Oct 26th 2011

1. Muhammad Ashraf Nazir
Field Supervisor: Leslie Topola
Academic Supervisor: Dr. Gerry Uswak

2. Outline
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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.

3. 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”

4. 
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.

5. 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

6. 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.

7. 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.

8. 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

9. 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.

10. Lack of awareness and recognition
regarding the importance of oral health
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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.

11. 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

12. Dental caries
http://www.mndental.org/features/2009/02/02/93/management_of_ra
mpant_caries

13. 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

14. Gingivitis and Periodontitis
http://www.drchetan.com/causes-of-bleedinggums.html
http://cosmeticdentistry01.files.wordpress.com/2010/03/gum4.jpg
http://www.cda-adc.ca/JCDA/vol-67/issue-2/figs.html
http://hubpages.com/hub/bleeding-gums

15. 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

16. 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

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

18. 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.../dandanpez
eshki.ppt

19. 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)

20. 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/1566564637

21. 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.

22. Diabetes Mellitus

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Periodontitis should be
considered sixth “classic”
complication of 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)
Periodontal disease
increases the severity 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 .

23. 
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

24. 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.

25. 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.


26. 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

27. Position Statement of Canadian
Dental Association
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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.

28. 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

29. Recommendations
1.
Collaboration, advocacy, and lobbying.
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Creation of the office of chief dental officer in the province.
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Provision of oral care through publically funded program.
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Establishment of dental public health department in Health
Regions.
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Inclusion of Canadian Dental Association’s (CDA)
recommendations on oral health care for the residents in LTC
facilities.
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Regulation regarding the provision of space for dental treatment
in the LTC facilities.

30. 
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.