DRAFT 5-20-11
Best Practice Approaches
for State and Community Oral Health Programs
A Best Practice Approach Report describes a public health strategy, assesses the strength of evidence on the
effectiveness of the strategy, and uses practice examples to illustrate successful/innovative implementation.
Date of Report: _____________
Best Practice Approach
Adult and Older Adult Oral Health
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VII.
VIII.
Description (page 1)
Guidelines and Recommendations (page 13)
Research Evidence (page 14)
Best Practice Criteria (page 15)
State Practice Examples (page 16)
Acknowledgements (page 17)
Attachments (page 18)
References (page 19)
Summary of Evidence Supporting
the Adult and Older Adult Oral Health
Research
Expert Opinion
Field Lessons
Theoretical Rationale
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See Attachment A for details.
I. Description
A. Adults and Older Adults in the U.S.
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In 2009, U.S. population was 301.5 million for all ages.
Table 1
2009 U.S. Population
There were 72.1 million adults aged 55 and over, 37.8
http://www.census.gov/population/socdem
million adults aged 65 and older and 17.4 million adults
o/age/2009_older_table1.xls
aged 75 and over (Table 1). 1
In 2009, 6.5 million (17.2 %) Americans age 65 and over
.Under 55 years
229.4M
were in the labor force (working or actively seeking work).
55
to
59
years
18.8M
They constituted 4.2% of the U.S. labor force.2
.60 to 64 years
15.5M
The majority of older adults exhibit at least one medical
.65 to 69 years
11.8M
problem. Disabilities associated with chronic illness
increase sharply with advancing age.3 As individuals grow
.70 to 74 years
8.6M
older, their physiologic functions decline, making them more
.75 to 79 years
7.3M
susceptible to stress and infection and less able to perform
.80
to
84
years
5.7M
activities of daily living (ADL). These factors are largely
responsible for the spread of disease, particularly among
.85 years and over
4.4M
institutionalized older adults.
In 2006-2008, the most frequently occurring conditions among older persons were: hypertension
(38%), diagnosed arthritis (50%), all types of heart disease (32%), any cancer (22%), diabetes
(18%), and sinusitis (14%).2 The oral status of medically compromised older adults is largely the
result of a combination of local and systemic factors. Poor oral health can exacerbate a medical
condition, cause pain or discomfort, alter nutrition, and decrease a person’s self-esteem.3
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Best Practice Approach: Adult and Older Adult Oral Health
1
1. U.S. Census Bureau, Current Population Survey, Annual Social and Economic Supplement, 2009.
http://www.census.gov/population/www/socdemo/age/older_2009.html
http://www.census.gov/compendia/statab/2011/tables/11s0034.pdf
2. U.S. Dept. of Health and Human Services, Administration on Aging. Profile of Older Americans 2010.
http://www.aoa.gov/aoaroot/aging_statistics/Profile/index.aspx
3. DeBiase CB, Austin SL. The American Dental Hygienists' Association, Continuing Education Series: Oral Health & Older Adults.
http://www.adha.org/CE_courses/course11/common_conditions.htm
B. Significance of Oral Health for Adults and Older Adults
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The mouth is the gateway of the body. It serves as an early warning system for diseases
(HIV/AIDS, Immune system problems, general infections, stress), signals nutritional deficiencies,
and is associated with diseases such as diabetes, cardiovascular disease and stroke.
Oral diseases and disorders affect health and well-being throughout life.
Adult oral problems are extensive and may be particularly severe in vulnerable populations.
Oral problems include the common dental diseases and other oral infections (which can occur at
any stage of life with the chronic facial pain conditions) and oral cancers seen in later years.
Oral diseases and conditions and their treatments may undermine self-image and self-esteem,
discourage normal social interaction, and lead to chronic stress and depression as well as incur
great financial cost. They may also interfere with vital functions such as breathing, eating,
swallowing, and speaking and with activities of daily living such as work and family interactions.
Oral health is essential to an older adult's general health and well-being.
1. Oral Health in America: A Report of the Surgeon General (Executive Summary)
http://www2.nidcr.nih.gov/sgr/execsumm.htm#partOne
C. Oral Diseases and Conditions
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There are threats to oral health across the lifespan:1
1. Nearly one-third of all adults in the United States have untreated tooth decay.
2. One in seven adults aged 35 to 44 years has gum disease; this increases to one in every four
adults aged 65 years and older.
3. Nearly a quarter of all adults have experienced some facial pain in the past six months.
4. Oral cancers are most common in older adults, particularly those over 55 years who smoke
and are heavy drinkers.
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Oral diseases and conditions include the following for adults and older adults: 2
1. Tooth Loss: More older adults are retaining their teeth. Statistics show that nearly 40 years
ago, 75% of those aged 75 and older were edentulous. Recent data suggests that no more
than 40% of persons in this age group are edentulous. 3 Although edentulism is less
prevalent, overall there is still a high incidence in those of lower socioeconomic status.
2. Dental Caries (Tooth Decay): The most significant risk for tooth loss in older adults is dental
caries, in particular, root caries. Xerostomia, fixed or removable partials, abrasions at the
cementoenamel junction, and diets composed of soft, sticky and/or sugary foods are also
contributing factors to root caries.4
3. Periodontal Disease (Gum Disease): Periodontal disease is another area of concern in the
older adult population. Studies have reported that 40% of ambulatory older adults have
gingivitis, while 33 to 60% have some degree of periodontal destruction.5
4. Oral Pain: When oral health care is neglected, many older adults face various problems, such
as oral pain that can affect their quality of life and cause them to withdraw socially. Oral pain
can lead to more severe dental and systemic problems by compromising nutritional intake.
5. Oral Cancer: Approximately 15,000 older adults are affected each year by oral cancer. CDC
reports that oral cancer is responsible for nearly 8,000 deaths each year. More than half of
these deaths occur among those aged 65 and older.4
1. CDC Website: Adult Oral Health
http://www.cdc.gov/OralHealth/topics/adult.htm
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Best Practice Approach: Adult and Older Adult Oral Health
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2. DeBiase CB, Austin SL. The American Dental Hygienists' Association Continuing Education Series: Oral Health and Older Adults.
http://www.adha.org/CE_courses/course11/characteristics.htm
D. The Burden of Disease
The burden of oral diseases and conditions include the following:
For Adults:1
1. CDC Website, Fact Sheet, Oral Health for Adults
http://www.cdc.gov/OralHealth/publications/factsheets/adult.htm
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Over the past 10 years, the number of adults missing all their natural teeth has declined from
31 percent to 25 percent for those aged 60 years and older, and from 9 percent to 5 percent for
those adults between 40 and 59 years. However, 5 percent means a surprising 1 out of 20
middle-aged adults are missing all their teeth.
Over 40 percent of poor adults (20 years and older) have at least one untreated decayed tooth
compared to 16 percent of non-poor adults.
Toothaches are the most common pain of the mouth or face reported by adults. This pain can
interfere with vital functions such as eating, swallowing, and talking. Almost 1 of every 4 adults
reported some form of facial pain in the past 6 months.
Most adults show signs of gum disease. Severe gum disease affects about 14 percent of adults
aged 45 to 54 years.
