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1 Oral Biology Research, 2017; September 30, 41(3): Copyright c 2017, Oral Biology Research Institute DOI: /obr Original Article ORAL BIOLOGY RESEARCH Suggestion for understanding and activation of the nursing home dentist system Jung-Min Kwag 1, Inn-Im Park 2, and Mee-Kyoung Son 3,4 * 1 SK Chemicals Dental Clinic, Seongnam 13494, Republic of Korea 2 Goodface Dental Clinic, Seoul 06212, Republic of Korea 3 Department of Prosthodontics, School of Dentistry, Chosun University, Gwangju 61452, Republic of Korea 4 Oral Biology Research Institute, Chosun University, Gwangju 61452, Republic of Korea (Received Aug 18, 2017; Accepted Sep 25, 2017) ABSTRACT Various medical policies for elderly patients have been introduced in the era of aging. Recent implementation of nursing home dentist systems is a positive opportunity to recognize the significance of oral health care in managing general healthcare and improving the quality of life for elderly people. In addition, it is necessary to strengthen dentists competencies and key roles in recovering oral function and rehabilitation with changes in the customer-oriented dental care paradigm. This study suggests the path towards stabilizing and activating nursing home dentist systems by understanding the background and current status of nursing home dentist systems, and identifying ways of improving the systems. KEY WORDS: Era of aging, Nursing home dentist, Oral function, Oral rehabilitation 서 론 최근노인인구의증가에따른고령화문제가다양한분야에서화두가되고있다. 특히우리나라는전세계에서유래를찾아보기힘들정도의빠른속도로고령화가진행되고있으며, 2026년에는만 65세이상의노인인구가총인구의 20% 이상인초고령사회에진입할것으로예상된다 [1,2](Table 1). 이와같은급속한고령화는경제및사회전반에대한변화와더불어보건복지분야에서의새로운정책의도입과이를기반으로한의료시스템의변화필요성을가속화시키고있다. 고령자를대상으로한보건복지정책의발전을살펴보면, 우리나라는 2007년노인장기요양보험법을제정하고, 2008년부터노인장기요양보험제도를실시하였다. 노인장기요양보험시행에맞춰보건복지부는 2008년 7월부터치매, 중풍등노인성질환을가진노인요양시설 *Corresponding author: Mee-Kyoung Son Department of Prosthodontics, School of Dentistry, Chosun University, 309 Pilmun-daero, Dong-gu, Gwangju 61452, Republic of Korea Tel.: , Fax: son0513@chosun.ac.kr 입소자들에대한서비스강화를위해촉탁의 ( 노인복지법 시행규칙제22조를근거로함 ) 제도를도입함으로써노인요양시설내에서처방전을발급할수있게되었다 [3]. 2009년 7월 1일부터는노인요양시설에서의진찰, 처방, 응급시이송대책등의료적측면을강화하기위한협약의료기관제도를도입하였다. 이와같이노인인구를대상으로하는다양한의료복지정책이제정되고시행되었지만, 노인장기요양보험에적용되는노인환자들에게구강보건서비스를제공하기위한제도적장치는미비했다. 삶의질과관련하여구강건강관리의중요성이지속적으로제기되면서 2016년에야비로소장기요양시설에입소한노인의건강을관리하는촉탁의가의사, 한의사에서치과의사로확대된 치과촉탁의제도 가개정되었다. 그러나치과촉탁의제도가새롭게개정되었음에도불구하고, 2017년현재촉탁의로활동하는치과의사는 17개기관에서 15명 ( 서울 3명, 대구 1명, 경기 7명, 충남 1명, 경북 3명 ) 으로매우적다 [4]. 이는치과촉탁의제도가노인환자및요양기관관계자들에게충분히홍보되지못한점과더불어치과계내부에서조차도이에대한교육과인식이아직부족하기때문으로판단된다. 이에, 본논문에서는먼저우리나라의장기요양보험수

