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Authors : Dr. Hemant Goel, Dr. Ajay Gupta, Dr. Tushyata Chandhok.

Who Are the “Frail Elderly”?

Ettinger and Beck1 developed a functional definition of the elderly based upon an older person’s physical ability to seek dental services. The categorization that they developed is threefold:
  • The functionally independent older adult
  • The frail older adult
  • The functionally dependent older adult.

According to this schema, the vast majority of older adults, 70 percent, are able to get to the dentist and are categorized as functionally independent. About 14 percent of community dwelling elderly fall under the frail adult category. These are persons with chronic conditions that create major limitations in mobility. About 5percent of community-dwelling elderly are homebound or functionally dependent.2 Another group of functionally dependent older adults are those who are institutionalized in nursing homes.

Another way to classify the frail elderly is to count the seniors who have one or more physical or mental disabilities. The concept of disability includes several dimensions of health and functioning, and several conceptual frameworks have been used to define this term. The percentages with disabilities increase sharply with age. The percentage of those age 80 or older having difficulty with activities of daily living is about double that of the 65 or older population.3

Older adults who face great dental access barriers due to physical limitations and functional dependence will be referred to as the “frail elderly.” This includes the medically compromised and homebound living in the community, as well as those institutionalized in nursing homes.4


Some older adults, dependencies resulting from chronic illness are managed by a combination of family and/or professional services provided in their homes. Although homebound, these individuals maintain some level of independence. Strayer5 characterizes the homebound elderly as:
  • Dependent in physical function.
  • Cognitively impaired.
  • Incontinent.
  • Economically disadvantaged.
  • Users of home services.
  • Less likely to be living alone.

When the severity of impairment, whether physical, medical, or emotional, can no longer be managed in the home, institutionalization and loss of independence results. The 1995 National Nursing Home Survey6 describes elderly nursing homes residents as:
  • Female.
  • 75+ years of age.
  • White, non-Hispanic.
  • Widowed.
  • Dependent in Activities of Daily Living (ADL; i.e. bathing, dressing, eating, transferring, toileting.)
  • Dependent in Instrumental Activities of Daily Living (IADL; i.e. care of personal possessions, managing money, securing personal items, using the telephone.)
  • Incontinent.
  • Relying on Medicaid as primary source of payment.


As American’s life expectancy lengthens-and the older population, in turn,increases- dental professionals will be treating more older adults. Yet the 2004 qualitative assessment of dental care access indicates that older patients face a wide range of barriers to oral care management issues and frustration for dental professionls.

What are these barriers? And how can practioners overcome them to improve the oral health- and overall quality of life- of older patients as part of a thriving, more effective and rewardingdental practice?

Barriers to Dental Care

Barriers to dental care have been investigated in adult populations for several years.7 Recently, it was found that the importance of barriers varies according to various population segments. Penchansky and Thomas8 define these barriers as availability, accessibility, accommodation, affordability and acceptability.

Barriers to dental care occur for both the functionally independent individual and the functionally dependent person residing at home or in an institution. The main barrier is the perceived need for oral health care. Even though there is now a higher utilization of dental care,1 those aged 65 and older are still least likely to use dental services (except for children under six).9 The majority of dentate and edentulous elderly believe they have no need for dental care until they develop pain or eating difficulties, or suffer from social embarrassment.10,11 Institutionalized elderly have a higher normative need and a lower perceived need than less dependent groups.12

Additional barriers include the functional and medical status of the individual, transportation and accessibility difficulties, financial considerations, previous patterns of dental utilization, lack of education, and fear.13,14 It is important, therefore, that education in geriatric dentistry include not only the practical, clinical aspects of treating the elderly, but the social, environmental, psychological, behavioural and financial aspects as well. Dentists’ attitudes toward the treatment of older patients can also create barriers. We must be aware that the time is fast approaching when the demand for geriatric care will far exceed the number of dentists currently willing and able to provide such care.


Office buildings should be accessible to the physically and mentally challenged, and private dental offices or dental departments should be designed for easy access. Some important factors to consider are:15
  • carefully selecting and placing signs to support the communicative independence of the elderly patient;
  • using firm, standard-height chairs with arms for support;
  • providing adequate lighting in each room, to minimize any visual disorientation or mental confusion; and avoid small prints. Use contrasting paper and ink colors for written materials.
  • setting up office furniture to promote and facilitate good communication and access. It should be not low to the floor, firm, with arms.
  • No stairs (ramp or elevator)
  • Adequate, safe parking
  • To reduce risk of falls, flooring should be consistent throughout the office. No deep pile carpeting.
  • No throw rugs or clutter on the floor (watch hoses and cords).
  • No slippery area/ surfaces

