Is Europe prepared to meet the oral health needs of older people?
Dr Anastassia E. Kossioni, Department of Prosthodontics, Athens Dental School, Thivon 2 Goudi, Athens 11527, Greece.
Is Europe prepared to meet the oral health needs of older people?
Objective: To discuss the preparedness of the social and health care systems and the health workforce in Europe to manage the increasing general and oral health care needs of older adults.
Background and discussion: There are large inequalities across European countries and regions in the demographic, socioeconomic and health status of the elderly. The ageing of the population and the economic crisis put at risk the existing social and health care systems and are expected to further widen the existing inequalities. Despite the increase in funding for the general health care, public funding for dental care has reduced, limiting the access for the disadvantaged elderly. Dental care is isolated from health care policies and funding. At the same time there is a significant shortage of adequately trained personnel in the care of the elderly and a shortage of training opportunities particularly at a postgraduate and continuing education level.
Conclusion: Immediate action is needed and appropriate strategies need to be implemented. Oral health prevention, delivery policies and funding should be integrated within the general health care system. Clinical protocols and guidelines need to be developed on the oral care of the elderly. Interdisciplinary training in the care of the elderly needs to be implemented for all health care workers (dentists, physicians, nurses, health care aids, social workers) at all education levels to enhance comprehensive care.
Europe has a great diversity in history, culture, demography, education, health, socio-economic status, national policies, social protection and healthcare systems. However instead of noticing convergence, inequalities in health outcomes are widened during the last decades of the 20th century for many EU countries1. Health inequalities are related to social inequalities and social exclusion1.
The Commission of the European Communities working document on the Future ‘EU 2020’ strategy emphasised the social effects of one of the worst economic and financial crises to hit Europe2. Older people in Europe are among the most vulnerable citizens. One of the main EU targets is to keep older Europeans in the labour market and increase human capital. The 2006 Synthesis Report on Adequate and Sustainable pensions reported that nearly all Member States are developing policies to promote longer working lives and reform their pension systems3. However without major improvements in the health of the older population, the increase in the participation of older people into work will not be plausible4.
Public expenditures on health and long term care are significantly higher in the older populations5,6 and are expected to increase further in the near future.
The Council of the European Union published a report on the future of health care and care for the elderly5 discussing the projected changes in the demand due to demographic ageing, better income, better education, increased consumer awareness, increased labour market participation of women, geographical mobility and changes in family. The Center for Health Workforce Studies in the USA also commented on ‘the Impact of the Ageing Population on the Health Workforce in the United States’6 presenting the changing demographic profile of older Americans which will affect health care demand: different needs, demands and health care utilisation patterns, more racial and ethnic diversity, better education demanding more sophisticated treatment, more income, better health, having fewer family caregivers and more likely to live alone.
This changed profile of future aged cohorts, combined with the retention of more natural teeth will also affect the demand for oral care 7.
At the moment there are no accurate published data on oral healthcare expenditures in Europe8, but there is a tendency for reduced public funding in many countries9. Oral health is often neglected in comprehensive approaches to the promotion of general health 10 and public funding for dentistry is reduced as compared to medicine. Regarding dental health policies, much attention in recent years was focused on children’s oral health while the oral health for the fastest growing segment of the population, the elderly, was neglected.
Are the welfare and health care systems, as well as the health workforce prepared to meet older people’s general and oral health needs? Will health inequalities in Europe further widen? What will be the effect of the financial crisis on oral care which is increasingly left to the private sector?
The aim of this paper is to discuss: (i) the demographic, socioeconomic and health profile of aged Europeans, (ii) the models for oral healthcare in Europe, (iii) the preparedness of the social and health care systems to manage the general and oral health care needs of the elderly and (iv) the opportunities for oral care in the elderly.
Demographic inequalities in Europe
Europe is the Continent with the highest proportion of older people in the world. According to the 2008-based national population projections, EUROPOP2008, in EU27 the proportion of people over 65 years in the total population will increase from 17.1% (2008) to 30.0% in 206011. The population is expected to become older in all member States, Norway and Switzerland, but there are large variations across countries. The percentage of the population over 65 years was 19.8% in Italy (2006), 18.5% in Greece (2006) and 18.3% in Germany (2004). On the other hand, the aged population was 8.2% in Albania (2004), 11.7% in Iceland (2005) and 13.4% in Malta (2005) 12. The proportion of women increases with age. They comprise 71% of the population over 85 years.
