Diann Azevedo makes house calls.
As a registered dental hygienist in alternative practice whose clients include the frail, homebound elderly as well as the developmentally disabled she is part of a growing movement to take routine dental care out of the office and into vulnerable patients' homes.
She even totes a portable dental chair in her car, along with a large kit stuffed with dental supplies.
"Has your mother had any changes in her medications?" she asked Jeanne Andrews, whose mother, 80-year-old Dolores Hanson, has advanced-stage Alzheimer's disease and Lewy body dementia.
For Hanson, the dental chair wasn't necessary.
The symptoms of her illness include rigidity and loss of balance. She can't walk and she no longer talks. She sometimes can't even sit. Her awareness flickers in and out. Illness has restricted her life to a hospital bed in a bedroom of the small Roseville apartment she shares with Andrews, who cares for her.
Propped into place with pillows in the hospital bed, Hanson gazed at Azevedo's face as the dental hygienist gently began a routine cleaning and examination. Reflex kicked in, and Hanson bit down on the toothbrush.
"It's OK," Azevedo said softly, and she retrieved a rubber bite block from her bedside supplies.
In an aging nation with the population of older adults soaring with the graying of the baby boom generation maintaining seniors' oral health has become an unexpectedly urgent issue.
To meet the growing need, California a decade ago began licensing registered dental hygienists in alternative practice, or RDHAPs, to take routine care into nursing homes and private residences.
"It's a job of the heart," said Susan Lopez, president of the California Dental Hygienists' Association. "The frail, elderly homebound are so fragile."
Today, 400 RDHAPs such as Azevedo provide care across the state, along with 17,000 dental hygienists in traditional practice. Twenty-two more states are considering legislation to expand the scope of hygienists' care beyond the office.
According to a surgeon general's report, infections related to dental problems are a silent epidemic, with almost one-fourth of people ages 65 to 74 suffering from periodontal disease that can become so severe it leads to systemic inflammation.
"When you have a high bacterial load, it affects your respiratory system and blood system," said Lopez. "People have a low-grade infection all the time. They feel rotten."
Or worse: They can suffer heart disease and stroke as a result of infections that begin in the mouth, and some studies show a strong link with diabetes as well.
"Infection of gum tissue is invasive," said Azevedo. "An abscess is serious. People can die because an infection left untreated can go to the brain."
That's exactly what happened a little more than a year ago, when the death of a 24-year-old Ohio man from severe, untreated gum infection made national news. He'd lost his job and couldn't afford dental insurance, according to reports.
The connection with older adults? Many lose their dental insurance when they retire, leading them to forgo the routine dental treatments that could prevent problems from developing.
For seniors in particular, delaying care can lead to dire complications as well as higher medical and dental costs, not to mention a whole lot of pain.
"The cost of neglect is enormous," said Lopez. "Having dental work done in the emergency room is the most costly way of providing dental care."
The elderly are more prone to oral health issues anyway.
Many medications as well as certain cancer treatments can cause dry mouth, which can lead to root decay, according to experts. And gum disease can result in diminished sense of taste, digestive problems, jawbone loss and loss of teeth.
Only 30 years ago, almost half of people 65 and older had lost some or all of their teeth to neglect, gum disease, accident or age; that number has dropped to only 25 percent, Lopez said.
"We used to accept losing teeth as a part of aging," she said. "We don't accept that any more. The baby boomers will not accept that."
No, they won't.
"And when people have dentures, everything has a plastic taste," she said. "Everything you eat has a mouthful of plastic with it."
But even with dental insurance, access to office care in advanced age can grow iffy as a result of physical problems everything from debilitating arthritis pain, which can limit mobility, to the encroaching toll of dementia.
For as long as Hanson was able to walk, her daughter took her to Azevedo's Rocklin office for routine cleanings.
"But after a few years, she couldn't walk up the stairs any more," said Andrews, 56, who does part-time medical transcription work at home so she can care for Hanson.
And so began Azevedo's house calls.
"It's important to have her teeth and gums checked, because if you don't, it leads to pain," said Andrews. "We're trying to prevent things that cause pain, so my mother can have the highest quality of life possible. If she was in pain, I'd be in misery.
"This way she can enjoy food. It's one of the few things left to her, along with music and her cats. It's that simple."
Frank Sinatra's music played softly in Hanson's bedroom as Azevedo peered into her mouth, gently brushing, scraping and checking her gums and teeth. A fluffy cat named Misty hopped onto a nearby windowsill to supervise.
After a half-hour examination and cleaning, Azevedo pronounced Hanson's mouth healthy.
"We're almost done," she said, finishing with a quick swabbing of topical fluoride varnish on Hanson's teeth. "You need a rest. I can tell."
To find a registered dental hygienist in alternative practice, go to www.cdha.org.