eBriefing

Collaborative Health Care for Older Adults: Uniting Medicine and Dentistry

Collaborative Health Care for Older Adults
Reported by
Marilynn Larkin

Posted January 11, 2010

Overview

As the baby boom generation gets older and lives longer, sheer population numbers alone mean that cardiovascular disease, stroke, Alzheimer’s disease, and other medical conditions related to aging are likely to increase in prevalence in the coming years. The picture is similar in dentistry, where root caries, oral fungal infections, oral cancers, and osteonecrosis of the jaw (a rare side effect of taking bisphosphonates to prevent osteoporosis) are emerging as areas of increasing concern. Despite this important demographic shift, the United States healthcare system does not have sufficient doctors and dentists trained in geriatric medicine and dentistry to address it. Considering mounting evidence suggesting that oral health is a reflection of and contributes to systemic health, there is also a lack of awareness among doctors of oral health issues relevant to their work, and among dentists of important medical issues that affect oral health.

In an effort to improve communication and collaboration between disciplines, this conference explored areas where oral and systemic health overlap in the aging population, and considered how to create more effective partnerships between dentists and medical doctors to ensure better, more integrated geriatric health care. In addition to the topics mentioned above, speakers addressed connections between oral health and Alzheimer's, issues related to pain management, new salivary diagnostics for systemic health, relationships between candidiasis and immune system dysfunction, and future convergences between disciplines in the context of regenerative medicine.

The event, Collaborative Health Care for Older Adults: A Symposium for Creating Dialogue between Medicine and Dentistry, was a continuing medical education activity sponsored by the College of Physicians & Surgeons, Columbia University. Conference program copyright © 2009 Trustees of Columbia University. All rights reserved.

Video Interviews


Marie A. Bernard

Video
The Silver Tsunami


National Institute on Aging Deputy Director Marie Bernard explains why the aging of America over the coming decades will place unprecedented strains on the U.S. healthcare system.


Ira B. Lamster

Video
Dentistry for Aging Adults


Ira Lamster, Dean of the Columbia University College of Dental Medicine, describes the challenges of delivering good oral care to older patients, and why integrating medicine and dentistry can improve patients' overall health.

Use the tabs above to find a meeting report and multimedia from this event.


Speakers featured in this eBriefing include:

Marie Bernard (National Institute on Aging)
Douglas B. Berkey (University of Colorado Denver)
Cynthia Boyd (Johns Hopkins Bloomberg School of Public Health)
Kenneth Brummel-Smith (Florida State University College of Medicine)
Daniel Malamud (New York University College of Dentistry)
Jeremy J. Mao (Columbia University College of Dental Medicine)
Richard Mayeux (Columbia Uniersity College of Physicians and Surgeons)
Carol Raphael (Visiting Nurse Service of New York)
M. Cary Reid (Weill Cornell Medical College)
Joshua Willey (Columbia Uniersity College of Physicians and Surgeons)
David J. Zegarelli (Columbia University College of Dental Medicine)


Presented by

  • Columbia University College of Physicians and Surgeons
  • Columbia University College of Dental Medicine
  • Oral Health America
  • The New York Academy of Sciences

This eBriefing supported by

  • DentaQuest Foundation

For a complete list of supporters, please click the Sponsorship tab.

Health and Aging: Opportunities for Medical/Dental Collaboration


Marie A. Bernard (National Institute on Aging)
  • 00:01
    1. Introduction; NHANES findings
  • 04:58
    2. Dental utilizaton data; Incidence of oral cancer
  • 09:50
    3. Taste modalities and food sensation
  • 15:00
    4. Bisphosphonates and osteonecrosis; Funding opportunities
  • 22:44
    5. The Human Microbiome Project; Publications for lay population
  • 23:59
    6. Summary and conclusio

Epidemiology of Stroke


Joshua Willey (Columbia University College of Physicians and Surgeons)
  • 00:01
    1. Introduction
  • 03:48
    2. Surrogate markers; Stroke as acute illness
  • 06:45
    3. Mortality and burden; Cardiovascular and lung disease prevalence
  • 10:15
    4. Stroke prevalence; The Northern Manhattan Study; Age and gender
  • 12:54
    5. Established risk factors
  • 15:58
    6. New risk factors; The INVEST Study
  • 20:38
    7. Conclusio

Epidemiology and Genetics of Alzheimer's Disease


Richard Mayeux (Columbia University College of Physicians and Surgeons)
  • 00:01
    1. Introduction
  • 06:55
    2. Amyloid cascade hypothesis; ApoE and SORL1
  • 11:46
    3. CLU, PICALM, and CR1; NIA-LOAD family study
  • 15:57
    4. Genetic variants and risk factors; Disease genes and risk genes
  • 18:31
    5. Summary and acknowledgement

Issues Related to Pain and Pain Management in Later Life


M. Cary Reid (Weill Cornell Medical College)
  • 00:01
    1. Introduction and overview; The prevalence of pain in chronic disease
  • 03:26
    2. Epidemiology; Morbidity and mortality; ADL impairment
  • 06:18
    3. Impairment in physical functioning; Pain and mortality; Assessment issues
  • 12:02
    4. American Geriatric Society guidelines; Opioid use
  • 15:27
    5. Nonpharmacologic treatments; Treatment barriers
  • 18:00
    6. Initiatives; Conclusio

Saliva and Salivary Diagnostics: Implications for the Geriatric Population


Daniel Malamud (New York University College of Dentistry)
  • 00:01
    1. Introduction; Decision tree; Oral samples
  • 06:33
    2. Oral tests; Proteome study
  • 12:12
    3. NIDCR funded projects
  • 14:07
    4. Oral diagnostics and the geriatric population
  • 18:12
    5. Biomarkers for Alzheimer's disease
  • 21:21
    6. Conclusion and acknowledgement

Diseases of the Oral Mucosa in Older Adults


David J. Zegarelli (Columbia University College of Dental Medicine)

Retooling for an Aging America: Building the Health Care Workforce


Carol Raphael (Visiting Nurse Service of New York)
  • 00:01
    1. Introduction
  • 04:38
    2. Committee findings
  • 13:51
    3. Recommendations
  • 20:40
    4. Summary and conclusio

Geriatric Education: Now and the Future


Kenneth Brummel-Smith (Florida State University College of Medicine)
  • 00:01
    1. Geriatric practice and education
  • 06:16
    2. Florida State's curriculum
  • 11:36
    3. References and conclusio

Geriatric Dental Education and Training


Douglas B. Berkey (University of Colorado Denver)
  • 00:01
    1. Introduction
  • 04:43
    2. Retooling geriatric dental education
  • 11:30
    3. Training new faculty
  • 16:47
    4. Resolution 5H-2006
  • 19:10
    5. Summary and conclusio

Improving Health and Health Care for Older Adults with Multimorbidity


Cynthia Boyd (Johns Hopkins Bloomberg School of Public Health)
  • 00:01
    1. Introduction; Background data
  • 03:45
    2. Clinical practice guidelines and comorbidity; Prioritization
  • 06:21
    3. Guidelines study
  • 14:28
    4. Implications; Thinking beyond disease
  • 19:24
    5. Summary and acknowledgment

Web Sites

The American Geriatrics Society
A not-for-profit organization of health professionals devoted to improving the health, independence and quality of life of all older people. See their collections of professional education and public education for providers, as well as their comprehensive set of links to additional online information.

