Our health system neglects the oral health of dependent seniors with tragic consequences

By Mary McNally

Some years ago, a retired university professor visited my dentistry practice. He was fit and had a pleasant smile. He hadn’t seen a dentist in over five years, partly because he had lost his private health benefits when he retired, so it wasn’t surprising that he needed dental care. He had most of his own teeth but required a couple of extractions for advanced gum disease along with some other minor routine care.  His was not an unusual pattern for someone 76 years old, but there was no reason to predict that he would lose any more teeth if they were looked after.

I didn’t see this patient again for three years. The change in his dental health was dramatic.

Shortly after our first visit, the professor had a stroke.  As a result, he spent 18 months in acute and rehabilitative care and had been living at home with home support care for over a year.  When I saw him this time, we were able to save only four of his teeth with the remainder lost to rampant decay and gum disease.

The professor’s downward spiral seems dramatic, yet stories like his are becoming increasingly common for older adults.

Like many others of his generation, he was likely the beneficiary of the protective effects of fluoridated water and toothpaste throughout his life. He had a good education and a good job with dental benefits. He was a senior who should not have been destined for dentures.

So what happened?

“With age comes a mouthful of trouble” is a cautionary line that rings all too true.  When my patient retired and lost dental benefits, regular visits to the dentist ceased – possibly when he needed them most.  Following his stroke, he was required to rely on in-patient acute care, rehabilitative care and then continuing care to support his routine personal mouth care needs. 

In Canada, these care systems are known to have inadequate infrastructures and standards of care in place to support oral health.  Advocating for a dependent loved-one, retired Nova Scotia nurse Lillian Sutherland recently challenged others to “have a look in your loved one’s mouth to see his/her state of care.  Can you imagine not having your teeth cleaned for months, or never?”  That’s the reality for too many Canadian seniors. 

The mouth is the entry point to a healthy body — to eat, drink and breathe — and to life’s pleasures of socializing and communicating with others. Yet as a focus of general and personal health, the mouth remains separate from the body in our publicly funded healthcare system. This is a double-edged problem for the increasing numbers of Canadians who are frail and dependent.

Although it tends to get the greatest attention, the problem doesn’t arise only from difficulty accessing professionally delivered oral health services external to the public health system.  Often an oral health crisis comes about simply because the necessary day-to-day oral health care required from within publicly supported institutions and programs fails our seniors.  

On the surface, brushing and flossing may seem to be mundane tasks.  But when providing this care for others, it requires skill, the right resources and the commitment and will to ensure it is done well and regularly.

Efforts are being made to respond to these needs.  For example, the Registered Nurses Association of Ontario has developed the Oral Health Nursing Best Practice Guidelines which aims to address the daily oral care needs of dependent adults and are applicable to multiple care settings including acute, residential and community practice settings. 

In Nova Scotia, Brushing up on Mouth Care translates oral care best practices into user-friendly and accessible toolkits and resources to enhance care, also across multiple care settings. 

Yet, until meaningful policy is introduced by relevant provincial health ministries to ensure that best practices for oral care assessment and care-planning are being met within each of these settings, gaps in this essential element of personal care will persist. 

Care providers in medicine, nursing, dentistry, rehabilitation and continuing care represent those whose voices for advocacy could go a long way toward improved quality of life for their patients, clients and loved ones.

Mary McNally is an expert advisor with EvidenceNetwork.ca,
a Professor in the Faculties of Dentistry and Medicine (Bioethics)
at Dalhousie University in Halifax, Nova Scotia and a member of
Canadian Frailty Network.  Her clinical and research interests largely
focus on developing pragmatic solutions and policy recommendations
to address inequity and access to oral health care for vulnerable populations.