Abstract: Comprehensive oral health coverage would allow us all to have good oral health, better overall health, and improved quality of life. Oral health is important to occupational therapy because both eating, and hygiene (including oral care) are activities of daily living. Additionally, good oral health is directly linked to better overall health and well-being!

Have you ever had a dream where all your teeth have shattered, or you lost them all, or there’s something wrong with your mouth and you don’t know what to do? Some psychologists hypothesize that nightmares like this are directly linked to your level of confidence, or the feeling you have during this nightmare; shock, horror, anxiety, confusion, sadness, disbelief. For many older adults, this is not a bad dream, this is reality.

A Healthy Smile Never Gets Oldreport, created by the Center for Oral Health (COH), provides data on older adults and oral health. The COH surveyed over two thousand older adults living in California from 2016 to 2017. They found almost half (48%) of older adults living in nursing facilities, and one third of community dwelling adults had untreated tooth decay. Tooth decay is important; if left untreated it can lead to tooth loss. The COH found 18% of community dwelling older adults had lost all their natural teeth, while the rate is 35% for older adults living in skilled nursing facilities. Of these numbers, 18% of community dwelling older adults have no dentures, 12% only have one pair of dentures, and 36% of older adults living in skilled nursing facilities have no dentures. These numbers are even worse for people living in rural areas; older adults in rural areas are 10% more likely to experience tooth decay, they lose more teeth, and are even less likely to have dentures. This means your nightmare reality includes the inability to chew or eat solid food.

For older adults, poor oral health impairs health, wellness, and quality of life. For these individuals, their friends, and family, this additionally causes occupational deprivation. Occupational deprivation is defined as a person’s inability to do what is important and necessary due to factors out of their control; for example, being deprived of the ability to eat solid food (Whiteford, 2000). Occupational deprivation will affect all areas of your life. including your physical health and well-being, participation and engagement in all occupations, and ultimately your mental health and quality of life. Without a healthy body occupational therapy interventions will be non transferable. If you are unable to eat and receive proper nutrition, you will not be able to build muscle or regain strength. As occupational therapists we have a responsibility to improve the public’s health, as it is fundamental to our ability to provide rehabilitative and habilitative services.

Poor oral health may mean no steak, no pizza, no salad, and no fruits of vegetables unless they’ve been pureed or prepared in a very specific tedious manner. Pureed food has poor flavor, texture, and appeal. Consumers of pureed food are especially vulnerable, as this diet often results in malnutrition, if not strictly supervised by a dietitian. Malnutrition leads to muscle wasting, weakened immunity, decreased energy and drive, an inability to attend to tasks, and poor digestive health, just to name a few problems (Vucea et al., 2018). All of these factors limit the individual’s ability to participate in meaningful occupations.

No Christmas ham, challah bread, Philly cheesesteaks, New York bagels, fair food, cheese burgers in the summer – food is a central aspect of religious, cultural, and social engagements. The inability to eat solid food due to pain, tooth loss, and/or an absence of dentures, affects individuals roles, rituals, and social participation. In addition to the occupation of eating, oral health and hygiene also affect socialization; the smell of your breath, your smile, your confidence, and self-esteem. Denial of the opportunity to eat solid fool, participate in desired roles and rituals, and decreased participation leads to social isolation.

The cumulative effect of older adults experiencing poor oral health and occupational deprivation is devastating. The impact this has on one's physical health, the change in roles and rituals, and the ability to participate in all occupations, ultimately leads to mental health challenges. Physically, a poor diet or malnutrition in a precursor to the development of anxiety, mood disorders, and depression in older adults (Harbottle, 2019). The loss of one's ability to perform roles and rituals that define them as an individual, in conjunction with a loss of control, leads to emotional turmoil. The emotional turmoil brought on by occupational disruption and deprivation can be described as strong negative emotions, including frustration, profound distress, feeling as though life is going downhill, increased vulnerability and thus anxiety, and overall extremely difficult emotionally (Nizzero, Cote, & Cramm, 2017). The results become cyclical; oral health affects the occupation of eating, a poor diet affects physical and mental health, your overall health affects volition and appetite, thus leading to malnutrition and the cycle continues.

Myth: decreased oral health is inevitable within the aging process. Fact: tooth decay, tooth loss, denture loss, and poor oral health are all preventable. Occupational therapists can play a key role in breaking the cycle of poor oral health and occupational deprivation in the older adult population. Occupational therapists can incorporate education, screening, and training during morning and night time ADLs in addition to meal times. Additionally, comprehensive oral health care through Medicare is gaining national support. Occupational therapists can and need to advocate for their clients, family, friends, and community by expressing support of this oral health coverage under Medicare to prevent the occupational deprivation caused by decreased oral health.

Resources from The Children’s Dental Health Project and Families USA :

• Letter to Congress on prioritizing oral health in proposals to expand health coverage
• Toolkit, Putting Teeth in Medicare for All: An August Recess Toolkit for Oral Health (FamiliesUSA)
• State by state fact sheets on Medicare oral health coverage (Families USA)
• Analysis, Oral Health Coverage in the 2019 State Legislatures (Families USA)
• Blog, CDHP urges Congress to unlock every families’ potential by meeting their oral health needs (Children’s Dental Health Project)
• Resource page, Family factors shape kids’ ability to achieve good oral health, and fact sheet (Children’s Dental Health Project)

Resources from The Justice in Aging:

• January 2019: Justice in Aging Comments on the Surgeon General’s 2020 Report on Oral Health
• January 2019: Creating an Oral Health Benefit in Medicare: A Statutory Analysis
• October 2018: Webinar – Oral Health and Nursing Facility Residents
• October 2018: Oral Health and Nursing Facility Residents Webinar PowerPoint Presentation
• June 2018: Oral Health for Older Adults in California: Advocate Guide
• February 2018: Justice in Aging Letter to Little Hoover Commission
• February 2018: Webinar-Dental Coverage for Low-Income Older Adults
• January 2018: Beneficiary Oral Health Pamphlets
• English
• Spanish
• July 2016: Issue Brief-Oral Health in California: What about Older Adults?
• July 2016: Webinar-Oral Health in California: What about Older Adults?

Putting Teeth in Medicare for All