Muhammad Ashraf Nazir

Field Supervisor: Leslie Topola Academic Supervisor: Dr. Gerry Uswak

Outline Introduction Status of oral Health among older Adults Factors responsible for poor oral health Significance of Oral health Financial impact Oral health programs and services in Other

Canadian provinces Position statement of CDA Conclusion Recommendations.

Introduction Older individuals aged 80 are fastest growing group of

population & Saskatchewan has highest percentage of seniors.

Chronic diseases and physical and cognitive disabilities

increase the risk of poor oral hygiene and associated oral disorders.

WHO says that “Oral health is part of total health and essential to quality of life.”

U.S. Secretary of Health and Human Services described “Oral health is integral to general health...you cannot be healthy without oral health”

The US Surgeon General’s 2000 report on oral health described oral health of older individuals as “silent epidemic of profound and consequential dental problems”

Oral disease particularly periodontal disease is

associated with > cardiovascular diseases > ischemic stroke > respiratory infections > diabetes mellitus > nutritional deficiencies and weight loss > more than 100 systemic illnesses have oral manifestations.

Oral conditions and dysfunctions are extremely painful

and can devastate the quality of life of an individual.

Status of Oral Health among older Adults

The Importance of Good Oral Care. Health and Legal Implications for LTC & AL Settings – DHFS Presentation/ Webcast Madison, WI . May 17, 2007 http://www.dhs.wisconsin.gov/rl_dsl/training/OrlCrPwrPnt.pdf

Saskatchewan Pilot Project According to Saskatchewan pilot project, 67% of residents required dental treatment .

50% retained their teeth while 50% were edentulous (without

teeth). 89.5% of edentulous residents had dentures out of which > 46% had faulty dentures > 71.5% of dentures were without client identification. Approximately 71.5% of the residents had dental caries.

Factors responsible for poor oral health

Increasing population and associated High prevalence of chronic diseases.

Population of older individuals will experience “doubling

phenomena” > population over age 65 will double by 2030 > population over age 85 will double by 2030 Seniors are retaining more teeth. Retention of natural teeth put them at risk for dental and oral

diseases such as caries and periodontal diseases.

For example, 48% of individuals aged 65 and over without natural teeth in 1990 and 30 % of seniors were edentulous in 2003.

Low income among older individuals. Individuals with low income and no insurance do not have access to

oral health care and are much more likely to have poor oral health status

In Ontario, individuals with high income made more visits to dental clinics and used 26% more services than low income subjects

Oral health does not appear to be a priority of the governments.

Various Canadian surveys show strong support for publicly funded

oral health program For example, in a survey of 24 nursing homes, more than 90% of

nursing homes were interested > in an oral health care program provided by the public health department of the health region > willing to offer support for such publicly funded dental health program

Most of lowest income Canadians prefer publicly funded dental care, and 80.9% of dentists believe that oral health care should be provided in public settings.

Approximately 72% of residents of long term facilities reported that routine oral hygiene is their greatest single need.

In Saskatchewan, almost one dollar per senior per year was spent on oral health services compared to 100 dollar per senior per year for physician services in Saskatchewan 2002/03.

Out of 12 health regions in Saskatchewan, none have an established dental public health department.

Out of approximately 1,650 staff members there is only one dental caregiver (a dental therapist) in Cypress Health Region looking after the oral health needs of a population of 44,000 individuals.

Many LTC facilities have physical, occupational department and

hair salons but no provision of space for dental treatment.

Lack of awareness and recognition

regarding the importance of oral health

Nurses. Nurses are reluctant to provide oral care to elderly because mouth care assistance is perceived as

> more unpleasant, > trivial, and > unrewarding than other nursing activities. A study was designed to assess that how much importance is

given by the nursing assistants to oral hygiene, > only 16% of residents received oral health care > the average time for tooth brushing only 16.2 seconds. Policy makers. oral diseases are not considered life

threatening or oral health is not recognized as “sick care. Historically, policy development and practice was dominated by the profession of medicine, therefore oral care was not part of primary health care.

