Factors affecting dental service utilisation among older Singaporeans eligible for subsidized dental care - a qualitative study.

BACKGROUND: The World Health Organization has highlighted the paucity of research into the oral health needs of older adults. In Singapore, until recently, publically funded/subsidized oral health care for adults has been limited to basic primary care at government-funded polyclinics. Access to a more comprehensive range of subsidized care in the private sector was widened through the government-funded Community Health Assistance Scheme (CHAS) in 2012 and Pioneer Generation (PG) scheme in 2015. Little is known about the attitude to dental service utilization among older adults in Singapore since then. METHODS: We conducted semi-structured individual interviews with 25 participants above 65 years of age who were eligible for subsidized dental care plans. Participants were recruited from a public teaching hospital and a public primary care clinic in Singapore. The duration of each interview was 15-30 min. Interviews were transcribed verbatim and the transcripts were analyzed thematically using a phenomenological approach. RESULTS: Pertinent themes emerged related to four major areas: (a) general awareness towards oral health, (b) life course perspective of oral health, (c) barriers to visit the dentist, (d) shaping dental service utilisation behaviours through provision of financial subsidies for dental care. Most participants perceived a strong relationship between oral health and systemic health. However, there were erroneous traditional beliefs such as oral health is not part of physical health and edentulous participants did not need to visit a dentist. Fear, anxiety, previous negative experience and lack of knowledge were barriers to visiting the dentist. Trust and convenience were considerations for patients when deciding whether to switch from public to private dental services where CHAS/PG were only available. CONCLUSION: Our study provided important insights regarding oral health perceptions and beliefs of older people residing in the community which may affect their dental service utilization. This further highlights the importance of understanding the concerns of this group when implementing healthcare policies for elderly in Singapore. The findings of our study will serve as a baseline for future studies in Singapore and inform studies in other countries that implement targeted schemes for older adults.

Acceptance of silver diamine fluoride use in community dwelling older adults, nursing home residents, and caregivers.

OBJECTIVES: To compare the level of acceptance of silver diamine fluoride (SDF) treatment between different functional groups of older adults aged 65-years-old and above. METHODS: Three groups were recruited representing functionally-independent ("Community dwelling"), frail ("Nursing home"), and functionally-dependent older adults ("Caregiver": proxy respondent involved in caring for an older adult of all functional levels). Participants viewed a video on SDF and an interviewer-led questionnaire collected demographics, dental experience and perception on SDF use. RESULTS: The study recruited 201 participants (100 "Community dwelling", 51 "Nursing home", 50 "Caregiver"). Overall, 73 % of participants were accepting of SDF treatment. Those in the "Community dwelling" group were most accepting (85 %), followed by the "Nursing home" group (61 %) and "Caregiver" group (60 %) (p<0.001). Participants were more accepting of SDF use on posterior (73 %) compared to anterior teeth (46 %). They were more accepting when SDF was presented as a treatment to avoid infection and pain (87 %), and general anesthesia (78 %). In a regression analysis, "Nursing home" and "Caregiver" participants were three times less likely to accept SDF (OR 0.27 [95 % CI: 0.13 to 0.60], and OR 0.27 [95 % CI: 0.12 to 0.58] respectively) compared to "Community dwelling" participants. After adjusting for other factors, only the "Caregiver" group remained significant (Adjusted OR 0.32 [95 % CI: 0.13 to 0.78]). CONCLUSIONS: Older adults were accepting of SDF and this treatment modality has the potential to be a routine treatment option in dental caries management in this population. However, this was less certain among frail and functionally dependent older adults. CLINICAL SIGNIFICANCE: An SDF program to manage caries is likely to be well-received by functionally-independent older adults. However, the acceptance among frail and functionally-dependent older adults were lower even though SDF is mostly likely to benefit these populations. There is a need to investigate this relatively lower levels of acceptance.

Functional Dentition, Chronic Periodontal Disease and Frailty in Older Adults-A Narrative Review.

BACKGROUND: The likelihood of experiencing the impact of chronic disease rises with age, and cumulative functional deficits over time increase the risk of frailty in older adults. The exact causes of frailty are not clear, and research is needed to identify appropriate intervention measures to reduce risk of developing frailty in old age. OBJECTIVE: To review the evidence on the relationship between frailty, dental status and chronic periodontitis and to determine if improvements in oral health of older adults can contribute to reversal of frailty. RESULTS: The oral cavity is the entry point to the gastro-intestinal tract, and natural teeth facilitate efficient mastication of food prior to swallowing and subsequent digestion. The loss of natural teeth, which is gradual and cumulative over the life course, is associated with diminished nutritional intake, especially in older adults. Furthermore, chronic periodontitis has been postulated as a risk factor for frailty. The evidence supporting a strong relationship between oral health status and frailty is not clearcut. Cross sectional studies suggest an association with missing teeth and chronic periodontal inflammation. However, there are very few longitudinal studies and accordingly, it is not currently possible to claim a causal relationship. As yet, there is no evidence to suggest that improvements in oral health contribute to reversal of frailty. CONCLUSION: Longitudinal studies with robust designs are required to better inform the relationship across functional dentition, chronic periodontitis and frailty in older adults.