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.

1. Dental Neglect in Older Adults
Janet G Bauer, DDS, MSEd, MSPH, MBA
Professor
Disciplines: Aging and Evidence-Based Research and Practice
Loma Linda University School of Dentistry
Professor Emerita
UCLA School of Dentistry

2. Elder abuse - Definition
• “ is harmful behavior
directed towards older
adults by family members
or professional caregivers
whom the older adult loves
or trusts, or upon whom
they depend for assistance.”
• Elder upon him or herself
(Self-abuse)
• Caregiver
• Society

3. Physical Abuse (26%)
– 75% of abuse in head and
neck area
• Bruises, lacerations, rope
marks
• Bone and skull fractures or
breaks
• Untreated injuries
• Broken assistive
devices, dentures, glasses
– Consider whole patient
• General appearance
• Hands, feet, mobility

4. Emotional Abuse (35%)
- Red flags for dentists
- Threats, humiliation, intimidation by caregiver
- Not allowing the patient to express
concerns/wishes
- Social isolation
- Cultural considerations
- Adult parent living alone

5. Financial Abuse
- Improper use of an adult’s funds, property or resources by
another individual
- Treatment decisions by caregiver based solely on finances
- Financial abuse 30%

6. DENTISTS
ARE
MANDATED
REPORTERS

7. Who do I report to?
Adult Protective
Services (APS)
(888) 436-3600
www.dss.cahwnet.gov

8. GENERAL DENTISTRY
State of Dental Care Services
“At the University of California at Los Angeles School of
Dentistry, researchers are pursuing what in medicine would be
analogous to curing the common cold. They want to eliminate
tooth decay altogether. If successful, David Noel, DDS, MPH, chief
dental consultant for the California Department of Health
Services, says, the Denti-Cal program can change its emphasis
from treatment to absolute prevention."
CDA Journal Vol. 28, No. 1, January 2000

9. ORAL HEALTH AGING
“This is continues to be the era of the elderly. However, changes are
emerging to have people living longer than in prior years. Much
understanding has been made in a relatively short period of time to
deal with the physical, mental, and emotional problems unique to
the elderly. This necessitates dentist to make educational and
behavioral changes to enter the arena of primary care. These
problems will not go away and time may not be the issue…..To
practice prevention, we need to understand more about
supports, then medical and dental diseases alone.”
Bauer, 2011 (Adapted from Massler, 1989)

10. Teleological Measurement of care
The goal for any
concept of care
is health!
Physical
well-being
Mental
well-being
Social
well-being

11. This is not your older adult patient.York Garrett, 100;
Practicing Pharmacist
THIS IS!
Beatrice Favre, 113
Edna Parker, 115
This is not your older adult patient.

12. Journey encompasses the world of health
What is the
difference to
dentists that
will change
practice in
the future?

13. 20th Century dentistry
• Traditionally, delivery of dental
care to the elderly meant
providing services to repair teeth,
and their supporting tissues, or to
replace missing teeth. During this
period, the dentist experienced
high dental disease rates in the
community he/she serviced. Thus,
the approach was one of triage. In
other words, the dentist
concentrated most of his/her
patient care time to assigning
degrees of urgency to carious-
involved teeth. Then, the dentist
would decide, or prioritize, which
teeth were the most likely to be
salvaged in order to provide an
optimal level of functioning for the
individual patient.

14. PREVENTION – THE HALLMARK OF DENTISTRY
It was only in the later half of the 20th
century that prevention rose to be the
hallmark of dentistry, that is, the
possibility that dental disease could
be prevented. This then forecasted an
approach for the 21st century that
emphasizes prevention over
treatment.

15. “Treatment options and
procedures are the same.
If an individual, any
individual, needs
specialized skills to meet
their specialized
needs, age is not a factor.
Dentistry has many
disciplines to service these
needs. In the case of the
most difficult treatment
and procedural
scenarios, for
example, the discipline of
Hospital Dentistry can
meet these specialized
services.”
Hospital Dentistry
Operating Theater

16. Elder abuse - Types
• Neglect (49%)
– Self neglect (most
common)
– Caregiver neglect
• Physical
• Psychological
• Material injury
• Mistreatment
• Maltreatment

17. Elder abuse – Legal
• Crime – abuse that results in injury or violates an older adult’s
individual rights as defined by law.
• Neglect – failure to fulfill a caregiving responsibility, even
though the caregiver does not intend to harm the older
person.

