Southern Nevada assisted living residents’ perception of their oral health status and access to dental care
Georgia Dounis, DDS, MS
Associate Professor, Clinical Sciences, School of Dental Medicine, University of Nevada, Las Vegas, 1001 Shadow Lane MS 7410, Las Vegas, NV 89106-4124, USA
Southern Nevada assisted living residents’ perception of their oral health status and access to dental care
Objective: Oral health is an integral component of general health, and quality of life. The purpose of this study was to determine the perceptions of oral health status and acces\s to dental care by Southern Nevada Assisted Living Facilities Residents.
Methods: A cross-sectional questionnaire study design was used to survey residents between 34 and 99 years old residing in Assisted Living Facilities. Seventy respondents (42 males and 28 females) completed a survey that included personal oral hygiene, access to care, and demographic information. Data analyses included descriptive statistics and chi-square.
Results: Mean age was 75.78 years, and the majority had a college education (n = 41). Four currently smoked cigarettes. Twenty-nine (males = 14; females = 15) reported having dental insurance. Eleven respondents had seen a dentist twice a year, while 33 reported a visit less than 6 months. Forty-one reported the facility did not provide oral health care with majority (n = 64) indicating that accessing oral health care was difficult. Self-rated response to oral hygiene, a majority (n = 64) reported their oral hygiene as fair and five reported their oral hygiene as poor.
Conclusions: Assisted living residents in Southern Nevada reported difficulty accessing dental services within and outside of the facility. Oral care models to address this unique population should be explored.
Quality of life for older adults may have improved over a generation, yet access to oral care post-retirement continues to be a challenge and a burden. Advanced chronological age is not a disease, yet with advanced age, chronic systemic conditions become prevalent; oral health care needs are more complex and challenging; and gaining access to oral health care services involves needs beyond comprehensive health care services. The Institute of Medicine has defined access to care as ‘timely use of personal health services to achieve the best possible health outcomes’1. Utilisation of services (visits, procedures) is influenced by access to care with barriers identified as structural, financial and personal. Defining access to care requires identification of areas of health care services influencing the health status and poorer outcomes for certain populations. Only then can problems relating to access be addressed1.
Oral health is one of the domains of health that can affect total health and emotional, psychological and functional well being. Diseases of the oral cavity are silent, chronic, least familiar to the public, and often referred to as the ‘neglected epidemic’2. Transmissible bacterial infections of the hard and soft oral tissues compounded by medical conditions, functional limitation, and social habits, as well as adverse affects of prescription medications, may lead to edentulism, oral cancer and xerostomia. Older adults develop dental decay at a higher rate than children3 and develop higher rates of severe periodontal disease4–6 yet do not perceive oral health to be impaired until symptoms of disease affect function7,8. Throughout life, employer-provided dental insurance facilitates high quality, complex, and sophisticated treatment modalities that enable the retention of the natural dentition, however after retirement, dental benefits are frequently lost and access to oral health care becomes a financial burden. Dental benefits are not offered under the Medicare public programme and Medicaid provides limited coverage that is only available in less than half of the States in America. Also, older adults post-retirement have reduced financial resources when access to oral health care becomes an out-of pocket expense9.
In the USA, nearly 9 million older adults residing in community dwellings have difficulty with one or more activities of daily living (ADLs), and nearly two million have difficulty with three or more ADLs, are severely disabled and require home care10. Approximately 1.57 million reside in long-term care facilities and over 1 million live in assisted living facilities. State and federal regulations mandate the provision of oral health care to institutionalised residents. Most assisted living facilities, long-term care facilities are Joint Commission on Accreditation of Health Organisations (JCAHO) accredited, and the majority (80%) report offering dental services to their residents11. The purpose of this study was to determine Southern Nevada assisted living centre residents’ perceptions of oral health status and access to dental care.
