For Immediate Release
Date: Sep 12th, 2016
Contact: Dr. Robert Henry
Understanding the Aging Phenomenon/The Aging Tsunami: Demographic Imperative
The State of Aging Report for Kentucky has spawned the material for this issue of KDA TODAY. This report is the first in a yearly series by the Institute for Aging, designed to raise the awareness of the Cabinet for Health and Family Services, the State Legislature, and the citizens of Kentucky about the aging population in Kentucky and the problems faced by seniors, their families and the State. Our own Dr. William Mansfield is a contributor and member of the Institute for Aging. The entire report can be found at: http://chfs.ky.gov/NR/rdonlyres/1FA4CD17-871A-435E-9750-086ABC3670C5/0/2015ReportoftheInstituteforAging.pdf
It contains three main parts, information on selected demographic, economic and social characteristics of seniors in Kentucky, the most recent reliable statistics on the delivery of services to older adults and those who care for them, and in-depth considerations of rural transit, long term care, and recommendations for an “Age Friendly Kentucky”.
Please note that graphics refered to in this article may be viewed in our online virtual publication located elsewhere on our website.
Older people are flooding dental offices everywhere! In fact worldwide, seniors (defined as persons 65 and older), are increasing at an unprecedented growth rate never experienced before. The aging of the population, or population aging, is a term for shifts in the age distribution of a population toward older ages. Worldwide populations are aging as a direct result of global fertility (birth rates) declining and mortality (death rates) declining at older ages. Population aging is expected to be among the most prominent global demographic trends of the 21st century. (Ref #1. Population of aging)
The current level and pace of population aging vary widely by countries and regions within countries (states in the U.S.) but virtually all nations in all countries worldwide are now experiencing growth in the numbers of senior residents. The aging structure of the United States continues to be marked by the large birth cohorts of the baby boom population (people born from 1946 to 1964). The first of those turned 65 in 2011, and this group reached age 70 in 2016 (this year). The baby boom population in the U.S. adds 10,000 new people every day to the Medicare population (those 65 and over). (Ref #2. Population of aging)
In 2010, 40 million people age 65 and over lived in the United States, accounting for 13 percent of the total population. As seen by Figure 1, (Population of Older Americans), the older population grew from 3 million people in 1900 to 40 million in 2010. The oldest-old population (those age 85 and over), grew from just over 100,000 in 1900 to 5.5 million in 2010.
Figure 1-U.S. Aging Population 65+ and 85+
The aging population is often measured by increases in the percentage of elderly people in retirement ages. The definition of retirement ages varies but the typical cutoff is 65 years. It is said that a society (in a certain area, region, state, or country), is considered to be relatively old when the fraction of the population aged 65 and over exceeds 8-10%. By this standard, the percentage of elderly people in the U.S. stood at 12.6% in 2000, compared with only 4.1% in 1900 and a projected increase to 20% by the year 2030. (Ref #3. Population of aging)
As health, financial situation, and consumption patterns may vary greatly between 65-year-olds and 80-year-olds, simple ratios conceal important differences in the elderly population. Increasing attention is being paid to the “oldest olds”, those people age 80 and over. Similarly, the number of centenarians, those over age 100, is growing even faster. Estimated at 180,000 worldwide in 2000, it could reach 1 million by 2030. (Ref #4. Population of aging)
Since population aging refers to changes in the entire age distribution, any single indicator may be unable to describe it sufficiently. Therefore, perhaps the best approach to study population aging is by looking at a set of percentiles, or graphically by analyzing the population pyramids. Demographers use population pyramids to describe both age and sex distributions of populations. Figure 2 depicts three population pyramids; the country of Nigeria in 2000, representing a youthful population, with a broad base of young children and a narrow apex of older people; the United States in 2000, representing an intermediate population, with the baby boom population representing the largest group in the years 30-50, and the projected United States in 2025, representing older populations characterized by more uniform numbers of people in the age categories (known as rectangularization of the survival curve). (Ref #5. J. Aging Health, rectangularization of survival curve)
Figure 2: Population pyramids of Young, Intermediate, and Old Populations
Implications of Population Aging
Although having massive numbers of people surviving to old ages represents, in one sense, a great success story for mankind, it also poses significant challenges to public institutions that must adapt to a changing age structure. The first challenge is associated with the dramatic increase in the older retired population compared to the shrinking population of working ages, creating financial and political pressure on social security programs. In the United States for example, the social security system will face a crisis if radical modifications are not enacted. Cuts in benefits, tax increases, massive borrowing, lower cost-of-living adjustments, later retirement ages, or a combination of these options are being discussed as possible solutions which may be necessary to sustain the current public retirement programs in Medicare and Social Security. (Ref #6. Aging of Populations)
In regard to health care “systems”, such as hospitals and long-term care facilities, as nation’s age, and the prevalence of disability, frailty, and chronic diseases (Alzheimer’s disease, cancer, cardiovascular diseases, stroke, diabetes, etc.) increase, some experts raise concerns that populations in developed countries may become “global nursing homes”. (Ref #7. Eberstadt, 1997) The cost to maintain healthy people increases as chronic disease and disability increase, which is inevitable as populations age.
