#51391: Controversial Issues in Dentistry

Rapid cell division and organ development occurs between the second and eighth week of pregnancy. During this time, the fetus is most susceptible to the effects of stress and teratogens. Approximately 50% to 75% of all spontaneous abortions (miscarriages) occur during this period [57]. Dental treatment should be limited to basic periodontal prophylaxis, if needed, and emergency treatment of traumatic injuries, acute odontogenic infections, and/or pain of dental origin. Radiographs should only be done if required for diagnosis of an emergent dental problem. This is also an excellent time to educate patients about the importance of oral hygiene and the challenges that they may face during pregnancy.

A number of changes in the oral cavity have been associated with pregnancy, including caries, perimylolysis, tooth mobility, xerostomia, pregnancy granuloma, and ptyalism/sialorrhea [58]. Perhaps most commonly, the hormonal changes that occur during pregnancy have been linked with gingivitis. Approximately 60% to 75% of women will develop pregnancy gingivitis [59]. This can range from mild to severe gingival inflammation that can develop despite meticulous oral hygiene and the absence of chronic irritants such as plaque and calculus. Shifts in hormone levels may cause changes in the established microbiota, with overgrowth of certain bacteria species, increases in the ratio of bacterial anaerobes to aerobes, and changes in the proportions of Prevotella intermedia, Prevotella melaninogenicus, and Porphyromonas gingivalis [58,60,61]. Pre-existing subclinical gingivitis may become exacerbated during pregnancy to the point that clinical signs become apparent, including swelling, redness, bleeding, and tenderness [62]. These signs may begin to be noticeable in the second trimester and peak around the eighth month. Anterior teeth may be more apparently involved than the posterior. Mouth breathing is a potential exacerbating factor. A woman who has poor oral hygiene runs the risk of even greater gingival problems, although gingivitis can develop in women with no changes in their plaque-management behavior. Postpartum studies have shown that after delivery, the mother's level of gingivitis decreases as the constituency of the microbiota changes back to approximate its prepregnancy status. With the inflammation comes an increase in tooth mobility. Xerostomia is also reported in a high percentage of patients.

In a study published in 2010, researchers evaluated the way in which changing hormone levels influenced the gingival tissues in 48 pregnant and 28 nonpregnant women. In analyses of the subjects clinically and microbiologically, the researchers found that the proportions of the subgingival pathogens did not differ during pregnancy but did differ significantly after delivery. Patients who were P. gingivalis-positive presented with increased gingival inflammation that was not related to plaque [61]. Receptors for female sex hormones are located on human gingiva. The presence of progesterone, for example, may lead to greater gingival exudate. The inflammatory response also appears to be triggered as levels of estrogen and progesterone rise [60,63,64,65].

In addition to generalized gingival changes, a solitary, tumor-like growth, frequently referred to as a "pregnancy tumor" or "pregnancy granuloma," may appear. This lesion is often found associated with anterior interdental areas and has a histologic appearance similar to a pyogenic granuloma. Often, the lesion will regress after delivery, so decisions about surgical removal are best delayed until some time postpartum. Also, removal of the lesion during pregnancy may result in a recurrence [58].

By the second trimester, fetal organ formation is complete, so some elective dental procedures may be performed at this time. The increasing fetal size and weight during the second trimester can place pressure on the inferior vena cava and compromise the return of blood to the heart when the patient is in a supine position. This can lead to maternal hypotension, decreased cardiac output, and loss of consciousness. Turning the patient on her left side will relieve the fetal weight against the inferior vena cava and allow the resumption of the appropriate blood flow. Radiographs should only be taken if absolutely necessary.

While dental treatment poses a minimal risk to the fetus in the third trimester, increasing fetal size and weight can make the mother feel uncomfortable in any position for dental treatment. Appointment duration should be kept to a minimum and should address basic oral hygiene procedures and emergent dental issues. Contact in this period presents an opportunity to educate the mother about the oral hygiene needs of young children and the need for the child to see a dentist or pedodontist early in life so a preventive regimen can be instituted to promote optimal oral health. Pregnant patients should be provided with information about the importance of proper brushing techniques of deciduous teeth and about whether or not fluoride supplements are recommended for the child.

