Oral Health Disparities Among the Elderly:

Interdisciplinary Challenges for the Future

Marsha A. Pyle, D.D.S., M.Ed.; Eleanor P. Stoller, Ph.D.
Abstract: The elderly, like other population groups, have experienced varying levels of oral health among their diverse demographic subgroups. For those in poverty, experiencing social isolation, residing in long-term care institutions, and with complex
medical illness, oral health care may be unreachable. Various models of training, education, and community, public, and
professional collaboration have been proposed, yet few strategies have been implemented. Interdisciplinary approaches that
bring interested partners together as equal stakeholders may create faster tracks in improving access to health care for those
geriatric patients who lack it. This article explores past and present recommendations for interdisciplinary collaborations, reviews
the current and future needs of the geriatric population, discusses educational models and content, and expresses the need for
leadership to address oral health disparities in the elderly. Finally, strategies for making improvements in the existing oral health
disparities are discussed.
Dr. Pyle is Associate Dean for Academic Affairs, School of Dental Medicine, and Dr. Stoller is Selah Chamberlain Professor of
Sociology, Department of Sociologyboth at Case Western Reserve University. Direct correspondence and requests for reprints
to Dr. Marsha A. Pyle, Associate Dean for Academic Affairs, Case Western Reserve University School of Dental Medicine,
10900 Euclid Avenue, Cleveland, OH 44106-4905; 216-368-3968 phone; 216-368-3204 fax; map6@po.cwru.edu.
Submitted for publication 7/23/03; accepted 10/14/03

he first ever Surgeon Generals Report (SGR)

on Oral Health in 20001 brought to the forefront the idea of oral health as a part of general health. Despite advances in oral health across
the lifespan, the report identified segments of the U.S.
population that have not benefited from these advances. The geriatric population is as a group often
at risk of disease and often experiencing limited access to oral health care because of place of residence,
economic factors, complex medical illness, social
isolation, and other individual and social factors
(Table 1). The projected aging of the U.S. population heightens the urgency of addressing needs for
the increasingly dentate elderly who are at risk for
dental disease and oral health decline.1,2 The SGR
presented strategies to engage communities of interest in creating new educational models for both professional and community settings. It focused dialogue
on public and private collaborations to improve oral
health and address identified disparities,3-6 including
oral health for the elderly.
The purpose of this article is to discuss the need
for greater interdisciplinary training in geriatrics to
help resolve disparities in oral health care for the elderly. We examine historical policy recommendations
in education, curriculum implications for dentistry
and medicine, and strategies to increase interdisciplinary training. This review reveals a discrepancy
between past educational recommendations and the
current approach to preparing oral health profession-

December 2003

Journal of Dental Education

als to care for the future burgeoning elderly population.

Background: Needs of the

Elderly
Since 1900, the proportion of the U.S. population over the age of sixty-five has grown from 4 percent to 12.7 percent.7 Increasingly, cohorts of the elderly are aging with natural dentition. In the 1988-91
Third National Health and Nutrition Examination
Survey (NHANES), nearly 72 percent of adults aged
sixty-five to seventy-four were dentate, with an average of more than eighteen teeth.8 Dentate individuals therefore remain at risk for dental disease, especially caries and periodontal disease, as well as soft
tissue pathology. A growing population of older patients who have more teeth presents a combination
that impacts dental needs. A lifetime of dental disease experience, partial tooth loss, medical conditions, and medications adds to the complexity of treating these patients. The elderly, as well as disabled
and medically compromised populations, have a disproportionate amount of oral disease.9
Todays older individual is also a more frequent
utilizer of dental care services than previous cohorts.
Reports from the 1960-70s characterized the elderly
as infrequent users of oral health care.10,11 More re-

1327

cently, according to the 1987 National Health Interview Study, the mean number of dental visits annually for senior citizens exceeded that of younger age
groups.12 Meskin and Berg examined the impact that
older adult patients have on private practices. They
found that the percentage of office visits, services
provided, and expenditures attributed to patients 65
years of age or older exceeded the percentage of the
population in that age group.13 Over a ten-year period, a 30 to 64 percent increase in the number of
older adults seen in dental practices13 demonstrates
the growing influence that senior adults will continue
to have on oral care service utilization.
While Meskin and Berg investigated patients
in private practice, the vast majority of whom live
independently, the accessibility of oral care for individuals needing assistance with activities of daily
living and those institutionalized is often extremely
limited.14 Approximately 5 percent of the population
over sixty-five reside in long-term care settings
(LTC). An additional 5 to 10 percent of this population group is homebound.15 There is little data about
homebound patients,16,17 but data affirms that oral
health of individuals in LTCs is consistently
poor.14,18,19
Linkages of oral health and general health have
received increased public attention since the publication of the SGR and research suggesting oral-systemic health relationships. Periodontal disease has
been associated with cardiovascular disease, atherosclerotic lesion formation, increased risk of ischemic
stroke, and all-cause mortality.20-23 There is increasing evidence linking an oral infection-inflammation

Table 1. Summary points from surgeon generals

report related to geriatric oral health care
Disparities remain for access-limited groups
despite oral health improvement for many
Americans.
Dentists have the opportunity to play an
expanded role in the interdisciplinary team.
Integration of general and oral health programs
is insufficient.
Public health structure is insufficient to meet the
needs of access-limited groups.
Medically necessary oral health care remains
limited especially for those most likely to need it
(elderly).
New dentist practice choices may reflect the
level of debt-load at graduation.
Nursing homes have limited capacity to deliver
needed oral health care services.

