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Abstract |
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 Top Abstract Aging and Utilization of...Dental health care delivery...Comparing elder dental care...SummaryReferences |
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Aging and Utilization of Dental Services in Europe |
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TopAbstractAging and Utilization of...Dental health care delivery...Comparing elder dental care...SummaryReferences |
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For the purposes of this article, the term "access" has been defined as a population’s potential entry to the health care system, whereas "use of dental services" refers to realized access.4 Dental service use has been further defined by the following parameters: 1) annual number of dental visits per person, 2) proportion of persons visiting a dentist within a year, 3) reported first dental visit in a series of visits, 4) lack of dental visits within a specific period of time, 5) aggregated expenditures for dental visits, and 6) routine vs. emergency care.5,6
In principle, four different models of dental needs7,8 have been suggested:
Each definition can be divided into need for preventive services and need for restorative services. There is a huge discrepancy between the outcome measures of the different assessments of need for any given individual; these differences may be more significantly demonstrated among frail and institutionalized populations.
Needs associated with oral health cannot be met without rethinking concepts that define oral health and quality of life.9 It is often difficult for oral health care providers to consider offering and/or providing treatment options considered less than optimal under normal circumstances. The professionally assessed need for dental treatment, based solely on clinical diagnosis, often leads to an overestimation of the true need for treatment, especially among frail and functionally dependent elderly people, some of whom do not want treatment, either because there is no perceived need or no expressed demand. Others are very ill and some in such poor mental condition that they cannot express any demand for treatment and might not benefit from treatment such as new dentures. Thus, the "realistic" or "feasible" need is an attempt to assess the "true" need for treatment in relation to the benefit provided.8 It is a combination of the professionally assessed need, the self-perceived need, and the expressed demand and takes into account the mental and physical state of the patient as well as ethical considerations. The establishment of outreaching preventive and restorative oral health services for these subgroups of elderly people is dependent on the allocation of resources and, hence, is a political decision. Assessments based on the realistic treatment need, however, may create a meaningful basis for practical communication with political decision makers, institutional staff, and health planners.
The present review will be based mainly on studies conducted in Denmark, Sweden, Norway, the United Kingdom, and Germany and, where appropriate, compared to findings of studies from the United States.
Frequency of Utilization
In Sweden, a recent retrospective study of adults over the age of eighty, using many past years of patient records gathered from general dental practitioners, found that 66 percent of the dentate individuals made regular dental visits every or every other year in the 1990s.10 On average, 3.3 visits were made per treatment period. A small fraction (10 percent) had records with a great number of emergency visits. The findings of this study regarding regular dental attendance are of the same general magnitude or slightly lower than those reported in other studies of similarly aged, dentate older adults living in Sweden.11,12
In a study of individuals aged seventy-nine and eighty-eight years living in Northern Sweden, Nordström et al.13 found that only one-fourth of these elderly had visited a dentist at least once per year during 1981–90. Their sample, however, included edentulous people as well, which, in part, may account for lower utilization rates. A study using insurance claims from public and private dental clinics during a three-year period (1990–92) found that visits to the dentist decreased with age.14 Many received emergency treatment at some time during the observation period, but the majority had regular dental care habits, defined as having received complete dental care at least two of the three years.
A recent study compared the utilization of dental services between Swedish citizens and Danish citizens aged sixty to sixty-nine.6 After controlling for gender, dental status, and income, more than 80 percent had visited a dentist in the preceding twelve months. However, 77 percent of the Danes reported dental visits twice a year compared to 28 percent of the Swedes. Although the Danes made more frequent use of dental services, they had poorer dental conditions than the Swedes. These findings suggest that higher utilization does not necessarily lead to better oral health. According to the authors, the amount of dental treatment per visit, the different dental insurance systems, and, in particular, the different organization of the dental health care delivery system in these two countries are major factors underlying this discrepancy.
In the United Kingdom, McGrath et al.15 reported that nearly 50 percent of older people claimed that they visited a dentist within the past year, while 10 percent claimed that the reason for their last visit was an emergency. Forty-three percent were classified as regular attendees, defined as having visited the dentist within the last year for a non-emergency.