In 1989, studies by Mattila and colleagues determined that there was a higher rate of caries, periodontitis, periapical lesions, and pericoronitis among patients with recent myocardial infarctions [67]. Chang and colleagues noted that poor oral hygiene was associated with increased risk of stroke [68]. Studies continue to explore the relationship between periodontal disease and cardiovascular health, suggesting factors that may constitute the basis of this relationship (e.g., systemic inflammation, poor oral hygiene) [69,70,71].

Researchers have hypothesized both direct and indirect pathways by which the pathogenic bacteria associated with periodontal disease may cause damage to the vascular endothelium, with the subsequent development of atherosclerosis. Atherosclerosis is the primary cause of myocardial infarction, stroke, and peripheral vascular disease. While research in this area continues, and a direct cause-and-effect relationship between periodontal disease and cardiovascular disease has not yet been established, a 2020 consensus report from the European Federation of Periodontology and the American Academy of Periodontology concludes that there is now a significant body of evidence supporting independent associations between severe periodontitis and chronic noncommunicable disease, including cardiovascular disease [70,71,72,73].

Periodontal disease is unequivocally a major complication of diabetes, and poorly controlled diabetes and periodontal disease are closely linked [84,85,86]. Susceptibility to periodontitis is increased by approximately threefold in people with diabetes. [86]. Individuals with diabetes frequently complain of oral changes, including diminished salivary flow and/or xerostomia, altered saliva composition, inflammation, loss of sensation, changes in taste perception, numbness, burning mouth syndrome, and lesions of the oral mucosa and tongue [87]. Although these are not all symptoms of periodontitis, the oral changes can predispose an individual for the development of gingivitis and periodontitis. There is evidence of a relationship between periodontal disease severity and diabetes (particularly poorly controlled diabetes), but the exact mechanism by which one might influence the other has not been definitively determined [86]. Emerging evidence suggests the existence of a two-way relationship between diabetes and periodontitis, with diabetes increasing the risk for periodontitis and periodontal inflammation negatively affecting glycemic control [79,86]. Many believe that the host of oral changes evidenced in patients with diabetes may act synergistically to predispose these individuals for periodontitis [88].

Both diabetes and periodontal disease share a common pathogenesis that involves enhanced inflammatory response at the local and systemic levels. This inflammatory response is mainly caused by the chronic effects of hyperglycemia and specifically the formation of biologically active glycated proteins and lipids [86,89]. Patients with diabetes, especially uncontrolled diabetes, are at an increased risk for impaired healing, and the periodontal pocket can experience persistent inflammation and bacterial infection in patients with periodontal disease, which can be made worse by this impaired healing [88,90]. Loss of teeth because of aggressive periodontitis may also occur [90].

The pathophysiology of endothelial dysfunction and inflammation is the root cause of much of the microvascular and macrovascular deterioration associated with diabetes [86,90]. The normal metabolic response to a glucose load is an increase in free fatty acids and insulin. These changes result in a transient decrease in endothelium-derived nitric oxide production and in endothelium-mediated vasoconstriction. In the presence of normal glucose tolerance, endothelial nitric oxide production and vasodilation return to normal within two hours. However, in patients with diabetes, endothelium-mediated vasoconstriction continues for hours [91]. This impaired blood flow can affect collagen synthesis, maturation, and homeostatic turnover, all of which can result in impaired healing and the development of periodontal disease [88].

In addition to vasoconstriction, endothelial dysfunction is correlated with aggregation of platelets, a proinflammatory state characterized by the accumulation of leukocytes and coagulation products on the endothelium. Fibrinolysis is decreased, and thrombosis is increased. As the secretion of prostacyclin and nitric oxide induce vasoconstriction, plasma cytokine and prothrombin factors levels increase. This makes the plasma markedly procoagulant and antifibrinolytic, promoting atherosclerosis [90]. The Insulin Resistance Atherosclerosis Study also demonstrated that chronic hyperglycemia was positively associated with increased intimal-medial wall thickness [89]. These changes in both the microvascular and macrovascular systems lead to reduced vascular reactivity and increased production of glycation end products [91]. The accumulation of advanced glycation end products in the gingival tissues is generally responsible for the oral complications of diabetes. In fact, individuals with poorly controlled diabetes have a two- to three-fold increase in the prevalence of oral lesions and periodontal disease.

Smokeless tobacco by definition is non-pyrolytic (not burned or combustible), and there may be an erroneous belief that because it is not smoked, this tobacco is safe. However, this is demonstrably untrue.

