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The dental public health aspects of population aging in Hong Kong



As in other developed countries, the population of Hong Kong has been aging. Oral health care should be an essential component of overall care for the older population because of the intimate relationship between oral and general health. A rapid increase in the number of frail older people living in the community is expected, and making oral health care accessible to them will present a great challenge. New dental public health initiatives are required to meet the oral health needs of the aging population in the context of conflicting priorities among the older persons, their family members, and other care professionals. Specialists in community dentistry are facing challenges in developing oral care programs for frail older persons, as such care must include early prevention and the goal of treatment is not the elimination of dental diseases. This paper describes the challenges facing local dental professionals, especially specialists in community dentistry, and refers to available literature on the subject.
56 © Hong Kong Dental Association
The dental public health aspects of population
aging in Hong Kong
Correspondence to:
Dr. Frankie Hon-Ching So
Wan Chai Dental Clinic, 99 Kennedy Road,
Wanchai, Hong Kong
Tel : (852) 2575 2850
Fax : (852) 2591 5508
email :
As in other developed countries, the population of Hong Kong has been aging. Oral health
care should be an essential component of overall care for the older population because of
the intimate relationship between oral and general health. A rapid increase in the number
of frail older people living in the community is expected, and making oral health care
accessible to them will present a great challenge. New dental public health initiatives are
required to meet the oral health needs of the aging population in the context of conicting
priorities among the older persons, their family members, and other care professionals.
Specialists in community dentistry are facing challenges in developing oral care programs
for frail older persons, as such care must include early prevention and the goal of treatment
is not the elimination of dental diseases. This paper describes the challenges facing local
dental professionals, especially specialists in community dentistry, and refers to available
literature on the subject.
Key words: Aged; Hong Kong; Public health dentistry
Hong Kong Dent J 2011;8:56-62
Frankie Hon-Ching So*
BDS, MDS, FHKAM (Dental Surgery), FCDSHK
(Community Dentistry)
* Department of Health, Hong Kong SAR
Government, Hong Kong
As people live longer today, there is a higher likelihood of experiencing general health
conditions that will ultimately limit the ability of individuals to perform daily oral self-
care and access dental health professionals. As a result, a dental public health problem is
emerging in that there is a growing number of frail older adults suering from more and
more dental problems who are not adequately covered by the existing oral care system.
This paper describes the challenges facing local dental professionals, especially specialists
in community dentistry, and refers to available literature on the subject.
Population aging
Similar to aging trends in other developed countries such as the USA 1, UK 2, Australia 3 and
Japan 4, the proportion of adults aged 65 years or above in Hong Kong has been increasing
in the past few decades (Table 1 5). Locally, during the period 1969 to 2009, the proportion
of 65- to 79-year-old adults increased almost 2.5 fold, but the increase in those aged 80
years or more was even more dramatic (almost 7 fold). In mid-2009, about 13% of the Hong
Kong inhabitants were aged ≥65 years; whilst the number of older people is estimated to
increase from today’s 0.9 million to 2.5 million (28% of total population) in 2039 6. Social
Hong Kong Dent J Vol 8 No 1 June 2011 57
Dental public health in Hong Kong
Conflicting priorities
The oral health care for IOPs is a complex issue, as other
parties involved include: the IOPs family members, as
well as the administrators and caregivers in RCHE. Since
the priorities of these parties may conict, the planning of
dental public health programs for this population requires
due consideration 29.
A substantial proportion of IOPs is unable to perform
daily oral hygiene self-care and must rely on caregivers.
Studies in other countries found that such care was often
given a low priority due to heavy workloads 23,30,31. Both
administrators and caregivers in RCHE agreed that a formal
organizational structure with eective communication and
integration of nursing and dental professionals should be
in place 32. Standards for oral care formally advocated by
authorities in the RCHE environment would also enhance
successful implementation 33. A comprehensive systematic
review 24 agreed that resident uncooperativeness (forgetting
or not understanding caregivers’ directions, not opening
their mouth, biting the toothbrush or caregiver, kicking/
hitting out and using abusive language/yelling) is a major
factor inuencing the success of providing oral hygiene
to demented IOPs. Some caregivers reported concerns of
human integrity and respect when attempting to impose
oral hygiene care for such patients 34,35, while others feared
of damaging the recipients’ teeth and/or dentures due to
their eorts 36. Oral health education programs implemented
by dental professionals mostly target improving oral
health knowledge and attitudes of the caregivers, but are
regarded as ineective for changing health behavior 37.