Signs and symptoms of soft tissue diseases such as cold sores are common in adults and affect
about 19 percent of those aged 25 to 44 years.
Chronic disabling diseases such as jaw joint diseases (TMD), diabetes, and osteoporosis affect
millions of Americans and compromise oral health and functioning.
Women report certain painful mouth and facial conditions (TMD disorders, migraine headaches,
and burning mouth syndrome) more often than men.
Every year more than 400,000 cancer patients undergoing chemotherapy suffer from oral
problems such as painful mouth ulcers, impaired taste, and dry mouth.
Patients with weakened immune systems, such as those infected with HIV and other medical
conditions (organ transplants) and who use some medications (e.g., steroids), are at higher risk
for some oral problems.
Employed adults lose more than 164 million hours of work each year due to oral health problems
or dental visits. Customer service industry employees lose 2 to 4 times more work hours than
executives or professional workers.
For Older Adults:2-3
2. New Series of Reports to Monitor Health of Older Americans
http://www.cdc.gov/nchs/pressroom/01facts/olderame.htm#ORAL HEALTH#ORAL HEALTH
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More older people are keeping their natural teeth than ever before. However, among those aged
65 years and over there are sharp differences by income, with those in poverty twice as likely as
those with higher incomes to have lost all their teeth.
Many older Americans take medications for chronic conditions that have side effects detrimental
to their oral health. These include antihistamines, diuretics, and antidepressants.
One-third of adults aged 65 years and over have untreated dental caries; slightly over 40 percent
have periodontal disease.
Only 22 percent of older persons are covered by dental insurance; most elderly dental expenses
are paid out-of-pocket.
3. CDC Website, Fact Sheet, Oral Health for Older Americans
http://www.cdc.gov/OralHealth/publications/factsheets/adult_older.htm
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Best Practice Approach: Adult and Older Adult Oral Health
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Older Americans with the poorest oral health are those who are economically disadvantaged, lack
insurance, and are members of racial and ethnic minorities. Being disabled, homebound, or
institutionalized also increases the risk of poor oral health.
Many older Americans do not have dental insurance. Often these benefits are lost when they
retire. The situation may be worse for older women, who generally have lower incomes and may
never have had dental insurance.
Medicaid, the jointly-funded Federal-State health insurance program for certain low-income and
needy people, funds dental care for low income and disabled elderly in some states, but
reimbursements for this care are low. Medicare, which provides health insurance for people over
age 65 and people with certain illnesses and disabilities, was not designed to provide routine
dental care.
About 25 percent of adults 60 years old and older no longer have any natural teeth. Interestingly,
toothlessness varies greatly by state. Roughly 42 percent of Americans over age 65 living in West
Virginia are toothless, compared to only 13 percent of those living in California. Having missing
teeth can affect nutrition, since people without teeth often prefer soft, easily chewed foods.
Because dentures are not as efficient for chewing food as natural teeth, denture wearers also
may choose soft foods and avoid fresh fruits and vegetables.
Periodontal (gum) disease or tooth decay (cavities) are the most frequent causes of tooth loss.
Older Americans continue to experience dental decay on the crowns of teeth (coronal caries) and
on tooth roots (because of gum recession). In fact, older adults may have new tooth decay at
higher rates than children.
Severity of periodontal (gum) disease increases with age. About 23 percent of 65- to 74-year-olds
have severe disease, which is measured by 6mm loss of attachment of the tooth to the adjacent
gum tissue. At all ages men are more likely than women to have more severe disease. At all
ages, people at the lowest socioeconomic level have the most severe periodontal disease.
Oral and pharyngeal cancers, which are diagnosed in some 31,000 Americans each year, result
in about 7,400 deaths each year. These cancers are primarily diagnosed in the elderly. Prognosis
is poor. The five-year survival rate for white patients is 56 percent and for African American
patients is only 34 percent.
Most older Americans take both prescription and over-the-counter drugs. Over 400 commonly
used medications can be the cause of a dry mouth. Reduction of the flow of saliva increases the
risk for oral disease, since saliva contains antimicrobial components as well as minerals that help
rebuild tooth enamel attacked by decay-causing bacteria. Individuals in long-term care facilities—
about 5 percent of the elderly—take an average of eight drugs each day.
Painful conditions that affect the facial nerves are more common among the elderly and can be
severely debilitating. These conditions can affect mood, sleep, and oral-motor functions such as
chewing and swallowing. Neurological diseases associated with age, such as Parkinson's
disease, Alzheimer's disease, Huntington's disease, and stroke also affect oral sensory and
motor functions, in addition to limiting the ability to care for oneself.
E. Access to Dental Care and Dental Service Utilization
National Trends for Adults and Older Adults in the U.S.1-2
 For every adult 19 years or older without medical insurance, there are three without dental
insurance.
 A little less than two thirds of adults report having visited a dentist in the past 12 months. Those
with incomes at or above the poverty level are twice as likely to report a dental visit in the past 12
months as those who are below the poverty level.
 Only 22 percent of older persons are covered by dental insurance; most elderly dental expenses
are paid out-of-pocket.
Access to Dental Care3
 Concerns about the degree to which the dental workforce is prepared to meet the oral health
needs of older patients
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Best Practice Approach: Adult and Older Adult Oral Health
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Adequacy of the future workforce such as concern about training opportunities in gerontology and
geriatrics for dental and allied dental practitioners.
Utilization of Dental Services4
 Understanding why some people continue seeking preventive dental care throughout their lives
while others are lifelong irregular users and still others discontinue regular use after retirement or
relocation to a new community or long-term care facility.
 Determinants of older persons' dental service utilization, both barriers and enablers. Based on the
epidemiological and psychosocial literature available on this topic, barriers and enablers include
cohort and age, race and ethnicity, income and education, availability of dental and medical
insurance, urban vs. rural residence, physical access to a dental office, and systemic and
functional health. Attitudes toward oral health and dental care and other psychosocial variables
may override some of these demographic and structural variables.
Residents of Long-Term Care Facilities5
 The federal Omnibus Reconciliation Act of 1987 (OBRA) established some specific requirements
for dental services in more than 20,000 nursing homes across the country. The Health Care
Financing Administration (HCFA) mandated that all nursing homes receiving Medicaid and
Medicare reimbursements provide routine and emergency oral health care to their residents.71
These regulations were effective on April 1, 1992 and specifically required long-term care
facilities to 1) assist patients in obtaining routine and emergency dental care; 2) provide dental
care internally or obtain this care from an external source for each resident; 3) assist in
scheduling appointments for dental care and arrange transportation to the dentist; and 4) develop
an oral health program that includes annual staff in-service training, an oral examination within 45
