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As medicine continues to extend the human lifespan, ever-greater numbers of people are requiring dental care in their later years. Older people, however, often do not have access to quality dental care, due to cost as well as an inability to travel to a dentist’s office or clinic because of poor health. Columbia’s College of Dental Medicine (CDM) has launched a new program – ElderSmile – to address the growing need for dental care for the elderly. The program is intended to serve as a prototype for other dental schools.
    “The lack of quality dental care for a new population of older Americans is a looming health crisis. Because dentistry in the aged population has not received significant attention in the past, the dental community is essentially unaware of the problem and does not have a coordinated plan to address the issues,” says Ira Lamster, D.D.S., M.M.Sc., dean of CDM.

Broad-based Program
ElderSmile, which began in May 2004, takes a multifaceted approach, combining outreach, education, prevention, and treatment, along with a program to train future dentists in geriatric dentistry. Dental school faculty, assisted by students, provide initial screenings and oral hygiene instruction at “prevention sites,” primarily in senior centers. “With this approach, we are able to access a large number of people without having the expense of setting up a full-scale dental clinic in each of these locations,” Dr. Lamster says.
    Patients who need more in-depth dental care are referred to ElderSmile treatment
Susan Crawford-Lemelle, assistant clinical professor
Susan Crawford-Lemelle, assistant clinical professor, Division of Operative Dentistry, with a patient at a dental clinic that opened in June in Washington Heights to provide care for elderly patients. The four-chair facility is in NewYork-Presbyterian Hospital's Ambulatory Care Network Geriatric Practice.
centers. Two facilities are currently operating: one at the Thelma C. Davidson Adair Medical/Dental Center in the Mannie L. Wilson Senior Residency Towers in Harlem and a second that opened in June in conjunction with NewYork-Presbyterian’s Ambulatory Care Network. Another site is planned in partnership with the Isabella Geriatric Care Nursing Center in Washington Heights.
    During summers, a mobile dental van visits senior centers to provide additional patient education and screening. As the program grows, new treatment centers will be added and the current ones will expand their capabilities. The treatment is paid for by Medicaid (if the patient is eligible), or by patients on a sliding-scale basis. Unfortunately, the Medicare program does not provide any meaningful dental coverage. Dr. Lamster says that as dentistry advances, offering cutting-edge treatments such as implants will present financial challenges. The start-up of Eldersmile’s service component is made possible by grants from the Fan Fox and Leslie R. Samuels Foundation and the Stella and Charles Guttman Foundation.
    In anticipating the continued and growing need for dentistry for older Americans, ElderSmile also incorporates a crucial student-training aspect. The current shortage of dentists educated and equipped to manage the particular dental issues of the senior population is minor compared with what it may be in the near future. The over-65 U.S. population grew by 12 percent between 1990 and 2000 and is expected to nearly double by 2025. “We need to prepare our dental students to provide care to older patients who present with chronic diseases and social service needs, and develop a program to train future leaders in the field,” says Dr. Lamster.
    CDM students can choose geriatric dentistry as a concentration and go to the treatment centers to learn from attending dentists and through practice carefully monitored by faculty. Unlike similar dental school programs that provide care for underserved populations, ElderSmile care is provided by faculty, residents and students. “That is our framework for education. Residents and students will rotate into a site and provide some care under the supervision of the attending dentists,” says Stephen Marshall, D.D.S., M.P.H., associate dean for extramural programs, who directs the development of ElderSmile.
    Geriatric dentistry requires advanced knowledge of the dental and medical problems unique to older people. Not only do older people need special care that takes into account a lifetime of use of the teeth, but also dentists who can look at them from the perspective of the entire patient.
    Many older people are on medicines that cause “dry mouth,” for example, a problem, since saliva is the body’s first-line defense against cavities. And cavities in older adults can lead to problems because of exposed root surfaces. Recent research has also linked chronic oral infections to diseases such as diabetes, heart and lung diseases, and stroke. CDM research focuses on evaluating the prevalence and risk factors for oral diseases in older adults. “It’s not just about identifying and treating dental problems. It’s about all the attendant problems that accompany these patients,” says Dr. Lamster. “Dentists need to recognize and understand problems like these and consider the systemic concerns.”
    For Gila Insler, SDOS ’06, the decision to specialize in geriatric dentistry grew out of personal experience. “My grandmother may have been hunched over but her mind was sharp,” she says. “Despite that, she was rarely treated as a fully functioning individual. I thought she deserved better.” And caring for her first geriatric patient, a Holocaust survivor, cemented her decision. “I think the desire to help older people stemmed from these relationships.”
    Personal experience also motivated Dr. Lamster to take action. “When my mother went into a long-term care facility, I saw that after about six months she began to experience significant dental problems,” Dr. Lamster says. “When I spoke to the center’s dentists, I was told that they only provided palliative care. But she was aware that her appearance had changed.
    “This experience made me think – if I as dean of a dental school encountered this type of problem, what challenges were others encountering when trying to secure care for older relatives? What are the elderly themselves going through?” This realization, he says, was the personal “tipping point” that led him to develop ElderSmile.

—Keely Savoie