Smokeless tobacco is also known as dip, chew, snuff, or chewing tobacco and generally exists in two forms. Snuff is finely ground tobacco that can be moist, dry, or placed in pouches. Moist snuff comprises about 81% of the smokeless tobacco market. With this product, a pinch (or "dip") is placed between the gingival tissues and the cheek or lip [100]. Expectoration is required. More rarely, finely ground snuff may be sniffed or inhaled through the nose. Chewing tobacco exists in the form of loose leaves, as tobacco leaves condensed together as a plug, or as tobacco leaves that are twisted together like a rope. The loose leaf form of chewing tobacco accounts for about 18% of the smokeless tobacco market [101]. In 2020, approximately 2.3% of adults, or about 5.7 million individuals 18 years of age and older, in the United States currently used a smokeless tobacco product [102].

While smokeless tobacco eliminates the risks of secondhand and thirdhand smoke to bystanders, it remains highly addictive and harmful to users. Nicotine from smokeless tobacco is absorbed more slowly through the oral mucosa, compared with the rapid systemic absorption and distribution from cigarette smoke [103]. However, the effects of nicotine absorbed through the oral mucosa are more protracted. Although the route of absorption varies, the potential for addiction remains the same.

Smokeless tobacco contains 28 carcinogens and is a known cause of oral and pancreatic cancers [104]. The extended contact time of smokeless tobacco products on the oral mucosa allows these carcinogens ample time to begin changing the cells of the mouth and esophagus. Smokeless tobacco users may develop squamous cell carcinoma, smokeless tobacco keratosis (also known as snuff pouch lesion or snuff dipper's lesion), and/or verrucous carcinoma. Potential adverse effects to the periodontium include gingival recession, periodontal disease, and necrotizing ulcerative gingivitis [51].

The rise of e-cigarettes in the past decade has introduced new variables in the prevention and treatment of nicotine addiction. Originally marketed as a smoking cessation tool, e-cigarettes are electronic products that typically deliver nicotine in the form of an aerosol [105]. Most e-cigarettes consist of a cartridge (which holds a liquid solution containing varying amounts of nicotine, flavorings, and other chemicals), a heating device (vaporizer), and a power source (usually a battery) [105,106]. In many e-cigarettes, puffing activates the battery-powered heating device, which vaporizes the liquid in the cartridge. The resulting aerosol or vapor is then inhaled (called "vaping") [106]. It is unclear if this delivery method decreases the risks seen with conventional tobacco smoking; however, it does introduce the risks of toxicity associated with consumption of the potent e-liquid.

In 2020, 3.7% of adults, 3.3% of middle school students, and 14.1% of high school students were current e-cigarette users [105]. In 2019, among current adult e-cigarette users overall, 36.9% also currently smoked cigarettes ("dual users"), 39.5% formerly smoked cigarettes, and 23.6% had never smoked cigarettes. Among current adult e-cigarette users, the percentage of those who have never smoked cigarettes is highest among those 18 to 24 years of age and is lower in older age groups [105].

From 2017 to 2018, adolescent use of e-cigarettes increased from 11.7% to 20.8%, making it the number one form of tobacco used among youth. The rate increased again in 2019 to 27.5%, but decreased in 2020 to 19.6% [107]. In 2018, the FDA issued more than 1,300 warnings and fines to retailers who illegally sold e-cigarette products to minors [108]. In 2020, the FDA banned mint- and fruit-flavored e-cigarette cartridges in an effort to halt uptake among children [109].

Because e-cigarettes have been used in the United States for a relatively short period, the long-term effects on oral and systemic health are not totally clear. Elimination of exposure to tar is a benefit for e-cigarette use. However, the chemicals that are inhaled while using e-cigarettes are associated with known health hazards. Nicotine remains a highly addictive compound regardless of its source. People who use e-cigarettes can experience nicotine withdrawal symptoms if they discontinue the use of the device. One study demonstrated that formaldehyde, a known carcinogen, can be produced during the vaping process, with the potential for the user and bystanders to inhale vapor that contains the carcinogen [110]. In general, e-cigarettes cannot be considered a safe alternative to cigarette smoking.

