Prevention over intervention
Gerry McKenna, president of the European College of Gerodontology 2014–2015, asks who is picking up the bill for the ageing population?
Over the past 20 years, there have been major changes in the oral health profiles of patients across 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 functional impairment and dental disease in old age, with high risk of further tooth loss.
The current figures regarding total tooth loss indicate that it is largely confined to the elderly and has a prevalence ranging from 14 per cent in Lithuania, to 53 per cent in Bulgaria for those over 65 years of age. Differences in tooth loss prevalence reflect the varying approaches in oral healthcare delivery in various European countries, between–country socio–economic status differences and, differing patient attitudes to and awareness of the importance of oral health. Along with increased tooth retention rates, the prevalence of oral disease has also increased in most countries.
Dental caries is the most prevalent, non–communicable infectious disease in the world. Tooth decay 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 oral health–related quality of life. Severe periodontitis disproportionately affects older adults and, left untreated, causes pain, tooth loss and represents a chronic source of infection which can also negatively 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 increasingly periodically.
The burden of replacement accumulates through life, ensuring that the risk of tooth loss also accumulates as patients age. These adverse effects are complicated by the medical, economic and social circumstances of older patients, particularly the onset of xerostomia, which is physiological, yet common in old age as a secondary effect of medications such as anti–hypertensive or anxiolytics. Oral dryness reduces the host response to bacteria that cause oral diseases, and increases the risk of oral disease and tooth loss.
Additional factors, such as anxiety or reluctance related to attending oral healthcare professionals, impact on the provision of oral healthcare in the elderly. Also, patients*rsquo; priorities associated with health in general might change with the onset of multi–morbidities.
Interventions for oral disease have a high public health relevance. Oral disease affects 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 per cent in the past 20 years as a consequence of population growth and ageing1. Costs of care are also increasing dramatically, and there is evidence that these costs result in inequality of access to oral healthcare for the elderly2.
Current estimates indicate that treatment of oral disease accounts for 5 per cent of public health spending in the EU with annual treatment costs rising from €54 billion in 2000 to a projected €93 billion in 2020, a cost greater than the management of stroke and dementia combined. European health systems are currently 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, with tooth loss affecting food choice, quality of life and general health3. Oral and chewing function in particular diminish as natural teeth are lost. Tooth loss can also have a negative impact on appearance and self–esteem.
Surveys have indicated a growing concern among older adults regarding tooth loss, with a markedly decreasing acceptance of the condition in older patients4. 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 healthcare5.
Accordingly, tooth loss disproportionately affects older adults. 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.
There is currently a lack of understanding of the factors which influence partially dentate older patients treatment choices, particularly their choices for replacing missing teeth. Tooth loss is conventionally addressed in partially dentate older patients by replacing missing teeth with removable partial dentures (RPDs). RPDs can be difficult to maintain and can ultimately make oral hygiene procedures more complicated for patients. There is also a high degree of non–compliance with wearing removable partial dentures, particularly those which only replace missing posterior teeth in the lower arch.
Implant retained prostheses are an alternative to RPDs, where prosthetic teeth are secured to implants surgically placed in the jaw bone. This approach is effective but costly and beyond the financial resources of many older adults and publicly funded healthcare systems. Fear of surgery among older adults may also be a barrier to this treatment approach, and this has been shown to be a barrier to acceptance of this treatment in patients with no natural teeth6.
Current conventional approaches to natural tooth replacement emphasise 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 hygiene7.
The concept is underpinned by taking a minimally–invasive approach to management of decay with atraumatic restorative techniques and avoiding the use of removable partial dentures to replace missing teeth. There is a requirement to enable patients to maintain low levels of plaque, and this is best achieved with a personalised oral healthcare package tailored to an individual*rsquo;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 alternatives8.
Currently, there is wide variation in access to prevention–based, minimally–invasive oral healthcare for older adults across Europe, indicating a lack of coherence in policy making and evidence based dental treatment guidelines for the elderly9. 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. This includes the need to develop third–party insurance schemes for oral healthcare.
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 in an affordable way, and incentivise dentists to take a minimally invasive approach to oral healthcare rather than prioritise continued intervention–based care.
This paper is taken from information presented at the Spring Invitational Lecture 2015 at the University of Bern, Switzerland by Dr McKenna.
About the Author
Dr Gerry McKenna is a senior lecturer and consultant in restorative dentistry in Queens University Belfast. A native of Northern Ireland, he completed his PhD and specialist training in University College Cork before joining QUB in 2014. As well as teaching undergraduate dental students, he is an active clinical researcher and member of the Centre for Public Health in QUB. Gerry is immediate past president of the European College of Gerodontology and a member of the EU Platform for Better Oral Health. He is a fellow of the Royal College of Surgeons in Edinburgh and serves as the college’s dental adviser for Northern Ireland.
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