National Institute on Aging
Health and research information from the NIH's leading agency on aging issues. A summary of the report Retooling for an Aging America: Building the Health Care Workforce is available, along with information on grants and training.

Oral Health America
A nonprofit organization working to improve the overall oral health of the American public through access, education, and advocacy.

Portal of Geriatric Online Education
A free public repository of geriatric educational materials in various e-learning formats, including lectures, exercises, virtual patients, case-based discussions, simulations, as well as links to other resources.


Medical Issues of Interest to Dentists

American Geriatrics Society Panel on the Pharmacological Management of Persistent Pain in Older Persons. 2009. Pharmacological management of persistent pain in older persons. Pain Med. 10: 1062-1083.

Beissner K, Henderson CR Jr, Papaleontiou M, et al. 2009. Physical therapists' use of cognitive-behavioral therapy for older adults with chronic pain: a nationwide survey. Phys. Ther. 89: 456-469. Full Text

Bruckenthal P, Reid MC, Reisner L. 2009. Special issues in the management of chronic pain in older adults. Pain Med. 10 Suppl 2: S67-78.

Lee JH, Cheng R, Graff-Radford N, et al. 2008. Analyses of the National Institute on Aging Late-Onset Alzheimer's Disease Family Study: implication of additional loci. Arch. Neurol. 65: 1518-1526. Full Text

Mayeux R. 2008. Alzheimer's disease: epidemiology. Handb. Clin. Neurol. 89: 195-205.

Willey JZ. 2009. Prestroke physical activity is associated with severity and long-term outcome from first-ever stroke. Neurology 73: 572-573.

Willey JZ, Williams O, Boden-Albala B. 2009. Stroke literacy in Central Harlem. A high-risk stroke population. Neurology [Epub ahead of print]


Dental Issues of Interest to Medical Doctors

Ambatipudi KS, Lu BW, Hagen FK, et al. 2009. Quantitative analysis of age specific variation in the abundance of human female parotid salivary proteins. J. Proteome Res. 8: 5093–5102. Full Text

Chen Z, Mauk MG, Wang J, et al. 2007. A microfluidic system for saliva-based detection of infectious diseases. Ann. NY Acad. Sci. 1098: 429-436.

Denny P, Hagen FK, Hardt M, et al. 2008. Proteome of the human carotid and submandibular/sublingual gland salivas collected as the ductal secretions. J. Proteome Res. 7: 1994–2006.

Liu C, Qiu X, Ongagna S, et al. 2009. A timer-actuated immunoassay cassette for detecting molecular markers in oral fluids. Lab Chip 9: 768-776.

Mao JJ. 2008. Stem cells and the future of dental care. NY State Dent. J. 74: 20-24.

Woo VL, Kelsch RD, Su L, et al. 2009. Gingival squamous cell carcinoma in adolescence. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 107: 92-99.

Woo VL, Manchanda-Gera A, Park DS, et al. 2007. Juvenile oral lichen planus: a report of 2 cases. Pediatr. Dent. 29: 525-530.


Building Medical/Dental Partnerships

Berkey D, Berg R. 2001. Geriatric oral health issues in the United States. Int. Dent. J. 51 (3 Suppl): 254-256.

Bernard MA, Blanchette PL, Brummel-Smith K. 2009. Strength and influence of geriatrics departments in academic health centers. Acad. Med. 84: 627-632.

Boult C, Reider L, Frey K, et al. 2008. Early effects of "Guided Care" on the quality of health care for multimorbid older persons: a cluster-randomized controlled trial. J. Gerontol. A Biol. Sci. Med. Sci. 63: 321-327.

Boyd CM, Darer JD, Boult C, et al. 2005. Clinical practice guidelines and quality of care for older patients with multiple chronic diseases. JAMA 294: 716-724.

Boyd CM, Ritchie CS, Tipton EF, et al. 2008. From bedside to bench: summary from the American Geriatrics Society/National Institute on Aging Research Conference on Comorbidity and Multiple Morbidity in Older Adults. Aging Clin. Exp. Res. 20: 181-188.

Butler RN, Miller RA, Perry D, et al. 2008. New model of health promotion and disease prevention for the 21st century. BMJ 337: a399.

Eleazer GP, Brummel-Smith K. 2009. Aging America: meeting the needs of older Americans and the crisis in geriatrics. Acad. Med. 84: 542-544.

Institute of Medicine. 2008. Retooling for an Aging America: Building the Health Care Workforce.

Raphael C. 2008. A sense of urgency is needed. Solutions on long-term care demand action now. Mod. Healthc. 38: 24-25.

Weiss CO, Boyd CM, Wolff J, et al. 2007. Patterns of prevalent major chronic disease among older adults in the United States. JAMA 298: 1160-1162.

Scientific Organizing Committee

Kavita Ahluwalia, DDS, MPH

Columbia University College of Dental Medicine

David A. Albert, DDS, MPH, Course Director

Columbia University College of Dental Medicine

Sue Dodd, RDH, BA

Oral Health America

Evelyn Granieri, MD, Course Director

Columbia University College of Physicians and Surgeons

Ira Lamster, DDS, MMSc

Columbia University College of Dental Medicine

Panos Papapanou, DDS, PhD, Course Director

Columbia University College of Dental Medicine

Lynn Tepper, EdD

Columbia University College of Dental Medicine


Keynote Speaker

Marie A. Bernard, MD

National Institute on Aging
e-mail | web site | publications

Marie Bernard is deputy director of the National Institute on Aging. She was formerly the Donald W. Reynolds Chair in Geriatric Medicine, and professor and chairman of the Donald W. Reynolds Department of Geriatric Medicine at the University of Oklahoma College of Medicine. She served as the Associate Chief of Staff for Geriatrics and Extended Care at the Oklahoma City Veterans Affairs Medical Center. She has been President of the Association of Directors of Geriatric Academic Programs and President of the Association for Gerontology in Higher Education.

Bernard's research interests include nutrition and function in aging populations, with particular emphasis upon ethnic minorities. She was a member of the National Advisory Council for the National Institute of Aging, having chaired the Minority Task Force during her tenure. She has also served on a number of national committees and journal editorial boards.

Bernard earned her MD from University of Pennsylvania. She trained in internal medicine at Temple University Hospital in Philadelphia, PA, where she also served as chief resident. She has received additional training through the AAMC Health Services Research Institute, the Geriatric Education Center of Pennsylvania, and the Wharton School Executive Development program.


Speakers

Douglas B. Berkey, DMD, MPH

University of Colorado Denver
e-mail | web site | publications

Douglas Berkey is professor of applied dentistry at the University of Colorado Denver, with a position in the Department of Preventive Medicine and Biometrics. His specialties include geriatric oral health and epidemiology. He is the recipient of a number of awards, including the Rocky Mountain Study Club Professor of the Year, the Knuemann Distinguished Professorship at the University of North Carolina, and the American Dental Association Geriatric National Health Care Award.

Cynthia Boyd, MD, MPH

Johns Hopkins Bloomberg School of Public Health
e-mail | web site | publications

Cynthia Boyd is an assistant professor at the Johns Hopkins University School of Medicine in the Department of Medicine, Division of Geriatric Medicine and Gerontology. She is a core faculty member at the Johns Hopkins Center on Aging and Health and the Roger C. Lipitz Center for Integrated Health Care, with a joint appointment in the Department of Health Policy and Management. She is also a Robert Wood Johnson Physician Faculty Scholar. Trained in internal medicine, geriatric medicine, and epidemiology, Boyd's main interests include the clinical care of comorbid chronically ill and frail older adults both chronically and during acute illness such as hospitalization.