1328

pathway.24 Previously established associations between leukemia and gingival enlargement,25 oral
manifestations of systemic diseases,26,27 relationships
between diabetes and wound healing, diabetes and
aspiration pneumonia,28,29 and medication and oral
side-effects/consequences26,30 also underscore why it
is important for dentists to understand these relationships in order to provide competent care to the elderly population.
Therefore, based on the numbers and proportion of the aging population, their dentate status, the
impact of chronic medical conditions and treatment
on oral health, and the suggested relationships of
dental disease to general health, students of tomorrow must be prepared to face the unique challenges
of an aging patient group in the practice of general
dentistry. To increase the degree of understanding of
the medical complexity of these patients, interdisciplinary training that considers the whole patient will
be required. New models of curricula in dentistry,
medicine, and allied health professions must emerge.

Current Shortfalls in
Preparation for Care of
the Elderly
A complex set of factors has contributed to the
magnitude of oral health disparities in older populations. Factors include health and educational policy
and fiscal implications, insufficient evidence-based
research, and failure to examine nontraditional educational models in the health professions.

Educational Policy
A recent overview of oral health in the United
States31 documented concentrations of dental disease
and oral health decline among older Americans, particularly those who are disadvantaged by race/
ethnicity and socioeconomic status. Objectives for
improving access to quality health services and oral
health are listed in Healthy People 2010, the comprehensive, nationwide health promotion and disease
prevention agenda. 32 Two overarching goals of
Healthy People 2010to increase quality and years
of healthy life and to eliminate health disparities
are directly applicable to resolving the inequities of
oral health in diverse aging populations. Dental educational agendas should address these important disparities.

Journal of Dental Education Volume 67, Number 12

A variety of important reports in the last decade indicated that dental schools remain isolated
from interaction with other health care institutions.
In the early 1990s, the Pew Health Professions Commission noted that dental care delivery has changed
little over the last several decades and that dentists
have relatively little direct interaction with other
types of health care providers.2 The Pew report cited
dental educations inability to respond to demographic trends, changes in care delivery, and technology due to inflexible curricula. Clinical dental
education also provides little opportunity for interdisciplinary work in health care teams. It is time for
a new model of dental education that is more integrative with a variety of patients, health care providers, and individuals who are involved in health care
management and interdisciplinary health care.
Within dental education, progress has been
monitored in the growth of didactic and clinical training in geriatrics. The most recent study33 reported the
results of a survey of all U.S. dental schools. Although
there has been consistent growth in didactic curricula
among dental schools, growth in both intramural and
extramural clinical experiences has not increased to
the same level.33 To date, no surveys have investigated the level of interdisciplinary training or successes achieved. This is likely due to the fact that
this educational format is challenging and rarely used
or reported in predoctoral dental education.
The Institute of Medicines (IOM) report Dental Education at the Crossroads also underscored the
need for changes in dental education, citing the need
for preparation of students to care for the increasing
numbers of medically complex, dentate elderly. The
report suggested that dental education should become
more closely integrated with medicine on multiple
levels.34,35 Nearly a decade later, there has been slow,
limited progress in developing and implementing
new models of education that address these issues.

Fiscal Implications
The lack of inclusion of oral care services in
Medicare may have contributed to the preservation
of the dental professions independence, yet it has
also contributed to the access to care problem for
many older adults. Only 14.5 percent of patients over
the age of sixty-five retain dental insurance,36 requiring most people to pay for dental care with out of
pocket dollars. For individuals with Medicaid benefits, the scope of services varies by state, as this
program is a federal-state shared responsibility pro-

December 2003

Journal of Dental Education

gram. Recent state budgetary demands have impacted

the continuation of programs in some states and
caused the termination of various levels of benefits
in some, often the adult programs. The oral health
needs of the elderly and the demographic changes in
the U.S. population warrant a reassessment of the
role of oral care services in federal health programs
such as Medicare and revision of policies for Medicaid administration.
Likewise, dentists lack of willingness to serve
Medicaid patients and patients of LTC facilities, regardless of payment method, has contributed to the
access problem as well.37 Expanding professionalism and ethics curricula to include topics regarding
the right vs. privilege of oral health care could serve
to develop a greater sense of service to humankind
among dental students. Incorporating service learning programs as an integral part of clinical experiences would also help to internalize institutional
value systems that honor the professional and ethical obligations of dentistry to society.