Significance of Oral health

Poor oral health may lead to > dental and oral diseases > systemic diseases > denture problems > Nutritional deficiencies and Weight loss > social and psychological problems

Dental caries

http://www.mndental.org/features/2009/02/02/93/management_of_rampant_caries

Dental decay is a public health problem According to the 96% of adults have a history of

cavities. Dental decay may develop among older adults

at a higher rate than children. Dental decay > pain and infection> reduce

ability to eat > affect overall quality of life. Tooth loss not only > reduced chewing ability and intake of nutrients > risk factor for weight loss > increased risk of ischemic stroke > and poor mental health

Gingivitis and Periodontitis

http://hubpages.com/hub/bleeding-gums

http://www.drchetan.com/causes-of-bleeding-gums.html

http://cosmeticdentistry01.files.wordpress.com/2010/03/gum4.jpg

http://www.cda-adc.ca/JCDA/vol-67/issue-2/figs.html

Gingivitis and periodontal disease The most common human infections affecting almost 90% of

world population .

Periodontal disease is associated > diabetes mellitus > cardiovascular disease such as atherosclerosis, heart attack, coronary artery disease, congestive heart failure > rheumatoid arthritis > osteoporosis > pneumonia and pulmonary infections > ischemic stroke > and peripheral artery disease

Oralpharyngeal Candidiasis. Oral candidiasis affects 34 to 51% of older adults

A. Haerian. DENTAL CARE in ELDERLIES. www.ssu.ac.ir/fileadmin/templates/fa/.../MB.../dandanpezeshki.ppt

Oral Cancer . Seven times more common in individuals aged 65 years and older than those under the age of 65 years and kills roughly one person per hour, 24 hours per day in the U.S.

http://www.tobaccofacts.info/oral_cancer.htm

http://hubpages.com/hub/Oral-Cancer-and-its-Causes http://www.tobaccofacts.info/oral_cancer.htm

Dryness of Mouth Prevalence ranges from 20%

to 40% in community dwelling older individuals.

Lack of saliva results in

> increased risk of tooth caries & oral infection. > poor denture retention > intolerance to acidic & spicy food > difficulty in swallowing & speech > burning of mouth

A. Haerian. DENTAL CARE in ELDERLIES. www.ssu.ac.ir/fileadmin/templates/fa/.../MB.../dandanpezeshki.ppt

Denture problems. > denture stomatitis > denture hyperplasia > traumatic ulcers > ill-fitting dentures > and angular cheilitis

The Importance of Good Oral Care. Health and Legal Implications for LTC & AL Settings – DHFS Presentation/ Webcast Madison, WI . May 17, 2007 http://www.dhs.wisconsin.gov/rl_dsl/training/OrlCrPwrPnt.pdf)

Social and Psychological problems Poor oral health such as

tooth loss, caries, periodontal destruction have dramatic social impacts and can devastate the quality of life, thus affecting

> chewing, > swallowing, > speaking, > facial aesthetics, > Interpersonal relationships.

http://www.superstock.com/stock-photos-images/1566-

564637

Cardiovascular disease & Stroke Different measures of periodontal disease confer almost a 24

to 35% increase in the risk of coronary heart disease.

Meta-analysis of nine longitudinal studies has reported that periodontal disease may increase the risk of cardiovascular disease by roughly 20%, and risk ratio between periodontitis and stroke is even stronger.

Individual with severe periodontitis have 4.3 times higher risk of cerebral ischemia than the individuals with no periodontitis.

Diabetes Mellitus Periodontal disease

increases the severity of diabetes mellitus.

Periodontitis should be

considered sixth “classic” complication of diabetes mellitus.

Diabetic patients lose teeth more frequently than healthy individuals.

Periodontal treatment is associated with improve glycemic control in patients with diabetes mellitus .