Two main developments cause the ageing of the population: the low fertility rates and the increased life expectancy met in all European countries. According to the 2008 world population datasheet, the mean total fertility rate (the average number of children a woman will have in her lifetime) in Europe was 1.5, far below the 2.1 replacement level and many countries will see a decline in the population13. The lowest rates were observed in eastern and southern European countries13.
At the same time, life expectancy continues to increase in Europe. In 2008 life expectancy in EU27 was 76.1 years for males and 82.2 for females, reaching in 2030 80.0 and 85.3 years respectively14. However there are large variations between sexes and across countries. The mean life expectancy for males in Lithuania and Latvia were 66.3 and 67.0 years respectively, while in Sweden it was 79.2 years and in the Netherlands 78.4 years. The relevant figures for females were 77.6 years in Lithuania, 77.8 in Latvia, 83.3 in Sweden and 82.5 in the Netherlands14. A slowing down of life expectancy increase at age 65 was recorded in many European countries in the years 2000–2005 compared to 1995–2000; in the Czech Republic, Denmark, Estonia, Hungary, Latvia, Lithuania and Poland for men and in Czech Republic, Germany, Hungary, Latvia, Lithuania, Luxembourg, Poland, Portugal, Slovakia, Slovenia, Spain, and the United Kingdom for women15.
The socioeconomic inequalities in aged Europeans
In 2005, 21% of women and 16% of men over 65 years in Europe were at risk of poverty (having an equivalent disposable income below 60% of the national median) 16. There are large variations across countries: 52% of older women in Cyprus and 36% in Ireland were at risk of poverty compared to 5% in Luxemburg. In all countries there are more poor women than men.
The low pensions provided in many European countries are one reason for the increase in the level of poverty in the elderly and particularly for women. The already low pensions are now at further risk.
Longer working lives and active ageing, free of disease and disability, are supposed to ensure the financial sustainability of pensions. At the moment this is not plausible. Even if the Lisbon strategy targeted at an employment rate of 50% by 2010 by the Europeans aged 55–64 years, most of the Europeans aged 60–64 years in 2005 were pensioners (81% of women and 65% of men). Only in Sweden 52% of the women and 60% of the men were still working at this age. Even in younger ages (55–59 years) only 46% of the women and 65% of the men in Europe were working 16.
The employment rate after the age of 55 seems to be related to educational level. Forty-nine percent of men and the 34% of women aged 60–64 years, with tertiary education, were employed as compared to 27% of men and 13% of the women with basic schooling in 200516.
Unfortunately few older people in many European countries have completed secondary education. According to the SHARE study (Survey of Health, Ageing and Retirement in Europe) only 40–60% of people over 50 years in Denmark, Germany and Austria had completed secondary education, while this proportion dropped to less than 20% in Greece, Italy and Spain17.
Living alone in old age is also related to reduced access to health care. In 2005 more women (30%) than men (13%) lived alone at the age of 65–74, but those proportions increased to 52% and 21% respectively after the age of 75 years16. Living close to one’s children is a significant poverty alleviation factor in Southern Europe and in Germany18. In the poorer Mediterranean Europe, the older respondents in the SHARE survey received more financial help from their children than in Northern Europe18.
Living alone is predicted to increase in the elderly in the near future due to the increase in the divorce rates, particularly at younger and middle ages (although one cannot predict the percentage of remarriages) and the fewer number of children6 who at the moment support older parents in many countries. The divorce rates in the baby boomers and also in older adults are increasing over the past decades6.
What will be the profile of future aged Europeans? The Joint report for the future of health care and care for the elderly5 claims that the older Europeans will be better educated, wealthier, with longer working lives. The existing evidence only supports that they will be better educated and that they will be forced to live longer working lives. It remains to be seen if they will be wealthier and healthier, as health status is related to socio-economic status. The SHARE survey has shown that even before the economic crisis (2004) the older respondents in Germany, France, the Netherlands, Austria and Sweden reported more than 50% subjective probability that there will be a future decrease in their pensions19. It appears that their instinct was right.
