Introduction: Addressing the Needs of Dental Patients With Chronic Conditions: A Look Into the Future

GUEST EDITOR Jayanth Kumar, DDS, MPH, is the state dental director for the California Department of Public Health. Conflict of Interest Disclosure: None reported.

The coronavirus disease 2019 (COVID-19) pandemic has caused more harm to patients with preexisting, chronic conditions such as diabetes and obesity than healthy patients. As of June 30, 2021, the 65 and older age group accounted for 73.3% of 63,023 confirmed COVID-19-related deaths in California, suggesting an increased susceptibility in part due to higher rates of chronic diseases. [1] As a result, this pandemic has brought increased attention to the needs of older adults and those suffering from chronic conditions.

Moving forward, the needs of older adults will require greater attention from U.S. policymakers and health care providers. In the recently released “Master Plan for Aging,” Gov. Gavin Newsom wrote, “Ten years from now, California will be home to 10.8 million people age 60 and over — nearly twice as many as in 2010. One out of every four Californians will be older adults, a seismic demographic shift that will change every aspect of our lives, from the structures of our families and communities to the drivers of our state’s economy.” [2] According to this report, nearly half of all Californians will develop one or more chronic illnesses. Nearly 9 in 10 older adults take at least one prescription drug, with 1 in 4 finding their costs unaffordable, even with insurance coverage. Older adults are also at particular risk for mental health issues like depression. [3] Another challenge Californians face is that approximately 20% of all people 65 and older live in poverty. One-quarter of people over 65 rely almost entirely on their Social Security benefits, which average about $1,500 per month for retired workers and $1,250 per month for disabled workers.

This issue of the Journal spotlights the burden of chronic diseases and its implications for dentistry. The California Department of Public Health 2020 report titled “The Burden of Chronic Disease, Injury and Environmental Exposures, California” provides a snapshot of chronic conditions, injuries and environmental exposures in the state. [4] Approximately 40% of California adults reported having at least one chronic condition: serious psychological distress, high blood pressure, heart disease, diabetes or asthma. One in every six children in California and 1 in 3 teens are already overweight or obese, which is a risk factor for cardiovascular disease, cancer and other chronic diseases. In 2016, an estimated $141 billion in direct costs was spent treating six chronic conditions in California: cardiovascular diseases, arthritis, cancer, diabetes, depression and asthma. [5]

In a previous issue of the Journal, we discussed [6] the prevalence of tooth loss among Californians. In the combined years of 2014 and 2016, the prevalence of severe tooth loss among California adults (aged 25 years and older) was 41.4%. The prevalence of tooth loss was higher among people with diabetes compared to those without diabetes (63.6% versus 38.7%). It was also associated with smoking, a common risk factor for many chronic diseases. Furthermore, there was disparity with respect to race/ ethnicity, income and education. Severe tooth loss (six or more teeth) was more common among older adults (25.9%). The findings have enormous implications for dentistry. Future generations of older adults will have higher expectations to eat well, socialize more and enjoy a better quality of life. Therefore, older adults will likely opt for dental implants to replace missing teeth instead of unsupported dentures. While Medicare covers many types of implants, including cochlear, dental implants are not a covered benefit. This coverage gap is one of many challenges dentistry will have to face.

About 690,000 Californians aged 65 and older are living with Alzheimer’s disease. [7] In this issue of the Journal, Paul Glassman, DDS, MA, MBA, discusses the management of dental patients with dementia. He has offered a thoughtful approach, which consists of planning treatment, supporting behavior during dental treatment and encouraging daily mouth care. In addition, dental practitioners may explore the concept of “community-engaged oral health systems” to help people with Alzheimer’s disease and dementia obtain and maintain good oral health. Annually, an average of nearly 35,000 HPV-related cancers occur in the U.S., and more than 90% percent of HPV-related cancers are preventable through HPV vaccination. Yet, only about 54.2% of teens were fully vaccinated against HPV in 2019, a slight improvement compared to 51.1% in 2018. [8] In this issue, Alessandro Villa, DDS, PhD, MPH, and Dalton Pham, BS, discuss the role of dental professionals in preventing HPV-related cancers. Much like dental professionals’ role in addressing COVID-19 vaccine hesitancy, dental practitioners are well-positioned to promote HPV vaccination by providing counseling.

