Dental Neglect in Older Adults


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Dr. Janet Bauer of Loma Linda University addresses the growing issue of dental neglect in seniors, particularly those in early to mid-stage dementia who can no longer practice good dental hygeine without assistance. The presentation was part of the June 7, 2013 Glenner Symposium on Elder Abuse and Neglect for San Diego County health care professionals.

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Dental Neglect in Older Adults

  1. 1. Dental Neglect in Older AdultsJanet G Bauer, DDS, MSEd, MSPH, MBAProfessorDisciplines: Aging and Evidence-Based Research and PracticeLoma Linda University School of DentistryProfessor EmeritaUCLA School of Dentistry
  2. 2. Elder abuse - Definition• “ is harmful behaviordirected towards olderadults by family membersor professional caregiverswhom the older adult lovesor trusts, or upon whomthey depend for assistance.”• Elder upon him or herself(Self-abuse)• Caregiver• Society
  3. 3. Physical Abuse (26%)– 75% of abuse in head andneck area• Bruises, lacerations, ropemarks• Bone and skull fractures orbreaks• Untreated injuries• Broken assistivedevices, dentures, glasses– Consider whole patient• General appearance• Hands, feet, mobility
  4. 4. Emotional Abuse (35%)- Red flags for dentists- Threats, humiliation, intimidation by caregiver- Not allowing the patient to expressconcerns/wishes- Social isolation- Cultural considerations- Adult parent living alone
  5. 5. Financial Abuse- Improper use of an adult’s funds, property or resources byanother individual- Treatment decisions by caregiver based solely on finances- Financial abuse 30%
  7. 7. Who do I report to?Adult ProtectiveServices (APS)(888)
  8. 8. GENERAL DENTISTRYState of Dental Care Services“At the University of California at Los Angeles School ofDentistry, researchers are pursuing what in medicine would beanalogous to curing the common cold. They want to eliminatetooth decay altogether. If successful, David Noel, DDS, MPH, chiefdental consultant for the California Department of HealthServices, says, the Denti-Cal program can change its emphasisfrom treatment to absolute prevention."CDA Journal Vol. 28, No. 1, January 2000
  9. 9. ORAL HEALTH AGING“This is continues to be the era of the elderly. However, changes areemerging to have people living longer than in prior years. Muchunderstanding has been made in a relatively short period of time todeal with the physical, mental, and emotional problems unique tothe elderly. This necessitates dentist to make educational andbehavioral changes to enter the arena of primary care. Theseproblems will not go away and time may not be the issue…..Topractice prevention, we need to understand more aboutsupports, then medical and dental diseases alone.”Bauer, 2011 (Adapted from Massler, 1989)
  10. 10. Teleological Measurement of careThe goal for anyconcept of careis health!Physicalwell-beingMentalwell-beingSocialwell-being
  11. 11. This is not your older adult patient.York Garrett, 100;Practicing PharmacistTHIS IS!Beatrice Favre, 113Edna Parker, 115This is not your older adult patient.
  12. 12. Journey encompasses the world of healthWhat is thedifference todentists thatwill changepractice inthe future?
  13. 13. 20th Century dentistry• Traditionally, delivery of dentalcare to the elderly meantproviding services to repair teeth,and their supporting tissues, or toreplace missing teeth. During thisperiod, the dentist experiencedhigh dental disease rates in thecommunity he/she serviced. Thus,the approach was one of triage. Inother words, the dentistconcentrated most of his/herpatient care time to assigningdegrees of urgency to carious-involved teeth. Then, the dentistwould decide, or prioritize, whichteeth were the most likely to besalvaged in order to provide anoptimal level of functioning for theindividual patient.
  14. 14. PREVENTION – THE HALLMARK OF DENTISTRYIt was only in the later half of the 20thcentury that prevention rose to be thehallmark of dentistry, that is, thepossibility that dental disease couldbe prevented. This then forecasted anapproach for the 21st century thatemphasizes prevention overtreatment.
  15. 15. “Treatment options andprocedures are the same.If an individual, anyindividual, needsspecialized skills to meettheir specializedneeds, age is not a factor.Dentistry has manydisciplines to service theseneeds. In the case of themost difficult treatmentand proceduralscenarios, forexample, the discipline ofHospital Dentistry canmeet these specializedservices.”Hospital DentistryOperating Theater
  16. 16. Elder abuse - Types• Neglect (49%)– Self neglect (mostcommon)– Caregiver neglect• Physical• Psychological• Material injury• Mistreatment• Maltreatment