Health and disability inequalities in the older European population
Recently, attention was focused not only on life expectancy but to the quality of the life spent. As we age, disease and disability increase and it is important to know the ‘disability-free life expectancy’ (DFLE) or the ‘healthy life years’ (HLY) of a population, defined as the number of years that a person is expected to continue to live in a healthy condition (absence of limitations in functioning/disability)20. This indicator is based on both mortality and morbidity statistics and is very important also from a political and economic point of view, as it shows the ability of an older person to continue working efficiently. It is related to the labour-force participation years and the cost of the healthcare and pension systems, which suffer from the demographic trends, the increased rate of unemployment and the current financial crisis.
Unfortunately, we have added more years to our lives, but not all of them will be necessarily healthy. In 2007 the HLY indicator for EU27 was 61.6 for the males and 62.3 for the females21. HLYs are not closely connected with life expectancy. In France where life expectancy is long, the healthy-life-years are below the EU average. Again, there are large variations among populations: HLY in Latvia was 53.7 for females and 50.9 for males compared to 72.8 for males and 71.7 for females in Iceland. The prevalence of chronic morbidity increases with age and it is more prevalent in females15,16,22. Although women live longer, they spend more years of their lives with disability as compared to men.
Global chronic morbidity measured by the question: ‘Do you suffer from any chronic illness or condition (health problem)’ varies across European countries15,23. More than 80% of men and women aged 65–74 years in Poland and the Czech Republic reported having a long-standing illness or health problem, compared to less than 42% in Greece and Belgium16. At age 65, men in Denmark spend 34.8% of their remaining life with chronic morbidity, compared to 77.0% of the remaining life of men in Finland, while women in Denmark spend 40.5% of their remaining life span with chronic morbidity compared to 79.6% of the remaining life span of women in Finland15. There was a tendency for people in the new Member States and particularly the women to perceive their health as being poor16.
As expected, more of the older old Europeans (75–84 years) perceived their health as being bad. However, even in this very old age group, more than 40% of people in Belgium, Denmark, Germany, Ireland, Netherlands, Sweden and the UK perceived their health as being good16. It should be noticed that self-perceived health for the oldest-old presents low validity, because they often underestimate disease, they do not have a diagnosis, they have declining cognitive functions and do not remember their disease, or they do not know the disease24.
The differences in self-perceived health and disability are also a manifestation of differences in reporting styles25. In all health interview surveys one should bear in mind the effect of cultural variations on the interpretation of good and bad health and disability.
Future projections are not clear. A decrease of disability was only noticed in Denmark, Finland, Italy and the Netherlands26. It appears that longer working lives will be difficult to achieve in many European countries due to illness and disability.
In most studies on the consequences of illness and disability, oral disease is not discussed. However it has a severe impact on individuals and communities from the pain, the suffering, the impairment of function and the reduced quality of life27. Moreover, there is increased evidence of a close association between general medical conditions frequently met in the older adults (diabetes, heart conditions, respiratory infections) and oral disease28–31. Although the WHO Oral Health Report29 has pointed out that: (i) oral health is integral and essential to general health, (ii) oral health is a determinant factor for quality of life and (iii) there is an interrelationship between oral and general health, oral care is isolated from medical care and general health policies.
The influence of socio-economic factors on health indicators and health service utilisation
The health inequalities observed in Europe are, amongst others, related to reduced access to health services and to various socio-economic inequalities (social support systems, education, living and working conditions, differences in health-related behaviour)1,4.
In the EU25 countries in 2005 a positive relation was observed between HLYs at age 50 and gross domestic product (GDP) and expenditure on elderly4. Self-perceived health in Europe was positively related to prosperity, while HLYs were reduced in the less privileged social groups4. A higher per head GDP eases access to goods and services (health-care and social-care services)4. The large socio-economic disparities in physical health exist despite many years of universal healthcare coverage in Europe25.
Dental disease (tooth loss, dental caries and periodontal disease) is also related to socio-economic factors (income, education, social class)27,29, while many studies have reported on the significant effect of various socio-demographic (income, education), geographical, general health and dental status factors affecting the level of dental service utilisation in the elderly8,27,32–34.The Swedish National Surveys of Public Health in 2004 and 2005 showed that people with severe socio-economic disadvantage were seven to nine times as likely to refrain from dental consultation35.