As an indicator of service use, Nitschke et al.16 compared the accuracy of self-reported time since last dental visit with the actual dental records in a sample of German elders aged seventy to 103 years. Only 13 percent remembered correctly when they had last seen a dentist (less than a thirty-day variance), another 55 percent were mistaken by one to six months, and the remainder by more than six months. Self-reported time since last dental visit varied from two weeks to fifty-two years. This study confirms that research using a self-reporting technique may find higher dental care consumption than research using more objective insurance claim registration or dental records as a data source, leading to an overestimate of actual consumption. Among older adult age groups, this recall bias may be more prevalent and pronounced than in younger cohorts.
Determinants of Utilization
Many factors have been identified as possible mitigating determinants of utilization rates among elderly people (Figure 1
) and may also interact in a complex fashion with each other and with other factors, particularly attitudinal factors. A few key determinants are discussed below.
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Several investigators have reported that the main reason for infrequent dental service utilization was low perceived need,12,22 whereas Suominen-Taipale et al.19 found self-perceived need to be a minor predictor among older adults in Finland. The latter finding was based on a postal questionnaire that was subsequently checked by a nurse. In addition, a substantial proportion (41 percent) of the study participants reported being edentulous. It is plausible that lower rates of perceived need among edentulous persons, compared to dentate persons, may help explain this finding.
Other studies have found that the degree of significance that older people attach to specific symptoms, including general health symptoms, is an important factor for seeking care.23 Most dental diseases are insidious and the early stages are often overlooked or ignored because the patients do not associate the typically nonsevere symptoms with initiation of a potentially serious dental/oral condition. Because the dental health care systems for independently living older adults are passive and rely on the patients to enter the system and initiate care, this lack of awareness may account for low utilization of dental care among some subgroups of older people.
Independent of dental status, the study by Lundgren et al.12 revealed that factors such as loneliness, low level of education, and functional impairments were significantly associated with low demand for dental services. Several studies have found that education is associated with regular use of dental services.16,18,20,24 It has been suggested that education reflects other important factors related to the use of dental services, such as knowledge, attitudes, and the value placed on oral health, factors that are known to be related both to education and use of services.24,25 Further, education may serve as an indicator of socioeconomic position and may determine individual membership in certain societal subcultures, which have their own norms about health, not governed by individual knowledge.26
Österberg et al.,27 in a study of seventy-five-year-old men, reported that self-assessed impaired general health, number of medications taken, and economic problems were significantly associated with irregularity of utilization of dental care, independent of number of teeth. In women, living alone and smoking tobacco were also significant factors. In a subsequent study based on interviews by Statistics of Sweden, Österberg et al.18 found that the relative risk for not visiting a dentist within the last year, adjusted for age, gender, and dental status, was higher in dentate subjects with low income and education, not married, not native born, living in rural areas, smokers, and having low social and physical activity. The results of the logistic regression analysis showed that, among the elderly, functional ability and general health factors had lower significance for time since last visit to a dentist than socioeconomic factors, social relations, and lifestyle factors.
In Denmark, Petersen and Nørtov28 studied the interrelation among oral health, lifestyle, and social network among sixty-seven-year-olds. Sixty percent of those with high scores on lifestyle activity (participation in a number of social and cultural activities) had regular dental visits compared to 31 percent of those with low activity. Regular dental attendance also was lower among elderly persons who had weak contacts with friends and were living alone.
A Danish longitudinal study of individuals aged seventy-five to eighty showed that community-dwelling persons with general functional limitations (mobility problems at both measurement times) sustained from age seventy-five to eighty had nearly double the risk of being nonusers of regular dental services at age eighty and that persons with deterioration in mobility had a 1.7 times higher risk of becoming non-users.29 In a subsequent study, Avlund et al.30 found that independently living very old people with cognitive decline had a four times higher risk of not using dental services regularly than those with better cognitive function.
Institutionalized and Functionally Dependent Populations.