Materials and methods
Sample and sample size
A cross-sectional questionnaire study design was used to survey residents between 34 and 99 years of age residing in Assisted Living Facilities in Southern Nevada. A letter of invitation was sent to 80 Southern Nevada Assisted Living Facility administrators describing the research study, seeking permission to contact the residents, and to request that they facilitate data collection. Eleven facility administrators agreed to participate by providing contact information and access to the residents. A packet of information including a description of the study, an informed consent, and the oral health questionnaire was provided to each of the residents. Only those residents with diminished cognitive function were excluded from participation. Based on a power analysis, a minimum of 60 subjects was required to achieve 0.80 power (p = 0.05; d = 0.30), a convenience sample of volunteer respondents returned the signed informed consent to facility personnel at which time a face-to-face survey interview with the research staff was scheduled. The survey was conducted within the federal and state requirements’ and laws governing residents’ rights.
Instrumentation and statistical analyses
A one-page survey was designed to assess Assisted Living Facility Residents perceptions of oral health status and access to care. Content and Face validity were assessed by a team of calibrated (2) experts in gerontology. Face validity was assessed to be a good translation of the construct. These experts further compared the survey against the relevant content domain. Internal reliability was assessed using Cronbach’s alpha (r = 0.76). Prior to starting the survey interview, the investigator met with the resident and re-affirmed a resident’s interest to participate.
The survey (Table 1) included five demographic items: age, gender, educational status, social habits, smoking status, and dental insurance coverage. Fourteen items regarding self-perception of oral health status addressed perceived ratings of oral hygiene practices and conditions of natural or prosthetic dentition status. Other questions addressed the presence of gingival bleeding, dry mouth, dental caries, tooth brushing, use of dental floss, tooth loss within the last year, difficulty eating, swallowing, parafunctional habits such as the grinding of teeth, use of medication for dental health, and presence of halitosis. Questions elicited ‘Yes’ and ‘No’ responses. Another suite of six items assessed access to care with questions designed to identify the facility’s provision of in-house oral care, and transportation. Questions explored the frequency of visits to the dentist, the time span since the last dental visit, experiences with dental problems that were not managed by a dentist, and if they were unable to see a dentist within the past year. Only aggregate data were used in this study. All personal identified information was coded in accordance with the requirements set forth by the UNLV Human Subjects Review Board. Descriptive statistics were reported and Chi-square analyses were used to assess the differences between various demographic variables.
Table 1. Demographic profile of study sample.
|Gender (n = 70)|
| Male (mean age = 79.93; SD = 12.05)||42 (60)|
| Female (mean age = 69.57; SD = 18.65)||28 (40)|
|Dental insurance (n = 69)|
| Yes||29 (42)|
| No||40 (58)|
|Smoking status (n = 64)|
| Currently smoke||4 (6.25)|
| Do not currently smoke||60 (94.69)|
|Educational status (n = 69)|
| Completed High School||28 (40.6)|
| Attended or completed College||41 (59.4)|
Seventy respondents (males = 42; females = 28) completed a survey that included 25 items addressing personal oral health, access to care, and demographic information. The mean age was 75.79, SD = 15.76 (males = 79.93; SD = 12.05; females = 69.57; SD = 18.6) (see Table 1). A majority of the residents had a college education (n = 41). Of the respondents, only four reported that they currently smoked cigarettes. Twenty-nine (males = 14; females = 15) reported having dental insurance. Responses to questions addressing access to care are shown in Table 2. Only 11 respondents saw a dentist twice a year, with 33 indicating that it had been less than 6 months since their last visit. Forty-one reported that the facilities did not provide oral health care for the residents, with a majority (n = 64) indicating that accessing oral health care was difficult. When asked how they would rate their oral hygiene, a majority (n = 64) reported their oral hygiene as fair, but five reported their oral hygiene as poor; no resident reported having excellent or good oral hygiene.
Table 2. Respondents’ perceived access to care.
|Facility provided oral health care to residents|
| Yes||29 (41.4)|
| No||41 (58.6)|
|Available transportation by facility|
| Yes||44 (62)|
| No||26 (38)|
|How often residents see a dentist|
| 1x per year||14 (20)|
| 2x per year||11 (16)|
| For emergencies only||11 (16)|
| Never||34 (48)|
|How long since last visit|
| Less than 6 months||33 (47.1)|
| Within 12 months||3 (4.3)|
| More than 12 months||34 (48.6)|
|Did residents have dental problems that were not taken care of?|
| Yes||21 (30)|
| No||49 (70)|
|In past 12 months, did you have problem where you could not see a dentist?|
| Yes||21 (30)|
| No||49 (70)|
Chi-square analyses were conducted to determine any significant differences between male and female residents and selected variables. There were no significant differences between males and females on the average frequency of visits to the dentist (p = 0.928) and in access to a dentist when they had problems (p = 0.72). There was a significant difference between male and female residents in the length of time since their last visit (χ2 = 8.841; p = 0.012), with more women going for check-ups in less than 6 months (women = 28; men = 14).