The SHARE study has shown that people with low socio-economic status and low income are associated with a higher risk of reporting less than good self-perceived health, long-term problems and activity limitations due to health problems25. The lower socio-economic groups had a 30–65% higher risk of reporting pain, heart problems, breathing problems, coughing and fear of falling than those with higher socio-economic status25. Moreover, they smoked more, were less physically active and more likely to be obese or overweight36.
The SHARE project also reported some interesting findings on the factors affecting the level of medical and dental consultation in Europe. The number of reported medical consultations over the past 12 months was strongly related to age, to female gender and to poor subjective health, but inversely associated with the level of education33. This last finding was explained in terms of the better state of health in better educated people. The higher educated consumed a significantly lower number of drugs and reported less hospital admissions and surgeries33. Only 6% of people over 85 years did not consult a doctor in the past year.
Most of the above associations were found to be reversed when dental consultation was considered. While 63% of persons 50–54 years had visited the dentist in the past 12 months, only 25% of those over 85 years reported dental consultation. Moreover dental consultation was positively associated with good or very good health and with a higher level of education. As Matthews has mentioned: ‘dental patients are frequently well when they attend for care and treatment37. While 73% of persons with tertiary education had visited the dentist in the past year, only 29% with lower education or primary school education reported dental care33. There were also large variations among countries in the report for dental care at least once in the past 12 months. More than 70% of persons in Sweden, Denmark and Germany reported dental care compared to less than 39% in Greece, Italy and Spain33.
Unless the socio-economic problems of the older Europeans diminish, the levels of general and oral health care will not improve.
Models for oral health care in Europe
The limited dental consultation rate can also be related to the limited dental care coverage by many health care systems in Europe and the increased level of poverty in the elderly restricting access to private dental care.
Acute general care needs are the first priority for many health care systems, which often view dental health separated from general health.
In Western and Southern Europe out-of-pocket payments for general health care were recorded and ranged from 11% to 42% of health expenditures, even if the majority of the population was covered by public health systems (out-of-pocket refer to services partially covered or not reimbursed by the public or private insurance schemes)38. The poorest spent a higher share of their income on health expenditures38.
Oral disease is the fourth most expensive disease to treat in most industrialised countries27. Between 6 and 10% of the National Health budgets are related to oral health care in the EA/EEA Member States9.
Although access to public health care in Europe is either a constitutional right or a stated principle, the general rule is that dental care is provided through direct patient payments to a greater extent than general health care8.
General health care and oral health care services in Europe are the responsibilities of the European Member States9. This explains the wide variation in the oral health care systems. Private practitioners provide oral care in all EU countries. However in all countries there is a system of paying prospectively for dental care through insurance, taxation, or both8. According to the Manual of Dental Practice8, the oral care system in Europe is usually a part of or closely reflects the system of funding for the general health care system. There are two main models of healthcare provision in the European countries8: The National Health Service type, which is public and financed by taxes and patients’ co-payments and the Social Insurance type or ‘Sick Funds’ which is compulsory public health insurance, sometimes supplemented with voluntary insurance, where patients make co-payments for claim reimbursements. The National Health Service type can be categorical (limited to certain groups like children, the elderly and the poor) (Cyprus, Iceland, Ireland, Malta and Spain) or universal but with limited treatment choices (Denmark, Finland, Greece, Italy, Norway, the UK)8. The Social insurance type may have an income ceiling (Germany) or no income ceiling but with some criteria for access (elderly, children, medically compromised, poor) (Austria, Belgium, Bulgaria, Croatia, the Czech Republic, Estonia, France, Hungary, Latvia, Liechtenstein, Lithuania, Luxembourg, the Netherlands, Poland, Portugal, Romania, Slovakia, Slovenia, Sweden and Switzerland)8.
In all countries there is some form of financial assistance or special services for oral care for some population groups who cannot pay for dental care or have special needs (children, the elderly, the handicapped, the unemployed, the poor)8,27. For the elderly in some countries, some form of dental care is either free or with reduced fees (e.g. Denmark, Hungary, Portugal, Lithuania, Norway)8,27.