2 Jung-Min Kwag et al. Table 1. Population aging in leading countries Division Aging Society (7%) Target Year Aged Society (14%) Superaged Society (20%) Necessary Period (year) Aged Society Enrollment Superaged Society Enrollment Korea Japan Germany the USA France Data from Ministry of Health and Welfare (2009). 급현황을살펴보고, 우리나라보다앞서인구의고령화를겪고이를대비하기위해개호보험을도입하여구강보건서비스를활발히제공하고있는일본의사례를통해치과촉탁의제도를안착시키고활성화하기위한방안을제시하고자한다. 재료및방법 1. 우리나라의장기요양보험수급현황 2015년조사결과, 우리나라인구의기대수명은남자는 79.0세, 여자는 85.2세 [5] 이지만 (Fig. 1) 건강수명은 73세로약 9년의차이를보인다 [6]. 이와같은기대수명과건강수명의차이는점점더커지는양상을보이고있으며이는요양을필요로하거나요양시설에거주하는기간이점점 길어지고있음을의미한다. 노인실태조사에따르면, 65세이상노인은평균 2.5개의만성질환을가지고있고 [7], 장기적으로요양이필요한노인들은만성질환과더불어기능장애도동반하고있어요양필요와진료필요가동시에발생하고있다. 현재, 장기요양서비스를제공받기위해서는공단에장기요양등급신청서를제출하고, 등급판정을받게되며, 1등급에서 3 등급의장기요양등급이나치매특별등급 (5등급) 을받으면재가급여나요양시설서비스를이용할수있다. 국민건강보험공단의 2016 노인장기요양보험통계연보 에따르면, 2016년 65세이상노인은 694만명으로 2012 년대비 17.2% 증가하였고, 장기요양보험신청자는 31.9% 증가한 84만 9천명, 인정자는 52.1% 증가한 52만명으로나타났다 (Fig. 2, Table 2). 장기요양보험인정자 52만명의각등급별인원현황은 Table 3과같다. 이처럼장기요양보험인정자가증가추 Fig. 1. Life expectancy reported by National Statistical Office (NSO) in Fig. 2. Long-term care insurance pensioner (2016 Statistics Annual Report on Long-term Care Insurance for Senior Citizen). Table 2. Recognition on long-term recovery (2016 Statistics annual report on long-term care insurance for senior citizens) (Unit: per person) Division Rate of increase compare to 2012 Aging Population (65 and over) 5,921,977 6,192,762 6,462,740 6,719,244 6,940, % Applicant 643, , , , , % Judging population (in-grade +out-grade) 495, , , , , % Recognized population (Rate of recognition 341, , , , , % compare to judging population) (69.0%) (70.7%) (72.5%) (74.2%) (76.3%) Rate of recognition compare to aging population 5.8% 6.1% 6.6% 7.0% 7.5% Total medicaid population (excluding the dead).

3 The role of dentist under long-term care insurance Table 3. Number of people on rate of recognition (2016 Statistics annual report on long-term care insurance for the aged) (Unit: per person) Division 2016 Total 1 st Grade 2 nd Grade 3 rd Grade 4 th Grade 5 th Grade Rate of Recognition 519,850 40,917 74, , ,888 29,911 In general 336,070 27,237 48, , ,017 20,860 Reduction 94,630 6,768 13,889 35,093 34,125 4,755 Medical cost 6, ,266 2, Supplemental security income 82,884 6,458 11,212 27,869 33,407 3,938 Table 4. Current state of specialists in long-term recovery institute for senior citizens Division Market Share Rate of increase compare to the year before Total 253, , , , , % Social workers 6,751 7,506 11,298 13,923 14, % 5.5% Doctors (including part-time employee) 1,142 1,233 1,324 1,415 1, % 18.9% Nurses 2,735 2,627 2,683 2,719 2, % 1.6% Nurses aides 6,560 7,552 8,241 9,099 9, % 0.2% Dental hygienists % 25.0% Physical therapists 1,626 1,740 1,813 1,952 1, % 1.1% Care workers 233, , , , , % 6.2% Dietitian ,046 1, % 8.0% Fig. 3. The change of population pyramid in Japan. 