Oral Disease Prevention Model in Long Term Care: WHO Systems Thinking Framework

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PROJECT SUMMARY Currently, 1.5 million older adults live in Long Term Care (LTC) facilities and that number is increasing. Their need for dental care is also growing since almost 70% of older adults are now dentate. Even though dental caries and periodontal disease are preventable, 96% of dentate adults over age 65 years have caries experience, at least 20% are living with untreated decay and 68% have periodontal disease. Both conditions are the result of dynamic processes which are accelerated by polypharmacy, comorbidities, and frailty. Although there is no national data regarding the oral health status of long-term care (LTC) residents, small cohort studies consistently document that LTC residents have substantially worse oral health than the population of community-dwelling elders. Faced with the burden of declining health and diminished independence, older adults in LTC are less likely to access dental care and more likely to develop new cavities and worsening periodontal disease, hence preventive care is vital. However, most research in oral health and LTC has focused on care-pathways for receiving restorative treatment, but significant barriers exist which limit LTC residents’ ability to access this care. Alternatively, there is a focus on having care assistants perform oral hygiene care (OHC), when in practice they are often not provided adequate training or time to offer the OHC. This is further complicated by the fact that the residents of LTC are experiencing diminishing independence and increasing frailty. Given the complexity of the LTC setting, a siloed biomedical approach to disease management is also unlikely to reduce new dental caries and periodontal bone loss and the resultant burden. To address this complexity, this project will use the Health Co-design toolbox together with the WHO Health Systems thinking framework to co-design a system intervention to reduce the increment of caries and periodontal disease. This investigation will seek to understand the experiences of residents and staff as a starting point for developing a comprehensive model of preventive oral health care. Initially, the current system supporting oral health in LTC will be mapped through a retrospective clinical audit and a series of focus groups. Then, a design team of stakeholders will work with investigators to co-design an intervention that works on multiple agents and processes within the system. Possible examples include, clinicians assessing caries risk and prescribing preventive agents, equipping in-house dispensaries with oral hygiene aides, and EMRs prompts to initiate oral health referrals for certain medical diagnosis. Simulation Modelling, based on system mapping data, will conceptualize the effects of the intervention by using different mechanism of prevention and different patterns of disease. An external advisory panel will provide feedback on qualitative data and the system intervention protocol. If proven effective, this model has the potential to inform public policy and reduce the oral health inequities experienced by 1.5 million LTC residents in the U.S.