In the Nordic countries public health care is predominant, while in the Mediterranean countries the private sector predominates9,37. In Central and Western Europe, the public sector, providing limited access to a wider range of citizens co-exists with private practice and in Eastern Europe there is a transition from the public to the private sector9,37. The changing socio-economic environment in Europe may lead to significant changes in the existing health and social care systems. Significant changes are already recorded in the new Member States (the Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Slovakia and Slovenia) who are heading from the old public oral care system to an insurance based oral care model9.
The access to domiciliary dental care is limited in Europe. In some countries, it is provided mainly by public health dentists (e.g. Denmark, Finland, Island, Ireland, Latvia, Malta, Norway, Sweden and the UK), while in the other countries it is either not provided or provided by general practitioners on request and is paid less by public than private funds8.
It is true that ‘financial resources have come under pressure as a result of the financial crisis’2. According to the ‘EU 2020’ strategy ‘this is a time of deep transformation in Europe’. One suspects that public general and oral health provisions are at further risk. Will Europe find the way to save and even improve the social and welfare system for which we all had high expectations some years ago?
Are health professionals prepared to meet older people’s health needs?
As more people are getting older the demand for formal and informal care provided by most healthcare workers will increase. The European Commission Joint Report on Social Protection and Social Inclusion1 has addressed the problem of workforce shortage and inadequate training, particularly in the formal and informal homecare sector. In developed countries, greater numbers of health care workers will be needed, as well as changes in the way services are being provided to the elderly6,39. Most of the health workers will treat elderly patients and need to be educated in the care of the aged40.
The health workforce in Europe is ageing. Between 1995 and 2000 the number of physicians under 45 in EU dropped by 20% and the proportion of those aged over 45 increased to over 50%1. Recruitment of younger staff is needed to support the increased health needs as physicians in most specialties are required to treat an increasing number of geriatric patients.
Another significant problem in all Western Societies is that there are many informal caregivers for the aged without any previous information and education for the demands of their duties1,40.
In the USA, almost 22 professions and occupations are providing health care to the aged population6, most of them inadequately prepared40. Employment of all physicians and surgeons in the USA is expected to grow by 18% due to expansion of health care and the aged population6. The growth for many occupations, particularly in home health care and residential care, is more than 60% between 2000 and 2010 in the USA6 (nurses, home health aids, personal care aids, physical therapists, occupational therapists, social workers, psychologists, dieticians, pharmacists etc). The workforce shortage in USA is particularly significant for nurses, social workers, home aides, home health aides40. Dentists and dental hygienists will face a growth of 24% in nursing home care and 70% in residential care6.
Few physicians are adequately trained in Geriatric Medicine. The numbers of new geriatricians in the USA has declined, mainly due to lower income, and cannot meet society’s needs6,40,41. In 2007 there were 7,128 physicians certified in Geriatric Medicine and 1,596 certified in Geriatric Psychiatry, while by 2030 USA will need about 36,000 geriatricians40.
The European Union Geriatric Medicine Society (EUGMS), representing all the National Societies of Geriatric Medicine in the European Union and TFTA countries, comprises 10,000 doctors whose main activity is to care for frail older people42. If one considers that in the USA 36,000 geriatricians will be needed by 2030, the projection for Europe is further disappointing.
The Global Survey on Geriatrics in the Medical Curriculum reported that Geriatric Medicine was taught in 41% of 36 countries with national regulations for Medical School curricula43. In the first years of our century, Geriatric Education in Europe varied among countries and was not very promising44. Most of the Central and Southern European countries show a lack of Geriatric Medicine education in spite of the fact that the population is ageing fast. The specialty of Geriatric Medicine has been recognised in Austria, Belgium, Denmark, Finland, France, Germany, Ireland, Italy, the Netherlands, Spain, Sweden, Norway and the United Kingdom, with large variations in training across countries44. In the UK, there is a decline in Geriatric Medicine content in the curriculum and a decline in the number of Medical Schools with separate departments or divisions of Geriatric Medicine45.
Although Geriatric Medicine is required in the undergraduate curricula of most US Medical Schools, the education provided is inadequate6,40,41. Part of the problem is related to lack of appropriately-trained faculty41. Geriatric Medicine has been an approved specialty of both Family Practice and Internal Medicine in the USA since 1985, providing that the physicians qualify for a certificate of Added Qualifications in Geriatrics6.