Aging of populations in developed and developing countries is a global phenomenon that will require international coordination, national commitment, and local actions. The United Nations and other international organizations have developed recommendations with the intent to mitigate the adverse consequences of population aging. These recommendations include reorganization of social security systems, changes in labor, immigration and family policies, promotion of active and healthy life styles, and more cooperation between governments in resolving socioeconomic and political problems posed by population aging. (Ref #8. Aging of populations)
On the positive side, the health status of older people is improving more than any time in history because more recent generations have a lower disease load. Older people are living more active and vigorous lives until a much later age than in the past. If given the opportunity, older adults can be economic contributors as well. Finally, technological advances and biomedical anti-aging research may provide ways to extend the healthy and productive period of human life in the future. (Ref #9. deGrey et al, 2002)
In Kentucky, the aging population boom is affecting all areas. The following section describes what we currently know about our aging citizens and what recommendations for meeting their needs have been made.
State of Aging Report 2015
The State of Aging Report is the first of an annual series prepared by the Institute of Aging (Ref #9. Department of Aging and Independent Living, Inst of Aging) designed to raise the awareness of the Cabinet for Health and Family Services, State Legislature, and citizens of Kentucky, regarding making funding decisions for needs of Kentucky’s older citizens. This Report provides selected summary information on the status of the older adult population of Kentucky, the delivery of services to this population and key issues identified by the Institute as critical to the future service needs of its older citizens. The intent here is to highlight the sections of the report which will be pertinent to dental providers who see older patients in their practices every day and will help them to understand some of the characteristics of our state’s aging population and some of the issues elders face when they seek our services.
According to the U.S. Census Bureau, Kentucky’s total population in 2010 was 4,314,113 and is expected to increase to an estimated 4,554,998 by 2030. In 2010 the population of persons 65 and older was 578,227, comprising 13.3% of the total population. There were 829,193 persons aged 60 and older in the Commonwealth, comprising 18.8% of the total population. The “Baby Boom Generation” (persons born between 1946 and 1964), make up the greatest proportion of persons 65+, with the first cohort of those turning 65+ 5 years ago (2011), and in 2016, for the first time, the Baby Boom generation has reached age 70! The proportion of older adults in Kentucky, is expected to increase to 25.6% by 2030. Figure 3 represents the Age Composition of the Older Adult Population by the 15 Area Development Districts (ADD) and published in 2010. (Ref #10. State of Aging Report)
Figure 3: Age Composition of the Older Adult Population (2010)
According to the State of Aging Report, almost one in five Kentuckians (18.8%) lives on an income below the poverty level. This compares to 11.3% (poverty level) nationally. In rural Kentucky 23.4% of the population is living at or below the poverty level. The differences in income between Kentucky’s urban and rural residents is significant with rural residents earning incomes on average of about $10,000 less than those of urban residents. Of interest is the fact that of the 120 counties in Kentucky, 30 are on the list of the “100 most impoverished counties” in the United States. Most of these counties are located in rural, eastern Kentucky. There is a growing income disparity between the sexes regarding income with individual men aged 65+ earning median incomes of $29,327 versus women 65+ reporting median incomes of $16,301. Since women live longer than men on average, they tend to live in poverty for longer period of time.
According to Kentucky Law (KRS 12.450 to 12.4), “disability” is defined with respect to an individual as: 1) a physical or mental impairment that substantially limits one or more of the major life activities of the individual (bathing, dressing, eating, toileting, transferring, and walking). 2) A record of such an impairment or 3) being regarded as having such an impairment.