Kenneth Brummel-Smith, MD

Florida State University College of Medicine
e-mail | web site | publications

Kenneth Brummel-Smith holds the Charlotte Edwards Maguire Professorship at the Florida State University College of Medicine, where he founded the Department of Geriatrics. Prior to holding this position, he served as the medical director to the PACE Elderplace program, was Bain Chair of the Providence Center on Aging, and a professor of family medicine at the Oregon Health Sciences University. He has served as the Section Chief for Geriatrics in the Department of Family Medicine at University of Southern California, and as Division Chief, Geriatrics, Department of Medicine, Oregon Health Sciences University. He is a past president of the American Geriatrics Society. He is also a member of the National Advisory Council on Aging at the National Institute on Aging. He is the chair of the Association of Directors of Geriatric Academic Programs, and has been selected by his peers 11 times as one of the Best Doctors in America.

Ira B. Lamster, DDS, MMSc

Columbia University School of Dental and Oral Surgery
e-mail | web site | publications

Ira Lamster is dean of the Columbia University School of Dental and Oral Surgery. He joined Columbia in 1988, serving as director of the Division of Periodontics before being named vice dean of the School of Dental and Oral Surgery in 1998. He obtained his DDS degree from the State University of New York at Stony Brook and completed graduate specialty training in periodontology and oral medicine at the Harvard University School of Dental Medicine. Lamster also received graduate degrees from the University of Chicago (SM) and Harvard University (MMSc).

Lamster has extensive experience in oral health research, spearheading initiatives in a wide variety of subject areas (such as diagnostic testing and risk assessment for periodontal disease, the interrelationship of oral infection and systemic disease, and chemotherapy for periodontal diseases) and serving as chairman of the Dental and Craniofacial Research panel of the American Dental Association's Future of Dentistry project. He has served on the editorial boards of Journal of Periodontology and Journal of Clinical Periodontology and is a diplomate of both the American Board of Periodontology and the American Board of Oral Medicine.

Daniel Malamud, PhD

New York University College of Dentistry
e-mail | web site | publications

Daniel Malamud specializes in the development of anti-HIV agents and oral-based diagnostics. Current studies focus on a point-of-care microfluidic cassette that can detect multiple analytes present in bacterial and viral pathogens. A second project deals with alterations in the gastrointestinal track following administration of antiviral therapy to HIV+ individuals. In this study research teams are monitoring proteomics, microbiomics, and alterations in the innate immune system. Dr. Malamud's research, which has been continuously funded by the NIH for over 30 years, deals with HIV pathogenesis, the design of anti-HIV drugs, and novel diagnostics using oral samples. His investigations in these areas have involved human salivary proteins that inhibit HIV infectivity and the discovery and development of anti-HIV compounds that can be used to prevent HIV infection.

Jeremy J. Mao, DDS, PhD

Columbia University College of Dental Medicine
e-mail | web site | publications

Jeremy Mao is an oral surgeon and the director of the Tissue Engineering and Regenerative Medicine Laboratory (TERML) at Columbia University, as well as a professor of dental medicine and biomedical engineering at the University. He has published over 300 scientific papers, book chapters, conference proceedings, and other articles in the areas of tissue engineering, stem cells, and regenerative medicine. He also serves on the editorial boards of several scientific journals, including Tissue Engineering and the Journal of Biomedical Material Research. Mao holds numerous patents in the areas of stem cells, tissue engineering, and regenerative medicine and is a standing member of the Musculoskeletal Tissue Engineering Study Section of the NIH. In addition to serving as a review panelist for the NIH, Mao's scientific expertise has also been sought on a regular basis by NSF and the U.S. Army, as well as many other significant grant-review panels in over 18 countries.

Richard Mayeux, MD

Columbia University College of Physicians and Surgeons
e-mail | web site | publications

Richard Mayeux is the Gertrude H. Sergievsky Professor of Neurology, Psychiatry and Epidemiology, and the Director of the Gertrude H. Sergievsky Center at Columbia University, a center devoted to the epidemiologic investigation of neurological diseases. He is also the Co-Director of The Taub Institute for Research on Alzheimer's Disease and the Aging Brain.

In 1992, he received the Leadership and Excellence in Alzheimer's Disease award from the National Institute of Aging and in 2004 a MERIT award for his work on the genetic epidemiology of familial Alzheimer's disease. Since 2002 he led the National Institute on Aging—Late Onset Alzheimer's Disease family study. He is a Fellow of the American Academy of Neurology and the New York Academy of Sciences, and a member of the American Neurological Association and the Association of American Physicians. In 2000 he was elected to the Institute of Medicine of the National Academies, and in 2007 received the Potamkin Award for research on Alzheimer's disease and related disorders from the American Academy of Neurology.

Carol Raphael, MPA

Visiting Nurse Service of New York
web site | publications

Carol Raphael is President and Chief Executive Officer of Visiting Nurse Service (VNS) of New York, the country's largest voluntary home health care organization. She manages VNS programs in post-acute, long-term care, family and children services, rehabilitation, hospice, mental health and public health as well as its health plan for dually eligible Medicare and Medicaid beneficiaries. Raphael also developed the Center for Home Care Policy and Research, which conducts policy-relevant research focusing on the management, and quality of home and community-based services.

Previously, Raphael held positions as Director of Operations Management at Mt. Sinai Medical Center and Executive Deputy Commissioner of the Human Resources Administration in charge of the Medicaid and Public Assistance programs in New York City. She is a member of MedPAC, the commission that advises Congress on Medicare payments and policies. She serves on several Robert Wood Johnson Foundation advisory committees and New York State panels including the Medicaid Reform Task Force, and the New York State Hospital Review and Planning Council, for which she chairs the Fiscal Policy Committee. She is on the Boards of Lifetime Healthcare Companies, the American Foundation for the Blind, Pace University, and is a member of the Pfizer Hispanic Advisory Board and the Kaiser Permanente Planning Group for Geriatric Care.

M. Cary Reid, PhD, MD

Weill Cornell Medical College
e-mail | web site | publications

Cary Reid is a doctor at the Weill Cornell Medical Center's Irving Sherwood Wright Center on Aging. His clinical specialties include clinical epidemiology, geriatric medicine, and internal medicine. His research is directed towards improving the management of pain among older persons. Current projects include testing non-pharmacologic strategies for pain among older persons in both clinical and non-clinical settings, identifying barriers to the use of self-management strategies for pain, and examining optimal strategies for managing pain across ethnically diverse populations of older persons. Additional areas of interest include the epidemiology and treatment of substance use disorders in older persons. A graduate of the University of South Carolina School of Medicine, Reid completed his residency at Dartmouth-Hitchcock Medical Center as well as fellowships in both clinical epidemiology and geriatric medicine at Yale University. He is currently a Robert Wood Johnson Generalist Physician Scholar and a Paul Beeson Faculty Scholar on Aging Research.

Joshua Willey, MD, MS

Columbia University College of Physicians and Surgeons
e-mail | web site | publications

Joshua Willey is an assistant professor of neurology at Columbia University College of Physicians and Surgeons in New York City, and assistant attending neurologist on the Stroke Service at New York Presbyterian Hospital. Willey received his undergraduate degree from Cornell University in 1999, and his medical degree from Columbia University in 2003. After a neurology residency at Columbia-Presbyterian Hospital, he completed a two-year neuroepidemiology and stroke fellowship at Columbia-Presbyterian Medical center; while there he also earned an MS in epidemiology. He joined the faculty of Columbia College of Physicians and Surgeons in 2009.