Frail and functionally dependent elderly people, living in long-term care facilities or at home, have special difficulties in accessing dental care because the problems of attending a dental clinic often appear insurmountable. The accessibility of the dental office is important too, especially for functionally disabled older patients. To help overcome these barriers, onsite dental equipment may facilitate access in larger nursing homes, while mobile or portable dental equipment may be the appropriate method of choice for smaller care facilities and for older people living at home with similar health problems and lack of mobility.31
Fenwick et al.32 studied the association between medical problems and dental treatment needs of old people referred to the National Health Service (NHS) Community Dental Service in the United Kingdom. General dental practitioners referred most of the patients, but some referrals came from physicians in long-term wards. The most prevalent medical problems among the referred patients were dementia, stroke, Parkinson’s disease, and cardiovascular diseases. Several patients suffered from a clustering of concomitant chronic diseases and problems. A further complicating factor was lack of mobility: only 6 percent were mobile, and 19 percent were bedridden. In addition, 18 percent suffered kyphoscoliosis, which can present problems in correctly positioning the patient in the dental chair for treatment. Two-thirds of the sample had problems of mental confusion. Overall, most types of treatment procedures ultimately provided by NHS dentists were reported to be relatively simple. Over two-thirds were treated at home. The data indicated that, for the large majority, the treatments were well within the scope of a competent general dentist; further, likely reasons for referring these patients were not shortcomings in technical skills, but rather patient management issues in dealing with physical and/or cognitive disabilities. In addition, the cost and time involved for general dentists to provide care for these patients might be additional factors, especially for those patients for whom domiciliary (home) care was considered to be the appropriate method of dental care delivery.
This raises an important question as to whether undergraduate and/or postgraduate training programs in geriatric dentistry will help ameliorate dentists’ reluctance to treat frail and functionally dependent patients due to perceived patient management problems. There are only recent data available on geriatric dental curricula in a few European countries: Germany, Austria, and Switzerland.33 In addition, there is very limited information about the impact of teaching programs in geriatric dentistry on dental students’ willingness to carry out dental care for these subgroups of old patients after graduation. A study from the United Kingdom reported that providing dental students with an experience with medically compromised elderly patients in a rehabilitation unit in a large hospital successfully improved the students’ understanding of and attitudes towards elderly people.34 According to the authors, the students learned to understand and appreciate that these patients had special needs as well as special abilities and that many patients did not know that they could obtain domiciliary dental care. Studies from the United States found that undergraduate dental school programs in geriatric dentistry enhanced dental students’ confidence in dealing with geriatric patients.35,36
Thus, old age in itself does not seem to be a major factor in determining the use of dental services when populations are stratified by dentate status. The number of natural teeth has been described as a major determinant of dental attendance among older people. Consequently, the aim should be to identify groups of aging persons who are at risk and would benefit from treatment. Among elderly persons in the European countries, socioeconomic factors, social relations, general health status, physical and cognitive disabilities, and consequent problems with access to services seem to be important barriers to regular dental care. Thus, several factors—including the education of dentists—determine the extent to which oral health care is accessible to the elderly population.
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Dental Health Care Delivery Systems in Several Countries |
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Denmark
In Denmark, all nondependent, community-dwelling older adults can choose among private dental practitioners only. The most common preventive and restorative treatments are reimbursed up to approximately half of a fixed fee set by the national health insurance. Dentures, crowns, and bridges are paid totally by the patient or by a combination of out-of-pocket expense by the individual and private health insurance.
For the majority of nursing home residents and for the very disabled noninstitutionalized elderly, only episodic emergency care was available until 1994, when it became compulsory for the municipalities to provide systematic, outreach oral health care, almost free of charge, to frail, dependent elderly. In principle, these patients may choose treatment by private dental practitioners or by the public dental service. In reality, however, the majority of these patients are treated by the public dental service in most of the municipalities following the recommendations of the realistic treatment need. The counties also provide systematic oral health care programs on-site for elderly in long-term psychiatric care institutions.