Research Needs
The role of interdisciplinary collaboration is
apparent in reports addressing research needs. In
2000, the American Dental Education Association
(ADEA), responding to the American Dental
Associations Report on the Future of Dentistry
Project,38 noted the need for dental education to be
sensitive to changing population demographics, disease patterns, and health care delivery and emphasized the need for more research opportunities for
students. The need for interdisciplinary collaboration in basic and clinical dental and craniofacial research was emphasized, especially where studies
could lead to increased interdisciplinary interaction
and practice. There is also a need for greater value to
be placed on educational research to identify effective training models that can contribute to contemporary educational practices.
The National Institute of Dental and Craniofacial Research (NIDCR) 2002 report on elimination
of dental health disparities39 discussed that population subgroups, including older Americans, have poor
oral and general health but cautioned that good research data is often nonexistent. Dental education
can play an important role in fostering research on
educational and health promotional strategies appropriate to the social and cultural frameworks that characterize these subgroups. Cooperation among researchers in basic science, clinical science,

1329

demography, and social science will be required to

effectively reduce oral health disparities. In the
NIDCR Health Disparities Plan outlined in the report, educational initiatives were not overtly described, yet the context in which the research needs
are described is amenable to all types of research in
educational institutions. The plan acknowledges that
there is often a gap between research knowledge and
practice, an important emphasis for overcoming oral
health disparities.

Interdisciplinary Educational
Implications
More recently, the IOM convened an interdisciplinary summit in 2002 to develop recommendations for reform of health professions education. The
goal of the summit was to facilitate discussion on
change in education that would enhance patient care
quality and safety. The report of that summit40 called
for approaches related to oversight, training environment, research, public reporting, and leadership.
Table 2 outlines the five competency areas identified by the summit as key elements for all health
professions education. This report again highlighted
the necessity for interdisciplinary training among the
health professions to address our countrys changing demographics characterized by aging, ethnic and
racial diversity, chronic illness, and a population with
a need for access to health care information. Unfortunately, dentistry was not represented at this important summit that considered how health professions
education must change.
Despite recurring evidence that leaders in education and health care policy have long seen a vision
of interdisciplinary training and collaboration among
medicine, dentistry, and other health professions,
there has been slow progress in developing demon-

Table 2. IOM competencies for all health professions

education
Competencies are the habitual and judicious use of
communication, knowledge, technical skills, values, and
reflection in daily practice.

Provide patient-centered care

Work in interdisciplinary teams
Employ evidence-based practice
Apply quality improvement
Utilize informatics

Source: Hundert EM, Hafferty F, Christakis D. Characteristics of the informal curriculum and trainees ethical
choices. Acad Med 1996;71(6):624-42.

1330

stration projects and implementing best practices

from successful programs. A review of interdisciplinary training involving dentistry and other health
professions reveals that most of these collaborative
efforts do not involve dentistry. A literature search
of interdisciplinary teams and dental terms since
1990 netted only ten articles, none of which related
to geriatric training and only four dealt with educational models. Another search of geriatric interdisciplinary teams and dental found no matches since
1990. Of the articles that did describe collaborative
training models, most involved medicine and social
work, allied health, nursing, pharmacy, nutrition,
chiropractic, occupational therapy, or other health
professions.

Interdisciplinary Models
Interdisciplinary or multidisciplinary teaching
teams have been utilized to help educate health professions students in geriatrics for years.42-50 These
programs have used a diverse group of educational
models to link various health professions (not including dental students) and community service agencies to academic institutions for training in care of
the elderly and to address ethical issues training for
the purpose of stimulating educational collaboration.
Programs such as these report improvement in student attitudes towards the elderly and in skills in assessing patients decisionmaking capacity, negotiating care plans, and appreciating the broad range of
elderly patient life experiences.51 There has been little
effort to study and report on programs that include
dental professionals in interdisciplinary team learning units. The historical isolation in dental education has not fostered collaborations in joint projects
to train more health professions students together.
A recent literature review indicated that there
are few medical journal articles that point to the need
for interdisciplinary training or cross-education
involving dental professionals. Increasing suggestions of oral-systemic health interactions clearly indicate the need for interdisciplinary training models
to enhance the ability of health professionals to treat
the ever-growing population of elderly. With more
medically complex patients and limited oral health
information within medical education,52 new initiatives to redesign predoctoral medical and dental curricula seem timely.
One of the most visible examples of interdisciplinary training involving postdoctoral dentistry has