Some caregivers opined that the provision of oral health
education materials is of little value and demanded
strategies requiring the active involvement of dental
professionals 23,29,30,32,38-41. According to the author’s personal
experience working with caregivers in local RCHE, for IOPs
who are mobile and capable, daily oral care is practiced in
the form of supervision on toothbrushing and cleaning of
dentures. Active assistance in brushing was not commonly
mentioned. Local caregivers also reported the need for more
formal training and support in the provision of daily oral care
for their charges. It is necessary for dental professionals to
integrate into the care delivery system, so as to understand
the training needs of caregivers, and provide training and
active support to enhance the daily oral care for IOPs.
policy strategists are therefore urging the government to
study these implications on the development of retirement
benets, housing, long-term health care, and social support.
Oral health is an integral part of general health 7. It is
increasingly evident that medical conditions like diabetes 8,
cardiovascular diseases 9,10, and chronic respiratory diseases 11
may be inter-related to periodontal status 12. Poor oral hygiene
is also related to aspiration pneumonia 8,13. Hence, oral health
care should be an essential component of the overall care for
the older persons. With the lifetime accumulation of dental
diseases and treatment, older adults may require increasingly
extensive treatments, involving multiple dental disciplines
(periodontology, endodontics, restorative dentistry, prosthetic
dentistry, and may be dental implantology) 14-16. It is common
to nd chronic medical conditions among older adults, many
of whom are also taking long-term medications with possible
dental relevance 17. Their aordability for dental care may
also be aected after retirement 18. Nevertheless, oral health
care for older adults continues to be a two-party interaction;
and the extent of dental treatment undertaken is a joint
decision between the older adult and the attending dentist.
However, a small proportion of elderly persons need other
considerations due to physical and/or cognitive impairments
arising from their medical conditions 19. It is common to nd
such frail older people in residential care homes for the elderly
(RCHE) due to their dependence on additional nursing care
for their activities of daily living. Epidemiological studies on
such institutionalized older persons (IOPs) draw attention
to two issues. First, most IOPs had not seen a dentist for a
long time 20,21; in Hong Kong, more than 80% had not seen
a dentist for at least 3 years 22. Second, attention to daily
oral hygiene was uncommon or of low priority, owing to the
heavy workload of caregivers 23,24. As a result of the lack of
both self-care and professional care, the oral health of IOPs
is usually very poor 1-4,15,22,25-28.
Table 1 Proportion of adults older than 65 years in the
Hong Kong population * 5
Year (mid-year) 65-79 Years ≥80 Years
1969 3.7% 0.5%
1979 5.3% 0.8%
1989 7.0% 1.2%
1999 8.9% 1.9%
2009 9.3% 3.4%
58 Hong Kong Dent J Vol 8 No 1 June 2011
Two earlier large-scale oral health surveys in Hong
Kong both showed that the demand for dental care among
older people was low 60,61. Regular dental check-ups were
uncommon and there was a convention to consult a dentist
only for pain or other problems 60. In 2001, more than half of
all community-dwelling older people had not seen a dentist
within the previous 3 years 61. Perhaps the socio-dental
history of the Hong Kong older adults (Table 2 62) can help
explain their low demand for dental care. Persons aged 65 to
74 years in 1991 were born between 1917 and 1926 (cohort
1 in Table 2). During their early adulthood, there was a
period of internal strife in mainland China and World
War II. They could hardly benefit from the introduction
of water fluoridation in 1961 because damage due
to dental caries were already established by the time
they reached middle age. It was also an economically
difficult period, and dental care was a luxury. Not
surprisingly, if there were problems, tooth extractions
became the practical and affordable options and were
performed by ‘market place tooth pullers’ 63. This cohort
of subjects may therefore have developed a habit of acting
only when there was a toothache or other problem. Such
socio-dental experiences also applied to older adults aged
Dentists are not willing to work in RCHE because of
unfamiliar working conditions, limited treatment options,
lack of training, pressure from private practice, and low
nancial rewards 42-45. There is no information on the views
of Hong Kong dentists about the provision of care to IOPs,
but there is no reason to believe that their views dier
from dentists in other countries. A signicant challenge to
serving IOPs is the ethical dilemma of planning treatment
for such frail individuals 46,47. It is well recognized that
dental treatment should be rational rather than aimed at
achieving technically ideal results 26,48-50. Realistic treatment
needs are inuenced by risk-benet assessments and the
older persons’ propensities to treatment. According to
rather subjective and relatively vague criteria, terms such
as ‘treatment not possible or not suitable’, ‘will not benet
from treatment’, or ‘low treatment intention’ are commonly
used to describe the option of withholding curative dental
treatment for frail older persons. The proportion so described
ranges from 3% to 54% 25,51-56. This strategy to depart from
basic dental training to treat or eliminate dental disease
is dicult, especially for new dental graduates 46,47. Dental
students and dentists require more training in managing
these special aspects of oral health care for IOPs 57-59.