Sweden
Able-bodied Swedish elderly can choose treatment from private dental practitioners or from the public dental service, which is administered by the counties. Treatment is not free of charge, but the national health insurance covers a certain amount of the expenses. Sweden introduced national dental health insurance in 1974 and, as a result, dental treatment was heavily subsidized until recently. The guiding principle was "high cost protection." This meant that the patient pays a relatively lower percentage of the fee for more extensive treatment interventions compared to routine services. The goal of this all-encompassing dental insurance was to make comprehensive dentistry available to all citizens regardless of income.
The national dental health insurance was changed in 1999, when a new method of financing dental care for institutionalized, ill, and functionally dependent patients was introduced. According to the new law, the counties are responsible for performing oral health assessments and for counseling of patients and nursing staff, as well as for providing "necessary" dental care, while the national dental health insurance is responsible for providing increased reimbursement of expenses for "necessary" treatment. Patients do have the option, however, to choose treatment by a private dental practitioner and pay a fixed fee per visit. These expenditures are added to expenses for general health care, including prescribed drugs, up a maximum of SEK 900 (equivalent to approximately US$120) within a twelvemonth period. The costs for dental treatments exceeding this amount are paid in total by the national dental health insurance. Oral health assessments and counseling are free of charge. Many long-term care institutions have systematic on-site dental care units. The counties organize the oral health care services for elderly in a different manner.
Norway
In Norway, the national health insurance does not cover dental care for independent elderly patients; rather, patients have to pay the total costs of treatment out-of-pocket. Almost all treatment of healthy elderly patients is provided in private dental practices.
According to the Dental Service Act of 1983, Norwegian counties are responsible for the availability and accessibility of adequate dental care services to the entire population. In addition, the public dental services must provide free regular and outreach services to the following groups, listed according to priority:
The county is responsible for planning and coordinating both public and private services. The county is required by law to prepare a dental health plan, which must be approved by the chief administrative body of the county and by the Department of Social Affairs. According to the Dental Service Act, frail and dependent elderly are included in the third priority group.
United Kingdom
In the United Kingdom, dental care for community-dwelling elderly patients is provided by the National Health Service (NHS) and by private dental practitioners. The NHS was established in 1948; subsequently, inexpensive oral health care became available to all residents.38 At that time, extraction of teeth and their replacement with dentures were perceived as an acceptable and perhaps even a preferable approach to treating substantial dental problems. The NHS is financed through public revenues. Dentists can choose to work for the NHS or in private practice or both. Currently, dentists who work for the NHS are paid a set amount per item of care as well as a small capitation fee for retaining an individual as a registered patient with their practice. Patients are required to pay a substantial portion of the costs of their care to the dentist, although relief from payment is available on the basis of financial hardship. The fee scale is determined by national negotiation between the British Dental Association and the UK’s Department of Health, within a strict, government-imposed financial limit. This process has driven down the costs of care over the years and now covers treatment with the least expensive materials available only. It has been argued that this method of payment encourages replacement of restorations and other active work for patients rather than prevention and maintenance, as the latter are not rewarded by the system. In addition, a substantial number of dentists in the UK now feel that they cannot function as an economically viable practice in this system and are withdrawing from the NHS altogether, resulting in problems with access to care.
In 1999, the NHS treated 28.5 million patients, while around one million patients had private health insurance. On average, each dentist had 1,499 patients registered.39 A survey of adult residents of a district of Buckinghamshire indicated a substantial unmet perceived treatment need, with more than one-third of this population preferring continuing NHS dental services but being unable to access them.40 Another recent national survey has shown that the NHS treats over two-thirds of adults and less than one-third have private dental care.41 The latter survey further showed that one in five adults experienced difficulties in finding an NHS dentist. This would suggest that many people are being forced to pay privately for dental care when they would prefer to obtain dental care through NHS means. Difficulty in obtaining an NHS dentist was associated with age (greater than sixty-five years), gender (men), social class (higher social class background), and area of residence (residents of the South of England [London, South East, South West] were more likely to report that they experienced difficulties in obtaining an NHS dentist compared with those living elsewhere in the UK). It is suggested that the latter finding may reflect the change in the workforce that has occurred in the South of England with a greater number of dentists providing dental care through independent and private modes. Moreover, the study showed that difficulty in obtaining NHS care was also associated with dental service-related factors (time since last dental visit, use of emergency dental services).