  17. 17. Elder abuse – Legal• Crime – abuse that results in injury or violates an older adult’sindividual rights as defined by law.• Neglect – failure to fulfill a caregiving responsibility, eventhough the caregiver does not intend to harm the olderperson.
  18. 18. AgeismCurrent perceptions regarding the care of older patients: Profession Patients Surrogates
  19. 19. Practicing dental clinicians-Survey• Dentists just don’t want todeal with older adults.• Money and time are keyfactors in treating older adults.• Did not receive mucheducation on dental care forthe elderly when in dentalschool.• Need more continuingeducation in RemovableProstheticsKing and Kaufman, 2008UCLA School of Dentistry, Class 2011Teeth and Procedures
  20. 20. Dental NeglectOlder Adults• Users– 53.5% in 1999 - 14 years ago– Up from 43.2% in 1989 – 24 yearsago• Non-Users– Don’t value oral health or esthetics– Ethnic minorities– Lower education achievement andincome– Lack of dental insurance– Rural vs Urban– Poor general health and functionalstatus– No teeth– Traditional beliefs about dentaldecline– Self esteemProfession• Opt out of Medicare –Universal coverage• Transportation• Time• Equipment• Patient flow• Costs in relationship to:– Effectiveness– Benefits
  21. 21. Caregivers – Dental Care• Distance• Values• Decline• Overwhelmed• Dental knowledge– Education– Skills– Personal careImmediate family memberFriendsHired caregivers
  22. 22. CHANGEProfessionSocietyHealthEstheticsRecovery of youthProprietary companiesProductsAdvertising
  23. 23. Dentistry and Primary Care• Interdisciplinary approach• Coordinated, comprehensive and continuous care• Mobile dentistry
  24. 24. Combine medical indices and oral health into Center for overall healthassessments and oral health servicesSaliva diagnostics and genetic engineering (Biomarkers)Assess risksEvaluate services neededCENTERS FOR DENTAL MEDICINE
  27. 27. Functional independence measure (fim)• The FIM (1996) is the most widely accepted functionalassessment measure in use in the rehabilitation community.• The FIM(TM) measures independent performance in self-care, sphinctercontrol, transfers, locomotion, communication, and socialcognition.
  28. 28. Measure• The FIM is an 18-itemscale that assessprogress duringinpatient rehabilitation.By adding the points foreach item, the possibletotal score ranges from18 (lowest) to 126(highest) level ofindependence.• Use is mostly in hospitaland nursing home settings.• See the complete scale goto :
  29. 29. Interdisciplinary team• An interdisciplinary team is agroup of professionals fromdifferent disciplines whoseactivities are coordinated andperformed toward a commongoal, that is, the prevention ofdisease and the promotion andmaintenance of health andfunction in an individual patient.Team meetings or conferencesmay also include the:• Patient• Family members• Familial caregivers or supports• Payer representatives
  30. 30. ADOH• Functional assessment tool tomeasure functional dependency(or return to independence) inoral self-care.• Scores are given fordemonstrated (or non-demonstrated) performance of ageneric self-care regimenincluding oral rinses, fluorideapplication, brushing, andflossing.• Full dependency warrants ascore of 16 for dentateindividuals, 8 for edentateindividuals.Activities of Daily Oral Hygiene(ADOH)
  31. 31. Oral Rinses
  32. 32. Flossing
  33. 33. Tooth brushing
  34. 34. Denture brushing
  35. 35. Oral health risks• Root caries• Periodontal disease• Cancer– Removable prostheses– Oral tissue– Metastases
  36. 36. Prophylaxis• Adults 85 years and older– Prophy at 3 month intervals• Adults with medical conditions, dementia, or definitive signsof senescence– Prophy at 3 month intervals to 1 month intervals• RDHAP – Registered dental hygienist with privileges inalternative practice.– Informed consent for shared dental records– Share COMPLETE chart or duplicate with email/fax updates
  37. 37. Daily Home Care• Regimen– Flossing– Toothbrushing usingbrand of toothpaste thathas high dose offluoride;example, Prevident 5000• Tongue brushing withscraper• Brush and soakremovable appliancesusing Efferdent• Informed consent:– High dose fluoride – Keepout of reach of children 6years old and younger dueto toxicity• Emergency – Milk and ERvisit for stomach pump; ifleft to absorb in a 3 yearold, could be lethal
  38. 38. Daily Home Care (cont…)• Regimen– Oral rinses• Listerine• Chlorohexidine;example, Periogard• Informed consent:– Chlorohexidine• Avoid with antibiotic usein older adults– Can cause Candidainfections for whichantifungal loges areindicated;example, Nystatin
  39. 39. QUESTIONS?