Table 2 Socio-dental history of older adults in Hong Kong * 62
Year Social event Dental event Age of cohort 1
(born 1917-26)
Age of cohort 2
(born 1927-36)
Age of cohort 3
(born 1937-46)
2011 Second oral health survey 85-94 years 75-84 years 65-74 years
2001 First oral health survey 75-84 years 65-74 years 55-64 years
1997 Hong Kong sovereignty returned
to China
1985 Sino-British negotiation over future
of Hong Kong
First batch of local dental graduates
1981 55-64 years 45-54 years 35-44 years
1980 School Dental Care Service and Oral
Health Education Unit established
1974 Cultural revolutions in mainland
White paper The further development of
medical and health services in Hong Kong
1971 45-54 years 35-44 years 25-34 years
1961 Fluoridation of drinking water 35-44 years 25-34 years 15-24 years
1951 25-34 years 15-24 years 5-14 years
1949 People’s Republic of China founded
1941-5 Second World War and Japanese
invasion of Hong Kong
15-24 years 5-14 years 0-5 years
1940-1 Internal war in mainland China Dentist Registration Ordinance
1914 The Dentistry Ordinance in Hong Kong
Hong Kong Dent J Vol 8 No 1 June 2011 59
Dental public health in Hong Kong
collaboration between administrators and caregivers, so
as to identify training needs and strategies to integrate
them into the existing IOP care system.
(3) To target patient-oriented rather than technically
ideal outcomes, and plan treatment accordingly (after
due discussion with IOPs and their family members).
Preferably all IOPs should be regularly examined and
informed of their oral status and dental treatment
(4) To aim principally at developing outreach services, with
appropriate clinic support to cater for demands that
cannot be dealt with on-site.
(5) To consider the quality and choice of treatment,
which should be comparable to that enjoyed by other
community-dwelling older adults and could entail
treatment options such as atraumatic restorative
Specialists in community dentistry are facing
challenges in designing oral care programs for IOPs as the
goal should not be the elimination of dental diseases, and so
appropriate indicators must be developed to monitor and
evaluate suitable oral care programs.
Start prevention early
Future cohorts of older people will no doubt have beneted
more from water uoridation, whilst also experiencing more
dental care associated with economic development and the
increase of dental manpower since the 1980s. How this will
aect oral health status and oral health behavior is yet to be
seen, though future cohorts of older adults will be expected
to retain more of their natural teeth. Such dental longevity
may actually become a double-edged sword, as diminished
oral self-care skills associated with functional dependence
have far greater deleterious eects when natural teeth
remain 71. In which case, it may be too late to provide remedial
care when older persons become frail and dependent, so
that dentists may have to face the same ethical dilemmas
as we face today. Organized preventive care should start in
places where risk factors can be identied early, for example,
in stroke rehabilitation centers and geriatric clinics treating
elderly patients with dementia. Specialists in community
dentistry should liaise with other health professionals to
integrate preventive oral care into the overall care of geriatric
65 to 74 years in 2001 (cohort 2 in Table 2). However, this
cohort may have beneted more from water uoridation,
as they were only between 25 and 34 years old in 1961.