A hookah is a type of waterpipe comprised of a head or bowl, plate, body, jar, hose, and mouthpiece. The body of the hookah fits down into the jar, which is partially filled with water, although any liquid (e.g., alcohol, juice) can be used. Tobacco is placed in the bowl at the head of the body and covered with a filter, such as perforated tin foil, and then burning embers or charcoal is placed above it (and sometimes covered by a cap). The hot air from the charcoal roasts the tobacco and the ensuing smoke is passed down into the liquid in the jar, where it is partially filtered, diluted, and cooled. The smoke then bubbles up and passes through the hose and mouthpiece for inhalation. Repeated inhalation is required to keep the tobacco burning. The plate stores dead coals/embers. The types of tobacco used for hookah are ajami or tumbak, which is a pure, dark tobacco paste; "honeyed" tobamel or maassel, containing 70% honey or molasses and featuring flavors (e.g., apple, mango, banana); or jurak, which may be sweetened or contain fruits or oils. It is commonplace to use 10–20 g at a time, and these tobaccos may be mixed with other drugs [111]. Smoking sessions last up to an hour or longer, and it has been reported that the nicotine content of the tobacco used for hookah is higher than that in cigarettes [112]. Thus, the smoker is exposed to a higher volume of smoke for longer periods (not to mention those in the vicinity). A report from the World Health Organization states that a hookah user may inhale as much smoke in one session as a cigarette smoker would after consuming at least 100 cigarettes [113].

Contrary to popular belief, waterpipe smoking is not safer or less addictive than cigarette smoking [114]. The FDA began regulating the manufacture, import, packaging, labeling, advertising, promotion, sale, and distribution of tobacco mixtures used for hookah in 2016 [115]. Hookah smoke contains higher concentrations of carbon monoxide, nicotine, tar, heavy metals, and carcinogens, likely because of its method of use (i.e., tobacco mixtures heated by quick-burning charcoal or wood embers and inhalation through use of a plastic hose for an hour or longer) [116,117]. It is also common to share a hookah, so users are also at risk of exposure to infections (e.g., herpes due to sharing of the mouthpiece) [118]. Hookah pipe smoking may be a gateway to cigarette smoking and other drug use. Although policies are in place to ban smoking in many public places, many times, hookah use is exempt because it is done in places which identify themselves as "tobacco bars," waterpipe smoking areas are set up outside, or the smoking is done in places where tobacco is sold.

Prior to initiating invasive dental treatment for any patient who is using an anticoagulant medication, the first step is to identify the underlying condition. A variety of conditions require anticoagulation, including venous thrombosis, pulmonary embolism, and prevention of recurrent myocardial infarction or stroke. In many cases, patients with these conditions have additional comorbidities, such as hypertension and diabetes. A patient's entire medical history should be considered before dental treatment is initiated, and consultation with the patient's physician should be sought if there is concern about proceeding with treatment. It is important to note that only a physician should make the decision to withhold anticoagulant therapy.

Anticoagulants reduce vitamin K-dependent synthesis of coagulation factors II, VII, IX, and X in the liver. Warfarin has been the most commonly prescribed anticoagulant in the United States, although other agents (e.g., apixaban, dabigatran) are growing in popularity [120]. The therapeutic effects of warfarin can be monitored using the international normalized ratio (INR), which is a ratio of the patient's prothrombin time against a laboratory control. The INR of a person whose blood clots normally and is not taking an anticoagulant would be 1. Values greater than 1 indicate a lengthened time to coagulation. The therapeutic range of INR depends on the medical problem for which it is prescribed. Laboratory values obtained within the last 48 hours are the most accurate [121]. An INR of 3 or less generally indicates it is safe to perform minor oral surgery without a temporary discontinuance of the warfarin [122]. However, INR values should only serve as a guide, because there is no universally accepted value at which a patient on warfarin is guaranteed to achieve hemostasis after an invasive dental procedure. Other factors that can adversely affect hemostasis include hepatic disease, alcoholism, thrombocytopenia (low platelets), renal failure, and the nature and the extent of the planned surgical procedure.

As noted, while warfarin is the most common anticoagulant, other agents are commonly used, including dabigatran (a potent inhibitor of free thrombin) and the selective factor Xa inhibitors rivaroxaban and apixaban. INR is not useful for these medications, and evidence-based guidelines are lacking for the dental management of patients using these agents, so consultation with the patient's physician is advisable prior to the initiation of any invasive dental procedure [123].

Patients who remain on anticoagulant therapy during invasive dental treatment should not use NSAIDs (e.g., naproxen, ibuprofen), as these medications can inhibit platelet aggregation. When this action is coupled with the actions of an anticoagulant medication, the potential for postprocedural bleeding increases.