As happens in Geriatric Medicine, the educational needs for Gerodontology in Europe and in other developed countries are not yet fully met. In Europe, USA and Canada few dental practitioners are trained in Gerodontology and there is a shortage of dentists skilled to manage the oral problems of the elderly. Inadequate financing, insufficient qualified dentists and facilities, insufficient demand by patients and the lack of multidisciplinary collaboration limit the adequacy of oral care in the elderly46.
Gerodontology is not a recognised specialty in Europe, Canada or in the USA and the opportunities for advanced training in Gerodontology are limited47,48. A limited number of dentists have been trained in Gerodontology in Europe in the last decades attending the master’s programme in Gerodontology at the University of London, which unfortunately ceased with the retirement of the Director, Professor Robin Heath.
The total number of dentists trained in Geriatric Dentistry in the USA does not exceed 200, while the projected need was for 6,000 dentists with substantial training and 2,000 with clinical experience in the management of the elderly48. If one considers that the population in the USA is approximately 60% of that of EU27 population and that the proportion of the elderly in Europe is larger than in the USA, one can conclude that Europe will need a significantly larger number of gerodontologists.
Increased emphasis should be placed on education in Gerodontology in the undergraduate curricula and in mandatory continuing education courses in Gerodontology49. Undergraduate curriculum guidelines in Gerodontology in Europe were published in 2009 by the European College of Gerodontology7 and were included in the updated document on the ‘Profile and Competences for the European Dentist’ published by the ADEE50.
However the extent of Gerodontology education in the undergraduate curricula of European Dental Schools varies significantly51–54. The data recently collected by the European College of Gerodontology (2010, unpublished data) have confirmed that Gerodontology is included in the undergraduate curricula of most EU Dental Schools, either as a separate course or integrated in other courses (prosthetics, community dentistry, etc.) in Belgium, Czech Republic, Croatia, Denmark, Estonia, Finland, Germany, Greece, Hungary, Ireland, Norway, Poland, Portugal, Sweden, Switzerland, Spain and the UK. It is not, however, clear whether Gerodontology teaching conforms to the existing guidelines.
Curriculum guidelines for Geriatric Dentistry in the USA were updated in 198955. Although in 2001 all US Dental Schools taught at least some aspects of Gerodontology56, the opportunities for promoting the related competences were not significant57. Only 67% of the Dental Schools offered a clinical component in Gerodontology which was required in 54% of the schools56.
A significant proportion of the graduate class of 2002 in the USA reported that they were not adequately prepared to manage the oral problems of the elderly during their undergraduate studies58, while the attitude of recently graduated dentists towards the institutionalised elderly in Belgium was rather negative and their knowledge of ageing was poor, despite the actual level of Gerodontology education in the undergraduate curriculum54.
Many studies have shown that dentists hesitate to provide domiciliary services, because of financial aspects, unfavourable working conditions, lack of time, lack of training, lack of appropriate equipment, apathy of residents and staff in LTC59–62. The older dentists in Belgium were more reluctant to provide domiciliary services, while prosthetic treatment and extractions were the most common procedures61.
At the moment undergraduate education in domiciliary oral care is limited in Europe8,52, but is steadily increasing61.
There are significant barriers in Gerodontology education, well-defined by many authors, such as the crowded curriculum, the lack of trained staff, the lack of financial resources, the teaching faculty working in other departments with other main teaching priorities and the limited administrative support48,53,63.
The opportunities for oral care in the elderly
The WHO Global Oral Health Programme has clearly stated the appropriate strategies to improve the oral health of the older people27. Oral diseases share common risk factors with non-communicable diseases like cardiovascular disease, diabetes, cancer and chronic obstructive pulmonary diseases27,29. As general health and oral health are interrelated29, oral care should be integrated within the general health care system in terms of education, funding and mechanisms of provision. Unless oral care is regarded as a part of general medical care, the funding for oral care will not be increased and appropriate policies will not be implemented. This will have an enormous effect on the future of the oral care of the elderly and for the dental profession as a whole.
We also have to think about re-orientation of dental education. To better serve the oral healthcare care of the elderly, a strong emphasis on medical education is necessary. The ECG guidelines emphasise the close connection of Gerodontology with Medicine and the need for an interdisciplinary approach in dental education7.