세에있지만, 장기요양기관은 2016년기준 75,708개소, 입소정원은 212,601명 [8] 으로시설을이용할수있는인원이제한적이고, 노인인구대비인정률도 7.5% 로, 요양서비스가필요함에도불구하고많은노인환자들이서비스사각지대에놓여있는실정이다. 우리나라의노인장기요양서비스는서비스를제공받는장소에따라분류되고있다. 시설입소는주로 1,2등급에해당되며장기간입원및생활을지원하는서비스인반면, 재가급여는재가요양시설의전문인력이가정에방문하여신체활동및가사활동을지원하고목욕, 간호등을제공하는것으로, 전문인력에의한정기적인모니터링과처치가필요한경우제공된다. 또한주야간보호센터나 1~3개월의단기간보호서비스도재가급여에포함된다. 재가급여의방문간호에치과위생사에의한구강위생관리도포함되어있으나, 2016년현재전국에 5명의치과위생사 [9](Table 4) 만이이서비스제공에종사하고있을정도로구강위생관리서

4 Jung-Min Kwag et al. 비스와인력이매우미흡한상황이다. 2. 일본의개호보험과구강보건서비스 일본은우리나라보다 30년전인 1970년에고령화사회에진입한이후, 1994년에고령사회, 2005년에는초고령사회에도달하였다. 1948년을전후로하여태어난세대가모두 75세가되는 2025년에는 75세이상의인구가전인구의 18% 이상을차지할것으로예상되고 2060년에는 65 세이상이전인구의 40% 이상을차지할것으로예상되는등고령화가매우심각하다 (Fig. 3)[10]. 인구고령화및출산율의감소에더하여, 노인요양을가족이부담하던전통적인경향이가족규모의축소, 자식과의동거세대감소, 노인부부와노인독거세대의증가, 여성의사회적진출의확대등으로인해변화하면서사회적인제도의필요성이대두되었다. 이러한사회적상황속에서일본은 1990년대중반기부터고령사회에즈음하여기초지방자치단체인시정촌의역할강화, 주민공동체의식에기초한노인복지서비스의시행, 장기요양을필요로하는노년층의자립생활지원체제의구축및노인의삶의질향상등을목표로오랜연구와검토기간을거쳐 2000년 4월 1일부터개호보험제도를도입하고시행하였다 [11]. 개호보험은지역사회에기초한생활지원, 개호예방과재택개호, 주거지원, 의료지원등을지역포괄지역센터중심으로개호대상노인에게제공하고있다. 장애인이나거동불편자를포괄적으로포함하여치과방문이어려운취약계층및시설입소자에제공하는일본의구강보건서비스는개호보험서비스와방문진료로나눌수있다. 서비스는대상의등급에따라지원필요 1,2급과개호필요 1~5급으로나누어제공하며, 지원필요 1,2급은예방목적의구강보건서비스를, 개호필요 1~5급은구강 관리서비스지도및구강위생관리, 틀니관리, 섭식 연하기능훈련등을제공한다 (Table 5, 6). 개호보험서비스이용자또는그가족은 10% 의자기부담금을내며, 교통비는실비를지급한다. 일본의치과의료기관중개호보험에의한재택서비스를실시하는기관 Table 5. Long-term care insurance clause on dental health service ( 10 per unit) Instruction cost for domestic care implemented by 500 unit dentists Instruction cost for domestic care implemented by 350 unit dental hygienists Include oral improvement in prevention benefit 150 unit Include oral improvement in care benefit 150 unit Include oral function maintenance system 30 unit Include oral function maintenance 110 unit I. 28 unit Include oral maintenance II. 5 unit Table 6. Medical insurance clauses on dental health service ( 10 per unit) Medical fee for personal visit to the dental hospital 850 unit, 380 unit Include respond to patients at home and 170 unit, 50 unit acute dentistry disease (same building or not) Add of assistant for Dentist visit treatment 110 unit, 45 unit Include regional medial solidarity system 300 unit dental disease home treatment fee 140 unit Include oral