days of admission that is repeated annually for each resident, and a daily oral hygiene preventive
care plan for each resident. Each facility should have an agreement with a dentist to deliver oral
health care services and make referrals.72
1. Oral Health in America: A Report of the Surgeon General (Executive Summary)
http://www2.nidcr.nih.gov/sgr/execsumm.htm#partOne
2. New Series of Reports to Monitor Health of Older Americans
http://www.cdc.gov/nchs/pressroom/01facts/olderame.htm#ORAL HEALTH#ORAL HEALTH
3. Dolan TA, Atchison K, Huynh TN. Access to dental care among older adults in the United States. J Dent Educ. 2005
Sep;69(9):961-74.
4. Kiyak HA, Reichmuth M. Barriers to and enablers of older adults' use of dental services. J Dent Educ. 2005 Sep;69(9):975-86.
http://www.ncbi.nlm.nih.gov/pubmed/16141083
5. DeBiase CB, Austin SL. The American Dental Hygienists' Association Continuing Education Series: Oral Health and Older Adults
http://www.adha.org/CE_courses/course11/legislation.htm
F. Barriers to Achieving Optimal Oral Health
Barriers to attaining oral health such as:
 Failure to reduce the bacteria that cause dental caries and periodontal disease.
 Less than optimal exposure to fluorides to prevent tooth decay.
 Cultural, social and economic influences on oral health such as dietary practices, home care and
beliefs.
Barriers to accessing and utilizing professional dental care such as:
 Lack of dental insurance and dental coverage.
 Inadequate dental workforce and workforce models.
 Limited dental safety net services, capacity and infrastructure.
 Lack of financing that supports prevention and dental disease management.
 Low value/priority placed on regular dental visits for preventive care.
Additional barriers for older adults to seeking oral health care1-2
 Many older adults are not regular users of dental services and may experience significant barriers
to receiving necessary dental care.
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Best Practice Approach: Adult and Older Adult Oral Health
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The older adult population is more likely to have chronic conditions that may affect their oral
health, but they are less likely to visit an oral health care provider than younger adults.
Chronic health conditions can inhibit older adults from seeking oral health care because such
health conditions take precedence. Chronic health conditions and physical impairments may also
keep the older adult from being able to get to the dental office.
They may not be ambulatory or they must rely on others to transport them or utilize public
transportation.
Cost of dental services is another consideration. When persons retire they tend to lose their
dental insurance coverage. Medicaid and Medicare provide limited or no coverage for routine oral
health care. Out-of-pocket expenses can be very challenging for those on a fixed income.
Attitudes and beliefs also can influence obtaining oral health care. Many of the older age groups
(age 75+) still believe that losing one’s teeth is a part of the aging process.
1. Dolan TA, Atchison K, Kuynh TN. Access to dental care among older adults in the United States. J Dent Educ. 2005
Sep;69(9):961-74. http://www.ncbi.nlm.nih.gov/pubmed/16141082
2. DeBiase CB, Austin SL. The American Dental Hygienists' Association Continuing Education Series: Oral Health and Older Adults.
http://www.adha.org/CE_courses/course11/barriers.htm
G. Consequences of Oral Diseases
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Locker’s model1-3 states that there are five consequences of oral disease—impairment, functional
limitation, pain/discomfort, disability, and handicap—and that these are sequentially related.
Impairment (structural abnormality, e.g., edentulousness) leads to functional limitation
(restrictions in body functions, e.g., difficulty chewing) and pain/discomfort (self-reports of
physical and psychological symptoms), which, in turn, lead to disability (limitations in performing
daily activities, e.g., unsatisfactory diet) and then to handicap (social disadvantage, e.g., social
isolation). Functional limitation may also lead directly to handicap. This multidimensional model
provides a scientific model for the understanding of oral disease and its consequences.
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In addition, families, communities and the health care system are strained in coping with oral
disease consequences. Human and economic cost of oral diseases include: time missed from
work, morbidity associated with treatment, inappropriate use of over the counter pain medication,
personal and family stress, loss of attentiveness and performance, costs associate with travel,
eating and sleeping dysfunctions, misuse of ER resources, infection and death
1. Locker D (1988). Measuring oral health: a conceptual framework. Community Dent Health 5:3–18.
2. Locker D: Concepts of oral health, disease and the quality of life. In Measuring oral health and quality of life. Edited by Slade GD.
Chapel Hill: University of North Carolina: Dental Ecolog; 11-24.
3. Baker SR. Testing a Conceptual Model of Oral Health: a Structural Equation Modeling Approach. JDR August 2007 vol. 86 no. 8
708-712 . (http://jdr.sagepub.com/content/86/8/708.full)
H. An Overview of a Strategic Framework to Promote Adult and Older Adult Oral
Health
Strategies to prevent and control oral diseases and conditions of adults and older adults include personal
strategies, systems of care, and public health practices.
Personal Strategies1
 Drink fluoridated water and use a fluoride toothpaste for protection against tooth decay.
 Brush and floss teeth to reduce dental plaque and prevent gingivitis.
 Avoid tobacco use in any form—cigarette, pipes, and smokeless (spit) tobacco—which
increases the risk for gum disease, oral and throat cancers, and oral fungal infection.
 Avoid heavy use of alcohol, a risk factor for oral and throat cancers. Alcohol and tobacco
when combined are greater risk factors for oral cancers.
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Best Practice Approach: Adult and Older Adult Oral Health
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Avoid snacks full of sugars and starches and limit the number of snacks eaten throughout the
day. Fiber-rich fruits and vegetables stimulate salivary flow to aid remineralization of tooth
surfaces with early stages of tooth decay.
Visit the dentist regularly to detect early signs of oral health problems and can lead to
treatments that will prevent further damage, and in some cases, reverse the problem.
Professional tooth cleaning (prophylaxis) also is important for preventing oral problems.
For diabetic patients, maintain control of the disease to help prevent the complications which
include increased risk of periodontal disease.
Manage a dry mouth by working with the physician to substitute for other medications, drink
plenty of water, chew sugarless gum, and avoid tobacco and alcohol.
Have an oral health check-up before beginning cancer treatment to prevent or limit oral
complications or tissue damage from radiation to the head or neck and/or chemotherapy.
Systems of Care Strategies
 Provide an adequate and competent workforce to promote oral health and manage oral
diseases and conditions. Trained professionals at all levels are needed to assess risk,
identify disease, manage the disease process, manage behavior issues for safe treatment,
and deliver care to restore oral health.
 Integrate oral health and coordinate dental care services with care systems supporting adults
and older adults (e.g., medical and social service systems). Professionals working in these
systems can help identify those at risk and facilitate early preventive and treatment services.
Public Health Practices Strategies
 Utilize population-based approaches. Public health focuses on the health of the population
rather than individuals,2 such as obtaining a high level of oral health throughout society.
Population-based approaches use a community perspective, population-level data and
evidence-based practices, with an emphasis on prevention and effective outcomes.3
 Promote public and private partnerships. Determinants of health are the province of many
