Addressing Geriatric Dentistry: Challenges and Solutions

Not long ago, I asked my dentist if he and his colleagues were prepared to handle the dramatic influx of elderly patients predicted by demographic statistics. His response was dismissive: “No one ever graduates from dental school with the intent of practicing geriatric dentistry.” He went on to note that because Medicare doesn’t cover dental care, he has few elderly patients. My dentist is a leader in the state dental society and a frequent participant in continuing education programs. It saddens me that our future together is limited by his unwillingness to manage the comorbidities of my age, but I recognize he is a product of his era.

Historically, old age meant toothlessness. Over 50% of Americans born before 1940 lost all their teeth, making dentures the norm for older generations. Today, thanks to advances in water fluoridation and preventive care, older adults are holding onto their natural teeth longer than ever before. Yet, ironically, today’s dental professionals remain largely unequipped to provide complex clinical treatment to this aging population.

This gap exists because dentistry has long been segregated from traditional medical care. During the political battles surrounding the creation of Medicare in 1965, dentistry was excluded from regular medical insurance. That distinction was political, not scientific. A coalition of dental association lobbying groups, insurance companies, and fiscal conservatives opposed to the looming expense of a new government benefit successfully kept dentistry out of the program.

Left outside the bounds of major medical insurance, the industry shifted. Dentistry increasingly focused on elective and cosmetic procedures, which boast profit margins of 40% to 60%—happily unencumbered by insurance caps or government reimbursement limits. Today, 75% of dental expenses for Americans over 65 are paid entirely out of pocket, though some states offer limited adult dental benefits under Medicaid to offset costs for low-income seniors. While many dentists take pride in participating in community-based pro bono clinics, these sporadic events cannot replace consistent, long-term care and follow-up.

Yet, modern science continuously validates that the mouth is the gateway to the rest of the body. Chronic inflammation and bacteria associated with gum disease (periodontitis) can trigger blood vessel inflammation, significantly increasing the risk of heart attacks and strokes. Oral bacteria have also been linked to endocarditis, while periodontal disease shares dangerous links with diabetes and even cognitive decline. (Keep brushing those teeth!)

Despite this systemic connection, the dental community has been slow to fully embrace its role as a medical profession. Of the specialized areas recognized by the American Dental Association, geriatric dentistry is still not recognized as an independent specialty, instead lumped under the broad umbrella of “Special Needs Dentistry.” While dental schools have recently added basic coursework in geriatrics, and a few now offer advanced certificates, a 2021 study concluded that “current dental training is clearly inadequate to prepare students to manage the oral health needs of older adults with multiple chronic conditions.”

Innovative treatment models are beginning to fill the vacuum that mainstream private practices ignore. For example, our senior living community contracts with Elderdent, which provides on-site care to our health center residents using a fully equipped mobile dental van. Similar traveling practices and in-home dental services are on the rise nationwide.

Ultimately, dental care for us 80-year-olds suffers from the same structural fractures as the rest of healthcare: a severe shortage of trained practitioners, a lack of holistic understanding regarding complex, simultaneous health issues, and the logistical hurdles brought on by limited mobility.

The depth of this crisis was laid bare in Oral Health in America, a comprehensive report published by the National Institute of Dental and Craniofacial Research (NIDCR) in December 2021. The report concludes with three urgent recommendations to improve oral health equity and access to care:

• Eliminate Systemic Barriers: Reduce social, economic, and geographic inequities that dictate oral health behaviors and restrict access to care.
• Integrate Care: Bring dental and medical professionals together to provide integrated oral, medical, and behavioral healthcare in schools, community health centers, nursing homes, and primary care settings.
• Transform Workforce and Education: Diversify the composition of oral health professionals, reduce the exorbitant costs of dental education, and expand the research enterprise dedicated to improving public health.