Antiplatelet medications act by inhibiting platelet aggregation; aspirin and clopidogrel are popular examples. The most common indications for antiplatelet medications are the prevention of arterial and venous thrombosis in patients with ischemic heart disease, the prevention of platelet aggregation in patients who have cardiac stents or heart valve implants, and prevention of recurrent stroke in patients who have experienced one in the past [124]. These medications have no impact on coagulation factors. In most cases, patients who use aspirin for antiplatelet therapy do not experience more postsurgical bleeding than patients who do not take aspirin [125]. Similarly, studies have demonstrated that the use of clopidogrel is not equated with excessive bleeding during or after minor oral surgery procedures [126].

As with patients who use anticoagulants, the underlying condition necessitating antiplatelet therapy should be documented. Consultation with the patient's physician is advisable to understand the current status and prognosis of the patient's cardiovascular or cerebrovascular problem and to determine if any other co-existing systemic illnesses complicate the ability to provide dental care for the patient.

Platelets are not actually cells but are fragments of a larger progenitor cell called a megakaryocyte. These fragments lack a nucleus but contain a host of chemicals that are essential to the clotting process. Because antiplatelet medications interrupt varied phases of the process by which platelets adhere to a damaged blood vessel and to each other, there is a concern about the ability to achieve hemostasis after an invasive dental procedure. The risk of bleeding during or after an invasive dental procedure if a patient remains on antiplatelet medications should be weighed against the risk of an adverse cardiovascular or cerebrovascular event if these medications are held temporarily.

The American Heart Association, the American College of Cardiology, the Society for Cardiovascular Angiography and Interventions, the American College of Surgeons, and the American Dental Association have published a consensus opinion about drug-eluting stents and antiplatelet therapy [127]. It stresses the importance of maintaining antiplatelet medications to minimize the risk of stent thrombosis and recommends that the patient's cardiologist should be consulted to discuss the patient's antiplatelet regimen and the optimal management of the patient for invasive dental procedures [128]. A decision to temporarily discontinue aspirin, clopidogrel, or any other antiplatelet medication is made by the cardiologist.

While studies indicate that patients who continue antiplatelet therapy during invasive dental procedures are not likely to experience excessive bleeding, it remains a possibility. The nature and extent of the procedure, hepatic disease, alcohol abuse, and/or any coagulopathy should be considered. If the medications are continued and intra-operative or postsurgical bleeding is a concern, the procedure may need to be completed in a hospital or an outpatient treatment center.

The use of NSAIDs for analgesic relief of pain adjunctive to dental treatment is common, and these medications can inhibit platelet aggregation and prolong the bleeding times in some patients [129]. If antiplatelet therapy and NSAIDs are taken concurrently, the risk of bleeding will increase. Therefore, an alternative analgesic, such as acetaminophen, should be considered.

As compared to decades ago, dental health has improved across the United States, which is primarily attributed to fluoridation of water and toothpaste and greater awareness of optimal oral hygiene. However, rural areas have a variety of factors that continue to contribute to poorer oral health in this population [130]:

Dental care is a problem largely because of a lack of practicing dentists and insufficient dental insurance. There are fewer rural dentists (per capita) available to address oral disease than in urban settings, and the majority of dental health professional shortage areas lacking access to dental services are rural [131]. An estimated 8,600 additional dentists will be required nationally to meet care needs by 2025 [131]. To address this problem, areas with fewer dental professionals may qualify for a federal dental health professional shortage area designation. Having this designation can qualify the area to receive financial aid or recruitment aid from the government [132].

It is estimated that 70 million people in the United States live in areas in which access to dental care is limited [133]. Rural areas and areas in which there is a chronic high rate of unemployment can have difficulty in attracting dentists to these areas due to the high cost of maintaining a practice.

A shortage of dental practitioners in rural and micropolitan areas has resulted in emergency departments becoming the alternative for evaluation and treatment of dental conditions [134]. To address this problem, states have passed laws intended to expand the dental care workforce. In Minnesota, for example, additional license types (dental therapists and advanced dental therapists) have been added to help meet the need for dental professionals qualified to provide preventive and restorative dental care, in some cases with less direct supervision [135,136]. In this case, at least half of a dental therapist's patients must be considered underserved—that is, on public assistance, uninsured, or living in an area with a shortage of dentists [137]. Several states permit new dental profession types to provide dental care under varying levels of supervision by dentists, allowing these providers to meet dental care needs in nontraditional, tribal, school-based, and community settings [135]. In Alaska, where the majority of land is classified as rural, some clinics have sent out dental health aide therapists to distant rural sites to deliver routine restorative care. As a result of this initiative, many recipients were able to have regular access to dental care for the first time [137].