Willey has a clinical practice in neurology with a focus on cerebrovascular diseases and stroke. His research has focused on risk factors for clinical and subclinical cerebrovascular disease in the Northern Manhattan Study under the mentorship of Mitchell Elkind.

David J. Zegarelli, DDS

Columbia University College of Dental Medicine
e-mail | web site | publications

David Zegarelli is a practicing dentist at the Columbia University School of Dental & Oral Surgery and has a private practice in Tarrytown, NY. He is board certified in oral and maxillofacial pathology. He completed his medical training at Columbia, followed by an internship at New York Presbyterian Hospital and a residency at the Roswell Park Memorial Institute. His areas of specialty include oral pathology and medicine.


Marilynn Larkin

Marilynn Larkin is a medical editor, journalist, and videographer based in New York City. Her work has frequently appeared in, among others, The Lancet, The Lancet Infectious Diseases, and Reuters Health's professional newswire. She has served as editor of many clinical publications and is author of five medical books for general readers as well as Reporting on Health Risk, a handbook for journalists. She is currently head of publications for The Society for Biomolecular Sciences.

In 2004, Ms. Larkin started her own fitness consulting company (www.mlarkinfitness.com), and developed a class, Posture-cize, that helps people improve their posture, increase productivity, and reduce injury.

Supporters

Presented by

  • Columbia University College of Physicians and Surgeons
  • Columbia University College of Dental Medicine
  • Oral Health America
  • The New York Academy of Sciences

This eBriefing supported by

  • DentaQuest Foundation

Gold

Aetna® Dental

Colgate®

Silver

DENTSPLY International

Academy Friend

This conference was funded in part by the Life TechnologiesTM Foundation

At the conclusion of each session of this conference, attendees were asked a set of questions using an electronic audience response system (ARS). These surveys collected real-time data on participants' opinions about a range of topics important to the event. The results are compiled below.

Medical Considerations for Dentists

1. Patients with periodontal disease are at increased risk for developing carotid artery plaque.
Strongly Agree33% 
Agree53% 
Disagree10% 
Strongly Disagree3% 
 
2. Patients with neurodegenerative diseases are at increased risk for oral comorbidities.
Strongly Agree65% 
Agree24% 
Disagree10% 
Strongly Disagree1% 
 
3. Research studies consistently indicate that pain is "undertreated" in older adults. Do you believe
this to be:
A Provider Driven Problem17% 
A Patient Driven Problem1% 
Both A and B82%
 

Dental Considerations for Medical Doctors

4. What is the primary barrier to provision of oral health care for adults?
Lack of Funding Mechanisms64% 
Lack of an Oral Health Care Workforce7% 
Lack of Interest on the Part of Providers25% 
Lack of Interest on the Part of Patients4% 
 
5. How can we expand the workforce of providers willing and able to treat oral disease in older adults?
Mandate Increased Training in Dental School8% 
Utilize Mid-Level Providers33% 
Include Non-Dental Health Care Providers17% 
Improve Reimbursement42% 
 
6. What is the likelihood that salivary diagnostics will be widely utilized in the next ten years within
dental offices?
Very Likely31% 
Likely43% 
Unlikely26% 
 
7. What is the likelihood that salivary diagnostics will be widely utilized in the next ten years within
physician offices?
Very Likely46% 
Likely29% 
Unlikely25% 
 

Building Medical / Dental Partnerships

8. What are the biggest barriers to recruitment of professionals into geriatric care?
Status11% 
Reimbursement80% 
Ageism4% 
Lack of Role Models for Faculty5%
 
9. What do you think will be the biggest challenge for taking care of the growing aging population in the United States?
Financial or Resource Constraints51% 
The Number of Trained Practitioners22% 
The Number of Institutions Offering Specialty...0% 
Generational Conflict0% 
The Sustainability of Government Entitlements27% 
 
10. In caring for the oldest old (> than age 80) dental and medical care should be practiced collaboratively to insure optimal outcomes.
Strongly Agree95% 
Agree3% 
Disagree2% 
Strongly Disagree0% 
 

Audience Demographics

11. Are you?
Male53% 
Female47% 
 
12. Which community do you work in?
Medical15% 
Dental77% 
Both8% 
Other0% 
 
13. In what year did you graduate?
Before 198037% 
1991–199029% 
1991–200015% 
2001–20057% 
2006–20098% 
I am a student4% 
 
14. Which best describes your primary occupation?
Academic33% 
Clinician36% 
Research6% 
Policy3% 
Public Education3% 
Other19% 

Speakers:
Richard Mayeux, Columbia University Medical Center
M. Carrington Reid, Weill Cornell Medical College
Joshua Willey, Columbia University Medical Center

Highlights

  • Recent research has implicated periodontal disease as a potential cause of vascular disease; however, it would be premature to recommend periodontal treatment to help prevent heart disease or stroke.
  • Individuals with cardiovascular risks such as hypertension or diabetes have a significantly greater chance of developing Alzheimer's disease.
  • Chronic pain is poorly managed in older adults, contributing to activity restriction, disability, and loss of function.

Stroke and periodontal disease

"The emergence of periodontal infections as a potential risk factor for CVD is leading to a convergence in oral and medical care," said Joshua Willey of Columbia University Medical Center. Although researchers don't yet know whether the link is causative or if periodontal infections are simply a marker of overall ill health, it is yet another reason for interdisciplinary collaboration in the interest of public health.

"Worldwide, cerebrovascular disease is, by far, the most important cause of death from a neurological disease—more so than Alzheimer's disease or infections that may occur in the developing world," Willey said. In the United States, there are about 700,000–750,000 strokes annually. Stroke is the leading cause of serious disability, and the costs of caring for survivors are "staggering."

Stroke is mainly a disease of older individuals, he stressed. Unlike heart disease, which tends to peak in the 50s and 60s, stroke rises in incidence and prevalence when people are in their 70s and 80s. Stroke tends to be more severe in women, who also have longer hospital stays, the highest hospital mortality rates, increased prevalence of dementia after stroke and, as a result, a higher chance of being placed in a nursing home.

U.S. stroke deaths tend to aggregate in the buckle of the "stroke belt"—primarily North and South Carolina. However, a comparable number of deaths is seen in northern Manhattan—particularly central Harlem. Most of that mortality is likely related to untreated hypertension and socioeconomic status, Willey said, although dietary factors may also play a role.

Chronic infection and inflammation associated with periodontal disease may predispose an individual to vascular disease or accelerate its progression.

Beyond established modifiable risk factors such as smoking, excess alcohol use, physical inactivity, obesity, waist-to-hip ratio, and diet, recent research has implicated periodontal disease as a potential cause of vascular disease. The hypothesis is that the chronic infection and inflammation associated with periodontal disease predisposes an individual to vascular disease or accelerates its progression, Willey explained. Some recently discovered markers for cardiovascular disease—infectious burden, levels of c-reactive protein, and elevated white blood count—reflect the connection.

Researchers in the Oral Infections and Vascular Disease Epidemiology Study (INVEST), a nested study within the Northern Manhattan Stroke study, are investigating further. Findings from a subsample of the cohort—about 700 men and women with an average age of 66 who were free of vascular disease and chronic inflammation at the start of the study—revealed that tooth loss, which is a marker of past periodontal disease, was associated with a greater prevalence of carotid plaque. "If you had zero to nine teeth missing, you had a 45% prevalence of carotid atherosclerosis," Willey said. "With 10 or more missing, prevalence increased to 60%."