In Kentucky, 33.4% of the population ages 65-74, have some form of disability. This percentage increases to 56.2% after the age of 75 (Figure 4). These disabilities have a great impact on the use and cost of long term care services both in the community and in long term care facilities (nursing homes). If the prevalence of chronic disease in Kentucky continues, and the proportional increase of people who are aging, it is predicted that Kentucky will soon have highest population levels of disability requiring long-term care and support services in the nation.
Long-Term Care Issues and Options:
There are currently 3 categories of services and support for older adults and persons with disabilities requiring long-term care: Long-term care facilities (nursing homes), home and community services such as home health, and the family network of caregivers that provides assistance to family members.
Long-term facility care: The quality of care in Kentucky’s nursing facilities was ranked 51 of the fifty states and territory of Guam according to a report released in 2014 by the American Association of Retired Persons (AARP) titled “State Long-Term Services and Supports Scorecard.” The report compared states Nursing Facilities on five indicators of success: 1) affordability, 2) Choice of setting and provider, 3) quality of life and quality of care, 4) support for family caregivers, and 5) effective transitions. (See Table 1)
Table 1: Kentucky Long-term Care Services and Support (AARP, 2014)
In 2014, Governor Beshear responded to the findings in this report by creating a series of forums held across the state to evaluate the community’s perceptions of quality of care in the states LTC facilities. Over 4 months, 31 regional forums involving 756 individuals provided input to policy makers. While the complete report on these findings is available from the Dept. for Aging and Independent Living, two recommendations are listed below:
1) Care in the facilities (as well as in the community and home), should be person-centered and recognize the wants, needs and desires of the individual)
2) The training of all service providers should be reviewed to determine if content is adequate or needs updating.
Home and Community Services: There are multiple options for community based care. These include both federal and state funded programs targeting older adults and persons with disabilities.
Federal dollars from the Older Americans Act (OAA) and other federal programs are given to the Department for Aging and Independent Living (DAIL) and then contracted with the Area Development districts. The OAA federal allocation requires a 25% match from the state. Unfortunately, total state and federal funding for the Dept. for Aging and independent Living has decreased by a total of 26% as the elder population is increasing and the needs for services escalate. Figure 5 shows the current number of elder clients who utilize the major community-based long-term support programs funded by the U.S. Administration on Community Living (ACL) under the Older Americans Act and the waiting list of those who have applied and assessed as eligible for the services even though the funding is not currently available.
Figure 5: Department for Aging and Independent Living Reductions in Budget
Supportive Services such as adult day services, chore service, congregate meals, home delivered meals, homemaker services, personal care, information and referral, legal services, protective services, and transportation, are made possible by Title III of the Older Americans Act. Due to limited funding some services are not available in all areas of the state. The most consistent programs include: Meals and Nutrition, Grandparents Raising Grandchildren, and the Long Term Care Ombudsman program.
Family Network of Caregivers are the first line of defense against older Kentuckians being forced from their homes and into nursing homes or back in the hospital. Family caregivers help older adults and persons with disability remain independent and also help reduce unnecessary hospitalization and costly Medicaid-funded institutionalization.
Some notable facts regarding caregivers in Kentucky (Ref #11. Legislative Research Commission, Dec 2014) include the following:
· Approximately 735,000 Kentuckians are caregivers helping family members to age at home rather than in an institutional setting
· The average family caregiver provides 20 hours a week of assistance although many are on call 24 hours a day, 7 days a week – and often do not get to take a break
· Aging in a home setting with supports for seniors and family caregivers may be more cost effective than nursing home care. Kentucky’s Medicaid program pays about $48,000 per year for a nursing home bed compared to $15,000 for in-home supports
· Kentucky spends about 81% of all long-term care dollars on nursing home care and the remainder on supports to help older adults age at home
· Family caregivers of older adults are often stressed emotionally, physically, and financially.
· Transportation assistance for older adults (to health care appointments and perform household chores) is not consistently available across the state, especially in rural areas.
SUMMARY: Many of the 735,000 caregivers did not receive services funded by the state. The Department for Aging and independent Living is the Administrative agency for statewide programs for Kentucky’s for Kentucky’s older adult population and the people who care for them. Other services available are offered through local governments, community organizations, private and nonprofit agencies, religious organizations and state and national associations.