Journal of Dental Education Volume 67, Number 12

been the Faculty Training Projects in Medicine, Dentistry, and Behavioral and Mental Health, which is
funded by the Health Resources and Services Administration (HRSA).53 This federal program is an
interdisciplinary postdoctoral geriatrics training program that educates physicians and dentists together.
Originally mandated in 1986, geriatric psychiatry was
added to this federal program in 1992. The program
supports physicians who have completed residencies
in family medicine or internal medicine, mental
health professionals such as psychiatrists, and dentists who have completed residency programs or specialty training for two-year geriatric fellowships and/
or one-year geriatric retraining for faculty with previous interests in this area. The Bureau of Health
Professions (BHPr)-supported program is unique,
allowing an integrated program that is not limited to
single clinical sites and has flexibility in affiliations
and curriculum. The programs are organized around
interdisciplinary didactic instruction in all aspects of
geriatric care and clinical training concentrated in
the fellows discipline, with cross-participation in
clinics to the extent appropriate. Dentistry is always
included as a team member. The programs include
training in administration, teaching, research, and
clinical care. This is the only faculty training program of its kind in the United States that supports
training in geriatric dentistry. The number of programs and fellows trained are outlined in Table 3.
There are currently nine funded programs.
Early in the 1990s, the fellows completing these
programs were tracked to determine how many remained in academic settings, but this tracking mechanism has not continued. While there is no current
data on the status of fellows previously trained
through this program, it is likely that the dental fellows trained in this venue serve as the current core
of academic leaders training current dental students.
Yet, with expected needs for physicians specially
trained to serve the elderly estimated to be in the
thousands, the need for additional training would
seem evident for all health professions serving the
elderly.54 It is unlikely that the numbers of the elderly requiring health care will be matched by sufficient numbers of adequately trained physicians, dentists, and other health professionals in the near future,
unless expansion of programs or new programs are
instituted. Other geriatrics training programs
(masters level) exist in dentistry, but do not share
the same emphasis on interdisciplinary training as
the BHPr program.

December 2003

Journal of Dental Education

In summary, progress in effecting change in

the current mechanisms of training in the care of the
elderly has been slow. Recommendations from policy
sources to enhance interdisciplinary training have
been made without concomitant increases in training programs. There is a lack of sufficient training
mechanisms for predoctoral and postdoctoral programs. There is a critical need for educational research on models of training to prepare health professionals to care for the elderly. In many cases,
training does not address the critical issues of cultural competence, communication, and understanding patient value systems. Finally, dental education
and medical education remain isolated from each
other.

Future Needs in Dental

Education
Need for Leadership
It is critical to identify leaders who have the
skill and passion for making greater advances in geriatric interdisciplinary training including curriculum
revision. While dental educators have been considering ways to make that happen, the suggestions for
this change are more than ten years old. Dealing with
slow professional and institutional change can be
discouraging. A certain level of grassroots movement
and knowledge is required from the different health
professions. Medical, dental, and allied health education should collaborate with professional organizations, national testing organizations, accrediting
bodies, and licensing organizations to create efficient,
high-quality educational programs that will be re-

Table 3. Number of programs funded by year: faculty

training projects in geriatric medicine, dentistry, and
behavioral and mental health
Funding Year
(five-year funding,
except 1988 and 1991,
which are three-year)

1988
1991
1994
2000
2001
2002

No. of Programs
Funded

23
16
9
5
2
2

No. of Fellows
Trained

115
74
135
Data pending
Data pending
Data pending

1331

sponsive to the changing demographics of the society. Otherwise, educational innovators will be penalized for their leadership, creativity, and efficiency
by oversight groups who are unable to change at the
same pace when new educational models are instituted. A shared vision for change will be required.
The health professions should educate themselves
to understand, in concert, the needs of contemporary oral and general health care related to the elderly.
There is an opportunity for dental education
and organized dentistry to take the lead to address
the access to care issue from the grassroots level. If
local level activities are a link to facilitating greater
access to dental care for the elderly, then associations with strong lobbies such as the ADA and its
constituents (state level), as well as other national
agencies advocating for senior citizens, could be
important assets for securing new resources for training, research, and care.

Strategies for Change

Change is often viewed negatively by individuals unaccustomed to innovation, but careful planning
can minimize risk and uncertainty. First, compelling
evidence must exist to make the change. As previously discussed here, multiple reports already exist
to support new thinking about interdisciplinary collaborative training. Second, specific required elements must be identified early to guarantee that adequate time, knowledge, space, and resources are
available to effect change. Finally, there is a need
for motivated, visionary leaders who think
collaboratively, who are calculated risk-takers, who
realize a better game plan must be nurtured, and who
are willing to provide the opportunity for new ideas
to reach fruition. This suggests the need for interdisciplinary leadership training programs in geriatrics
and health professions education to develop the visionary talents of individuals who have the skill,
perspective, passion, and desire to lead the way. Coveted demonstration programs should be developed
that are interdisciplinary in nature and universally
recognized and supported. Opportunities for future
leaders to collaborate could assist the development
of emergent leaders who will facilitate educational
change that is responsive to the societal needs of an
aging population.
In times of lean economics, it makes great sense
to look for innovative opportunities to capitalize on
existing resources. For example, in one midwestern

1332

city, the university bought the property of an 800bed acute care hospital that had closed five years
earlier. The dean of a midwestern school of dental
medicine proposed the facility be used as an interdisciplinary training facility. A former dean of medicine was appointed to oversee the development of
this facility where a model of interdisciplinary outpatient care could occur. One year after the suggestion, the project remains an idea. Likely, many obstacles lie ahead in making this vision a reality, yet
this innovation shows genuine dental-medical collaboration and creative leadership.

