2017-03-23 17:50:03
 The New Old Age: With Age Comes a Mouthful of Trouble

Alex Maddalena had gone five years without seeing a dentist.

He knew that he needed to. It hurt to chew. A couple of teeth had grown discolored, so he tried not to smile broadly. His daughter kept urging him to get a checkup.

The reason he didn’t: money.

Medicare has never provided dental care, except for certain medical conditions, and California’s Medicaid program covers only some services, at reimbursement rates so low that most of the state’s dentists do not accept Medicaid patients at all.

By the time Mr. Maddalena, 79, made an appointment at the new nonprofit Gary and Mary West Senior Dental Center in January, he had advanced periodontal disease, a couple of large cavities and three teeth that needed extraction.

“The destruction had advanced to the point that we couldn’t save them,” said Dr. Karen Becerra, the center’s dental director.

Many Americans find it difficult to obtain adequate dental care, but the problem is particularly acute among older Americans like Mr. Maddalena. Fewer than half of Medicare beneficiaries have visited a dentist in the past year, a rate that sinks to 26 to 28 percent at lower income levels.

At the West Center, where the average patient lives on $850 a month, “they often haven’t seen a dentist in 10 or 20 years,” Dr. Becerra said. “They’d end up in the E.R. when the pain got unbearable.” She has seen patients who have pulled their own teeth.

About 20 percent of Americans over age 65 have untreated cavities, the National Center for Health Statistics has reported, with cavities much more prevalent among blacks, Hispanics and Asians. Among those over age 75, a quarter have lost all their teeth.

Still, better hygiene and fluoridation means more older people have more teeth to preserve, over lengthened life spans, than in the past. Decades back, “losing your teeth and getting dentures was the expectation,” said Dr. Stephen Shuman, who leads the Gerontological Society of America’s oral health group.

Yet dental health gets more challenging at older ages. Gums recede, exposing roots to decay, and bone loss makes teeth less stable. Older people produce less saliva — particularly because they often take drugs that produce dry mouth — which also leaves teeth vulnerable to decay.

Decades-old fillings and bridgework can crack or crumble. Regular brushing and flossing sometimes pose physical and cognitive challenges. “People who have worked a lifetime to maintain their teeth find them falling apart,” Dr. Shuman said.

These difficulties arise precisely when most Americans are leaving the work force and losing employer dental insurance, if they had it. Medicare offers no help, and Medicaid, varying by state, generally pays skimpily for limited procedures.

Preventive care actually lowers costs in the long run, researchers at the University of Maryland Dental School have reported. Though older people who receive preventive care like cleanings make more office visits, their care costs significantly less overall because they are less likely to develop problems requiring expensive treatments like root canals, said Dr. Richard Manski, a study co-author.

Even patients with dementia can maintain their teeth, a University of Minnesota study has found. With treatment, education and follow-up care, older adults with dementia are no more likely to lose teeth than those without dementia.

So efforts to bring more dental care to older adults are advancing on several fronts. “There are lots of pots bubbling right now,” said Dr. Shuman. “Oral health is an essential element of healthy aging.”

• The West Center, which expects to treat 1,000 people at sliding-scale fees its first year, demonstrates the possibilities for public/philanthropic alliances. The Wests’ foundation donated nearly $2 million to build and equip the clinic, located within a popular senior center; other foundations underwrite operating costs. A county grant supplied an expensive machine to make crowns on-site, and Denti-Cal, the state Medicaid program, pays some patient fees.

Not every town can tap such resources, acknowledged Shelley Lyford, chief executive of the West Health Institute. But “we can take elements of this model and integrate them into community health centers and senior centers across the country.”

• Dentists are not the only oral health care providers; dental hygienists and dental therapists operate in a variety of settings, at lower costs, when state legislatures allow them sufficient autonomy. Increasingly, they do.

In 39 “direct access” states, hygienists can treat patients without a dentist present, according to the American Dental Hygienists’ Association. But the permitted practice locations vary: Hygienists can work in nursing homes in Washington and Utah, but in Wisconsin, they cannot — yet. Some states allow them to visit homebound patients; others do not.

“Hygienists are such good health educators and motivators,” Dr. Manski said. “But they’re limited when patients have to go into a dental office to see them.”

• Dental school clinics can help fill the gap. Columbia University’s ElderSmile program, for example, conducts monthly screenings in senior centers in low-income neighborhoods.

The just-expanded University of Minnesota clinic — on the campus of Walker Methodist Health Center, a Minneapolis long-term care community — schedules about 2,000 visits annually for both residents and other seniors.

With older people a growing segment of the population, “we’re not seeing a geriatrics rotation as an elective anymore,” said Dr. Shuman, the clinic’s director.

• Technology could also play a role. The University of Minnesota dental school, working with a local aerospace company, has won a small federal grant to develop an antenna and smartphone app to track dentures, which frequently disappear in nursing homes.

Another small grant supports work on a tooth-cleaning mouthpiece for those who have difficulty brushing and flossing. “It’s like a carwash for your mouth,” said Dr. Shuman.

In San Diego, Dr. Becerra and a dental hygienist have worked week after week to restore Mr. Maddalena’s mouth. The retired hairdresser has had extractions, fillings and deep cleanings to reduce gum infection; the next step is a crown.

Elsewhere, these services would have cost him thousands of dollars. So far the center has charged $263, which he is paying off in $20 increments while faithfully following his hygienist’s home care instructions.

“These people are lifesavers,” Mr. Maddalena said. The final step in his treatment: partial dentures to restore his ability to chew well.

Afterward, he will just need to come to the clinic every six months for a checkup, like the rest of us.