The Importance of Good Oral Care. Health and Legal Implications for LTC & AL Settings – DHFS Presentation/ Webcast Madison, WI . May 17, 2007 http://www.dhs.wisconsin.gov/rl_dsl/training/OrlCrPwrPnt.pdf)

Aspiration Pneumonia. Proper oral hygiene reduces the risk of aspiration pneumonia and

improves cognitive status and alertness.

Almost one in 10 cases of death can be prevented in the residents of LTC facility by improving their oral hygiene.

Certain systemic diseases have a significant effect on periodontal tissues such as

> osteoporosis, > immunodeficiency diseases, > pregnancy, > renal dysfunction and diabetes mellitus. Some medical conditions make self oral care more

difficult > Depression > Dementia > Parkinson’s disease > Rheumatoid Arthiritis

Financial Impact of Poor Oral Health Various studies indicate that fewer health care dollar expenditures are

required if good oral health care is maintained.

According to a 2002 analysis , If only a 10% incidence of pneumonia among older adults is reduced due to the improvement in the oral health, then there would be a net cost saving of more than $300million in the United States.

An economic analysis in 2005-06 estimated that provision of oral care to older Australians aged 65 and over, could substantially reduce $412 million expenditures on systemic complications due to oral health disease.

Saskatchewan would bear a cost of $20 million ($20,096,083) incurred to the health care system due to major systemic complications resulting from oral diseases among seniors.

Provision of dental treatment by spending $ 200 per senior (currently only one dollar is spent) to 54% of older individuals who suffer from oral diseases would result in net cost saving of $ 4 million.

Oral Health Programs and Services in Other Canadian Provinces

Alberta. “Dental Assistance for Seniors programs” financial

assistance up to maximum of $ 5,000 every five years for Low to moderate income seniors for basic dental procedures.

British Columbia. University of British Columbia Geriatric Dentistry

Program covering approximately 2500 clients From 22 long term care facilities.

Ontario. Halton Oral health Outreach Program (HOHO). Toronto Public Health Dental services.

Manitoba Faculty of Dentistry, University of Manitoba’s Centre for

Community Oral Health program(CCOH). a. Dear Lodge Centre, b. Access Down Town Dental Clinic, c. Home dental care program (Mobile Dental Vans) d. Oral health promotion unit.

Prince Edwards Island Long -Term Care Facilities Program. (All the residents of 18

long term care facilities )

Senior’s Oral Health Strategy

Position Statement of Canadian Dental Association

Upon admission the resident should undergo oral health screening performed by a nurse as a part of routine collection of health information for minimum data set (MDS).

Residents should be supplied with tooth brushes, and fluoride containing tooth pastes, storage of denture and a brush for denture cleaning.

All dentures should be labelled / identified with resident’s name.

Residents who require assistance in maintaining their oral hygiene should be provided with a support worker, care aide or nurse.

A nurse should perform oral health screening of all the residents of long term care facilities every 3 month to update minimum data set.

Conclusion Prince Edwards Island and health regions in British

Columbia, Manitoba, and Ontario are providing excellent oral health services.

Out of 158 LTC facilities only one dental clinics in LTC facility in Regina is operational and two dental clinics Saskatoon are preparing to provide oral care in LTC facilities.

Just like general health, oral health care is basic right of individuals and therefore oral care should be covered in a similar way as the general health.

Saskatchewan is birth place of Medicare, and it is time for the province to realize the magnitude of this emerging epidemic

Recommendations 1. Collaboration, advocacy, and lobbying. Creation of the office of chief dental officer in the province. Provision of oral care through publically funded program.

Establishment of dental public health department in Health

Regions.

Inclusion of Canadian Dental Association’s (CDA) recommendations on oral health care for the residents in LTC facilities.

Regulation regarding the provision of space for dental treatment in the LTC facilities.

Funding for portable dental equipment, mobile dental clinic vans/bus,

dental supplies and denture labelling.

Incentives to geriatric health care workers and a fee guide specific to geriatric dental services.

2. More research. Research in to oral health needs of older individuals, and the issues

faced by caregivers, administrators , and health regions.

3. Education and training of dental professionals and other health care givers.