Access to care for all elderly is complicated by ability to pay for services, but other barriers, such as transportation, source of usual care, ability to navigate the dental care system, language, culture and medical, functional and cognitive declines play a major role in seniors' ability to utilize dental services. Further, the dental workforce, is not specifically trained to provide services to the elderly, making delivery of culturally, medically and functionally appropriate care difficult. Many of these barriers take on special significance based on seniors' living situations – cognitive declines and a poorly trained workforce are important issues for institutionalized elderly, while transportation and functional declines constitute a major barrier for community-dwelling elderly.

Community-dwelling vs. Institutionalized elderly

Institutionalized elderly

In 1987, the Omnibus Reconciliation ACT (OBRA ’87) revised the federal standards of care requirements for nursing homes. This legislation requires that nursing homes receiving Medicare and Medicaid provide services so that each resident can "attain and maintain her highest practicable physical, mental, and psycho-social well-being." Specifically, the legislation placed a greater emphasis on a resident’s quality of life and quality of care, mandated that each resident would receive a standardized assessment that would result in an individualized care plan. As a result of these measures, older adults in institutionalized settings receive a basic oral health examination at admission and annually in the long-term care (LTC) facility. A number of studies have suggested that the quality of examinations is poor and that the providers primarily charged with making oral assessments are not specifically trained to do so. While LTC facilities are required to provide palliative and emergency care, there is no federal or local requirement for the provision of comprehensive care, which is often dictated by the way in which the facility allocates Medicaid dollars and/or the resident’s ability to pay for private care. Further, the LTC facility is not required to provide on-site dental care, but to facilitate provision of care, implying that dental care can be provided by contract providers on a part-time or as-needed basis.

The OBRA legislation dictates that older adults residing in nursing homes do not experience transportation as a barrier to care. However, since most institutionalized adults have extensive medical, functional and/or cognitive co-morbidities, these represent significant barriers to professional care and personal daily care. Dental providers are not specifically trained to provide care individuals with significant cognitive decline who may be combative, refuse to open their mouths, or be afraid of procedures or instruments. Further, residents with severe cognitive dysfunction may be unable to articulate the need for care or describe symptoms of disease, and nursing home staff are not specifically trained to provide daily oral care.

Community-dwelling elderly

There is growing interest in preventing institutionalization of the elderly for economic reasons and also because social, cognitive and quality of life outcomes appear to be better for seniors living in the community. Although access to and utilization of dental services are not an issue for community-dwelling elderly who are able to pay for services, functional or cognitive declines may make access to dental services difficult even for older adults who can afford care. Dentists are not adequately trained to provide mobile dental services, or to manage patients with medical and cognitive complications in the home setting, and unlike institutionalized elderly, there are no federal or state provisions to provide periodic dental services to this population. As a result, community-dwelling elderly on a fixed income, especially those with functional, cognitive or medical co-morbidities are least likely to receive dental care.

Personal Care

Unlike many of the medical conditions experienced by the elderly, declines in oral health can be mitigated by regular professional and good daily oral care. Although the scope of practice of home health aides allows them to provide daily care services such as tooth brushing, home care workers are not required to receive training about the provision of daily oral care and it is not monitored. In addition, nurses in the homecare system are not required to assess the oral cavity or oversee daily oral care by home care workers.

Workforce

The cultural and structural barriers to care are compounded by a lack of geriatric oral health care professionals. Although the dental profession should be the primary caretaker of the older adult’s dentition, geriatric dentistry is not a specialty of dentistry; dental and dental hygiene students are provided with a small number of curriculum hours devoted to geriatric dentistry at the pre-doctoral level. Postdoctoral training is funded by the Health Resources and Services Administration (HRSA) through fellowship mechanisms but fewer than ten geriatric dentistry fellowships are funded by HRSA each year. Although a variety of continuing education courses on geriatric dentistry are offered, the effects of these courses on dentists’ professional practices is unknown.