State Funded Options
In addition to federally funded programs, Kentucky has programs and services funded by the Kentucky Legislature to serve elderly and disabled residents in their homes. These include the Homecare program and the Kentucky Family Caregiver Program.
The Homecare Program began in 1982, and was designed to assist older adults in remaining in their home. The Program provides supports and services for daily needs and coordination among caregivers and provider agencies for at-risk adults trying to remain in their own homes. Participants must be sixty (60) years old or older, unable to perform two activities of daily living, be at risk of going to an institution, or be in an institution, but able to return to a private home, if needed services are provided.
The Kentucky Family Caregiver Program provides a wide range of services including matching grandparent caregivers with support groups and provides information about resources counseling and training as well as small amounts for basics like school clothing and books. Decreased state funding has limited access to this program.
Significant number of older adults in Kentucky are currently on an “Awaiting Services” list. This may be due to lack of providers in their area or their needs exceed the funds available in the region.
Transportation: Kentucky published a document regarding statewide transportation in 2014 (Ref. #12) raising serious questions about Kentucky’s ability to meet the current and future transportation needs of its older citizens who no longer drive or have limited their driving. Medicare has no budget for transporting people. Medicaid currently provides funding for eighty percent (80%) of transportation cost for medical appointments. In areas where local transportation is available, non-Medicaid riders must pay $.80 - $1.75 per mile, especially difficult in rural areas where the distance to medical or other specialty services is greater.
Kentucky has no state wide plan for providing transportation for elders who are no longer able to drive and/or who have no local bus or other transportation in the community. Even the Medicaid transportation is limited and does not allow for needs such as grocery or pharmacy trips. Only major cities such as Louisville, Lexington, and Northern Kentucky have local programs funded through local allocations.
Age Friendly Livable Communities
Launched in 2007 by the World Health Organization, a new initiative is being adopted by a number of Kentucky communities concerned with improving the quality of life for people of all ages and generating a more “age friendly” environment in which to “grow up and grow old.” City planners, community leaders and government officials need to do a better job of preparing for the massive demographic shifts now taking place with the economic and social impact of these shifts being felt by communities regardless of size, every day.
In the U.S. this initiative has been led and supported by the American Association of Retired People (AARP), has grown from just 6 cities in three states in 2012 to 72 cities in 20 states in 2015. There are currently 288 cities in 33 countries taking part worldwide. In 2014, the city of Bowling Green in Kentucky became the first city in the southern United States to receive this designation. An age friendly livable community is one that is safe and secure, has affordable and appropriate housing and transportation options, and offers supportive community features and services.
On October 1, 2014, Major Jim Gray of Lexington held a press conference announcing a “Livable Lexington” initiative. The city is now in the process of developing an action plan to build on this initiative. Berea is a third city in Kentucky applying for a World Health Organization “age-friendly” status. This initiative has been endorsed by the Major and City Council, and is in the early stages of development.
The Institute for Aging is strongly supportive of the age friendly community movement, and is recommending a statewide initiative that covers the entire state and seeks the highest possible quality of life for people of all ages.
When patients can’t come to the Dentist: Nursing Home and Homebound Elders
In the most recent survey of Oral Health in Kentucky (Ref #13. Center for Health Workforce Studies (CHWS) February 24, 2016), one of the key findings suggested that particular population groups appeared to be at greatest risk for poor oral health outcomes, including the elderly. The report suggested that adults ages 65 and older in Kentucky (51.5%) were more likely than those across the US (39.6%) to have had 6 or more permanent teeth extracted, placing Kentucky at 5th highest in the nation on this negative measure of oral health. Kentucky also ranked 5th highest in the nation for the percentage of adults ages 65 and older who had all their natural teeth extracted (24.8%). The national rate of edentulism is 16.2%.
Although surveys typically place all elders into one category (those persons aged 65 and older), older populations represent a greater diversity from any other age group based on health status and residential settings. It is important to realize that the prevalence of utilization of oral health services as well as the actual oral health status of elders in Kentucky, vary significantly by these factors. In addition to the elders that are able to live in their own homes and still come to the dentist on a regular basis, known as independent or well-elders (WE), are elders that are confined to their homes and unable to provide their own transportation to obtain dental services (Homebound, HB) or nursing home (NH) elders, (those individuals confined to nursing homes). These two groups represent elders who normally can’t get to the dentist unless transported by the Nursing Home (as a service provided by the NH) or by family, friend, or ambulance in the case of the Home-Bound.
