The ageing population: who’s picking up the bill for oral care?
Dr Gerry McKenna examines a variation in access to prevention based oral healthcare for older adults across Europe, and a lack of coherence in policy making.
Over the past 20 years, there have been major changes in oral health throughout Europe, which reflects changing attitudes to the importance of oral health in older age. Throughout a life course, damage to teeth accumulates and consequently there is a high burden of dental disease in old age with a high risk of loss of more natural teeth. Current figures regarding complete loss of natural teeth indicate that it is largely confined to the elderly and has a prevalence ranging from 14% in Lithuania to 53% in Bulgaria for those over 65 years of age. Differences in toothloss prevalence reflect the varying approaches in oral healthcare delivery across Europe, between-country socio-economic status differences and, differing patient attitudes to the importance of oral health. Unfortunately as more patients retain natural teeth into old age, the prevalence of oral disease has also increased in most countries.
Dental decay (caries) is the most prevalent, non-communicable infectious disease in the world. Caries continues to be a major public health problem and affects most adults to varying degrees, resulting in pain, loss of chewing function, poor aesthetics and consequently quality of life. Severe gum disease (periodontitis) disproportionately affects older adults, and left untreated, causes pain, loss of teeth and represents a chronic source of infection which can impact general health. Restorations placed to fill cavities in teeth have a limited lifespan, and those placed earlier in the life cycle need to be replaced periodically. These adverse effects are complicated by the medical, economic and social circumstances of older patients, particularly the onset of dry mouth (xerostomia), which is common in old age as a secondary effect of multiple medications. Oral dryness increases the risk of oral disease and toothloss. Additional factors, such as anxiety or reluctance to attend oral healthcare professionals, impact on the provision of oral healthcare in the elderly.
Interventions for oral disease have a high public health relevance affecting an estimated 3.9 billion people worldwide. Daily adjusted life years (DALYs), a marker of the burden of oral disease, are estimated to have risen by 20% in the past 20 years as a consequence of population growth and ageing. Costs of care are also increasing, and there is evidence that these costs result in inequality of access to oral healthcare for the elderly. Current estimates indicate that treatment of oral disease accounts for 5% of public health spending in the EU with annual costs rising from €54 billion in 2000 to a projected €93 billion in 2020; greater than the management of stroke and dementia combined. European health systems are ill-prepared to cope with this escalating burden of care and its associated costs.
In the elderly, the effects of oral disease can be difficult to manage. Oral and chewing function in particular diminish as natural teeth are lost. Population surveys have indicated a growing concern among older adults regarding toothloss, with a markedly decreasing acceptance of the condition amongst the elderly. There is evidence of inequality of access to oral healthcare services for older adults in Europe, with adults over the age of 50 years experiencing income related barriers to preventive oral healthcare. Given the rapidly changing age profile of the European population, and their complex health needs, there is a need to develop new evidence-based approaches to healthcare, including oral healthcare, which yield better clinical outcomes for elderly patients but are also cost-effective.
Current conventional approaches to natural tooth replacement emphasize replacement of all lost teeth. However, oral functional needs change with age, and replacement of all lost teeth may not be required to deliver improved health outcomes in older patients. Recently, treatment philosophies have been developed that take a functionally oriented approach to oral healthcare with a focus on providing a reduced, but healthy, natural dentition which can be maintained with support of better oral hygiene. The concept is underpinned by taking a minimally invasive approach to management of decay, avoiding the use of removable dentures to replace missing teeth. There is a requirement to enable patients to maintain low levels of plaque in the mouth, and this is best achieved with a personalised oral healthcare package tailored to an individual’s particular circumstances, e.g, their level of manual dexterity. Functionally oriented dentistry is particularly relevant to patients at moderate to high level of risk of recurrent oral disease, i.e., adults over 65 years of age. A key component of the treatment philosophy is to reduce the burden of care and maintenance as much as possible whilst simultaneously meeting the oral functional needs of the patient with a reduced dentition. From a public health viewpoint, functionally oriented dentistry is attractive provided it can be shown to provide an acceptable level of oral function in a more cost-effective manner than conventional alternatives.
At present there is wide variation in access to prevention based oral healthcare for older adults across Europe, indicating a lack of coherence in policy making and evidence based dental treatment guidelines for the elderly. Affordability of care is an issue for many older patients, and there is a need to make a convincing argument for greater public resource allocation across Europe for oral healthcare in an ageing population. Ideally, this should be based on effective, prevention-based oral healthcare in primary care settings which are easily accessible to all older patients. Given that oral disease shares common risk factors with diseases such as cardiovascular disease, respiratory disease and metabolic disorders, an interdisciplinary management approach is likely to yield better outcomes for both oral health and general health, including quality of life. Across Europe policy making for the older patient must integrate oral examinations with health screening programmes, increase training of ancillary healthcare professionals to provide elements of preventive care to patients in an affordable way, and incentivise dentists to take a minimally invasive approach to oral healthcare rather than prioritise continued intervention based care.