The results of this study demonstrate that some older adults residing in Assisted Living facilities of Southern Nevada had difficulty accessing oral care within and outside the facilities. Residents in this sample were primarily male, had reported having dental insurance, and were college educated.
Oral health services, including an initial admissions oral examination, assistance with daily care, access to oral hygiene products and routine disease management were unavailable in the assisted living facilities that participated in this study. These findings are similar to surveyed institutionalised older adults identified in other studies11. It has been reported that only a small number of the residents received oral examinations and a very few of the facilities had an oral health care professional on the staff to examine residents. Furthermore, staff to supervise oral hygiene practices or promote oral disease prevention and management services was inadequate. It was determined that nursing personnel lacked skills, knowledge, experience and time to provide oral health care12,13. In 1989, Vigild reported that poor oral hygiene contributed to the onset of systemic disease in older patients and those facilities for older residents should institute preventative oral care programs14. This study supports previous findings that appear to remain a current day problem15. Fragmentation and lack of integrated health care delivery, as well as workforce preparedness to manage geriatric patients, particularly in the field of oral health, may be a major contributor to the outcomes reported here as well as in other studies16,17. Older adults have unique oral and systemic health care needs that require patient centred co-ordination of services18–23. A call for action to change health care providers’ perceptions and increase time devoted to oral health and disease topics in the education of non-dental para-professionals can contribute to the oral health status of older adults24. Those health professionals, who can make a difference in oral health services in assisted living facilities, may need additional education and skills included in their training to accomplish improved oral health outcomes for residents. The changes in demographics and health care needs of a rapidly growing older population offers a unique opportunity to reassess the traditional health education curricular structure and practice models, dissolve the traditional discipline barriers and develop the interdisciplinary health care team approach for health promotion, and disease prevention. Collaboration amongst the various health care professional accreditation bodies is necessary to influence the content of the various curricula to develop joint standards for each health care profession.
Residents with oral symptoms, who request oral care services and encountered difficulty in finding an oral health care provider outside of Assisted Living facilities could potentially experience compromised health status eventually leading to loss of life25–27.Residents in this study experienced similar barriers to oral health care reported by other institutionalised residents28,29. Assisted and long-term care facilities have been characterised as the hospitals of the future; however, the planning and design of facilities does not include dental treatment clinics for oral health care needs of the residents. On site, dental treatment clinics would eliminate the majority of transportation needs and would be equipped to address cognitive disorientation associated with unfamiliar alternate treatment sites that are now necessary for routine and emergency oral care30. Didactic geriatric dental training has improved over the years; however, the clinical experience at non-traditional practice settings are still inadequate and students report being unprepared to care for the older adults in private practice settings31. Dental universities as well as state and national licensing agencies will need to emphasise geriatric dental competence through curriculum reform and demonstration of competence.
Residents in this study, who were primarily male, reported having dental insurance while being unable to access outside oral health care provider services. Additionally they self-rated their oral health status as fair to poor. Self-perceived systemic health has become an important predictor of mortality and functional and cognitive impairment has been correlated with self-rated oral and systemic health. Thus, the perception of oral health status is an indicator of potential general health issues32,33.
This preliminary survey of the oral health care needs of elders living in assisted living facilities addressed issues and challenges for future. Although findings in this study were limited by the use of a convenience sample and the perceptions of oral health status and access to care in a select sample of Southern Nevada Assisted Living facilities, we have concluded that:
- 1 Southern Nevada Assisted Living facilities participating in this study did not provide initial, daily, routine dental care to the residents.
- 2 Residents with oral symptoms had difficulty accessing oral health care providers outside of the facility’s immediate environment.
- 3 Further research is required to understand factors that influence access to oral health in alternative group living facilities for the elderly and subsequently develop oral care models to address the needs of population’s residing in facilities but able to manage their own self-care.
This study was supported by Priority Care LTC Pharm.