Need for a Core Curriculum

There is clear evidence that medical, dental,
and health professions education must change in order to address health disparities among the aging
population.1,2,32,34,35,38,40 The reports reviewed contend
that the nature of medical, dental, and other health
professions education must change to better prepare
future practitioners to deal with health disparities
among the elderly. Federal funding could leverage
training opportunities in geriatrics. Since comprehensive working examples of interdisciplinary training
that include dentistry do not exist for predoctoral
dental curricula, there is a compelling need to establish demonstration projects that model medicine and
dentistry together. Many dental students do not
choose additional formal training beyond their dental school program, so adequate training to interact
with other health professionals in order to provide
quality care to the elderly must occur during dental
school. Medical and dental education must develop
a core curriculum that all students could share, with
interdisciplinary experiences beginning with the first
day of class.
While a number of new models of dental education have been proposed and several have been
implemented,55 a high priority is developing strategies for allowing more institutions to implement
change and overcome the obstacles encountered by
the experiences of the first wave of curriculum innovators. Greater efficiency and lessons learned could
help other institutions attempting to implement new
projects in health professions education. Likewise, a
fresh look at existing programs, such as advanced
training in general dentistry residencies, could create a view of mainstreaming what we currently call
special needs populations within the realm of general dentistry. If core curricula included geriatric didactic and clinical experiences, then a new cadre of

Journal of Dental Education Volume 67, Number 12

practitioners could be prepared to serve the needs of

the elderly.

Teaching to the Needs of Elderly

Patients
Within the discipline of dentistry, educational
change must occur in didactic and clinical formats
in predoctoral and graduate training. Developing
teachers of geriatrics, research initiatives for applications in clinical practice, and developing a cadre
of practitioners who have the knowledge, skills, and
values and are willing to commit their time in service to the underserved elderly would be important.
Approaches that recognize diversity and address cultural competency in our programs have been advocated.56 Sensitivity to understanding and valuing
other belief systems are also important concepts, in
addition to diversity issues, in general.57
Dental educations approach to treatment planning education, for example, has traditionally evolved
around ideal treatment planning from the providers
perspective, focusing on relatively healthy, average
patients. Yet treatment plans for frail elderly may be
complicated by barriers to care, disease, uncertainty
about risks and benefits, and inadequate knowledge
about patient preferences.58 There are few references
to understanding patient preference and value systems in oral care treatment decisionmaking.59 However, frail older patients at risk for dental disease often have significant medical, psychosocial, and
economic complications that impact their ability to
get care. Life situations define how they may make
oral care decisions about their preferences. Furthermore, both well and frail elderly patients may exhibit variation in the priorities they attach to different dimensions of oral health and dental treatment.60
A study of dental students confirmed that students
perception of the preferences and values of elderly
patients about oral health do not always agree with
those of elderly patients.61 Older patients oral health
goals may be framed by the context of the situation.
For example, in painful dental situations, patients
may know the strategy that is in the best interest of
their oral health, yet external factors may influence
their decisionmaking approach, derailing the bestchoice decision.62
Better understanding of patient value systems,
preferences, behaviors, and confounding life circumstances may help prepare students to communicate
with the elderly and to appreciate and work within

December 2003

Journal of Dental Education

their belief systems. In doing so, greater opportunity

to address the needs of the elderly patient may be
achieved. A recent student report in Special Care in
Dentistry noted that factors such as these are critical
for the ability of students to effectively deal with
treatment planning complex older patients.63

Need to Define Competencies

A set of educational principles and competencies should be developed to help define key broad
educational principles that will allow students of the
twenty-first century to meet the needs of the aging
population. A set of core competencies specific to
oral health care and dental education have been proposed through a Delphi study conducted by Dolan
and Lauer. Their contemporary detailed statements
of knowledge and skills across dental disciplines64
could serve as the basis for updating previously
(1989) published curriculum guidelines in geriatric
dentistry.65
However, a broader approach to competency
development in special care topics should be framed
to encompass educational objectives amenable to
both dental and medical education. The broad competencies could be framed within special patient care
to address the needs of the general patient population. These should be a part of all predoctoral dental
programs and are not unlike those proposed in the
IOM Summit summary.40 (See Table 4.) Defining the
educational outcomes will require additional study
and refinement, as will articulating the evaluation
strategies that will measure the level of quality and
accomplishment necessary. The competencies are
proposed as a beginning discussion of the definition
of the knowledge, skills, and values contemporary

Table 4. Competencies for geriatric oral care in

predoctoral programs
Graduates must be competent to collaborate in interdisciplinary teams to facilitate special patient care.
Educational outcomes
Students must:
Function within an interdisciplinary health
care team providing special patient care.
Integrate medical, dental, psychosocial, and
economic factors impacting patient care.
Prescribe treatment plans that are sensitive
to patient values and belief systems.
Demonstrate effective communication with
special care patients.