governmental agencies (e.g., agencies concerned with health and welfare)2 and many nongovernmental institutions (e.g., managed care organizations, community-based groups, and
academic institutions). The National Call to Action to Promote Oral Health acknowledges the
need for public-private partnerships at all levels of society.4
 Respond to emerging issues. The baby boomer generation will be the first where the majority
will maintain their natural teeth over their entire lifetime, having benefited from water
fluoridation and fluoride toothpastes. However, baby boomers are aging resulting in a
demographic shift to a growing number of older adults. With this large cohort, issues will
emerge as the demands of their health and healthcare increases with age. For adults’ and
older adults’ oral health, governmental agencies, dental providers in the private sectors, and
public-private partnerships will need to be more responsive as Baby Boomers continue to age
and enter retirement age. Healthcare services designed for the nation’s seniors need to be
re-evaluated.
1. CDC Oral Health Website. Oral Health for Adults. http://www.cdc.gov/OralHealth/publications/factsheets/adult.htm
2. Goslin LO, editor. Public health law and ethics: a reader. Berkeley/Los Angeles: University of California Press; 2002. 554 p.
Available from: http://www.publichealthlaw.net/Reader/ch1/ch1.htm.
3. Ibrahim MA, Savitz LA, Carey TS, Wagner EH. Population-based health principles in medical and public health practice. J
Public Health Manag Pract. 2001 May:7(3), 75-81. Available from: http://www.sagepub.com/upm-data/3989_Chapter_1.pdf.
4. U.S. Department of Health and Human Services. National call to action to promote oral health. Rockville, MD: U.S.
Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Dental
and Craniofacial Research; 2003. NIH Publication No. 03-5303.
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Best Practice Approach: Adult and Older Adult Oral Health
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I. A Conceptual Model of the Influences on Adult and Older Adult Oral Heath
<Is there a preferred conceptual model to use? The following model is just for illustration.>
Patrick and colleagues proposed a comprehensive conceptual framework that encompasses oral health
as a dynamic process in which a variety of forces operate both to perpetuate and to reduce social
disparities in oral health. (http://www.biomedcentral.com/1472-6831/6/S1/S4)
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Best Practice Approach: Adult and Older Adult Oral Health
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J. A Strategic Framework to Prevent and Control Oral Diseases and Conditions
of Adults and Older Adults
A strategic framework is proposed to prevent and control oral diseases and conditions for adults and
older adults. The strategic framework has four focus areas: (1) Prevention, (2) Disease Management,
(3) Access to Dental Care Services, and (4) Systems of Integration and Coordination. The four focus
areas are tied to personal, family and community levels of influences on oral health. The components
of each focus area also relate to the conceptual model’s five domains that determine health.
A Strategic Framework to Prevent and Control
Oral Diseases and Conditions of Adults and Older Adults
Four Focus Areas and Their Components
Systems of Integration and Coordination
Access to Dental Care Services
Disease Management
 Risk assessment
Prevention
 Fluoride
 Spectrum of
dental treatment
 Regular dental
visits
 Dental home
 Dental workforce
and professional
development
 Partnership with
health and adult
services providers
 State and local
dental public health
programs
 Policy development
 Reduction of
bacteria that cause
dental caries and
periodontal disease
 Avoidance of
tobacco and alcohol
use
 Education and
counseling
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Best Practice Approach: Adult and Older Adult Oral Health
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K. Components of the Strategic Framework to Prevent and Control
Oral Diseases and Conditions of Adults and Older Adults
1. Prevention
Actions can be taken by families, communities, and policymakers to prevent
tooth decay and delay its onset.
Prevention
 Fluoride
Fluoride
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Fluoride prevents and slows the progression of tooth decay and
can even reverse very early tooth decay.1
Sources of fluoride include drinking water with optimal levels of
fluoride and use of products such as fluoride varnishes, gels,
toothpastes, mouthrinses, and supplements:2
An adult or older adult’s caries risk (low, moderate or high)
should be considered in determining the use of fluoride treatment.
 Reduction of bacteria
that cause tooth decay
 Avoidance of tobacco
and alcohol use
 Education and
counseling
Reduction of Bacteria that Cause Dental Caries and Periodontal Disease
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Reduce the bacteria in the mouth. Reducing bacteria in the mouth of the adult or older adult
requires oral health education/counseling, preventive treatment, and home care.
Practices for high risk individuals may include using prescription mouthrinses to reduce
bacteria, having professional dental care to eliminate existing oral infection and dental caries,
and/or performing daily personal oral hygiene. .
Avoidance of Tobacco and Alcohol Use
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Alcohol, tobacco and illicit drugs have also been part of life for the baby boomer generation
and will be expected to be part of later life for this group.3
The aging of the baby boomer cohorts is expected to increase the prevalence rates of
substance use and abuse among older adults.
Education and Counseling for the Adults and Caregivers
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Education is recommended for adult or older adult, as well as their caregivers, to increase
awareness about the importance of maintaining good oral health by imparting knowledge,
discussing concerns, responding to questions, and developing realistic prevention strategies.
Health literacy and cultural considerations are important when communicating with adults and
their caregivers. Recent estimates indicate that over 90 million Americans are unable to
comprehend basic health information. Persons with low health literacy levels often have poor
knowledge of health-related information, show little ability to control chronic diseases, and
rarely maximize benefits from available preventive health services. 4
Early interventions for oral diseases and conditions of adults and older adults need effective
approaches in delivering health education and in modifying health behaviors.
1. Lynch RJ, Navada R, Walia R. Low-levels of fluoride in plaque and saliva and their effects on the demineralization and
remineralisation of enamel; role of fluoride toothpastes. Int Dent J. 2004; 54(5 Suppl 1):304-9.
2. Centers for Disease Control and Prevention [Internet]. Other fluoride products. Available from:
http://www.cdc.gov/FLUORIDATION/other.htm
3. Farkas KJ, Drabble L. Council of Social Work Education. Substance Use and Older Adults. Chapter 2. Prevalence of
alcohol, tobacco and other drug use among older adults. http://www.cswe.org/File.aspx?id=23741
4. Glick M. The Tower of Babel and health outcomes. J Am Dent Assoc. 2006 Oct; 137(10): 1356, 1358.
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Best Practice Approach: Adult and Older Adult Oral Health
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2. Disease Management
When early prevention does not stop the onset of oral diseases
and conditions, professional intervention is needed to manage the
disease. Disease management should minimize the severity and
consequences, reduce the need for extensive and costly
treatment, and improve the quality of life. This requires arresting
the disease process, repairing damage from the disease, restoring
oral health, and preventing recurrence of the disease.
Disease Management
 Adult Oral Health Risk
assessment
 Spectrum of dental
treatment
Adult Oral Health Risk Assessment
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