function maintenance 50 unit Fees for dental disease management 110 unit Combined medical cost of dental treatment of patient at home 140 unit Instruction cost for dental hygiene door-todoor (complex) 350 unit Instruction cost for dental hygiene door-todoor (single) 100 unit Instruction cost for solidarity of patients at home 900 unit Conference fee for patients at home in emergency 200 unit 은 2,531개로병원총수의 30% 정도이다 [12]. 또한일본은치과방문진료가가능하며의료보험에적용된수가에방문진료의특성을반영한가산이이루어져수가가책정된다. 치과방문진료의본인부담금은통상적인의료보험본인부담금과동일하며, 이경우에도교통비는실비로징수한다. 일본에서는노인이구강질환을포함한질병에걸리면, 고도급성기병원에서집중적인 1차진료를받고, 예후에따라의료기관이나자택또는요양시설에서방문진료및개호서비스를받는다. 이러한결정은재택의료연계거점과지역포괄지원센터의의료인과케어매니저등에의해매우체계적으로이루어진다. 3. 우리나라노인장기요양보험하의치과촉탁의의역할 요양시설입소노인의구강위생관리의중요성은단순한구강건강의유지차원이아닌전신건강그리고더나아가노인의삶의질의차원에서고려해야한다. 즉, 구강위생관리의미비로인한흡인성폐렴의증가, 치아상실이나치료방치, 섭식 연하장애등으로인한전신영양상태의저하, 구취로인한사회적인기능의저하등다양한측면에서구강위생관리의중요성이부각되고있다. 노인환자의증가에따라, 치과치료의패러다임도변화가필요하다. 즉, 현재까지의치과치료가단순히충치나치주질환과같은구강질환의치료나치아가상실된부분의보철수복과같은구강형태회복개념의치료였다면, 고령화를대비한치과치료는예방과구강기능의재활의범위까지의확대된치료개념이적용되어야한다. 예를들면, 고령환자들은뇌혈관질환이나인식장애, 또는고령으로인한근위축등으로인해타액이나음식의오연이빈번하게발생

5 The role of dentist under long-term care insurance 되고, 만약구강위생상태가불량했을때에는포도상구균이나그람음성간균등병원성세균의구강인두집락화가증가하여흡인성폐렴에노출되는것으로보고되고있다. 따라서, 구강위생관리와연하운동지도와같은예방과재활치료에있어치과의사의주도적인역할이요구된다. 고령화에따른또다른의료시스템의변화는환자가직접치과로내원하여치료를받는의사중심의치료에서치과로내원하지못하는고령환자를찾아가는수요자중심의치료로의변화이다. 즉, 시설이나가정에거주하는거동이불편한고령환자들을대상으로한구강건강관리에대한다양한정책적접근과노력이더욱요구되며이는치과촉탁의제도의안정화와활성화를통해더욱확대될수있을것이다. 촉탁의의제도가개정되기전에는재가급여방문간호중치과위생사가치과의사의지시에따라거동이불편한재가노인을방문하여구강위생관리를제공할수있는항 목이유일한구강보건서비스였다. 하지만, 치과촉탁의제도가개정된이후, 현재권장되고있는시설에서의치과촉탁의의활동은더욱구체화되고다양화되었다. 치과촉탁의에대한이해를돕기위해치과촉탁의의진료활동및내용을요약하면다음표와같다 (Table 7)[13]. 4. 입소노인의일상적인구강건강관리를위한지침치과촉탁의의활동과관련하여중요하면서도가장일상적인업무가구강건강관리이다. 치과의사나치과위생사가상주하지않는현재의요양시설의특성상일상적인관리는요양보호사에의해이루어지며, 간호사나사회복지사가이를지도하고관리할수밖에없다. 치과촉탁의가있는기관은최종적으로이에대한점검은치과의사가할수있지만, 일상적으로잘관리하도록교육하는일은매우중요하다. 이러한이유로, 현재치과촉탁의의업무중하나로일상적 Table 7. Dental examination in sanatorium Treatments Oral health assessment Oral hygiene management Oral topical pain management Improvement in oral function recovery Optional treatment Prescriptions Hospital transfer Educational activities Educational activities for residents Educational activities for care workers Contents Oral examination Oral hygiene management Oral malodor management Dentures hygiene management and instruction Oral soft tissue focus prevention and treatment Treatment on wound by dentures Treatment on side effect by medication Xerostomia treatment Instruction on dysphagia Dentures adjustment Oral hygiene management by specialists Contents Oral hygiene training, dentures management, training on strengthening muscles around mouth Daily oral hygiene management, Oral care product management, Managing methods on variety of symptoms caused by dysphagia Table 8. Guideline on daily oral health care for new-coming elders 1 Direct with systematic oral managing method to improve the quality of life of senior citizens in sanatorium. 