Dental Barriers: Some Seniors Challenged to Keep Teeth Healthy

Income and independence levels can be significant barriers to whether seniors get the dental care they need. Good dental hygiene is important to overall health, and chronic illnesses and medications can worsen oral health.

According to the American Dental Association, a fifth of people age 75 and older haven’t seen a dentist in the past five years. Many older patients can’t afford dental insurance or transportation and after-care. Some have impaired cognitive skills and don’t understand the need. Others are not mobile enough to get to a dental office.

“There are all these layers to the issue, where you can have problems along the way. It’s really complicated,” said Dr. Matthew Personius of Sierra Housecalls Medical Group. The majority of Personius’ patients are elderly and he often hears about or observes their dental issues.

“One of the biggest issues that people don’t necessarily realise, Medicare, the primary insurance for seniors, by and large, does not cover dental care. Some states do but the reimbursement is poor and negligible,” Personius said.

There are dental insurance plans available, but the ones offered by Covered California require the person to have a health plan as well. A lot of local plans are sold through Delta Dental, but many providers are in Modesto, said Debbie Schug, HICAP programme coordinator at Area 12 Agency on Ageing. “It’s a definite issue and stumbling block,” Schug said.

In addition to transportation or affordability, most dental plans have a waiting period, where you must pay first and then wait six months before you start services, Schug said. “There are no local resources for seniors without dental insurance.”

The Vietnam Veterans of America Chapter 391 used to host a “Stand Down” event in the fall where homeless veterans received free dental care by local dentists, but the event has been discontinued, said Frank Smart, former organiser. In the five years the event was held, about 20 to 25 homeless or at-risk veterans received care, including cleanings, fillings and one-day dentures. The Veterans Administration doesn’t cover dental care unless a person is 100 per cent disabled or has special circumstances, Smart said. “It is an issue.”

For some VA patients who cannot get to Bay Area providers, some dentists like Dr. Charles McKelvey of Twain Harte Family Dental Care offer services on an individual, case-by-case basis.

The senior population faces two major hurdles, said Dr. Michael Scherer, a Sonora-based prosthodontist. “No. 1, an ever increasing need of services as teeth and the body ages and No. 2, an ever decreasing amount of financial resources as years go beyond the workforce,” Scherer said. “What I focus on with my practice is maintaining patients as far as we can go, but then also to know when we need to move to dentures or implant procedures that facilitate a patient as they get ‘old-old’,” Scherer said.

People over 65 have a much higher level of complete tooth loss than those below 65, Scherer said.

The tooth loss comes from a variety of biological (decay, gum disease, infections) and non-biological sources (patient preferences, insurance coverage, what options are given to patients), Scherer said. Research shows that nutrition and quality of life is impacted when patients lose all of their teeth, he added. This decrease in quality of life can be reversed with dental implant procedures; however, dental implants can be expensive. Many patients don’t want to spend or simply can’t spend tens of thousands of dollars on dental treatment.

Scherer says he works to keep costs down and make procedures as affordable as possible and keeps his treatments in the few thousands of dollars price range. He said an increase in dental coverage might improve dental health for the elderly, but he thinks expanding Medicare could make it less solvent over time. In September 2014, Scherer was quoted in Inside Dentistry magazine about dental offices preparing their businesses for baby boomers. The article cited an online survey from 2013 that indicated 41 per cent of adults over 45 have dental coverage.

“I do find that most of my senior patients can easily afford basic dental treatment with or without supplemental dental coverage,” he said. Scherer added that the advent of community health centres like MACT and Tuolumne Mi-Wuk clinics can offer expanded services for low-income seniors without coverage.

According to the MACT website, some patients who don’t have insurance can qualify for up to 20 per cent discounts for services. For patients who don’t qualify for government programmes, the clinics offer special arrangements for eligible low-income patients.

Most dentists accept payment plans either through their offices or through Care Credit, Dr. Charles McKelvey of Twain Harte said. Many seniors also use credit cards to pay for care, he said. “I think we all give senior discounts.”

And if someone has an infection, they won’t ever be turned away if they seek care, he added.

While older patients are living longer, their medical complexity goes up, Scherer said. “It is more challenging to treat an older patient because many simply can’t have invasive dental procedures performed safely. We then make our best with what we can do.”

Twain Harte Family Dentistry has a dentist who is also a board-certified anaesthesiologist and the office gets referrals from all over for patients who are nervous, and some who have Alzheimer’s, McKelvey said. One of the biggest things McKelvey sees in his practice is the severe dry mouth side effect in seniors who take a lot of medications. Having dry mouth, or xerostomia, is the side effect in hundreds of medications, including those for cardiac issues, high blood pressure and high cholesterol, McKelvey said. It’s also a common side effect with radiation and chemotherapy.

If the gums and teeth aren’t kept moist by saliva and protected by the components of saliva, decay develops and spreads rapidly, McKelvey said.

Another dental issue that seniors face is the breakdown of old dental work, like fillings and crowns. “After it’s been in the mouth for 50 and 60 years, these things start to break down. Teeth can break and so forth,” McKelvey said.

Another issue is gum disease and losing bone support in the face. Tooth loss can change the shape of a person’s face and jaw and can affect the ability to eat comfortably.

For some older seniors, who’ve lost family, friends, independence, one thing that still brings them joy is eating, McKelvey said. If a person is 90 and has a broken tooth and the relatives don’t want to deal with getting it fixed, McKelvey will remind them that the person still enjoys eating. Plus, having teeth is a psychological thing, he said. “Everyone likes a nice smile.”

Abscesses are a serious concern in dental and whole body health. If a person has an infection, the bacteria can enter the bloodstream and affect the heart. Many doctors prescribe patients a pre-dental procedure antibiotic, so during the procedure when bacteria get released, they are less likely to get an infection, McKelvey said. “More than once, I’ve had patients come in with broken, abscessed, infected teeth. I take them out and they come back and say they haven’t felt that good in years.”

Independence is the biggest barrier seniors have to getting dental care, Personius said. “What it comes down to is, if you are capable and able to get around and do things for yourself, you have a better chance of having dental care or reasonable dental hygiene. If not, then it’s much less likely.”

For example, someone who is 85, cognitively impaired, can’t drive, can’t care for themselves after a procedure, has to radically change their diet after a procedure, it’s far less likely they will have treatment or successfully comply with a treatment plan. Some nursing facilities have a provider for their patients, said Personius. “People who are shut-ins might never see a dentist.” – Lacey Peterson, The Union Democrat

One-fifth of adults over 75 haven’t seen a dentist in the past five years and it can have serious health risks, but a lot of people don’t have insurance to pay for it. (Photo: Thinkstock)