1333

students of dentistry will need to function in the

health care system that will be caring for the increasingly older, more complex patient.

Summary
Despite compelling recommendations from
diverse sources that suggest dental education can and
should revise its mode of delivery and philosophy to
broaden interdisciplinary training venues, little
progress has been made in this area. The rationale
for increased interdisciplinary training in geriatrics
is evident in the demographics of the aging society
we live in. While a model interdisciplinary training
program exists, additional and expanded programs
that include predoctoral education will be required
to develop adequate numbers of health care provid-

ers to care for the elderly. Meeting this need will

demand new levels of leadership among individuals, the public and private sectors, educational institutions, professional organizations, and oversight
groups. New value for educational research will also
be important to facilitate the necessary changes.
Table 5 highlights proposed strategies for improving the health professions ability to diminish
geriatric oral health disparities. Dental education
leaders must work to ensure that dentistry is invited
to the table when the IOM committee meets, when
curriculum committees of universities convene, and
when professional organizations join together. Overviews of health disparities that fail to incorporate oral
health are incomplete.
The educational rationale for increasing interdisciplinary training has existed for a decade. The
next step is to identify visionary leaders who have

Table 5. Strategies for improving health professions ability to diminish geriatric oral health disparities
Take advantage of working interdisciplinary educational models that currently involve
dentistry: craniofacial teams.
Remove barriers to interdisciplinary care of the elderly.
Work to include special care patients in mainstream care.
Expand curricula and clinical experiences in general dentistry residency programs.
Expand predoctoral didactic and clinical experience.
Remove financial impediments.
Increase advocacy in an era of diminishing public assistance.
Revamp Medicaid system to remove dependency on optional state funding.
Partner with private and public groups, professional lobby groups.
ADA, AARP
Engage constituent and component dental societies.
Reassess oral health role in Medicare.
Increase federal funding for interdisciplinary models of education that include geriatrics.
Expand HRSA-BHPr geriatric training program.
Find new systems to fund oral health care for special care patients.
Create incentives to develop new integrated curricula in dentistry, medicine, and allied
health professions.
Create efficiencies by pooling resources.
Develop interdisciplinary RFPs for interdisciplinary curriculum models for predoctoral
education.
Create interdisciplinary training laboratories as a standard training format.
Create clinical space and educational opportunity for training health professions
students together as a usual format.
Create and publicize outcomes from demonstration projects and best practices. For example:
Senior living communities that include interdisciplinary health care facilities as training
sites for tomorrows practitioners .
Update allied health professions schools competency documents to reflect:
the importance of ability to be prepared for care of the elderly.
the need for interdisciplinary training as a part of necessary skills.
Assist accrediting and licensing bodies in incorporating new competencies into their
values and policies.

1334

Journal of Dental Education Volume 67, Number 12

the expertise and passion to make innovative curriculum revision in health professions education happen, so that the educational system improves and oral
health disparities for the elderly can be overcome.

Acknowledgment
The authors wish to express their gratitude to
L. Dahlstrom for editorial assistance with the manuscript.

REFERENCES
1. Oral health in America: a report of the surgeon general.
Rockville, MD: U.S. Department of Health and Human
Services, National Institute of Dental and Craniofacial
Research, National Institutes of Health, 2000.
2. American Association of Dental Schools. The dental profession: dental chapter of the Pew full report. J Dent Educ
1993;57:454-62.
3. Pyle MA. Changing perceptions of oral health and its
importance to general health: provider perceptions, public perceptions, policymaker perceptions. Spec Care Dentist 2002;22(1):8-15.
4. Allukian M. The neglected epidemic and the surgeon
generals report: a call to action for better oral health.
J Public Health 2000;90(6):843-5.
5. Evans CA, Kleinman DV. The surgeon generals report
on Americas oral health: opportunities for the dental profession. J Am Dent Assoc 2000;131(12):1721-8.
6. Ferrillo PJ, Chance KB, Garcia RI, Kerschbaum WE,
et al. Report of the ADEA presidents task force on the
surgeon generals report on oral health. J Dent Educ
2000;64(10):708-14.
7. Statistical abstract of the United States. 116th ed. Washington, DC: U.S. Bureau of the Census, 1996.
8. Brown LJ, Winn DM, White BA. Dental caries, restoration and tooth conditions in U.S. adults, 1988-1991. J Am
Dent Assoc 1996;127:1315-25.
9. Improving the oral health status of all Americans: roles
and responsibilities of academic dental institutions. Washington, DC: American Dental Education Association,
2003.
10. Wilder MH. Current estimates from the health interview
survey, U.S. 1970. U.S. Department of Health and Human Services publication 72-1054. Series 10, 72. Washington, DC: National Center for Health Statistics, 1972.
11. Jack SS, Ries PW. Current estimates from the national
health interview survey U.S. 1979. U.S. Department of
Health and Human Services publication 81-1564. Series
10, 136. Washington, DC: National Center for Health Statistics, 1979.
12. Schoenborn C, Marano M. Current estimates from the
National Health Interview Survey, U.S. 1987. U.S. Department of Health and Human Services publication 881594. Series 10, 166. Washington, DC: National Center
for Health Statistics, 1987.
13. Meskin L, Berg R. Impact of older adults on private dental practices, 1988-1998. J Am Dent Assoc 2000;
131(8):1188-95.