Other researchers have found associations between periodontal disease and intima-media thickness (IMT, a marker of atherosclerosis). Periodontal bone loss has also been associated with carotid atherosclerosis, bacterial burden, and a greater IMT.

Yet despite the growing association between periodontal disease and vascular disease, INVEST researchers caution that it would be premature to recommend periodontal treatment to help prevent heart disease or stroke. Rather, periodontal treatment should be recommended because of its oral health benefits, because people are not healthy without oral health.

Alzheimer's disease—a dental connection?

As the U.S. population grows older and people survive longer into old age, the prevalence of Alzheimer's disease is expected to increase from 5 million adults to about 12 million. As Richard Mayeux of Columbia University told attendees, "It's like the U.S. is in a rowboat and there's a tsunami coming across the ocean, and we're totally unprepared to deal with it."

Recent findings have found relationships between oral health and cardiovascular disease. In turn, cardiovascular risk factors have been associated with an increased risk of Alzheimer's disease. If the infection and inflammation associated with periodontal disease indeed predisposes to heart disease, then periodontal disease could be contributing—albeit indirectly—to the increased risk of Alzheimer's as well.

Recent studies have shown that people who survive a heart attack and go on to develop heart failure have an increased risk of developing Alzheimer's disease, Mayeux said. In fact, "if you have hypertension, diabetes, and heart disease, your risk of eventually developing Alzheimer's disease is about threefold greater." A recent study by his group showed that having a stroke increased the risk of developing Alzheimer's disease approximately twofold. That said, "lifestyle factors, cholesterol, and cardiovascular factors are probably secondary factors that don't directly cause the disease but modify one's genetic risk," Mayeux explained. "We're probably all at somewhat different degrees of genetic risk, but environmental factors and age do play a role."

During the question and answer session, an audience member asked whether controlling all cardiovascular risks and inflammatory disease would affect the risk of developing Alzheimer's. "I think there would be a major impact," Mayeux said. Studies in Northern Manhattan have shown that up to half of older adults in those neighborhoods have a history of hypertension, diabetes, and heart disease. Magnetic resonance imaging tests of healthy, symptomless older adults in that area revealed that about one-third of have had strokes. "That means we have an epidemic of silent vascular disease" Mayeux observed. "And one key to controlling both stroke and Alzheimer's disease is to get the cardiovascular and inflammatory risks under control."

Another participant asked whether treating adults who already have risk factors and disease could really lower the risk of Alzheimer's, given that the disease seems to start many years earlier than was originally thought. "The answer appears to be yes," Mayeux said. "If somebody has diabetes and hypertension for 20 years and you can effectively treat their lipids, hypertension, and other risks, then you may be able to reverse whatever process has already been set in motion and significantly reduce the burden of disease. The problem is that in most cases, these conditions are not well controlled. For example, only about 30% of people with hypertension are actually adequately controlled. So even though the goal would probably achieve the results, the goal is not being met on multiple levels," he concluded.

Several symposium participants noted that although it is important to maintain the oral health of people with stroke or Alzheimer's, their physical and/or mental condition often renders such care difficult. Speakers underscored the need for dental training modules addressing patients with special needs and innovative solutions such as mobile dental chairs that can be used in long-term care settings.

The role of chronic pain

"Pain is a highly prevalent symptom across multiple chronic conditions and is a significant and an underrepresented cause of disability and suffering in later life," M. Carrington Reid of Weill Cornell Medical Center told the audience. Chronic pain is also strongly associated with frailty: about 20%–45% of independent older adults report pain, compared with 42%–64% of home care recipients and as many as 82% of nursing home residents.

Recent studies showed that in a cohort of 18,000 older adults, one in four said they had moderate or severe pain, which correlated with increased difficulty in doing activities of daily living. Moreover, "people ages 50–59 with moderate or severe pain seemed to look like people who were two decades older," Reid said, meaning that pain itself—which could include pain from oral infections—may be playing a role in the disability process.

Prospective studies by Reid and his colleagues documented a reduction in gait speed as a result of pain, showing that the effect was not due to activity restriction alone. Investigations of 19 other causes of activity restriction—for example, dizziness, problems with balance, infection—showed that the time needed to walk 20 feet declined by about .3 seconds due to these causes. But gait reduction secondary to pain is twice that, indicating that there is "something special about pain" and its effects on activity restriction.

Clinicians should document the functional impact of pain, and assess how the patient is coping.

Speaking as a clinician, Reid speculated that pain leads to activity restriction and other mediators—specifically depression, social isolation, and less commonly, falls and substance abuse— "cascade into a problem of disability." Other studies have shown that severe pain is a cause of death due to suicide. To help counteract pain, clinicians should be "getting patients involved in activity programs, identifying and treating depression, and finding ways for patients to become engaged socially."

In addition, clinicians should be doing a physical exam that includes a documentation of painful areas, maintain records detailing the functional impact of pain, and assess how the patient is coping, Reid said. And they should be aware of recently updated guidelines for the management of pain in older adults, published in the August 2009 issue of the Journal of the American Geriatrics Society. Included are details on age-associated changes related to drug therapy; for example, fat-soluble drugs will have an extended half life, renal clearance declines with age, and older adults have increased sensitivity to CNS effects such as somnolence, confusion, and dizziness.

In contrast to the 1998 pain-management recommendations, the 2009 guidelines call for the avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs), meaning that patients will move from acetaminophen to opioids. Abuse rates for opioids seem to be very low, on the order of about 1%. "This is important because clinicians are concerned about precipitating or fostering abuse if I give they prescribe opioids," he said.

Exercise and other non-pharmacologic strategies such as mindfulness therapies, cognitive behavior therapy, distraction, and relaxation should be recommended for all older patients with pain, Reid stressed. Engaging patients in such strategies requires overcoming barriers such as fear of harm from exercise, and ageism—the idea that being older means a person will, a priori, be in pain. One patient told Reid that when he complains of pain, "my doctor tells me, 'well you're just getting older.'" Another remarked, "I showed my family doctor where I hurt and she said, 'it's only going to get worse, get used to it.'"

Two initiatives underway in New York City aim to turn those perceptions around and put effective pain-management programs into practice: The New York City Persistent Pain Working Group, and the Roybal Center/Cornell Columbia Translational Research Institute on Pain in Later Life, funded by the National Institute of Aging. The new center aims to promote the translation of behavioral, medical, social science research findings into treatments, intervention programs, and policies that can benefit older adults with or at risk of pain, and disseminate study findings and resources on the Web and elsewhere to researchers, practitioners, and policy makers, Reid concluded.

Speakers:
Daniel Malamud, New York University College of Dentistry and New York University College of Medicine
Jeremy Mao, Columbia University College of Dental Medicine
David Zegarelli, Columbia University College of Dental Medicine

Highlights

  • Salivary diagnostics could help detect systemic infections and diseases in older adults, although challenges must be overcome before such tools become mainstream.
  • Candidiasis, a common oral infection among the elderly, may be a symptom of systemic disease or a reaction to xerostomic medication.
  • Extracted or exfoliating teeth—now considered medical waste—contain dental stem cells that one day could be used to treat, and potentially cure, myriad diseases.