The NHS is undergoing a major revision of its working practices at present, with a change from the current fee per time of services to a capitation-based system. Under this new system, dentists are being employed (and paid a salary) by primary care trusts to provide care for a cohort of patients with local commissioning of services. These changes will be implemented in full by April 2006.
The Community Dental Service (CDS) will provide a safety net for dental care of frail and dependent elderly persons in the United Kingdom. However, these adult patients remain liable to meet the costs of treatment by the CDS on the nationally agreed scale of fees. The availability of this safety net is not uniform across the UK.
Germany
In Germany, dental care is provided by private practitioners and is embedded in the national social system.42 Historically, the German system of health care was part of the national social policy as initiated by Bismarck in 1883. Today, the social insurance system has five columns: health insurance, pension insurance, promotion of employment, occupational accident insurance, and long-term care insurance. About 90 percent of all German citizens belong to the national insurance system. A fee paid in equal parts by the employer and the employee finances the health insurance system. Currently, the total legal health insurance fee is approximately 14 percent of the employee’s gross income. At the start of the social health insurance system, no dental treatment was insured and, later, only extraction of diseased teeth and the manufacture of dentures were included. In the current dental health care system, extractions, apicoectomies, restorations with amalgam or composite, endodontics, nonsurgical periodontal treatment, and radiographs are free of charge. For dentures, crowns, and bridges, the patient pays 50 percent of the treatment; a bonus of 10 percent is refunded if the patient verifies annual dental appointments. As of 2005, dental prostheses are no longer refunded as a percentage of the total cost, but patients will receive a fixed amount based on their dental state. Preventive dental services, inlays, ceramic crowns on molars, and implants are not covered by insurance funds.
There are no special dental care programs for frail and dependent elderly within the legal health care system.
Germany is now facing economic problems, especially due to increased unemployment, the increasing number of old people, and the unification of East and West Germany. These problems have resulted in a lower income for the legal health insurance. Legislation has established a limit up to which dentists can be paid per year. If the total number of dental services exceeds this limit, payment for single treatments are reduced. A comprehensive review of the German health care system has been published recently.42
United States
There is no special financing or delivery system specifically designed to meet the oral health care needs of noninstitutionalized elderly people in the United States. Oral health care services are provided in private dental offices, but some older adults are treated at community health centers. Private dental practitioners primarily treat independently living older adults who require little or no assistance in their activities of daily living and access dental care as would younger adults.43
Dentists in the United States are generally reimbursed on a fee-for-service basis, paid totally by the individual or by a combination of out-of-pocket expense by the individual and private/public dental insurance. One important barrier to receiving dental care for low-income older adults is the cost of care.44
Through payroll deductions, all working people contribute to the federal Social Security program. The Social Security program also includes the Medicare program, which is the primary source of financing for geriatric medical care in the United States. Medicare does not reimburse expenses for routine dental care. Public financing of dental services is primarily limited to lower-income older adults through the Medicaid program, which is administrated by state governments. Federal law mandates a specific minimum of health insurance benefits and minimum eligibility standards that all state Medicaid programs must include. The federal benefit package mandates dental care only for children and adolescents. Medicaid does not provide coverage of dental services for older adults in every state. In fact, it has been reported that "twenty-seven states are failing to meet even the most minimal standards of care."45 Dentists have the option to accept or limit patients enrolled in the Medicaid program. Two reasons that are often given by dentists for not accepting Medicaid patients are that the fee paid to dentists for treating these patients is too low and that there are limitations on the procedures for which Medicaid will pay.46 Two other federally supported programs, the Old Age Pension Program and the Post Eligibility Treatment of Income (PETI) program, also provide limited payment for dental services.44 The advocacy group Oral Health America has characterized the overall grade for oral health care of older adults in America a "D" due to the many gaps in coverage and other access issues.45
Similar to Europe, the institutionalized and homebound or frail elderly in the United States are among those in greatest need of care, but they seem to have the least access to dental services.44 Nursing homes that receive Medicare or Medicaid payments are legally responsible for the dental care of their residents, including performing an oral health assessment, which must be completed within fourteen days of admission to the nursing home and must be updated annually. In reality, however, these requirements are far from being met in many long-term care facilities in a way that would improve the residents’ oral health. In addition, few dentists are willing to travel to these facilities to deliver treatment. A comprehensive review of these and related issues has been reported by Berkey and Berg.44
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Comparing Elder Dental Care Access in Europe and the United States |
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TopAbstractAging and Utilization of...Dental health care delivery...Comparing elder dental care...SummaryReferences |
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Theoretically, financial barriers to dental treatment ought to be less important in these European countries, except possibly in Norway, as compared to the United States. However, this assumption may not be entirely correct. Some of the studies referred to in this review indicate that costs of care might influence access for those of limited means.18,21,27 Research has consistently shown social inequalities in oral health and in the use of dental services in the Scandinavian countries20,47,48 as well as in the United States.49 Although Palmqvist et al.50 reported that higher income and education levels were significantly associated with "best dental status" among older adults in Denmark but not in Sweden, Avlund et al.24 found rather strong social inequalities in oral health status and use of dental services in a population of generally healthy, very old Swedes, within public health policies that have tried to minimize these inequalities.