Numerous risk factors lead to dental caries, periodontal disease, oral injury, oral cancer, etc.
in an adult or older adult. A risk assessment identifying factors within the context of the adult
or older adult, family, community, and culture can help achieve and maintain oral health.
Risk assessments should identify risk factors (biological, behavioral and nutritional factors);
clinically assess the disease process; and be simple, inexpensive, and have high predictive
values, sensitivity and specificity.
Examples of risks for oral diseases and conditions among adults and older adults:
Caries
Risk Factors
• Presence of cavities or multiple
fillings
• Gingival recession
• Xerostomia (medications, disease)
• Poor oral hygiene
• Poor access to dental care
• Low socio-economic and/or
education status
• Inadequate fluoride
• High frequency
foods/drinks/medications with sugar
• Special health care needs (oral
health often overlooked)
• Presence of partial dentures or other
appliances

Periodontal Disease
Risk Factors
•
•
•
•
•
Poor oral hygiene
Tobacco use
Diabetes
Osteoporosis
Medications (anticonvulsants,
methotrexate, calcium channel
blockers may cause gingival
hyperplasia)
Other Oral Disease
Risk Factors
• Tobacco and alcohol use
(cancers)
• Family history of oral cancers
• Lack of mouth guard use for
sports (oral injury)
• Methamphetamine use
(erosions)
• Bulemia (erosions)
• Significant gastroesophageal
reflux disease (erosions)
• Xerostomia (dry mouth)
• Heart disease, diabetes,
medication for depression,
For public health, risk assessment focuses on the population, rather than the individual. Risk
factors of tooth decay for a population include social and environmental factors, such as nonfluoridated community water systems and dental health provider shortage areas. The pubic
health practice of assessment identifies the extent of the problem in a community and unmet
needs, as well as underutilized resources or shortcomings of the service delivery system.
Public health risk assessment identifies population groups at risk.
Spectrum of Dental Treatment