December 2003

Journal of Dental Education

14. Ellis AG. Geriatric dentistry in long-term-care facilities:

current status and future implications. Spec Care Dentist
1999;19:139-42.
15. Leon J, Lai RT. Functional status of the non-institutionalized elderly: estimates of ADL and IADL difficulties.
DHHS Pub No. (PHS) 90-3462. Rockville, MD: Agency
for Health Care Policy and Research, 1990.
16. Strayer MS. Dental health among homebound elderly.
J Public Health Dent 1993;53(1):12-6.
17. Strayer MS. Perceived barriers to oral health care among
the homebound. Spec Care Dentist 1995;15(3):113-8.
18. Gift HC, Cherry-Peppers G, Oldkowski RJ. Oral health
status and related behaviors of US nursing home residents,
1995. Gerodontology 1997;14:89-99.
19. Weyant RJ, Jones JA, Hobbins M, et al. Oral health status of a long-term-care, veteran population. Community
Dent Oral Epidemiol 1993;21:227-33.
20. Kuramitsu HK, Kang IC, Qi M. Interactions of
Porphyromonas gingivalis with host cells: implications
for cardiovascular diseases. J Periodontol 2003;74(1):
85-9.
21. Jansson L, Lavstedt S, Frithiof L. Relationship between
oral health and mortality rate. J Clin Periodontol
2002;29(11):1029-34.
22. Joshipura KJ, Hung HC, Rimm EB, Willett WC, Ascherio
A. Periodontal disease, tooth loss, and incidence of ischemic stroke. Stroke 2003;34(1):47-52.
23. Joshipura KJ, Hung HC, Rimm WC, Ascherio A. Periodontal disease, tooth loss, and incidence of ischemic
stroke. Stroke 2003;34(1):47-52.
24. Hung HC, Willett W, Merchant A, Rosner BA, Ascherio
A, Joshipura KJ. Oral health and peripheral arterial disease. Circulation 2003;107(8):1152-7.
25. Wu J, Fantasia JE, Kaplan R. Oral manifestations of acute
myelomonocytic leukemia: a case report and review of
the classification of leukemias. J Periodontol
2002;73(10):1228.
26. Rose LF, Steinberg BJ, Minsk L. The relationship between
periodontal disease and systemic conditions. Comp Contin
Educ Dent 2000;21(10A):870-7.
27. Krall EA. The periodontal-systemic connection: implications for treatment of patients with osteoporosis and periodontal disease. Ann Periodontol 2001;6(1):209-13.
28. Taylor GW, Loesche WJ, Terpenning MS. Impact of oral
diseases on systemic health in the elderly: diabetes mellitus and aspiration pneumonia. J Public Health Dent
2000;60(4):313-20.
29. Limeback H. Implications of oral infections on systemic
diseases in the institutionalized elderly with special
focus on pneumonia. Ann Periodontol 1998;3(1):262-75.
30. Pajukoski H, Meurman JH, Sulkava R. Prevalence of subjective dry mouth and burning mouth in hospitalized elderly patients and outpatients in relation to saliva,
medication, and systemic diseases. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 2001;92(6):641-9.
31. Dental, Oral and Craniofacial Data Resource Center. Oral
health U.S., 2002. Bethesda, MD: National Institute of
Dental and Craniofacial Research, NIH and the Centers
for Disease Control, U.S. Department of Health and Human Services, 2002.