Salivary diagnostics hold promise

Many molecules present in blood can also be detected by sampling the oral cavity. Is there, then, a potential role for "oral diagnostics"—the use of salivary markers to detect and/or monitor systemic diseases—in older adults?

"I think it's obvious that if someone had a choice between being stuck with a needle [to draw blood] or having their mouth swabbed, they would probably choose the latter," said Daniel Malamud of New York University's College of Dentistry and College of Medicine. Oral/salivary tests are noninvasive, safe, cost-effective, and user friendly, he observed. And they sit at the interface between medicine and dentistry.

Most analytes in blood are also found somewhere in the oral cavity, although it's not always obvious where they are. "Sometimes we'll guess where an analyte is and other times we actually do a study and sample all of the possible locations. Once we know where it's coming from, we know the best way to collect it," Malamud explained. Analytes of interest may be located, for example, in whole saliva, duct saliva, gingival crevicular crevice, mucosal transudate, the inside of the cheek, or in plaque.

Where the analytes are, as well as whether a qualitative or quantitative result is needed, helps determine whether an oral test might be appropriate for home use, point of care, or solely for research purposes. An untrained health professional would likely have difficulty collecting a sample from the parotid or submandibular gland, or from the gingival crevicular fluid, for example, so whereas such a sample might be useful as a laboratory tool, it's unlikely to be useful as a point-of-care test.

Similarly, it's easier to get a "yes" or "no" answer—e.g., does someone have HIV infection—from an oral test than to calculate something like a person's blood glucose level. "It doesn't do much good to know that yes, there's glucose in the oral cavity. You need to know that it's correlated with the blood value—something that's often overlooked," Malamud explained.

A recent study identified all the proteins that can be found in the various salivas—914 in parotid, 917 in submandibular/sublingual, and an overlap of 665 between the two types. This means scientists studying a particular disease can search and find whether it has a marker that is present in saliva, Malamud explained.

But certain characteristics of the geriatric population must be taken into consideration before salivary diagnostic tools can become mainstream. Interestingly, researchers recently discovered that certain proteins are present in younger women (ages 20–30) but not in older women (55–65), and vice versa. These normal differences in protein expression will influence the interpretation of findings, both in research and clinically.

Number of parotid proteins by function at different ages.

A number of salivary gland alterations in older adults may also pose problems, Malamud said. Xerostomia and salivary gland hypofunction are extremely common in the elderly. These conditions may result from systemic diseases and their treatments. It's been estimated about 400 drugs—for example, anticholinergics, antidepressants, antihistamines, and diuretics—cause dry mouth as a side effect. Systemic diseases such as Sjögren's Syndrome—an autoimmune disease that affects secretions of the oral cavity and the eyes, mainly in postmenopausal women—also interfere with salivary analyses.

Nonetheless, a number of oral/salivary tests are in development. These include tests from Malamud's lab for HIV, tuberculosis, and malaria and, from other groups, tests for chronic obstructive pulmonary disease, asthma, oral cancer, and markers of cardiovascular disease. Of particular interest, Malamud said in closing, is new work suggesting that the five specific cytokines—epidermal growth factor, colony-stimulating factor 3, interleukin 1?, interleukin 3, and tumor necrosis factor—are associated with the development of Alzheimer's disease. As markers, the five cytokines had a predictive accuracy of 96%. Although the finding is an association, not causal, "all five are part of the innate immune inflammatory response, and significantly they're all present in saliva," Malamud enthused. "So, in terms of studying the link between inflammation and Alzheimer's, saliva may be a neat place to look."

What is the oral mucosa saying?

Moving from oral diagnostics to disease, David Zegarelli of Columbia University's College of Medicine described two conditions that he has seen most often in his 35-year practice, particularly with older adults, that may also be symptomatic of systemic disease.

"More than any other disease, I am dealing with candidiasis. I cannot emphasize that enough," Dr. Zegarelli said. Lichen planus is a distant second; however, it is potentially more dangerous in that it is sometimes associated with squamous cell carcinoma.

Medications that reduce salivary flow may promote oral disease.

Candidiasis is more common in older adults. It's said to be ubiquitous—up to 50% of people have candidal microbes in their mouth. The most common subtype is Candida albicans, which has the greatest potential for adherence to the oral mucosa compared with the other more than subtypes of candidal microbes. "It is almost always a secondary invader, and orally more common in women than in men," Dr. Zegarelli said. It's considered a secondary invader because xerostomia (dry mouth) seems to be the most common condition predisposing to candidiasis infection. Xerostomic medications include antibiotics that kill the oral mucosa and anti-inflammatory agents such as prednisone. If the compromising condition is not eliminated—for example, by switching medications—the infection tends to recur, he said.

Lichen planus, while much less common, may also be the result of medications, chemical substances, or the ingestion of spicy flavoring agents. Often exacerbated by stress, the condition appears in six forms: papules, laces, plaques, erosive, ulcerative, and bullous. Treatment with steroids or other medications is effective, but long-term monitoring is warranted, particularly because of the association of lichen planus with squamous cell carcinoma.

Sometimes, the solution is "not to add a medication, but to take one or more chemicals away," Dr. Zegarelli said. For example, in one patient, stopping an anticonvulsant and an antipsychotic were sufficient to remove oral lesions entirely.

Transforming dental stem cells

Also at the intersection of dentistry and medicine, but outside of the realm of clinical treatment for now, is regenerative medicine using dental stem cells. Jeremy Mao of Columbia University College of Dental Medicine believes "the future [of medicine and dentistry] is probably right around the corner, if not already in the present." Whereas contemporary medicine treats disease, "regenerative medicine, if it works the way it's supposed to, cures it."

From the oral health perspective, adult dental stem cells eventually could be used, with tissue engineering techniques, to fix disorders of the craniofacial region, Mao said. Work is also underway in various laboratories to differentiate adult dental stem cells into odontoblasts or osteoblasts in an effort to regenerate teeth and bones.

In parallel, Mao and others have differentiated adult stem cells into chondrocytes to make cartilage; fibroblasts for the regeneration of tendons, ligaments (including the periodontal ligament), and cranial sutures. More recently, Mao's team differentiated dental stem cells into muscle cells and into neuron-like cells, which have the potential to one day help cure muscular dystrophy and neurodegenerative diseases, respectively. They've also used dental pulp to produce pancreatic beta cell-like cells that produce insulin, and implanted the cells into diabetic animals to see if they can reverse diabetes.

Of course, a number of hurdles related both to science and cost must be overcome before such work moves into the clinic. But "despite the potential for failure, it is far worse not to get clinical trials started," Mao stated. "This is a symposium on the connection between dentistry and medicine. The extracted or exfoliating teeth that we [dentists] deal with on a daily basis currently are treated as medical waste—yet they contain stem cells that have potential for use in medical treatment."

Speakers:
Douglas Berkey, University of Colorado, Denver
Kenneth Brummel-Smith, Florida State University College of Medicine
Cynthia M. Boyd, Johns Hopkins University
Carol Raphael, Visiting Nurse Service of New York

Highlights

  • There is a tremendous shortfall in the health care workforce, including a dearth of physicians and dentists trained in geriatrics.
  • Specialties without specific training in geriatrics include such important fields as ophthalmology, neurology, dermatology, and otolaryngology.
  • Dental schools, like medical schools, fall short on geriatrics education, and the clinical care experiences that dental students receive are on well elderly, not those who are functionally impaired or frail.
  • Health care teams made up of physicians, dentists, nurses, other providers, and informal caregiver are essential for implementing care plans for older adults with multimorbidity.
  • The geriatric competence of the entire workforce must be enhanced.