An emerging area of clinical practice is the use of chemotherapeutic agents for caries
prevention and as an adjunct to traditional dental treatment.
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Best Practice Approach: Adult and Older Adult Oral Health
11
3. Access to Dental Care Services
To achieve optimal oral health, adults and older adults need
professional dental care over a lifetime.
Access to
Dental Care Services
Regular Dental Visits
 Regular dental visits

 Dental home
Regular dental visits with a dental professional for
preventive care and early restorative care.
 Dental workforce and
professional development
Dental Home



A dental home brings together patient, family, non-dental
professionals, and dental professionals to deliver oral health care in a comprehensive,
continuously accessible, coordinated, and family-centered way.
A dental home should emphasize prevention and disease management, as well as tailor care
to meet individual needs for better health outcomes at lower costs. A dental home should
also provide education and counseling and make necessary referrals to dental specialists.
The concept of a dental home is evolving. Additionally, medical and dental homes have led to
the concept of a “health home” to coordinate all health care needs.
Dental Workforce and Professional Development



To assure the oral health of all Americans, a sufficient dental workforce is needed with
professionals in diverse settings.
Several factors determine an adequate dental workforce: numbers, distribution, composition
(provider types), competencies, and coordination among various provider types and with the
medical systems.
Workforce strategies: train a variety of health professional on all aspects of disease
prevention and management that includes family-centered and risk-based interventions;
assure an adequate supply of dental professionals; assure equitable distribution of dental
professionals; improve capacity and efficiency of the dental workforce; and expand the
diversity of the dental workforce to meet current and future demands.
4. Systems of Integration and Coordination
Integrate and coordinate oral health into health, developmental
and education systems that support adults and older adults.
The collective efforts of provider groups, state/community
program administrators, advocates for adults/older adults, and
policymakers will be needed to implement effective strategies,
programs and services at the state and local levels.
Partnership with Health and Adult Services Providers



Systems of Integration
and Coordination
 Partnership with health
and adult services
providers
 State and local dental
public health programs
 Policy development
A range of provides (physicians, nurses, allied health
professionals, social workers, educators, etc.) provide
services to adults and older adults. These non-dental professionals must be engaged as
partners to advocate and support oral health.
Important that these providers be knowledgeable of the origin and associated risk factors
for oral diseases, empowered to make appropriate decisions regarding timely and
effective interventions, and able to facilitate dental care.
Partnerships of public and private stakeholders needed to integrate and coordinate
services for adult and older adult oral health.
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Best Practice Approach: Adult and Older Adult Oral Health
12
State and Local Dental Public Health Programs
State dental public health programs:
 Organized efforts to promote adult and older adult oral health through state and local
dental public health programs
 Provide a statewide and/or local assessment of the burden of disease
 Support state and local strategic plans developed and implemented by stakeholders and
constituents.
 Raise public awareness on the burden and consequences of oral diseases in adults and
older adults; dental service needs for disease prevention and control; mobilize partners to
integrate systems avoid duplicating services; and leverage resources.
 State dental public health programs focus on population-based and infrastructure-building
strategies.
Local dental public health programs:
 Provide all of the state dental public health program activities within their local settings.
 Also provide a range of frontline services to adults, older adults, families and
communities (e.g., education, case management, transportation, preventive dental
services, and dental restorative services)
Policy Development