Figure 6 depicts the prevalence of utilization of oral health services and the oral health status of elders in Kentucky by type of residential settings. Homebound elders (HB) and nursing home (NH) elders were more likely to have not visited a dentist in the previous year than independent elders (IE) (77.2% (HB) and 71.7% (NH) to 52.8% (IE). Other differences in the types of oral health problems seen include: cost as the main reason for no dental visit, untreated dental caries, and percent of edentulous (all significantly higher in the HB population.
Oral health care for older adults is a concern since many elders do not benefit from employer-sponsored insurance plans that include dental coverage. At age 65, many older Americans become insured by Medicare, which has no dental insurance benefit. The likelihood of utilization of oral health services is linked to having dental insurance; therefore, older adults without coverage are at risk of having unmet oral health needs. For Independent Elders (IE), unless they purchase health insurance with a dental plan, the majority will pay for dental care out-of-pocket. For Nursing Home (NH) and Homebound (HB) the provision of basic dental services (cleaning, restorative, and oral surgery) are tied to the Adult Dental Benefit in Medicaid. While limited in scope and reimbursement rate, the Medicaid enrollment in Kentucky appreciably increased from 2010 to 2014, allowing for older adults to at least some access to dental providers who may not have been eligible before. Recent recommendations by the Governor’s office proposed to eliminate the Medicaid Dental Benefit for Adults, which would eliminate the only viable dental insurance program for NH and HB elders. This would reverse the recent gains made under the past 6 years and jeopardizes the already poor oral health status seen in these most vulnerable populations.
In addition to residence or where elders live (IE, NH, or HB), differences in oral health status among elders in Kentucky were found with variation in oral health related to income, education, and geography. In 2014, adults ages 65 and older in 3ADDs in Eastern Kentucky, the Kentucky River ADD (40.7%), the Gateway ADD (37.5%) and the Cumberland Valley ADD (36.2%) were more likely than adults in Kentucky generally (23.9%) to have had 6 or more permanent teeth extracted (see Figure 7). (Ref #14. KY Behavioral Risk Factor Surveillance)
Nursing home and the homebound elderly, perhaps more than any other population groups, need complete, comprehensive and routine dental services to maintain an adequate level of oral health. Forgetfulness, lack of motivation, physical disabilities, mental changes and other chronic medical problems all contribute to a decrease in self-care ability and subsequently increase the risk of oral diseases. (Ref #15. Dental Clinics of N. America, Henry) In addition, difficulties with transportation to the dentist, accessing the dental office, lack of perceived need, preexisting attitudes and expectations, and financing the dental care provided, all remain obstacles for providing dental services to this population.
Although the great majority of older adults remain in their own home and function independently, approximately 2 million persons over the age of 65 (5% of all elders in U.S.) reside in nursing homes. Although this may seem like a small percentage, these statistics do not depict a true picture of the use of nursing homes among the elderly. Of those 65 and older, 36 to 45% will use a nursing home sometime before they die. Furthermore, although only a small percentage (1-3%) of those age 65 to 74 are nursing home residents, about 6% make up the age group 75 to 84, and almost 22% of people are age 85 or older. Because the fastest growing group of people in the U.S. is the cohort of older adults 85 and older, the need for nursing home care is likely to increase in the future. One study estimates that by the year 2040, 4 million people age 65+will need nursing home care, and an additional 8 million older adults will need long-term care at home. Not only will utilization increase but those in nursing homes will be older and more severely disabled.
For every person age 65 and older who lives in a nursing home, there are more than twice as many living in the community who require some form of daily assistance and long term care. This group of elderly, called the homebound, are defined as that group of elders who are unable to leave their home without the assistance of a wheelchair or a stretcher.
Oral Health Differences in Nursing home, Homebound, and Independent Elders
In 2002 through 2005 an oral health survey was done in Kentucky to determine the oral health status of elders in the state. Some of the highlights of that survey are listed here, and provides the most recent (albeit 10 years), snapshot, to the oral health status of these groups of elders in our state.
· 28% of elders report having current dental problems. This ranged from a low of 12.9% in the IE group to a high of 40% in the HB elders
· 19% of elders report have dental pain in their teeth, gums or jaws. The range was a low of 10% in the IE group to a high of 24% in the HB elders
· 22% of elders reported dissatisfaction with their ability to speak clearly as a result of their teeth, gums, or dentures. This ranged from a low of no reports (0%) in the SB group to a high of 14% in the HB elders
· Of those elders who have teeth (are dentate), almost one-fourth (24%) reported having active dental decay in their teeth. Ranged from a low of 1.6% IE group to a high of 31% in the HB elders.
