults is an effective tool to measure the extent and nature of dental needs in a population. The BSS collects data about number of teeth remaining in the dentition, untreated tooth decay, denture ownership and use, posterior tooth occlusion, presence of plaque and calculus, periodontal needs, dental fractures and tooth mobility, xerostomia, and suspected oral pathology (such as abscesses and tumors). However, such surveys are expensive and challenging to conduct, and most states do not have current survey data.²⁷

Model Programs in United States

At a more local level, there are other strategies that can be implemented to promote greater surveillance, which leads to improved diagnosis and treatment. These include surveys of older adult patients of private practices and safety-net providers. Training nursing staff in long-term care facilities to better assess oral health conditions in their patients is a crucial element in addressing this problem. This includes screening for oral cancer. Simple and routine oral cancer screenings must be done in care facilities to ensure more cancers are detected in their early stages when treatment is more successful and survival more likely. As present, only one-third of oral cancers are detected in their early stages, while two-thirds progress to more advanced stages and are less likely to respond to treatment.²⁸

There are outside agencies in various states and communities that serve as role models to stakeholders in other localities that seeking to improve the oral health of this population. In New York, Columbia Dental School’s initiative ElderSmile has provided screenings and referrals at senior centers.²⁹ In Minnesota, Apple Tree Dental operates mobile portable dental programs that serve older adults for whom a visit to a dental office would not be possible. Michigan’s Coalition for Oral Health for the Aging provides advocacy, professional and public education, and research in this domain. And Oral Health America’s Wisdom Tooth Project created educational programs for older adults and caregivers. These are just a few of the significant initiatives that can be emulated by other programs across the country with the same mission.

As described in detail in this course, another important consideration is to bring oral health education directly to seniors and their caregivers. ADA and University of the Pacific produced an outstanding course with this goal in mind, entitled Overcoming Obstacles to Oral Health.³⁰ Collaborations like these between professional and academic stakeholders are an effective method to distill best practices and make them available to the people who need them. This course serves to improve health literacy, as well as address cultural considerations. It addresses the unique needs for both daily oral care and professional dental treatment that patients with dementia and their caregivers need to understand.

Improving Geriatric Education in Dental and Dental Hygiene Schools

Geriatric dental education is an area that deserves greater emphasis and more time among dental curricula. This is true in both the classroom and the clinic. Too little time is dedicated to teaching geriatric dentistry and there is insufficient clinical education focused on this population. To remedy this deficit, the America Dental Education Association (ADEA) developed a series on geriatric dentistry. Geriatric training residencies and specialties should also be advocated and promoted in all states. One notable program that can serve as an example for training dental hygienists in this area is the geriatrics program for registered dental hygienists at the University of Minnesota.³¹ Continuing education courses in geriatric dentistry should also be developed and promoted by national, state, and local dental and dental hygiene associations.

Dental Coverage Under Medicare and Medicaid

For older adults, accessing dental care can be quite challenging. Those who are retired and had dental coverage as an employee benefit often no longer have dental coverage.³² This lack of coverage comes at a time in their lives when many of the factors discussed in this course make dental care a necessity for preventing infections, maintaining quality of life, and protecting other body systems impacted by oral disease. Since the inception of Medicare and Medicaid in 1965 under President Lyndon B. Johnson, it has been difficult for older adults to access dental care.

The primary purpose of Medicare is to provide healthcare for seniors, but dental care is only covered in very limited situations where it can be shown to be medically necessary (e.g., prior to organ transplants or cardiac valve replacement).³³ This excludes all the preventive and restorative care that is essential to the oral and overall health of every senior.

The primary purpose of Medicaid is to provide healthcare for those in financial need. Medicaid coverage has improved in many states, where adult coverage has been added for emergency or routine dental services in addition to the coverage of minors in all states. However, finding providers who accept Medicaid as well as coordinating care for patients living in facilities make available services difficult to access. Fortunately, many states have recently increased their Medicaid reimbursement for dental services.³⁴ Ohio is one of the latest to increase its reimbursement, by 93% in 2024.³⁵ Hopefully, the policy trends to include routine dental care for adults and to expand reimbursement will contribute improved access to dental care for seniors, particularly those facing barriers common to nursing home residents and care-dependent patients.

To address oral health regulations in long-term care facilities, each state will need to address both how dental care is funded and how oral health standards are set and regulated. Medicaid Reimbursement for adults varies from state to state for dental coverage. In order for seniors without dental insurance and without the means to pay privately to receive care, routine dental treatment—including preventive services—should be available to Medicaid-eligible adults. Also, although federal standards require regular dental assessment and treatment, in facilities receiving Medicaid funding, compliance with the standards is difficult to enforce or monitor, and oral care standards can be even harder to maintain in assisted living and hospice facilities. Funding must be allocated to ensure that these standards are actually monitored and enforced.¹ Furthermore, at the state level, oral health for nursing home residents and care-dependent adults will improve if each state requires that long-term care facilities conduct oral health assessments that screen for any signs and symptoms of oral disease and that care plans are regularly updated for all patients.

Federal and State Regulations

Nursing homes are required by federal law to assess the dental needs of their residents and coordinate access to necessary dental care.¹ In addition, state-specific requirements may reinforce or add to what is required by federal law. For example, the Ohio Revised Code requires that “The nursing home shall provide all residents who cannot give themselves adequate personal care with such care as is necessary to keep them clean and comfortable.”³⁶ However, nursing homes are neither equipped nor compelled through adequate enforcement to comply with such general yet far-reaching regulations. Only a multipronged approach that includes both policy changes and practical training for caregivers can begin to address this problem.