A summer break

In the past year of blogging about the impact and context for more preventive dental care, blog membership has expanded substantially and so has the subject matter.

Who would have thought that a new antibacterial tooth coating called Prevora, has anything to do with protocols for handling a new patient, with healthcare reforms marching through most industrial economies, with the informed healthcare consumer and how people now choose their dental services.

But that is what Prevora represents: an opportunity to re-brand and re-orient professional dental care to meet changing values and preferences in the aging community.

You will agree that your community has changed profoundly. For sure it is that much older, but it also interacts electronically, it shops differently, it has much less reimbursement of dental expenses, and it wants to be involved in its care like never before.

One recurrent theme in the blog is this: meeting these changing values and preferences is critical to renewed growth in professional dental services.

Let’s resume this conversation at the end of the summer. Have a good holiday.

Ross Perry

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Avoiding smokers and big spenders on dental care

As healthcare reforms promote more preventive care and associated healthy-seeking behaviour, some controversies emerge. I notice, for example, that American employers in their efforts to control healthcare costs, are taking a look at the extra-burden of an employee who smokes. One study shows that this behaviour imposes an additional $5,800 per year on the employer or the group in which the smoker purchases his/her healthcare coverage.

Some employers already know this and refuse to hire smokers (e.g. the Cleveland Clinic). And some lawmakers are responding to this practice, by making it illegal to discriminate by health-risk behaviour.

But the urgency of employers and groups to reduce healthcare costs could mean that such exclusions, in various forms, may be more widely adopted. Smokers, diabetics, obese people, those who don’t exercise regularly, those with high cholesterol, and those with “bad teeth” go against the grain of controlling health care costs.
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Parkinson’s Disease

Parkinson’s is one of those growing issues in an aging community. The incidence of this disease rises from 17.4 per 100,000 between ages 50 and 59 to 93.1 in 100,000 between ages 70 and 79. Unlike other neurodegenerative diseases such as Alzheimers, Parkinson’s patients remain in the community for a long period. The typical onset of Parkinson’s disease is insidious, with peak age at 55-65 years. It progresses slowly with a mean duration of fifteen years. Many Parkinson’s patients show little disability for twenty years. Others may be severely disabled after ten years.

Chances are most dental practices have at least one Parkinson’s patient, and will have more in the foreseeable future. And strategically, there is an even greater chance that one of your older adult patients knows of, or provides care to someone with Parkinson’s.

A recent study in Germany found Parkinson’s patients at the local hospital had significantly more oral disease and a significantly lower frequency of tooth brushing and level of salivary flow than healthy older adults (Table 1).
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Un-retiring and going to the dentist

In 2008, a national research firm reported that the oldest Canadians reduced their visits to the dentist significantly (Chart 1). About 1 in 4 stopped going to the dentist past the age of 70, and fewer than 5 in 100 visited frequently.

Much of this is explained by a loss of dental insurance for older Canadian workers, and by competing demands for fixed income.
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What makes you happy when you get older? (or why prevention is the new cosmetics)

Often times, this blog tries to connect the dots between an aging population and changes in the demand for dental services. In other words, we are trying to explain why the waiting room is less busy as the community grows old.

Well, could one factor be a profound change in self-perception and values with advancing age? After all, dentistry is certainly a healthcare service but it is also very much a personal service too.

A cute but poignant article in The Atlantic says so.

Let me quote some key observations from this article (emphasis is provided by this blog):

As we get older, illusions of immortality vanish. There is a mortgage that needs to be paid, a home that must be maintained, and children to be cared for.
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Menopause and dental decay

Surveys of adult patients in the waiting rooms of UK and Ontario dental practices show that almost half are age 50+. That means that 1 in 4 patients are women entering or experiencing menopause.

In the current issue of the Australian Dental Journal, a study shows that women in menopause produce significantly less saliva when given a stimulant such as citric acid (refer to S2 and S3 in Chart 1). The average age in the menopause group was 53 years while that in the control group was 29 years.
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Breadwinner Moms

From many accounts, mothers and wives are the primary organizers of the family’s healthcare – including dental care.

In this regard, a recent study by the Pew Research Center also indicates that mothers are a growing source of payment for dental services.

In today’s America, a record 40% of all households with children under the age of 18 include mothers who are either the sole or primary source of income for the family. The share was just 11% in 1960 (Chart 1).

These “breadwinner moms” are made up of two very different groups: 5.1 million (37%) are married mothers who have a higher income than their husbands, and 8.6 million (63%) are single mothers.
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What’s your New Patient routine?

I have been following and contributing to a group discussion on Linked In called “what’s your new patient routine?

And I was impressed with one of the following contributions:

“I always go out to the reception area and greet the new patient. My assistant does a cone beam survey, we show the 3D images of the skull then do digital bite wings, intra-oral photos, phase contrast microscope image on computer to show any pathogenic bacteria, perio hard and soft tissue exam. We then educate them about any incompatible dental materials like amalgam and show them this video http://m.youtube.com/watch?v=9ylnQ-T7oiA The next question after I show them the cracks and decay around the edges of their amalgams is “how soon can we get started?”

This protocol seems to say “welcome to surgery”.

Is this what the patient wants? Not at all, according to our numerous and on-going surveys of patients in the waiting room.
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Are we counseling our older patients?

Counseling the patient on eating habits and smoking are standard procedures for managing adult dental decay. Or at least they should be. A recent Swedish study reports that older patients did not receive the same level of counselling on eating or smoking, as younger patients (Chart 1) (Chart 2).

Chart 1

% of Swedish adults at high caries risk, receiving advice on eating habits from their dentist, 2008

Source: http://www.ncbi.nlm.nih.gov/pubmed/23230808

Chart 2

% of Swedish adults at high caries risk, receiving advice on smoking habit from their dentist, 2008

Source: http://www.ncbi.nlm.nih.gov/pubmed/23230808

Why the decline in counseling as the patient ages? One explanation might be the older patients do not recall professional counseling as well as younger patients. Another explanation is the dental professional simply differentiated his/her counseling by age – spending more time and effort on the younger at risk patients than on the older ones. The authors of this Swedish study believed the latter explanation, concluding that “Swedish dentistry has given up on the older age group where almost no information is provided regardless if the patient is experiencing problems or not.”
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Dental pricing in the New Economy

A previous blog described a long-term decline in visits to the American dentist since 2000. Certainly a primary contributor to this trend is a coincident decline in real household incomes for the majority of the middle class which pays for at least part of its dental services out of pocket. More recent data show that since the recession of 2008, only the wealthiest have enjoyed a gain in net worth (Chart 1).
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