18. Ageism
Current perceptions regarding the care of older patients:
 Profession
 Patients
 Surrogates

19. Practicing dental clinicians-Survey
• Dentists just don’t want to
deal with older adults.
• Money and time are key
factors in treating older adults.
• Did not receive much
education on dental care for
the elderly when in dental
school.
• Need more continuing
education in Removable
Prosthetics
King and Kaufman, 2008
UCLA School of Dentistry, Class 2011
Teeth and Procedures

20. Dental Neglect
Older Adults
• Users
– 53.5% in 1999 - 14 years ago
– Up from 43.2% in 1989 – 24 years
ago
• Non-Users
– Don’t value oral health or esthetics
– Ethnic minorities
– Lower education achievement and
income
– Lack of dental insurance
– Rural vs Urban
– Poor general health and functional
status
– No teeth
– Traditional beliefs about dental
decline
– Self esteem
Profession
• Opt out of Medicare –
Universal coverage
• Transportation
• Time
• Equipment
• Patient flow
• Costs in relationship to:
– Effectiveness
– Benefits

21. Caregivers – Dental Care
• Distance
• Values
• Decline
• Overwhelmed
• Dental knowledge
– Education
– Skills
– Personal care
Immediate family member
Friends
Hired caregivers

22. CHANGE
Profession
Society
Health
Esthetics
Recovery of youth
Proprietary companies
Products
Advertising

23. Dentistry and Primary Care
• Interdisciplinary approach
• Coordinated, comprehensive and continuous care
• Mobile dentistry

24. Combine medical indices and oral health into Center for overall health
assessments and oral health services
Saliva diagnostics and genetic engineering (Biomarkers)
Assess risks
Evaluate services needed
CENTERS FOR DENTAL MEDICINE

25. Access points for Center patients
PRIVATE PATIENTS MAY CHOOSE PRIVATE
PRACTICES, CLINICS, OR HOSPITAL OUT-
PATIENT SERVICES TO ACCESS POINTS.

26. Access points for center patients
WHEN CHANGES IN
HEALTH, FUNCTIONAL STATUS, OR
BOTH OCCUR, ACCESS POINTS MAY
CHANGE PER EPISODE.

27. Functional independence measure (fim)
• The FIM (1996) is the most widely accepted functional
assessment measure in use in the rehabilitation community.
• The FIM(TM) measures independent performance in self-
care, sphincter
control, transfers, locomotion, communication, and social
cognition.

28. Measure
• The FIM is an 18-item
scale that assess
progress during
inpatient rehabilitation.
By adding the points for
each item, the possible
total score ranges from
18 (lowest) to 126
(highest) level of
independence.
• Use is mostly in hospital
and nursing home settings.
• See the complete scale go
to :
http://www.chicagoz.com/
FIM.pdf

29. Interdisciplinary team
• An interdisciplinary team is a
group of professionals from
different disciplines whose
activities are coordinated and
performed toward a common
goal, that is, the prevention of
disease and the promotion and
maintenance of health and
function in an individual patient.
Team meetings or conferences
may also include the:
• Patient
• Family members
• Familial caregivers or supports
• Payer representatives

30. ADOH
• Functional assessment tool to
measure functional dependency
(or return to independence) in
oral self-care.
• Scores are given for
demonstrated (or non-
demonstrated) performance of a
generic self-care regimen
including oral rinses, fluoride
application, brushing, and
flossing.
• Full dependency warrants a
score of 16 for dentate
individuals, 8 for edentate
individuals.
Activities of Daily Oral Hygiene
(ADOH)

31. Oral Rinses

32. Flossing

33. Tooth brushing

34. Denture brushing

35. Oral health risks
• Root caries
• Periodontal disease
• Cancer
– Removable prostheses
– Oral tissue
– Metastases

36. Prophylaxis
• Adults 85 years and older
– Prophy at 3 month intervals
• Adults with medical conditions, dementia, or definitive signs
of senescence
– Prophy at 3 month intervals to 1 month intervals
• RDHAP – Registered dental hygienist with privileges in
alternative practice.
– Informed consent for shared dental records
– Share COMPLETE chart or duplicate with email/fax updates

37. Daily Home Care
• Regimen
– Flossing
– Toothbrushing using
brand of toothpaste that
has high dose of
fluoride;
example, Prevident 5000
• Tongue brushing with
scraper
• Brush and soak
removable appliances
using Efferdent
• Informed consent:
– High dose fluoride – Keep
out of reach of children 6
years old and younger due
to toxicity
• Emergency – Milk and ER
visit for stomach pump; if
left to absorb in a 3 year
old, could be lethal

38. Daily Home Care (cont…)
• Regimen
– Oral rinses
• Listerine
• Chlorohexidine;
example, Periogard
• Informed consent:
– Chlorohexidine
• Avoid with antibiotic use
in older adults
– Can cause Candida
infections for which
antifungal loges are
indicated;
example, Nystatin

39. QUESTIONS?