To adjust to age-related hearing loss:16
  • Stand closer to the patient
  • Enhance visual and additory clues
  • Remove mask
  • Maintain face-to-face, eye level, eye contact
  • Touch appropriately
  • Drop pitch, speak distinctly
  • May increase volume but do not yell
  • Minimize background noise
  • Use quiet locations for interaction
  • Turn off any music
  • Turn off dental equipment whenever possible

Other communication enhancements:
  • Use titles and surnames unless asked specifically to use first
  • name
  • Provide written instructions to reinforce verbal
  • Communicate with caregivers as appropriate
  • Do not communicate with caregivers at the expense of
  • speaking with the patient

In addition, the operatory should accommodate wheelchair patients or those who use walkers. In some cases, dentists might consider an operatory equipped to treat the patient in a wheelchair.


Portable dental equipment can be used to service the functionally dependent elderly at home or in nursing homes. This equipment varies from a domiciliary valise to a portable dental office, either housed in a van or set up in an available room in a nursing home. Investment will be governed by the amount of work available and the location of the service provided. For dentists wanting to supplement their practice by providing a domiciliary service, only a modest investment is necessary, but if a strategic move into geriatric treatment in nursing homes is envisaged, more complex and comprehensive equipment is necessary. Training and experience in the use of new portable equipment is clearly essential before embarking on such a service commitment.17
Mobile Equipment delivered during the evening

Attitude of Dental Professionals

Why is there a comparatively low utilization rate for dental care of the elderly despite the normative and perceived needs? Why has this market not been targeted? Why aren’t graduating dental students more willing to fill this void?

Possible answers to these questions include:
  • lack of experience and fear when treating geriatric problems;
  • lack of financial incentives;
  • transportation and access problems to the dental office;
  • special problems that exist in providing dentistry to homebound and institutionalized patients;
  • negative attitudes toward the elderly’s need for dental care and their low perception and motivation for oral health care;
  • the poor oral health status of the elderly, resulting in an edentulous state or teeth compromised by periodontal disease;
  • difficulties dealing with debilitating and life-threatening illnesses;
  • the problem of informed consent and of family members or residential facility staff members with negative attitudes.18

Dealing with the elderly requires an understanding of and a sensitivity to the medical, psychological and financial states of these patients. Our education system will have to change to address these emerging issues. The traditional educational and practice structures currently in place are based on serving the needs of a healthy and affluent population.19 An infrastructure that will allow these issues to be addressed will have to be created.

Unlike the United States, where a number of programs are already in place, Canada has not yet responded to this lacuna in the education of both undergraduate and graduate students. It is important that we learn from these experiences to ensure the success of future strategic moves in dental education.


Outlining the issues in geriatric dentistry is not enough. The threat exists for teeth that were carefully maintained throughout childhood and adulthood to be compromised due to diverse medical, behavioural and financial factors. Ensuring patients get the oralcare they need is an important part of every dental professionals’ practice management. Through awareness of patient barriers to regular oral care, strong communication, a complete understanding of patients overall health,and accessible facilities, dental professionals can help retain older patients as a part of the oral care system and improve oral health for this underrepresented demographic.

  1. Ettinger RL, Beck JD. Geriatric dental curriculum and the needs of the elderly. Spec Care Dentist1984;4:207-13.
  2. Leon J, Lai RT. Functional status of the non-institutionalized elderly: Estimates of ADL and IADL difficulties. Rockville (MD): U.S. Department of Health and Human Services, Agency for Health Care Policy and Research. 1990. DHHS Publication No. (PHS) 90-3462.
  3. Administration on Aging. Profile of Older Americans: 2000. Available at:www.aoa.gov/aoa/stats/profile/default.htm. Accessed February 2, 2001.
  4. Helgeson MJ, Smith BJ, Johnsen M, Ebert C. Dental Considerations for the Frail Elderly . Spec Care Dentist 2002; 22(3):40S-55S.
  5. Strayer M. Oral health care for the homebound and institutional elderly. J California Dent 1999;27:703-8.
  6. National Center for Health Statistics. National Nursing Home Survey. Available at: http://www.cdc.gov/nchs/about/major/nnhsd/ nnhsd.htm. Accessed February 3, 2001.
  7. Finch H, Keegan J, Ward K, and others. Barriers to the receipt of dental care — a qualitative research study. 1988. London. BDA.
  8. Penchansky R, Thomas JW. The concept of access — definition and relationship to consumer satisfaction. Med Care 1981; 19:127-40.
  9. Kiyak HA. Reducing barriers to older persons’ use of dental services. Int Dent J 1989; 39:95-102.
  10. Fiske J. Consideration of dental needs and barriers to and benefits from dental care in an elderly population [M. Phil. thesis]. University of London, 1988.

References Are Available On Request

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