“The life span of any civilizations can be measured by the respect that is given to its elderly citizens. Those societies which treat the elderly with contempt have the seeds of their own destruction within them” – A.Toynbee
The Geriatric Health Home model is an integrated collaborative delivery system designed for long care facility residents. This multidisciplinary approach requires a paradigm shift in dental health care from a surgical invasive approach to a preventive non-invasive interdisciplinary approach. The Geriatric Health Home model is built on evidence-based practice outcomes. This model supports the use of risk-based interventions.
The Health Home model supports this philosophy and allows for changes within the current structure that will be needed to achieve the desired paradigm shift in dental care for the frail and elderly.
Nearly thirty three percent of senior adults who have their teeth have untreated tooth decay or caries and fifty six percent of the adults have untreated periodontal disease. The treatment, management and prevention of oral disease will result in the reduction of oral related pain, weight loss and increase function that will improve their overall health and well-being. When oral infections arise and go untreated, seniors face heightened risk factors for diabetes mellitus, cardiovascular disease and respiratory disease.
The Oral Systemic Link
The review of oral health linkages with general health reveals implications for the clinical practice of both medicine and dentistry. The recognition of well-known and established signs and symptoms of oral diseases may assist in the early diagnosis and prompt treatment of some systemic diseases and disorders. Periodontal disease is a chronic inflammatory disease caused by the bacteria of dental plaque that results in biofilm formation. Periodontal disease results in the progressive destruction of the tissues that support the teeth namely the gingivae, the periodontal ligament and underlying bone.
The prevalence of chronic disease increases with age. Consistent with this prevalence is often substantial morbidity and mortality. Co-morbidities are frequently coexistent and complex requiring collaborative management of the elderly.
Oral pathogens may increase insulin resistance when released into the circulatory system in the presence of periodontal disease. Any lowering of blood glucose may enhance the onset and progression of diabetes. Health professionals must relate the presence of periodontal disease to possible systemic disorder such as poor healing of periodontal disease may alert them to the presence of diabetes. Likewise, know diabetes must be better managed for successful oral health treatment outcomes.
Poor oral health may contribute as a significant risk factor in the elderly by being a beginning inflammatory source for to cardiovascular disease. Serum inflammatory markers such as C-Reactive Protein have been shown to be predictive of mortality rates and functional decline in Skilled Nursing Facility. (Rueben, D.B. et al., Journal of American Geriatric Society, 2002).
Oral bacteria that cause periodontal disease enter the blood stream and embed in blood vessel. Endotoxins stimulate hosts cells to produce inflammatory mediators and result in the liver releasing C-Reactive Protein.
Respiratory diseases such as Chronic Obstructive Pulmonary Disease [COPD] and pneumonia have special relevance in the geriatric nursing home population. This population has increased chest wall stiffening and loss of elastic recoil resulting in decreased lung capacity and function.
Bacteria that are found in periodontal disease can be aspirated into the lungs to cause respiratory diseases such as pneumonia. Nursing home associated pneumonia (NAP) is the most common infection effecting nursing home residents. Pneumonia and Chronic Obstructive Pulmonary Disease is the number one reason for hospital transfers and one leading causes of morbidity and mortality for residents in Skilled Nursing Facilities.
In a 2006 article published in the Journal of Periodontology by Azarpazhooh and Leake, treatment aimed at reducing the oral microbial burden reduces risk of pneumonia for nursing home residents. There is good evidence that improved oral hygiene and frequent professional oral health care reduces the progression or occurrence of respiratory diseases in high-risk elderly adults living in long term care facility.
The geriatric population living in long term care facilities is prescribed an average of eight drugs. The oral health relations and the influences of these medications are essential to providing quality geriatric health care. There are currently more than 42 drug categories comprising 400 drugs that have xerostomia or dry mouth as side effects: antidepressants, antibiotics, antispasmodics, analgesics, anticonvulsants, antihistamines, antihypertensives, diuretics and sedatives.
Judicious application of drug therapies by medical and dental providers as well as heightened awareness of potential adverse oral effects is necessary to providing quality care for the Skilled Nursing Home residents. The relationship of drug induced xerostomia to systemic and local factors including lesions of the oral mucosa have to be approached by all health care professionals.
The lack of proper screening and early diagnosis for oral cancer will have significant consequences on residents living in long term care facilities. Oral cancer is often painless in the early stages and therefore it is essential that oral cancer screening be incorporated with soft tissue examination. The incidence of oral cancer in the geriatric population is greater than any other age group. When oral lesions are detected early the survival rate is approximately eighty percent but when oral cancer is detected late, the survival rate is only twenty two percent.
Oral Health Preventive & Maintenance Program
Minimal invasive dentistry in a Skilled Nursing Facility or Long Term Care Facility is an evidenced based approach whereby the disease is controlled by the dentist and oral health team. The components of this approach are to conduct an oral risk assessment with focus on early detection, prevention and monitoring with surgical intervention utilized only as an end state treatment option. Treatment options must be based on the resident’s comprehensive health care needs that include their identified barriers to oral health care to include: physical disabilities decreased sensory function and emotional disabilities.
In Health Home model residents must be seen on regular intervals based on their oral health risk assessment. Care for urgent care, preventive care and re-evaluation are the resident centered approach to quality integrated health care.
Geriatric Health Home
To achieve the establishment of a Geriatric Home there is a need for epidemiological research on oral-general health risks and linkages. The oral health care systems capacity must be built and reshaped based on age and disability for the geriatric population.
Improvement for integrated health and disease promotions in a public health setting must be shared by all health care professionals, third party payers and educational institutions. Educating health care professionals, older adults, caregivers and families on the geriatric health home are incorporated in the Health Home model. Improving health insurance with innovative integrated approaches for outcome based reimbursement are essential change models for the future.