We examined dental health service in the integrated community care system. At first we investigatedthree points to ascertain the present conditions.
First, we investigated the enforcement situation of the dental health service and cooperation with the dental agency for visiting nursing stations. Findings were that half of the facilities performed enforcement of the training about understanding oral status. As for ascertaining the method, most were observation of the nurse and information from the family. From these, it was thought that there was little cooperation with the dental staff.
The second investigated the enforcement situation of the dental health service among at-home elderly people in need of nursing care in municipalities in the whole country. Findings were that through all municipalities, there was an enforcement rate in the order of visiting oral health instruction, visiting dental practice, and dental checkups by service distinction. Both services tended to have a high enforcement rate in public health centers in cities, towns, and villages where the scale of the population scale was large.
For the third, we investigated the cooperation situation with care-related facilities of a local dental association. The most cooperative was a community general support center, followed by a health care center for the elderly, and a visit nursing station scored low. In addition, a tendency to take on individual treatment was strong for the health care center for the elderly and tended to establish the communication meeting at the community general support center and to measure cooperation. The cooperation rate with the visit nursing station was low, and the correspondence indicated much individual treatment. The cooperation service had much professional oral care and dental treatment in a health care center for the elderly and a visiting nursing station. There was a lot of oral care at the community general support center.
Consideration has been also given to a result of the interview survey about cases in forward areas.
Conditions such as “information sharing” and “high quality coordinators” are met so that dental health staff's role in inclusion care are more local than the above; “the cooperation that only a face gets” is necessary together, but let's be the first to perform cooperatively in business.
Labor will be required to offer dentistry after a dental health service start that a local dental association coordinates with mutual cooperation. In addition, it becomes the large focus of how dentistry pushes forward in cooperation with many types of jobs. The system propelling these is not nationally uniform, and we believe local characteristics should be kept alive and should propel it forward.
The Aging Society Research Group-Toyoshikidai Community in Kashiwa City was established to promote community development under close association with the University of Tokyo and the Urban Renaissance Agency. At present, Kashiwa City is conducting mainly two projects, the Lifelong Work Project and the Home Care System. Kashiwa City has performed five programs to promote home care, in cooperation with the medical association and other stakeholders, including: decreasing the burden among health care professionals, promoting of multidisciplinary cooperation, building informationsharing for community residents, and providing the base for community health care.
In this system, the dental association has developed a checklist of oral health care. The checklist is useful to assess the status of oral function for elderly individuals and their family members. If oral troubles are found after assessment, there is a route to connect the dental clinic in Kashiwa. Such a system has been established under a close relationship among various stakeholders.
Furthermore, Kashiwa City applied "home visiting rehabilitation office conducted by rehabilitation professionals" and "guidance for management of in-home long-term care conducted by dental hygienists" to the Comprehensive Special Zone System. In the latter, the dental association established an Oral Care Center. Dental hygienists from the Oral Health Center can conduct guidance for management of in-home long-term care under the employment contract of each cooperating dentist.
Moreover, Kashiwa City, the dental association, the home-visit rehabilitation association, and the dietetic association are discussing a new project, Total Health Care Station, to provide comprehensive services that include oral health, physical exercise, and nutrition. It is very important for each community resident to be provided sufficient dental care and oral health services by multidisciplinary cooperation in Kashiwa City.
For individual elderly people to continue living in their community with a healthy lifestyle that suits them, it is necessary to provide various kinds of support and appropriate health care and welfare services that match the status and changes of individual elderly people. As a system working toward this goal, the establishment and promotion of community-based integrated care systems are in progress.
A paradigm shift is urgently required from conventional health care services, completed in respective medical institutions, to integrated health care and long-term care that are supported by local communities. In the fields of dental and oral health and dental service (collectively "dental health care") as well, it is expected that diverse specialists will cooperate and collaborate with each other.