Oral health policy is needed to provide clear decisions and statements that will guide oral
health practices and actions.
Oral health policy is comprised of the decisions that determine how issues are addressed
either by those elected or appointed to represent communal interests (public policy) or
those involved in the delivery of health services (clinical policy):
A wide range of policy-related issues impact adult and older adult oral health including
surveillance; disease management; dental care services and safety net services; dental
care organization and financing; workforce; case management and beneficiary services;
and family-centered care.
Legislators, policymakers, and third party payors should be educated about adult and
older adult oral health.
L. Initiatives and Coordinated Efforts

List and briefly describe national initiatives and coordinated efforts to illustrate investment.
II. Guidelines & Recommendations from Authoritative Sources
A. Office of Surgeon General
Oral Health in America: A Report of the Surgeon General
The Surgeon General’s Report on Oral Health in America reported the following:

Effective disease prevention measures exist for use by individuals, practitioners and communities (most
focus on dental caries prevention such as fluorides).
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Best Practice Approach: Adult and Older Adult Oral Health
13


Many community-based programs required a combined effort among social service, health care, and
education services at the state or local level.
Primary prevention of dental disease is possible with appropriate diet, nutrition, oral hygiene, and healthpromoting behaviors, including the use of professional services.
National Call to Action to Promote Oral Health
The National Call to Action to Promote Oral Health calls for the following actions to achieve the goals of the
Surgeon General and Healthy People oral health objectives:

Change perceptions of oral health.

Overcome barriers by replicating effective programs and proven efforts.

Build the science base and accelerate science transfer.

Increase oral health workforce diversity, capacity, and flexibility.

Increase collaborations.
B. Healthy People 2020


OH-3
OH-4



OH-5
OH-6
OH-7


OH-14
OA-7
Reduce the proportion of adults with untreated dental decay
Reduce the proportion of adults who have ever had a permanent tooth extracted because of
dental caries or periodontal disease
Reduce the proportion of adults aged 45 to 74 years with moderate or severe periodontitis
Increase the proportion of oral and pharyngeal cancers detected at the earliest stage
Increase the proportion of children, adolescents, and adults who used the oral health care
system in the past year
Increase the proportion of adults who receive preventive interventions in dental offices
Increase the proportion of the health care workforce with geriatric certification (target
10% improvement for dentists)
III. Research Evidence
<Describe the current evidence to prevent and manage oral diseases and conditions for adults and older
adults. Address the need for evidence on the cost-effectiveness of interventions delivered in clinical or
community settings.>
The following sources of evidence-based reviews contribute to the body of evidence on adult and older
adult oral health prevention and management:
1. U.S. Preventive Services Task Force (USPSTF) is an independent panel of experts in primary care
and prevention, convened by the U.S. Public Health Service, to systematically review the evidence of
effectiveness and develop recommendations for clinical preventive services.
a.
b.
c.
Screening Oral Health Cancer (February 2004)
Concludes that the evidence is insufficient to recommend for or against routinely screening adults for oral
cancer.
Counseling for Dental and Periodontal Disease (1996)
Determined that there is no new evidence regarding the role of the primary care clinician in counseling for
dental services. The USPSTF will not update its 1996 recommendation.
Counseling and Interventions to Prevent Tobacco Use and Tobacco-Caused Disease in Adults and
Pregnant Women (April 2009)
Reaffirmed the 2003 recommendation on Counseling to Prevent Tobacco Use and Tobacco-Caused
Disease with respect to adults and pregnant women.
2. The Cochrane Reviews explore the evidence for and against the effectiveness and appropriateness
of treatments to facilitate the choices that doctors, patients, policymakers and others face in health
_____________________________________________________________________________________________
Best Practice Approach: Adult and Older Adult Oral Health
14
care (published in The Cochrane Library). A selection of Cochrane Oral Health Group Reviews
relevant to adult and older adult oral health are highlighted below:



Screening programmes for the early detection and prevention of oral cancer
Psychological interventions to improve adherence to oral hygiene instructions in adults with periodontal
diseases
Domestic violence screening and intervention programmes for adults with dental or facial injury
3. The ADA Center for Evidence-Based Dentistry provides systematically assessed evidence as tools
and resources to support clinical decisions to integrate evidence into patient care:
 Screening for Oral Cancer