In Europe there are two models of Dental Education; the stomatological one with a strong medical basis and the odontological one which is dentally orientated. The advantages and disadvantages of both should be discussed. In the Nordic countries there is an effort to combine the two approaches; dental education is based on the odontological model but with a strong influence from biomedicine, which will further strengthen in the future64.
Hendricson and Cohen in their article on the ‘Oral Care in the 21st Century’ have very accurately posed the dilemma for the US dental curriculum planners; the dental profession should decide whether it wants to become a more integrated component of the overall health care system supporting the ‘oral physician’ role or continue the ‘splendid isolation’ from the other health care providers65.
Interdisciplinary training is necessary not only for dentists, but also for all health care workers (dentists, physicians, nurses) to better serve the needs of older patients. The dentist must learn to closely collaborate with the physician in order to efficiently manage the oral problems of the elderly. On the other hand, as physicians and nurses are the ones who regularly visit the elderly, their training (undergraduate, specialist or continuing education) should include aspects of oral medicine, oral pharmacology, clinical intra-oral and extra-oral examination, guidelines for dental referral, and the interrelation of general and oral disease66. This is particularly important for oral care in domiciliary and long-term care settings.
Domiciliary dental care needs to further develop in Europe. One of the competences identified by the ECG was to ‘provide adequate treatment in patients’ homes and long-term care settings using appropriate dental equipment’. Dental Schools should seek collaborations with long-term care facilities and community settings to provide domiciliary training for their students and at the same time to serve the oral needs of the elderly7,60,67,68.
Clinical protocols and guidelines need to be developed on all aspects of oral care for the elderly. Research on oral health in the elderly should promote knowledge and translate it into practice for dental practitioners and for oral health planners and administrators27. Inexpensive and easy-to-apply preventive protocols should be developed and employed by staff in nursing homes and by the home carers for the dependent elderly49.
The development of continuing dental education Gerodontology programmes is even more important, as continuing education is the primary source of formal geriatric education for many health professions6. The Committee on the Future Health Care Workforce for older Americans has recommended that ‘all licensure, certification, and maintenance of certification for health care professionals should include demonstration of competence in the care of older adults as a criterion’40.
Modern distance-learning educational technology and international co-operation can help to overcome the problem of a lack of educators in geriatric medicine and geriatric dentistry, as well as the common barriers for the practising dentist: the lack of time and reduced financing for continuing education. An example is the international training programme for the European Masters in Gerontology, developed and delivered by a network of more than 20 European Universities including short, intensive course weeks in different European cities and home-study via distance learning69.Such an initiative in Gerodontology will be most welcome in Europe.
In 2007 the Council of European Dentists adopted a resolution on the ‘Profile of the Dentist of the Future’70, which considered the ageing of the population and the association between oral disease and general health as two major trends which should affect the competences of the European Dentist. The free movement of dental practitioners in EU requires that dental training in the EU countries conforms to the EU Dental Directive on the recognition of professional qualifications 2005/36/EC (PQD)71. The Annex for the Study Programme for Dental Practitioners (V.3/5.3.1) of the PQD, including the necessary training topics is soon to be adapted to current needs. Gerodontology will be included in this revision.
Last but not least, older people are now important for the politicians because they comprise a significant proportion of the voters. Hopefully, this will force the EU and the member states to take action.
There are significant inequalities in older Europeans in terms of demography, health and disability, income, education, working and living conditions and access to medical and dental care. The significant increase in the older population and in the demand for health care put the existing social security and pension systems at risk. Even under the present conditions significant out-of pocket expenditures for general health care are recorded, while oral care is increasingly left to the private sector, reducing the access for the vulnerable aged population. While the demand for general and oral health care provision in the aged is expected to increase, the health workforce is not ready to meet the needs because of shortage of staff and inadequate training. Immediate action is needed and appropriate strategies must be implemented. The opportunities to better serve the oral needs of the elderly in Europe are orientated towards the remodelling of oral health care services, the integration of oral care with general health care, the development of appropriate oral health promotion and education strategies, the development of necessary clinical protocols, the development of Gerodontology training opportunities at a postgraduate level, the increase in the recruitment of specialists in Gerodontology and the reorientation of dental, medical, nursing and other geriatric care providers education (undergraduate, postgraduate and continuing education) to enhance their competences in the prevention, diagnosis and management of the oral problems of the elderly.