Workforce issues

What are the chances that medical/dental collaborations will become a reality? Carol Raphael of the Visiting Nurse Service of New York was the first to address some of the obstacles, focusing specifically on the "woefully insufficient" numbers of skilled health care workers of all sorts to meet the needs of a rapidly aging U.S. population. Like Bernard, Raphael participated in the Institute of Medicine task force that grappled with the "retooling" of the health care workforce to better care for aging Americans. She emphasized that one out of five Americans will be over age 65 by 2030; in New York City alone, the population of older adults is projected to grow by 44% to 1.35 million.

Against that backdrop, issues of concern include the following:

  • Chronic disease prevalence—heart disease, hypertension, cancer—increases with age.
  • Health care utilization increases with age—while the over 65 population comprises 12% of the population, it accounts for 26% of all physician visits, 35% of hospital stays, 34% of all prescriptions filled, and 38% of EMS responses.
  • Health care utilization increases with the number of chronic conditions—compared to those with only one chronic condition, Medicare beneficiaries with five or more conditions see more than three times as many physicians (on average, 14 different physicians per year), visit physicians more than four times as often, and receive almost five times the number of prescriptions.
  • Nearly 70% of Medicare spending today is on behalf of the 23% of beneficiaries with five or more chronic conditions.

What is the workforce shortfall? Currently, there are 7100 geriatricians in the United States. By 2030, the number is projected to increase to 7750, whereas the need is for 36,000. Many available fellowships in geriatric medicine remain unfilled; new certifications in geriatric medicine have plateaued at a low level; and geriatricians have the lowest average earnings of any medical specialty.

New certifications in geriatric medicine, 1998–2004.

The dental workforce is also unprepared. Geriatrics is not recognized as a specialty for certification; there are only 13 programs for academic geriatric dentistry; no residency is specific to geriatrics; and geriatrics is not specifically tested on board exams.

Other components of the health care workforce—nurses, social workers, direct care workers, and family caregivers—are also lacking in numbers and subject to burnout, Raphael observed. Only 1% of pharmacists is trained in geriatrics, very few schools of podiatry include geriatrics, and there are only 1600 geriatric psychiatrists in the United States.

The most important recommendation to come out of the IOM report "is to enhance the geriatric competence of the entire workforce," Raphael stressed. "All of us who work in health care are going to be working with older adults, and therefore, all of us need to be competent in dealing with the issues that older adults face."

This will only be accomplished when all residents in settings where older adults receive care are trained in geriatrics, and when licensure and certifications require demonstrated competence in the care of older adults. Moreover, "targeted financial incentives" are needed to recruit and retain geriatric specialists, she concluded.

Bolstering medical education

Delving more deeply into the medical education needs for treating an aging population, Kenneth Brummel-Smith of the Florida State University College of Medicine, observed that although less than 4% of medical school graduates go into geriatrics, "we are the most satisfied of all physicians." That said, like Raphael, Brummel-Smith pointed to increasing shortfalls; the drop in numbers of primary care physicians from 62% of physicians in 1980 to less than 50% currently means that the pipeline for geriatricians—all of whom are family physicians or internists—is declining. Specialties without specific training in geriatrics include such important fields as ophthalmology, neurology, dermatology, and otolaryngology.

However, "some strides" have been made in geriatric medical education, Brummel-Smith acknowledged. "More schools have departments of geriatrics, and almost all schools report some dedicated casework." Nevertheless, only 23% have a required rotation in geriatrics (compared with 100% for pediatrics rotations) and only 48% integrate geriatrics into other clerkships.

To help close the gap in geriatrics education while opening the door to connecting medicine and dentistry, "collaborative and team-based training" is needed, Brummel-Smith said. He presented highlights of a special program at Florida State, created by a legislative mandate requiring "a continuing focus on the aging human throughout the four-year curriculum," that accomplishes these objectives.

The model program includes a "graduated curriculum that exposes students to health older adults first, to help negate some of the negative attitudes," he explained. Highlights include:

Year One: Introduction to the Older Person

  • Normal aging, myths and stereotypes
  • Psychosocial/spiritual development
  • Communication skills and physical examination of the older person

Year Two: The Older Adult at Risk

  • Family dynamics and caregiving
  • Pharmacogeriatrics
  • Functional assessment
  • Geriatric syndromes

Year Three: The Older Adult in Sickness and Health

  • Chronic illness/ multiple illnesses
  • Rehabilitation
  • Death and dying

Year Four: The Older Adult and the Health Care System

  • Care across multiple sites/transitions, including dentistry

Implicit in the approach is an effort to "geriatricize" clinical skills training by integrating the concept of aging throughout the lifespan, Brummel-Smith said. "We stress the importance of communication skills, the fact that all of us want to function as independently as possible, no matter what age we are; the fact that all of us live in social settings and utilize social supports, particularly when we're ill; and the idea that therapeutic review is more than just knowing the pharmacodynamics and kinetics of a drug. It also means knowing what non-drug approaches are available, and what types of approaches patients decide on for themselves. Ultimately, it's about integration, not specialization," he concluded.

Bolstering dental education

Dental schools, like medical schools, fall short on geriatrics education. Moreover, "the clinical care experiences that dental students receive are on well elderly—not those who are functionally impaired or frail," Douglas Berkey of the University of Colorado Schools of Dental Medicine and Public Health told conference attendees. As a result, "they don't have an opportunity to struggle with some of the real challenges associated with geriatrics and gerontology. Students and residents are not prepared to identify, prioritize, and treat the oral health care needs of this most at-risk group."

Although exit surveys of graduating dental students acknowledge a desire for more geriatric dentistry, opportunities are few and far between, Berkey said. Historically, there have been only three sources of such training: the government's Health Resources and Services Administration, Veterans Administration programs (which no longer exist), and a Masters of Science degree program at the University of Minnesota. As dentists who trained in the mid 1980s through the early 1990s prepare to retire, "there will be a significant brain drain in this area," Berkey warned.

A 1995 publication from the Bureau of Health Professions identified a number of potential solutions to "retool" geriatric dental education. These included having a formalized set of competencies and standards, requiring predoctoral geriatrics education, establishing core competencies in national boards and regional licensure exams, and deploying continuous quality improvement measures to bolster dental education and care. Yet little progress has been made in any of these areas, Berkey said.

However, going forward, most dental care for older adults will likely be provided by generalists, Berkey emphasized. "So if we can provide opportunities for advanced geriatrics training in general dentistry, that would be very good," he concluded.

Coping with multimorbidity

In the final presentation of the day, Cynthia Boyd of the Johns Hopkins University School of Medicine and the Bloomberg School of Health reminded attendees that many older adults have multiple comorbidities, rendering both medical and dental care very difficult. And although medical professionals tend to think of patients in terms of their systemic diseases, the fact that they also have dental issues, particularly periodontal disease, "is often unrecognized," she said.

Physicians who care for patients with multimorbidity face challenges that include managing treatment for various diseases, prioritizing which conditions are most important, and deciding how to use evidence-based medicine in the decision making process, Boyd said. Whereas 50% of older women have only arthritis, fewer than 20% of people who have heart disease, chronic lower respiratory tract disease, diabetes, or stroke have only one of those diseases. Complicating the picture is heterogeneity in health status even among those with multimorbidity, and lack of clinical practice guidelines that include older adults—much less older adults with comorbidity—when addressing a specific disease.