Aside from government actions to increase workforce numbers and to expand the scope of practice, dental care workforce capacity can be built using teledentistry. In California, dental hygienists use teledentistry to improve dental care access for the young and disabled. Dental hygienists go to community settings such as schools, Head Start public programs, and nursing homes, where patients are screened and data are transmitted digitally back to the dentist, who creates a treatment plan for the hygienist to implement [137]. These solutions have potential to mitigate dental disease in rural underserved communities.

Dental caries are the most common chronic childhood disease and are five times more common than asthma [138]. However, studies indicate that many children have not received even the most basic of dental care. A study of third-grade children in New York revealed that 54% had dental caries, with 33% lacking treatment [139]. In 2014, more than 18 million low-income children received no dental care [140]. There are many underlying reasons for this disparity of dental care among children, including lack of transportation, lack of insurance, poor understanding of the importance of deciduous teeth, and difficulty finding a pedodontist.

As compared with the general population and other racial/ethnic groups, American Indian/Alaska Native (AI/AN) children are disproportionately affected by dental disease, and oral health for school-aged AI/AN children 6 to 9 years of age did not change significantly between 2010 and 2018–2019 [141]. AI/AN elementary school children have a higher prevalence of both dental caries experience and untreated dental caries than the general U.S. population. Compared with the general U.S. population, AI/AN children are twice as likely to have untreated dental caries in their primary teeth and five times more likely to have untreated dental caries in their permanent teeth [141]. The compromised dental health of this population is believed to be rooted in differences in host, bacterial, behavioral, sociodemographic, and environmental risk factors, as well as historic economic adversity and poor social conditions [141].

The Indian Health Services Early Childhood Caries Initiative provides AI/AN children with oral assessments and interventions to mitigate early childhood dental disease, giving public health nurses the opportunity to be part of a collaborative team effort improving oral health. The Indian Health Services Early Childhood Caries Initiative involves multiple stakeholders, including dental and medical staff and other programs, such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). WIC is a social program for low-income women, infants, and children up to 5 years of age to provide healthy foods and referrals [142].

Numerous socioeconomic issues can present obstacles for patients of any age who wish to obtain dental care. However, geriatric patients may experience additional barriers in their attempts to maintain dental health.

Financing of dental care is the primary obstacle for many older adults. Most patients older than 65 years of age are retired and therefore no longer have dental insurance as an employee benefit. Without this option and income limited to retirement savings, social security income, and any pension plan benefits, the costs associated with dental treatment may not be easily accommodated. Funding from federal, state, and county sources is often limited, both in available funds and treatment coverage.

Available financial resources among the geriatric population vary considerably. Unfortunately, many older adults live near or even below the poverty level and have difficulty in affording basic preventive dental care.

Medical problems can also present a major obstacle in the provision of dental care for geriatric patients. As discussed, many older adults are afflicted with at least one chronic disease and most have experienced medical problems. Even with Medicare insurance, the cumulative costs of medical treatment and medications can escalate and contribute to budgetary concerns, making it difficult to afford dental care.

Coping with serious medical problems may leave older adults without the motivation and ability to seek dental care. Some medical problems may also lead to one spouse assuming the role of caretaker for the other. If this is the case, both can have difficulties in obtaining dental care. The caregiver spouse may have difficulty setting aside time for a dental appointment, while the morbidity of the medical problem and transport issues make dental appointments difficult for the infirmed. Patients in long-term care facilities may also face obstacles in obtaining dental care [143]. The cost of long-term care is often a strain and may limit patients' ability to afford dental treatment. Difficulties with transportation, especially to an outside dental office, may also be a barrier to seeking dental care. In order to overcome this barrier, some long-term care facilities may contract with a private dentist to provide care within the facility. However, the fees associated with this level of service are prohibitive to many.

While there are other barriers in the provision of dental treatment of geriatric patients, including the availability of clinicians specializing in treating older patients, financial and transportation issues are the most frequently encountered. Because oral health is such an important component to overall health and quality of life, efforts should be made toward the improvement of access to dental care for all within the geriatric population.