This phenomenon presumably accounts for their lower
prevalence of edentulism and higher mean number of teeth
retained. These two cohorts form the majority of IOPs today,
and despite their dental problems and tooth losses, they
reported little impact on their daily living and habitually
they only sought dental treatment when there was a
problem 64. Other diculties in accessing professional care
may further deter these IOPs from receiving treatment even
when they have pain or discomfort. Hong Kong IOPs were
reluctant to demand dental care because it was also viewed
as ‘bothering other people’ 22. Conceivably, this was because
a number of physically impaired IOPs perceived traveling
out to visit a private dental clinic as very demanding on their
RCHE and/or the family members. Clearly, outreach delivery
of professional dental care to meet the needs of IOPs should
be developed 65.
Dental public health considerations
The dental profession in Hong Kong has achieved
outstanding oral health improvements in the community
through several signicant community dental initiatives.
They include: uoridation of drinking water in 1961 63, the
setting-up of the School Dental Care Service in 1980 66, and
the graduation of the rst batch of locally trained dentists
in 1985 63. With the anticipated change in population
demographics, new community dental initiatives are
required to meet the changing oral health needs of the
aging population.
Oral health care for frail institutionalized
older persons
Frail older persons residing in RCHE are not adequately
covered under the current oral health care system. With
reference to the existing literature and the consideration
of the socio-dental history of local IOPs 67-70, dedicated oral
health care programs for such persons should be developed
with the following objectives:
(1) To address both the daily oral hygiene care of IOPs and
necessary dental treatment on demand.
(2) To educate caregivers on improving oral health
knowledge and attitudes, whilst facilitating
60 Hong Kong Dent J Vol 8 No 1 June 2011
Oral health surveillance
The Hong Kong government has recognized the trend
towards an aging population, and has adopted the
suggestion of ‘care in the community’ early in 1972 as the
guiding principle for development of services for local older
inhabitants 72. This envisions services aimed at enabling older
people to remain members of the community as long as
possible 72. This is a key social service policy principle for the
older adults in Hong Kong, and was reiterated as the policy
‘aging in place’ in the 2010-11 Budget Speech 73. Currently,
government-subsidized long-term care is provided to older
persons in need through the Social Welfare Department
(SWD). As of the end of 2009, there were almost 80,000
subvented and private residential care places, and about
35,000 places eligible for community support services.
Under the policy of ‘aging in place’, we expect a more
rapid increase in the number of frail older people living in
the community and corresponding expansion of the SWD
community support services. Compared to ‘captive’ IOPs,
it will be a greater challenge for the dental profession to
deliver outreach oral health care to community-living frail
elderly. For better planning of such programs appropriate
for this group of frail elderly, it is necessary to investigate
their future social and oral health needs and activities.
The dental profession in Hong Kong is confronted with an
emerging dental public health problem associated with
aging of the local population. With increasing numbers of
frail and dependent older people and the expectation of their
widespread distribution in the community, the profession
has to tackle this problem by developing appropriate
outreach services, as well as by means of surveillance,
prevention, research, and dental education.
The above content reects the personal view of the author
only and is not the stance of the Department of Health of
the Hong Kong Special Administrative Region Government.
The author thanks Dr. Joseph Chan for the advice in
preparation of the manuscript.