Boyd advocates a conceptual framework that does not rely on separate treatment of specific diseases and conditions, but brings together teams of professionals working together for the patient's health. Slide courtesy of Cynthia Boyd

Even when a treatment regimen for a patient with multimorbidity was cobbled together from existing guidelines, it was incredibly complex. Boyd cited the case of a 79-year-old woman with five conditions whose treatment regimen was developed according to guidelines and taking potential drug interactions and synergies into consideration. It included 12 medicines in 19 different doses; non-pharmacologic therapies, such as dietary modifications that were to take place at specific times of the day;, and non-pharmacologic therapies and self-management techniques that were "supposed to be done whenever you can all day long," Boyd explained. The costs in time and money of such a regimen are out of reach for many patients. And that's before considering that the patient also "is probably at very high risk of also having oral health problems, and that some of the medicines might affect the person's dental management."

Boyd's analyses of the evidence for various approaches to patient management has led her to endorse a conceptual framework in which the patient is more than simply the sum of his or her diseases and conditions. Both physicians and dentists need to acknowledge that these conditions "occur within the context of a patient, and that includes not just their physiologic health, but also their psychosocial circumstances," she emphasized. Health care teams made up of physicians, dentists, nurses, other providers, as well as informal caregivers are "essential for implementing care plans," she concluded.

As the baby boom generation gets older and lives longer, the United States health care system shows few signs of being ready to address its needs. A 2008 report from the Institute of Medicine points to a fundamental lack of preparedness in the healthcare workforce for this demographic shift. Medicine and dentistry are already experiencing higher demands for individuals trained in geriatrics, even as woefully few professionals choose to work in that area.

Marie Bernard, deputy director of the National Institute on Aging, was a leader in the preparation of the IOM report. In her keynote address to an October 16, 2009, New York Academy of Sciences symposium, she stressed the need to prepare for what she calls the upcoming "silver tsunami."

Sheer population numbers alone mean that cardiovascular disease, stroke, Alzheimer's disease, and other disorders related to aging are likely to increase in prevalence in coming years. The picture is similar in dentistry. Although there has been a marked reduction in the percentage of adults 60 and older who have lost all of their teeth compared with prior generations, root caries, oral fungal infections, and osteonecrosis of the jaw (a rare side effect of taking bisphosphonates to prevent osteoporosis) are emerging as areas of increasing concern.

Although the number of available first-year geriatric medicine fellowships is rising, a growing percentage remain unfilled.

In addition, while good dental care will be important for the aging population—and mounting evidence suggests that oral health is a reflection of and contributes to systemic health—few dentists are trained in treating older adults or cognizant of their often complex oral health needs. Meanwhile, because Medicare does not cover routine dental care and many Americans lack dental coverage, the cost of such care is out of reach for many who need it.

As researchers continue to explore connections between oral health and systemic health with regard to the more prevalent conditions related to aging, other problems are also emerging at the interface of medicine and dentistry. One example is oral cancer. Recent data show such cancers are most common at ages 55–64, and that mortality "is absolutely skewed to older ages," Bernard said. That could be due to multiple morbidities in older individuals, but lack of dental coverage could also play a role. "These days, a primary care physician is increasingly pressured to spend 15 minutes or less in a patient encounter, and so the tendency is to address the presenting reason for the visit, rather than doing a thorough evaluation," Bernard observed. "Therefore, many times the dental health professional is the only person who might see a harbinger of oral cancer—and if the person's not seeing a dental health professional, how will it be picked up?"

The sense of taste also diminishes with age, due to changes in taste buds and perhaps, secondarily, to a diminished sense of smell. Dry mouth and other salivary disturbances may also result from medications prescribed for systemic diseases. Such changes "clearly have implications for nutrition and health because if food isn't tasty and satisfying, you're not going to consume much."

Going forward, "there will be plenty of [funding] opportunities" for scientists engaged in research dealing these and other age-related diseases and conditions, Bernard emphasized.

Medical issues of interest to dentists

While it might seem logical that medical professionals would recognize the importance of  maintaining oral health, and that dentists would understand the health needs of their older patients, neither of these things is happening today. But efforts such as this symposium, organized in collaboration with the Columbia University College of Physicians and Surgeons and its College of Dentistry, are underway to develop collaborative approaches in which medical and dental professionals could coordinate to provide care for the whole person. The morning session looked at several medical conditions with connections to oral health.

Periodontal infection has emerged as a potential risk factor for some of the major diseases of the elderly, including cardiovascular disease and stroke. Joshua Willey of Columbia University Medical Center remarked that although researchers don't yet know whether the link is causative or if periodontal infection is simply a marker of overall ill health, it provides another reason for interdisciplinary collaboration among dentists and medical professionals.

Richard Mayeux of Columbia University suggested a potential connection between poor oral health and the development of Alzheimer's disease. Many researchers now believe that periodontal disease may contribute to cardiovascular disease by increasing the infectious burden. Mayeux's group's research has shown that "if you have hypertension, diabetes, and heart disease, your risk of eventually developing Alzheimer's disease should you survive is about threefold greater." M. Carrington Reid of Weill Cornell Medical Center stressed in his presentation that chronic pain, which is common across multiple systemic and oral conditions, is "an underrepresented cause of disability and suffering in later life." He underscored the need to overcome ageism among clinicians, who may be unwittingly fostering pain in their patients by telling them it's simply part of aging.

Oral health issues of interest to medical doctors

Approaching the need for collaboration from the dental side, Daniel Malamud of New York University's College of Dentistry and College of Medicine, provided insights into the promise of salivary diagnostics. A number of these noninvasive tests are in development for detection of, among other conditions, HIV, tuberculosis, chronic obstructive pulmonary disease, asthma, oral cancer, and markers of cardiovascular disease.

David Zegarelli of Columbia University's College of Medicine reminded the audience that diseases of the oral mucosa—particularly candidiasis—can reflect systemic conditions such as a compromised immune system. And Jeremy Mao of Columbia University's College of Dental Medicine demonstrated future convergences between dentistry and medicine, as new technologies—in particular, tissue engineering and stem cell advances—emerge. For example, regenerative medicine investigators are involved in differentiating adult dental stem cells into a variety of cell types, including cartilage-like cells to treat arthritis and neuron-like cells that might ultimately treat Alzheimer's and other neurodegenerative diseases.

Strategies for building medical/dental partnerships

Reprising the theme articulated by Bernard in her opening address, speakers in the final session focused on the dire need to build and "retool" the health care workforce to accommodate the aging population. Carol Raphael of the Visiting Nurse Service of New York stressed the need for geriatrics education across the board, while Cynthia Boyd of the Johns Hopkins University School of Medicine and the Bloomberg School of Health reminded attendees that many older adults have multiple comorbidities, rendering both medical and dental care challenging for all health care providers, regardless of education and clinical background.

Kenneth Brummel-Smith of the Florida State University College of Medicine presented the curriculum for a unique program that seamlessly integrates geriatrics into the core medical curriculum. However, Douglas Berkey of the University of Colorado Schools of Dental Medicine and Public Health stressed that few programs of this type exist in dental schools.

Summing up the goals of the event in an interview, Ira Lamster, Dean of the Columbia University College of Dental Medicine and a member of the scientific organizing committee, said, "A conference like this is critically important. When we increase the dialogue between physicians and dentists, the ultimate result is improved patient care."