Homebound, chronically ill, and institutionalized elderly people are considered to be a high-risk group in the oral health services. For these people, special dental care programs are available on-site in Denmark, Norway, and Sweden and are almost free of charge for the patient. Eligibility for non-institutionalized older adults to be enrolled in these programs is based on a medical evaluation. In the United States, nursing homes that receive Medicare and Medicaid payments are required by law to offer dental care for their residents. In the United States as well as in Europe, however, private dental practitioners are generally hesitant to provide domiciliary dental care to these groups of frail and functionally dependent patients. One reason may be that, due to high dental office overhead expenses, the dentist may be reluctant to spend time away from his or her main dental practice. Another reason may be problems related to management of medically compromised older patients, in particular, patients with dementia, stroke, etc.32 In Denmark, Norway, and Sweden, the public dental service may have a better basis for offering outreach dental services than private dental practitioners, because the municipalities (in Denmark) or the counties (in Norway and Sweden) make the investment in equipment, and the dentists are paid a fixed salary.
As previously mentioned, inadequate undergraduate or postgraduate training in geriatric dentistry also may discourage practitioners from seeking opportunities to treat geriatric dental patients with challenging oral health problems, medical challenges, and/or psychosocial concerns. Several European dental schools have undergraduate courses in geriatric dentistry. In some dental schools, geriatric dentistry has been established as a freestanding department or program, while in other dental schools, the curriculum is being taught integrated with existing courses. Some dental schools only give a series of lectures on geriatric dentistry, while other schools provide the dental students with a comprehensive intramural clinical component ("senior dental clinic") and/or an extramural rotation. In a few schools, dental students and dental hygiene students work together as a team and interact with nursing staff in long-term care facilities. There are no formal postgraduate specialty training programs in geriatric dentistry in any of the European countries discussed in this review; nevertheless, a few dental schools offer master of science programs or Ph.D. programs in gerontology and geriatrics, and their main focus is on research training.
Within the United States, dental schools utilize similar predoctoral geriatric dentistry training options. In contrast to the aforementioned European countries, since the early 1980s there have been a small number of one- or two-year postgraduate geriatric dentistry fellowship programs sponsored by both the federal government and universities. Thus, in the United States, there is a small core of well-educated dentists specially trained to meet the needs of medically compromised, functionally dependent, and institutionalized elderly patients. Many of these dentists also teach geriatric dentistry in dental schools and postgraduate courses. The shortage of skilled gerodontists, however, is still a pronounced problem in the United States as well as in Europe.
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Summary |
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TopAbstractAging and Utilization of...Dental health care delivery...Comparing elder dental care...SummaryReferences |
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In conclusion, the socioenvironmental context of a society, the oral health care system, and the personal characteristics of the individual may directly or indirectly influence the use of appropriate oral health services by aging populations.
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Acknowledgments |
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Footnotes |
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REFERENCES |
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