In this context, the revised Long-Term Care Insurance Act requires each municipality to make efforts to hold community-based care conferences as a key to the realization of community-based integrated care supported by collaboration and cooperation. While the act explicitly includes dentists and dental hygienists as members of the conferences, it cannot be said that the adequate participation of dental health care providers has been achieved at community-based care conferences.
Promoting collaboration between dental health care providers and other specialists in the community is urgently required. Nurses and public health nurses are expected to play significant roles in such collaboration. Public health nurses have established close relationships with dental health care providers through oral care services provided at infant medical checkups and long-term care prevention. As administrative health care professionals, public health nurses have recognized the importance of oral care, and have represented the administration in the effective deployment of home dental services as well as local dental service and oral health activities by dental health care providers.
In principle, it is required that community-based integrated care should be promoted as part of overall community development for all local residents, including not only elderly people but also children with disabilities and other vulnerable people. Public health nurses are expected to leverage their collaborative experience in past activities, thereby functioning as a hub and contact point for dental health care providers in the promotion of community-based integrated care. At the same time, dental health care providers are expected to start their engagement in initiatives toward the realization of community-based integrated care by participating in community-based care conferences, leveraging collaboration with nurses and public health nurses.
Improvement of oral function is effective to maintain healthy swallowing and to prevent declining vital function among the elderly individuals. Oral frailty caused by decreasing oral function has a close relationship with preventive long-term care.
First, we explain the concept of frailty and the distribution of subjects with frail symptoms among elderly residents. Second, we specifically focused on oral frailty, including chewing, swallowing, and eating. We analyzed the trend of studies related to the concept of oral frailty. In addition, health strategies regarding oral frailty and some oral function evaluation methods were reviewed.
Multidisciplinary coordination has been introduced for the maintenance and enhancement of oral function and improvement of nutrition mainly through Dr.Net Nagasaki. Dr.Net, which was established in 2003, has reduced the sense of burden on doctors by promoting coordination among urban clinics.
Meanwhile, various types of multidisciplinary coordination have been conducted. Since its establishment, an original registered dietician dispatch system has been constructed, in which two registered dieticians offer visiting nutritional counseling and outpatient nutritional counseling at multiple clinics. The Nagasaki Dietetic Association universalized coordination between Dr.Net and registered dieticians to form the Nagasaki Nutritional Care Station in October 2004, creating a mediation and dispatch system for requests for dieticians from clinics, hospitals, or medical associations. Simple recipes that can be made at home have also been created. In October 2005, a gastric fistula workshop was held in order to promote knowledge and technology. In 2012 a Manual for Gastric Fistula Home Management was created. Methods of counseling that had varied depending on whether they were conducted in hospital or at home were unified by working together with local related occupational categories. Dr.Net doctors worked in close coordination with dentists, dental hygienists, and dieticians to maintain and enhance oral function.
By cooking meals together with the user's family at home, registered dieticians were able to prevent the recurrence of aspiration pneumonitis, increasing the confidence and peace of mind of caregivers. Collections of simple recipes that could be made at home could also be useful for improving the nutrition of elderly patients. The gastric fistula workshop made it possible for doctors who had no such valuable experience to easily perform gastric fistula replacement and management. This initiative not only produced a gastric fistula management manual, but also led to improvement in the level of skill of general practitioners.
An institutional elderly individual experienced weight loss and decreased appetite as a result of lowered swallowing ability. Based on advice from a dentist, a dental hygienist instructed the patient's caregivers on how to offer the woman mastication training. As a result, improvements were noted in lip closing strength, muscles around the oral cavity, choking, and the swallowing state. Furthermore, the patient's food intake and body weight increased. Another dependent elderly patient living at home suffered a marked decrease in oral intake as a result of extensive brain infarction of the right middle cerebral artery. After evaluation by an otolaryngologist, counseling on swallowing food was offered by a dietician, the patient's dentures were adjusted by a dentist, and regular oral care was conducted by a dental hygienist. As a result, the patient's appetite and mastication were improved without a gastric fistula. Oral function was able to be maintained and enhanced, and nutrition was able to be steadily improved through the organic development of multidisciplinary coordination among occupational categories, including doctors, dentists, dental hygienists, and dieticians.
