Deborah Jacobi, RDH, MA

 />Dr. Sarah Crane is board certified in Internal Medicine and Geriatric Medicine and practices in Rochester, Minnesota. She, along with a mentor, Dr. Linda A. Ward, are also oral health champions. </p>
<p class=Dr. Crane shared with me one of several cases from early in her career that drove her to pursue a solution to meeting the dental needs of her vulnerable older patients. On rounds one day when she was a fellow at the Mayo Clinic under the supervision of Dr. Ward, a nurse reminded them that dental examinations were required under a new regulation. The elderly patient had been prescribed repeated rounds of antibiotics and hospitalized for fever of unknown origin. Donning gloves and running a finger along the patient’s teeth, the underlying problem became immediately clear: multiple broken and infected remnants of teeth.

In addition to the human cost of avoidable pain and infection in cases such as this one, the dollar amount required to pay for timely preventive dental care is a fraction of that required to treat the consequences of undiagnosed dental disease. Unbelievably to Drs. Crane and Ward, learning the source of infection was just the start of a many-month struggle to obtain care for this patient, and ultimately for many other older adults in the Rochester area.

When Drs. Crane and Ward began to make calls to find a dentist to remove the infected teeth, they discovered how few area dental offices accepted Medicaid. Also, most general dentists were not prepared to address the patient’s medical complexity. Determined searching was required before they found someone willing and able to remove the teeth, months later. How could this happen in Rochester, Minnesota, known internationally for high-quality health care delivery?

Barriers: cost, coverage, workforce and accessibility

The most often cited barrier to dental care is the cost. After years of employer-based coverage for routine preventive care and treatment, many older adults are dismayed to learn that dental services are not included in Medicare coverage. For those reliant upon Medicaid, dental benefits are optional, meaning they are determined by each state’s Medicaid program. In practice, they are limited in scope or significantly under-funded in most states. Beyond, and often exceeding the cost of care, are “hidden co-pays” such as transportation costs, including the cost of nursing staff time to accompany the patient to an office appointment from a nursing facility, and medical transportation fees. The nine recognized dental specialties do not include geriatrics or special needs. Most dental care is delivered in private offices, which are typically not well-equipped to treat medically complex patients with physical or cognitive disabilities.

Why does oral health matter for older adults?

The lack of both coverage and access to affordable oral health care comes at exactly the wrong time for older adults in this country. Through advances in dentistry over their lifetimes, more adults have kept more of their teeth than those in previous generations and, therefore, have higher expectations for their oral health as they age. They also are living to older ages, and therefore more likely to have developed chronic diseases such as diabetes and heart disease. Commonly prescribed medications for these and other conditions may cause dry mouth, reducing the natural cleansing flow of saliva, and leading to new decay along fillings, crowns and bridges. Decreased dexterity makes daily mouth care more difficult, increasing bacteria-laden plaque. The resulting mouth infections, tooth decay and periodontal disease can spread to other parts of the body, complicating the control of high-cost chronic diseases. Research shows that people receiving appropriate dental care have significantly lower overall health care costs.

Unwilling to watch the system fail their patients, Drs. Crane and Ward sought a lasting solution to meet the oral health care needs of vulnerable older adults in their community. Their search led them to Dr. Michael Helgeson, CEO and co-founder of Apple Tree Dental, a non-profit group dental practice established in 1985 to provide dental care to residents of nursing facilities in the Minneapolis/St. Paul area. Apple Tree now serves people of all ages and abilities in communities across Minnesota.

Drs. Crane and Ward were undeterred when Dr. Helgeson explained that, as a result of deep cuts to Minnesota’s Medicaid adult dental benefits, the non-profit was focused on sustaining existing programs and not in a position to expand. Not giving up, they convened medical, dental, philanthropic and civic leaders to highlight the problem and raise needed funds to bring Apple Tree to Rochester.

Apple Tree utilizes a proactive, prevention-oriented, patient-centered approach, called Community Collaborative Practice to advance its mission “to improve the oral health of all people, including those with special dental access needs who face barriers to care.” For older adults, dental hygienists visit long-term care facilities each month to provide mandated oral assessments and work with individual residents and direct-care staff to ensure appropriate daily mouth care. Dentists and dental therapists (a new mid-level provider in Minnesota,) provide examinations and treatment onsite using mobile dental offices for those residents choosing Apple Tree as their dental home. The team includes care coordinators who, using a cloud-based electronic health record, schedule appointments and needed consultations with medical providers. A dental liaison at each facility acts as point person and alerts Apple Tree of dental emergencies. Together, they are able to ensure that long-term care residents receive the preventive and restorative dental services needed for a healthy mouth.

Doctors Crane and Ward’s efforts led to the establishment of Apple Tree’s Rochester program in 2008 which today serves 13 assisted living facilities and nursing homes, two group homes and a behavioral health center, as well as community members of all ages. As a direct result, over 10,000 patients including 2,602 people over age 65 have received dental care since services began.

Does your community need an oral health champion, too?

Deborah Jacobi, RDH, MA is the policy director for Apple Tree Dental, a nationally recognized innovative nonprofit. Apple Tree operates six regional Minnesota dental programs, delivering comprehensive dental care in clinics and on-site care at more than 130 collaborating urban and rural community sites including Head Start Centers, schools, group homes, and long-term care facilities. In addition to her clinical dental hygiene background, she holds a Bachelor’s in Sociology and a Master’s in Public Policy and Health Administration from the University of Wisconsin – Madison.