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Answers to CPD Programme
Hong Kong Dental Journal
December 2010 issue
Hong Kong Dent J 2010;7:82-6
A new protocol for computer-assisted orthognathic surgery
1. b 2. c 3. a 4. d
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Objective: The objective of this systematic review was to report on the best available evidence relating to oral hygiene for adults with dementia in residential aged care facilities, including: INCLUSION CRITERIA: This review considered any randomised or non-randomised controlled studies, cohort studies, case-control studies, multiple time series studies, uncontrolled studies, descriptive studies and opinions of respected authorities (including theses and other publications) related to residents with dementia living in residential aged care facilities in Australia and overseas; community-dwelling adults with dementia; and special needs adult populations (for preventive oral hygiene care strategies and interventions).The review considered studies and publications designed to:1 quantify the oral health status of older adults living in residential aged care facilities;2 quantify the oral health status of adults with dementia living in the community and in residential aged care facilities;3 evaluate tools used to assess the oral health of residents by staff and carers working in residential aged care facilities;4 evaluate preventive oral hygiene care strategies and interventions used in special needs adult populations (including adults with dementia); and5 evaluate oral health care training and oral hygiene care provision, staff and carers working in residential aged care facilities.Dental outcome measures of interest were those relating to the prevalence, incidence, experiences and increments of oral diseases and conditions including: denture problems, coronal and root caries, periodontal diseases (plaque accumulation, gingivitis, loss-of-attachment), oral mucosal conditions, xerostomia and salivary gland hypofunction, tooth loss, difficulty chewing, behavioural problems and pain/discomfort. Related characteristics and outcomes of interest included: medical conditions, medications, cognitive status, functional status, nutritional status and sociodemographics. Search strategy: The aim of the search was to locate relevant English-language studies and publications appearing between 1980 and 2002. The search utilised a two-step approach, involving an initial search of electronic databases using combinations of key words followed by a second extensive search carried out using the identified key words. This was supplemented with a secondary search of the references cited in the identified studies. Electronic database searched were: Cinahl, Embase, Psycinfo, Medline and Current Contents. Methodological quality: All selected studies were critically appraised by two reviewers prior to inclusion in the review. Results: In regards to relevance, incidence, experiences, and increments of oral diseases and conditions, possible risk factors identified included: saliva dysfunction, polypharmacy, comorbid medical conditions, swallowing and dietary problems, increased functional dependence, need for assistance with oral hygiene care, and poor access and utilisation of dental care.Evidence on the use of assessment tools by carers to evaluate residents' oral health showed that successful assessment of residents with and without dementia by nursing staff requires appropriate staff training by a dental professional. Coupled with appropriate training, an oral assessment screening tool designed for residents with dementia has been successfully used by nursing and care staff to identify residents requiring further review by dental professionals. Expert opinion in the field indicates that oral assessment screenings by a staff member and then by a dentist would ideally be undertaken upon admission to a facility, and regularly thereafter by staff and/or dentists as required.Clinicians and researchers suggested that oral hygiene care strategies to prevent oral diseases and conditions were found to be effective in preventing oral diseases, and thus are relevant for use in the resident with dementia.In regards to the provision of dental treatment and ongoing management of oral diseases and conditions, the use of adjunctive and preventive aids were found to be effective when introduced in conjunction with a staff training program:Expert opinion suggests that behaviour management techniques will increase the potential of performing oral hygiene care interventions. Conclusions: This review suggests that the training of staff in the form of a comprehensive practically oriented program addressing areas such as oral diseases, oral screening assessment, and hands-on demonstration of oral hygiene techniques and products is likely to have a positive impact on the management of oral hygiene care within residential aged care facilities. The review also identified that regular brushing with fluoride toothpaste, use of therapeutic fluoride products and application of therapeutic chlorhexidine gluconate products are validated by research as effective for the general population and some populations with special needs.
In this study we examined how nursing home staff experienced assisting patients with oral health care. The results of a previous questionnaire indicated that oral health care is a low priority in nursing. The 22 in-depth interviews administered in this study showed that the quality of the oral health care received by the patients depended on several factors. It was found that often there were no specific routines for assisting oral health care in the nursing homes and that other activities were given higher priority. Assisting oral health care was described as passing a barrier, where the main problem was to gain access to the oral cavity. It was concluded that nursing staff working with geriatric patients need to be better educated in oral health care and should be seen by themselves and others as part of a team, where oral health care is clearly defined and included among other daily nursing activities.
This study developed and tested an intervention to promote use of preserved abilities in oral care among nursing home (NH) residents with dementia. Changes were made to environmental support for oral care and in how nursing staff provided oral care. Five NH residents participated. Changes in oral care independence and oral hygiene adequacy were assessed. Four (of 5) participants were more independent in key, in-the-mouth oral care tasks. Oral hygiene ratings improved 47% (±27%). All residents responded positively to the intervention. Although some staff complained initially, most embraced the changes after trying them.