Dental professionals can play a significant role in addressing hypertension and heart disease by screening their patients.

In California, approximately 63,000 people die each year from heart disease. Stroke and hypertension cause more than 21,000 deaths. [9] Dental professionals can play a significant role in addressing hypertension and heart disease by screening their patients. John Welby, MS, and colleagues discuss the Maryland Hypertension Screening in the Dental Setting pilot program to address a major risk factor for heart disease. Forty-seven dental practices were recruited and trained and conducted blood pressure screenings over 15 months. About 2,689 patients (7.2%) exceeded the blood pressure threshold and were referred to primary care practices for follow-up evaluation. This pilot program offered many lessons and identified opportunities for medical-dental integration.

At the national level, there are several initiatives to integrate medical and dental systems. The Centers for Disease Control and Prevention Division of Oral Health awarded funding to the National Association of Chronic Disease Directors to develop a national framework for medical-dental integration. The Health Resources Services Administration developed the Integrating Oral Health and Primary Care Practice (IOHPCP) initiative to improve the knowledge and skills of primary care clinicians and promote interprofessional collaboration across health professions. The “Oral Health Delivery Framework” developed by a partnership of experts offers a practical model for partnership between primary care and dentistry. [10] The National Interprofessional Initiative on Oral Health sponsored the “Oral Health Integration in Primary Care Project” to implement the framework. [11] As part of a paper commissioned for the Roundtable on Health Literacy of the National Academies of Sciences, Engineering and Medicine, Atchison and colleagues [12] discussed the importance of incorporating oral health literacy principles into all levels of a health care organization, establishing formal collaboration and referral networks, conducting research and demonstration programs on the integration of oral health into primary care and developing effective linkages between primary care teams and dentists in private practices.

As the population ages and develops multiple chronic conditions, dental practitioners will need to communicate more frequently with primary care providers. In the medical setting, this happens primarily through the electronic platform. However, dentistry is not well connected with such platforms. As noted by the Health Policy Institute of the American Dental Association, physicians are dissatisfied with current referral systems to dentists. [12] Resolving this will require the development of an integrated electronic referral management system. In addition, dental practitioners should also be prepared to collaborate with other health care teams to address the problems of patients with multiple chronic conditions.

REFERENCES

1. Tracking COVID-19 in California. Infections by group. Accessed July 1,2021. covid19.ca.gov/state-dashboard.

2. California Department of Aging. Master Plan for Aging. A Message from Governor Gavin Newsom, p. 2. 2021.

3. California Department of Aging. Master Plan for Aging. Goal Two. Health Reimagined, p. 10. 2021.

4. California Department of Public Health, Center for Healthy Communities. The Burden of Chronic Disease, Injury and Environmental Exposure, California, 2nd ed. 2020.

5. Yoo BK, Xing G, Hoch JS, Taylor C, Núñez de Ybarra J. Economic Burden of Chronic Disease in California in 2018.

6. Cigarette smoking and tooth loss in California: The role of dental professionals in promoting tobacco cessation. J Calif Dent Assoc 2019;47(2):97–102.

7. Alzheimer’s Association. 2021 Alzheimer’s Disease Facts and Figures. www.alz.org/alzheimers-dementia/facts-figures.

8. Elam-Evans LD, Yankey D, Singleton JA, et al. National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13–17 Years — United States, 2019. MMWR Morb Mortal Wkly Rep 2020 Aug 21;69(33):1109–1116. doi: 10.15585/mmwr.mm6933a1.

9. Centers for Disease Control and Prevention. Stats of the State of California. www.cdc.gov/nchs/pressroom/states/california/ california.htm.

10. Qualis Health. Oral Health: An Essential Component of Primary Care. White paper. June 2015.

11. National Interprofessional Initiative on Oral Health. Oral Health Integration Implementation Project. www.niioh.org/ Implementation-Guide.

12. Atchison KA, Rozier RG, Weintraub JA. 2018. Integration of oral health and primary care: Communication, coordination and referral. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, D.C. doi.org/10.31478/201810e.