Bridge over troubled water
Can poor oral health kill you? The answer: “Yes,” and, “It’s complicated.” In her landmark book Dying of Dirty Teeth – Why the lack of proper oral care is killing nursing home residents and how to prevent it, Angie Stone writes, “There are several causes of death that can be associated with poor oral health, including heart disease, stroke, diabetes, COPD and dementia. … While death certificates do not list oropharyngeal bacteria as the cause of death, they are certainly the origin of many illnesses that lead to death.” Current research linking inflammation with Alzheimer’s Disease is looking at the association of neurotoxins released from destructive oral bacteria that have passed through the blood-brain barrier.
In honor of National Dental Hygiene Month, let us take pause and delve a bit deeper into the rights and responsibilities of achieving oral health. As a direct provider of dental hygiene and limited dental therapy services to the homebound population here New Hampshire, I see first hand the challenges of the burden of oral diseases such as caries (tooth decay) and periodontal (gum) disease on those I serve. It’s as if a person reaches a tipping point in the management of aging and chronic disease where the mis-management of the burden of oropharyngeal bacteria results in an avalanche of decline.
It is very challenging for dental professionals to deliver services in non-traditional settings and it takes innovation and an eye toward improved health outcomes for real change to take effect. Dr. Ettinger wrote, the factors which influence decision making for oral health care are whether the patient has the will, the time or the finances to pay for care, while for clinicians, the decisions are whether they have the skill and the resources to carry out the treatment plan. For older adults, they are now complicated by the patient’s medical and medication problems, the side effects of the medications they are taking, their cognitive status as well as the cumulative effects of a lifetime on the dentition and the oral cavity.
A lack of effective reimbursement and delivery systems, coupled with cost of care, all lead to poor oral health for our elders, especially frail elders who require daily assistance to reduce the bacterial biofilm. “It is really odd to have picked out one part of the body and not provide health coverage for that part of the body when you’re providing health coverage for all the other parts of the body in a Medicare program,” said Paul Glassman, a professor of dental practice who directs the Virtual Dental Home project. “It’s a self-defeating policy that doesn’t actually end up saving the country money,” he said. According to a 2016 article in Health Economics, there is emerging evidence that there may be fiscal offsets – in the form of reductions in medical care costs – associated with increased use of dental care among patients with chronic conditions.
Further work and implementation will be necessary in the areas of medical-dental integration, fiscal policy, education, technology and innovation. We must begin to understand the roadblocks to achieving good oral health and work together to clear the way to reduce the costs of and barriers to oral healthcare by collaborating on solutions, supporting policy change and having the vision and tenacity to do so.
The American Dental Hygienists’ Association policy asserts that dental hygiene practice is an integral component of the health care delivery system and that the services provided by a dental hygienist may be performed in collaboration with other health care professionals. ADHA’s goal to advocate for the profession is defined by supporting state and federal advocacy efforts that advance direct access and the role of dental hygienists, and advance dental hygiene education programs to best prepare professionals for their evolving scope of practice.
New Hampshire created the Certified Public Health Dental Hygienist, a direct access provider that can initiate and treat certain populations, including the homebound, without the prior examination by a dentist as long as a collaborative practice agreement and annual record review by a supervising dentist are in place. This is a good start. Direct Access Dental Hygiene can be that Bridge Over Troubled Water unleashing our talents to work directly with the public we serve.
Joan K. Fitzgerald, ASDH, BS, CPHDH, CDP, is founder-president of Oral Healthcare At Home Inc.