Open-ended interviews were conducted with 109 individuals. These included: administrators, staff, dental personnel, residents, and family members, associated with 12 long-term-care (LTC) facilities to contrast different human resource and organizational strategies for managing the delivery of oral health care to the elderly residents. A multiple case-study analysis revealed that no particular organizational strategy was ideal, although three important components—oral hygiene, diagnostic assessments, and dental treatment—were common to all. The dental personnel everywhere believed that oral health in the midst of other conflicting priorities received inadequate attention, while the administrators and staff acknowledged that they were weak at recognizing oral disorders and assisting with oral hygiene. In all, the interviews offered a portrait of the conflicting priorities associated with LTC, and they provide practical insights to successful strategies of care in this population.
This study developed a list of target outcomes for long-term oral health care in persons with dementia. A three-round Delphi study was used to develop a list of target outcomes. Participants included 99 staff and 171 family members associated with the Dementia Special Care Unit in Bedford, MA. In Round 1 participants were asked to list five outcomes for long-term oral health care. Items were grouped, redundancies removed, and fed back in Round 2, when participants scored the items from 1 (least important) to 10 (most important). Round 2 responses were tabulated and the top 20 were fed back for scoring in Round 3. The top 10 target outcomes in decreasing order of importance were: patient will be free from oral pain, patient will not be at risk for aspiration, emergency dental treatment will be available when needed, prevent mouth infections, daily mouth care is as much a part of daily care as shaving or brushing hair, prevent discomfort from loose teeth or sore gums, teeth will be brushed thoroughly once a day, staff will be able to provide oral hygiene care as needed, provide dental care to prevent problems eating, and recognize oral problems early. Family and professional caregivers were remarkably consistent in their identification of the top 10 outcomes. Further work is needed to ensure broad international and interdisciplinary acceptance (including families and the long-term care residents themselves) of target outcomes for long-term oral health care in persons with dementia.
The improved dental health in most industrialized countries is not apparent among elderly and long-term care patients. Oral healthcare has been found to have low priority in nursing care. To create lasting positive effects in oral healthcare education, a new educational model was tested in an oral healthcare project. After approval from ethical committee, nursing assistant and nurses’ aides took part in a dental auscultation period at a dental clinic to serve as oral care aides additional to traditional oral healthcare education. Following this period, the aides were given responsibility for the oral healthcare at their ward. After serving as oral care aides for 1 year, interviews were made and analysed based on the Grounded Theory methodology. The aim was to investigate how the oral care aides had experienced their new duties regarding oral healthcare. The results indicated that, despite several environmental changes, reluctant residents and occasional lack of commitment from colleagues, the oral care aides felt responsible for the oral healthcare provision. The oral care aides expressed courage, the capacity to cope with reality, confirmation and empathy, characteristics that propelled them from novices to oral care aides with an expert competence.
Aim The aim of this study was to describe how nurse managers perceive oral health in general and the oral health of the care-receiver in particular. Background Oral health and general health are independent and influence each other through biological, psychological, emotional and developmental factors. To most adults, oral health is a natural daily routine of hygiene, whereas to people who are dependent on other people’s assistance, it is a procedure carried out by nursing personnel. Methods Data were collected through interviews and analysed according to the phenomenographical method. Findings Five categories emerged describing how nurse managers perceive oral health: maintaining patients’ well-being, having knowledge about oral health, behaviour towards the patient, feeling of being insufficient and creating the necessary conditions. Conclusion The nurses considered oral health an important and obvious, but neglected, part of nursing. They expressed the wish to be updated in the knowledge area concerned, both for themselves and for their personnel. A majority called for standards for oral care, including documentation, which was considered necessary for the successful implementation. Implications A suggestion for further research is to study whether the creation of national standards may increase its status and quality.
When an investigation designed to compare extant models of delivering oral health and dental services to the institutionalized elderly revealed that structural variables explained very little of the difference between effective and ineffective programs, secondary analytic techniques were employed to consider alternative explanations. The original study was a program evaluation based on a comparative case study of 12 long-term care (LTC) facilities. Data for each case included interviews with administrators, care providers, family members, and residents, administrative documentation, and clinical measures of oral health from the residents. The secondary analysis revealed the mechanisms through which the organizational context of each facility influenced the effectiveness of the oral health services. In addition, it revealed how administrative and leadership issues influenced the quality of care.