1335

32. Healthy people, 2010. Washington, DC: National Center

for Health Statistics, U.S. Department of Health and Human Services. At: www.healthypeople.gov/. Accessed:
May 20, 2003.
33. Mohammad AR, Preshaw PM, Ettinger RL. Current status of predoctoral geriatric education in U.S. dental
schools. J Dent Educ 2003;67(5):509-14.
34. Dental education at the crossroads: summary recommendations. J Am Coll Dent 1995;62(1):9-12.
35. Field MJ, Jeffcoat MK. Dental education at the crossroads:
a report by the Institute of Medicine. J Am Dent Assoc
1995;126(2):191-5.
36. Wall TP, Brown J. Recent trends in dental visits and private dental insurance, 1989 and 1999. J Am Dent Assoc
2003;134(5):621-7.
37. Damiano PC, Brown ER, Johnson JD, Scheetz JP. Factors affecting dentist participation in state Medicaid program. J Dent Educ 1990;54(11):638-43.
38. American Dental Education Association. Responding to
the American Dental Associations Future of Dentistry
project. J Dent Educ 2000;64:703-6.
39. A plan to eliminate craniofacial, oral, and dental health
disparities. Bethesda, MD: National Institute of Dental
and Craniofacial Research, February 2002. At:
www.nidcr.nih.gov/news/reports.asp. Accessed: May 20,
2003.
40. Health professions education: a bridge to quality. Washington, DC: Institute of Medicine, National Academy of
Sciences, 2003. At:
www.nap.edu/openbook/
0309087346/html/1.html. Accessed: May 28, 2003.
41. Hundert EM, Hafferty F, Christakis D. Characteristics of
the informal curriculum and trainees ethical choices. Acad
Med 1996;71(6):624-42.
42. Silver S, Turley C, Smith C, Laird J, et al.
Multidisciplinary team dynamics in the production of
problem-based-learning cases in issues related to older
adults. J Allied Health 1999;28(1):21-4.
43. Hartford geriatric interdisciplinary team training program.
Continuum, January-February 4-6, 1999.
44. Rosher RB, Robinson SB, Boesderfer D, Lee K. Interdisciplinary education in a community-based geriatric evaluation clinic. Teach Learn Med 2001;13(4):247-52.
45. Browne CV, Braun KL, Mokuau N, McLaughlin L. Developing a multisite project in geriatrics and/or
gerontological education with emphases in interdisciplinary practice and cultural competency. Gerontologist
2002;42(5):698-704.
46. Howe JL, Hyer K, Mellor J, Lindeman D, Luptak M.
Educational approaches for preparing social work students
for interdisciplinary teamwork on geriatric health care
teams. Soc Work Health Care 2001;32(4):19-42.
47. Bossenberger JS, Anderson MA. Interdisciplinary health
care as the link between nursing homes and educational
institutions. Geriatr Nurs 1999;20(4):214-6.

1336

48. Keough ME, Field TS, Gurwitz JH. A model of community-based interdisciplinary team training in the care of
the frail elderly. Acad Med 2002;77(9):936.
49. Swauger K, Tomlin C. Best care for the elderly at Forsyth
Medical Center. Geriatr Nurs 2002;23(3):145-50.
50. Hawk C, Byrd L, Killinger LZ. Evaluation of a geriatrics
course emphasizing interdisciplinary issues for chiropractic students. J Gerontol Nurs 2001;27(7):6-12.
51. Heath JM, Dyer CB, Kerzner LJ, Mosqueda L, Murphy
C. Four models of medical education about elder mistreatment. Acad Med 2002;77(11):1101-6.
52. Skelton J, Smith TA, Betz WT, Heaton LJ, Lillich TT.
Improving the oral health knowledge of osteopathic medical students. J Dent Educ 2002;66(11):1289-96.
53. At: bhpr.hrsa.gov/interdisiplinary/faculty.html. Accessed:
June 4, 2003.
54. Beck J, Cohen HJ, Ershler WB, Hazzard WR, et al. Will
you still treat me when Im 65? A report of the Alliance
for Aging Research. Washington, DC, May 1996.
55. Cohen MM. Major long-term factors influencing dental
education in the twenty-first century. J Dent Educ
2002;66(3):360-73.
56. Mouradian WE. Commentary on Dr. Michael Cohens
article: disparities, diversity, and dental education. J Dent
Educ 2002;66(3):374-9.
57. Kleinman A, Eisenberg L, Good B. Culture, illness and
care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med 1978;88(2):251-8.
58. Dolan T. Research related to optimal oral health outcomes.
Med Care 1995;33(11):106-22.
59. Johnson TE. Factors contributing to dentists extraction
decisions in older adults. Spec Care Dentist
1993;13(5):195-9.
60. Stoller EP, Pyle MA. Unpacking elderly patients preferences: lay perspectives on oral health goals. Unpublished
manuscript.
61. Pyle MA, Stoller EP. Gender differences in student perceptions of senior citizen oral care priorities (abstract).
Poster presentation, ADEA Second International Womens
Leadership Conference, Gteborg, Sweden, June 21, 2003.
62. Stoller EP, Gilbert GH, Pyle MA, Duncan RP. Coping
with tooth pain: a qualitative study of lay management
strategies and professional consultation. Spec Care Dentist 2001;21(6):208-15.
63. Lee SJ, Nelson LP, Lin J, Tom F, Brown RS, Jones JA.
Todays dental student is training for tomorrows elderly
baby boomer. Spec Care Dentist 2001;21(3):95-7.
64. Dolan TA, Lauer DS. Delphi study to identify core competencies in geriatric dentistry. Spec Care Dentist
2001;21(5):191-7.
65. Curricular guidelines in geriatric dentistry. J Dent Educ
1989;53:313-5.

Journal of Dental Education Volume 67, Number 12