Evidence-Based Clinical Recommendations Regarding Screening for Oral Squamous Cell Carcinomas
Infective Endocarditis
Prevention of infective endocarditis: Guidelines from the American Heart Association
Tobacco
Treating Tobacco Use and Dependence: Clinical Practice Guidelines from the US Department of Health and
Human Services
IV. Best Practice Criteria
The ASTDD Best Practices Project has selected five best practice criteria to guide state and community
oral health programs in developing their best practices. For these criteria, initial review standards, are
provided to help evaluate the strengths of a program or practice to prevent and control tooth decay in
adults and older adults.
1. Impact / Effectiveness
● A practice or program enhances the processes to improve oral health status and/or
improve access to dental care for adults and older adults.
Example: Increased number of programs to train physicians, nurses, and dentists to
provide preventive oral health services for adults and older adults or
increased number of providers being trained.
● A practice or program produces outcomes that improve oral health status and/or improve
access to dental care for adults and older adults.
Example: Reduced dental caries experience, untreated decay or periodontal disease
among adults and older adults; reduced risks of oral diseases and conditions;
or increased utilization of preventive services.
2. Efficiency
● A practice or program shows cost savings in preventing oral disease and reducing the
extent of treatment needs for adults and older adults.
Example: Increased savings based on the comparison of the cost for delivering
prevention services to the projected cost of restorative treatment for averted
tooth decay.
● A practice or program shows leveraging of federal, state, and/or community resources to
improve the oral health of adults and older adults.
Example: Expanded partnerships among public and private stakeholders to support an
oral health program for outreach, case management, preventive services, and
dental restorative care for high-risk adults and older adults.
3. Demonstrated Sustainability
● A practice or program that has demonstrated sustainability or has a plan to maintain
sustainability.
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Best Practice Approach: Adult and Older Adult Oral Health
15
Example:
A program that has served adults or older adults for many years and receives
agency line-item funding or reimbursement from public and private insurers.
4. Collaboration / Integration
● A practice or program establishes partnerships or collaborations that integrate oral health
efforts with other disciplines to improve the general health of adults and older adults.
Example: The state oral health and adults/older adults programs working collaboratively
to improve systems of care (such as coordination between medical and dental
homes) and financing for oral health.
5. Objectives / Rationale
● A practice or program aligns its objectives with the national or state agenda to improve the
oral health and general health of adults and older adults.
Example: Program objectives target Healthy People 2020 objectives to reduce caries
experience, untreated decay, and use of the oral health care delivery system.
V. State Practice Examples
The following practice examples illustrate various elements or dimensions of the best practice approach
of Adults and Older Adults Oral Health. These reported success stories should be viewed in the context of
the states and program’s environment, infrastructure and resources. End-users are encouraged to review
the practice descriptions (click on the links of the practice names) and adapt ideas for a better fit to their
states and programs.
A. Summary Listing of Practice Examples
Table 1 provides a listing of programs and activities submitted by states. Each practice name is linked to
a detailed description.
Table 1.
State Practice Examples Illustrating Strategies and Interventions for
Adult and Older Adult Oral Health
#
Practice Name
State
Practice
What other categories?
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Best Practice Approach: Adult and Older Adult Oral Health
16
B. Highlights of Practice Examples
Highlights of state practice examples are listed below.
VI. Acknowledgements
This report is the result of efforts by the ASTDD Best Practices Committee to identify and provide
information on developing successful practices that address the oral health of adults and older adults.
The ASTDD Best Practices Committee extends a special thank you to __________________ for their
partnership in the preparation of this report.
This publication was supported by Cooperative Agreement U58DP001695 from CDC, Division of Oral
Health and by Cooperative Agreement U44MC00177 from HRSA, Maternal and Child Health Bureau.
Suggested citation: Association of State and Territorial Dental Directors (ASTDD) Best Practices
Committee. Best practice approach: adult and older adult oral health [monograph on the Internet].
Sparks, NV: Association of State and Territorial Dental Directors; 2012 Month Date. __ p. Available
from: http://www.astdd.org.
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Best Practice Approach: Adult and Older Adult Oral Health
17
VII. Attachments
ATTACHMENT A
Strength of Evidence Supporting Best Practice Approaches
The ASTDD Best Practices Committee takes a broad view of evidence to support best practice
approaches for building effective state and community oral health programs. The Committee
evaluated evidence in four categories: research, expert opinion, field lessons and theoretical
rationale. Although all best practice approaches reported have a strong theoretical rationale, the
strength of evidence from research, expert opinion and field lessons fall within a spectrum. On
one end of the spectrum are promising best practice approaches, which may be supported by
little research, a beginning of agreement in expert opinion, and very few field lessons evaluating
effectiveness. On the other end of the spectrum are proven best practice approaches, ones that
are supported by strong research, extensive expert opinion from multiple authoritative sources,
and solid field lessons evaluating effectiveness.
Promising
Best Practice Approaches
Proven
Best Practice Approaches
Research
Expert Opinion
Field Lessons
Theoretical Rationale
Research
Expert Opinion
Field Lessons
Theoretical Rationale
+
+
+
+++
+++
+++
+++
+++
Research
+
++
+++
Expert Opinion
+
++
+++
Field Lessons
+
++
+++
A few studies in dental public health or other disciplines reporting effectiveness.
Descriptive review of scientific literature supporting effectiveness.
Systematic review of scientific literature supporting effectiveness.
An expert group or general professional opinion supporting the practice.
One authoritative source (such as a national organization or agency) supporting
the practice.
Multiple authoritative sources (including national organizations, agencies or
initiatives) supporting the practice.
Successes in state practices reported without evaluation documenting
effectiveness.
Evaluation by a few states separately documenting effectiveness.
Cluster evaluation of several states (group evaluation) documenting
effectiveness.
Theoretical Rationale
+++ Only practices which are linked by strong causal reasoning to the desired
outcome of improving oral health and total well-being of priority populations will
be reported on this website.
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Best Practice Approach: Adult and Older Adult Oral Health
18
VIII. References
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Best Practice Approach: Adult and Older Adult Oral Health
19