· Elders’ self-reported need for new dentures was 33%. This ranged from a low of 22.7& for NH elders to a high of 41% in the HB elders
· The time since an elder last made a dental visit for any reason was found to be as follows:
o Less than 1 year = 35%
o From 1-5 years 23%
o Greater than 5 yrs. = 33%
The homebound group went the longest time without visiting the dentist of any of the elder groups (45% had not visited in 5 or more years), followed by the NH group (33% had not visited the dentist in 5 or more years)
· The elders reasons for NOT going to the dentist are listed by order of prevalence:
o Majority did not go because they didn’t think they needed to (52%)
o Cost was the next most important factor (23%)
o Non-specific reasons were third (10%)
o “Can’t get to the office” 4.1% HB and 10.9% NH elders
o Dental fear and nervousness (2%)
· The elders top 3 reasons why they DID go to see the dentist:
o Prosthetics (dentures or partials) 39%
o Preventive (cleaning by hygienist) 30%
o Emergency (treatment or extractions) 15%
· Over 37% of elders reported difficulty in obtaining basic services (Exams/checkups, cleanings, fillings); 42% in obtaining advanced dental services (crowns, bridges, implants, extractions; 34% in obtaining prosthodontic care (dentures and partials, and 15% in obtaining emergency dental services
· Elders self-reported major barriers to getting dental care or services included:
o Lack of dental insurance (56%)
o Inability to afford care (53%)
o No way to get to dental office (25%)
o Medicaid not accepted by my dentist (7%)
o Other reasons (8%)
· The elders gave recommendations for improving access to dental care and services. The top 4 recommendations were:
o Make dentistry more affordable (55%)
o Use a mobile clinic/mobile van to access elders (28%)
o Have dentist or dental hygienist make house calls (22%)
o Make dental offices more handicapped accessible (15%)
Federal Law Requiring Dental Care in Nursing Homes
On December 22, 1987, the nursing home reform amendments of the Omnibus Budget Reconciliation Act (OBRA) were signed into law as public law 100-203. As a result of this law, all nursing homes that accept Medicaid and Medicare payments were held to providing a new, higher standard of care focusing on the residents “highest practicable physical, mental, and psychosocial well-being. This new standard of care directs nursing homes to “promote maintenance or enhancement of the quality of life of each resident” by supporting “individual needs and preferences.”
Since the initiation of this legislation, dental care has been identified as one of the 18 Resident Assessment Protocols (RAPs). Dental information in the initial assessment of the resident upon admission to the NH can trigger the need for interceptive dental care if such a need exists.
Under the provision of professional staffing services, the law states “each facility must provide (or arrange for the provision of) nursing, medically related social services, pharmacy, dietary, activities programs, and routine and emergency dental services to meet residents’ needs . These federal regulations require nursing facilities to provide or arrange for routine dental services as covered under Medicare or Medicaid and for emergency dental services.
The significance of the new federal law which took effect on April 1, 1992, was that provision of dental services for residents became the responsibility of the nursing facility. It also included provision for dentists to take a more active role in providing oral assessments and participating on the interdisciplinary team.
Although no such law was passed for the Homebound Elder, having access to dental care turns to be even more difficult than for the NH Elder. Lack of transportation, having dentists to accept Medicaid or reduced fees, and general physical or mental debilities, make seeing and treating this patient very difficult.
The most important and effective strategy for improving oral and dental health for both residents in the nursing home and homebound is to make a personal commitment to become involved. With the increase in nursing home residents and those who are homebound, there is a tremendous need and growing opportunity for dentists to serve in one capacity or another.
Although there are no additional training requirements for providing dental services to these individuals, it may be helpful to seek additional training to be knowledgeable and comfortable with these patients who are typically physically or mentally compromised or both. Continuing education and training program are growing in number around the U.S. for dentists who desire such information. The Special Care Dentistry Association at SCDA.org is a professional organization which has annual meetings, and a journal, devoted to providing dental care to these types of patients. For many practitioners, the reward is much more that monetary, when you can make the difference in improving the oral health of these patients.