Dental health services for the frail elderly should be provided under multidisciplinary cooperation within the community and not only by clinic-based dentistry. In this article, a medical and dental collaboration in Nagasaki was introduced, and the need for "medico-dental cooperation" to improve oral functions of the elderly was discussed. The concept of community rehabilitation was presented to the Committee on "Netakiri Zero Strategy in Nagasaki Prefecture", which was held in1991, and inevitably, the need for oral rehabilitation for the frail elderly, through eating support by the dental and medical occupations, was spread. In 1977 the Oral Care Network System for Stroke was started as a means of medico-dental cooperation in Nagasaki. Under the Oral Care Network System for Stroke, approximately 1,000 domiciliary dental visits have been conducted by the Nagasaki city dental association in each year after 1997. As the system for domiciliary dental services has been firmly established in Nagasaki, the situation has also spread to nationwide. It is important for more comprehensive oral health care to strengthen the cooperation with nurses, pharmacists, physical therapists, occupational therapists, speech therapists, and care managers, and to expand joint care with nutritionists from home care to hospital care, under cooperation with physicians providing domiciliary medical care. Providing multidisciplinary care is effective to support smooth eating for the frail elderly in the community.
Masticatory function is important for taking adequate nutrition. Evidence based on world wide observational studies shows that inadequate masticatory function reduce food intake mainly in vegetables and fruits and nutrition intake mainly in vitamins.
The masticatory function gradually became recognized in health policy and was adopted as a target value of Healthy Japan 21 (2nd edition). National Health and Nutrition Survey shows that the rate of person having good masticatory function is increasing. However estimated population having bad masticatory function is not decreasing because of increase of elderly population.
Mastication has similar characteristics in neural control to walking because they are semi-automatic movement. However mastication has higher rate of structural disorders resulted from tooth loss by dental caries and periodontal disease than walking before elderly life stage. Therefore viewpoint of life course epidemiology is necessary to attain healthy masticatory function. Standard program of "specified health checkups and specified health guidance" does not include oralhealth-related program. However, there are good practices which oral health related program in "specified health checkups and specified health guidance" produced good results. And its future diffusion is greatly anticipated.
The author, being a former senior medical officer and currently a consultant of the Nuclear Medicine Section, the Division of Human Health, the Department of Nuclear Sciences and Applications, the International Atomic Energy Agency (IAEA) to standardize the isotope and radiation technologies for health and medical care and transfer them to the IAEA member states to address their health issues, participated in an international cooperation project to survey the current situation of the health and medical care in Viet Nam and exchange opinions with the World Health Organization Western Pacific Regional Office Viet Nam Office and the Viet Nam Health Department coordinated by the Japan Public Health Association from 10th to 15th January 2016 and perceived efforts made and action plans for the health and medical care in Viet Nam by the international organizations of the IAEA and the World Health Organization (WHO). IAEA has verified various isotopes and radiation technologies up to now in the international field of health and medical care and has being offered them to the member states under the sustainable frame work of technical co-operation. However, the activity in the health and medical care field of IAEA is hardly recognized by the public health professionals in Japan. In order to attain the objective to improve and maintain human health under the umbrella of the United Nations system, the peaceful use of nuclear technology has been promoted in the field of non-electric applications of nuclear energy including human health and medical care by the IAEA. There are several discrepancies seen with the field and tactics of health and medical care between the IAEA and the WHO. In terms of measures to fight NCDs which should be an urgent issue in most of the member states, a comprehensive approach is often needed beyond the capability of IAEA as isotopes and radiation technologies. The IAEA should strive to solve issues on human health and medical care maintaining much more proactive and closer cooperation with the other internal organizations such as the WHO, universities, research institutes and
so forth around the world.