2 Provide oral management at least once a day to reduce the risk of pneumonia 3 All residents must take oral examination once a year. 4 Employ the systematic oral management to prevent the candida on dentures or oral and consult with the doctor to treat any infection. 5 In case of resident under state where oral care cannot be done once a day, use gauze with chlorhexidine to wipe or apply 1% chlorhexidine gel once a day. 6 Inspect the oral condition of resident with complaint of pain or nonverbal sign, then consult with doctor in case of any suspicious point. Nonverbal sign for oral pain includes change in behaviour, decrease in appetite and weight loss. 7 Consult with doctor on residents with severe malodor. 8 For residents with complaint of xerostomia, consult with doctor, maintain the humidity of residential environment and apply the moisturizer. 9 Consult with doctor on residents with sudden increase of dental caries and use prescribed fluorine. 10 Consult with doctor on oral side effects caused by medication

6 Jung-Min Kwag et al. 인구강건강관리를할수있도록교육하는업무가포함되어있으며이와관련한지침은다음표와같다 (Table 8)[14]. 요구되는고령환자의치료에있어주도적인역할이요구된다. 5. 치과촉탁의제도의개선점및활성화를위한제언현재치과촉탁의의업무범위는지나치게제한적이고수가또한진찰료에대한비용만책정되어있고행위료에대한진료수가가이루어지지않으므로적정한진료활동이이루어지기어려운실정이다. 이처럼현행촉탁의진료수가가매우낮게책정되어있기때문에치과촉탁의의진료활동은 권장되는활동 으로표현하고있다. 물론현재우리나라의장기요양시설은의료시설이아니라복지시설이고, 전문적인의료행위는의료기관에이송하여이루어지는것이바람직하다. 하지만, 입소노인은대부분거동이상당히제한적이고, 의료기관에가기위해서는시설종사자나가족이함께동반하여야한다. 장기노인요양등급판정노인은본인도건강보험료를지불해온후, 현재는가족이건강보험료를내고있는분들이다. 그런데, 본인의거동이불편하여의료기관에접근이제한되어적정한진료를받을수없는상황에처해있는것이다. 일본의경우처럼개호보험과의료보험의진료를받을수있도록할것인가는여러관점에서논의가필요하겠지만, 의료형평성의관점에서보아도현행촉탁의의활동범위는매우인색하다할것이다. 이를개선하기위해서는입소노인의진료필요를조사하고, 치과촉탁의의활동범위를최대한확대하며, 유관학회와대한치과의사협회의모니터링체계를확립하고, 일반환자와차별되는진료프로토콜을개발하여보급함으로써현재의제도안에서입소노인의구강건강을증진시킬수있는적극적인노력이필요하다 [15]. 즉, 치과촉탁의의활성화를위해서는먼저, 요양시설이나재가노인에대한방문치료가이루어질수있도록의료정책의유연성과의료시스템의확보가요구된다. 환자및시설종사자들에대한적극적인홍보및인식의전환도매우중요하다. 현재는월 2회에제한되어촉탁의를방문을요청할수있으므로장기요양시설의입장에서는기존의촉탁의사나한의사를지정하는경우가대부분이다. 하지만, 구강위생관리의중요성이전신건강에미치는영향이나또는구강기능재활에대한새로운진료모형이노인들의삶의질에미치는효과에대해교육하고인식시킴으로써치과촉탁의제도의점차적인활성화가이루어질수있을것이다. 현재전국에서치과의사로서촉탁의활동을하도록지정받은사람은 15명에불과한실정이다. 노인장기요양보험하에서치과촉탁의제도가안정적으로자리잡기위해서는무엇보다도치과의사들스스로치과촉탁의에대한이해가우선되어야하고, 의료업종간팀어프로치가 결론 요양시설입소노인에게적절한구강건강관리와구강기능의회복은일차적으로영양공급에따른전신적인건강과정서적만족감을회복해줄수있는것은물론, 인생의마지막을존엄하게지낼수있게해준다는측면에서중요한의미가있다. 또한전신질환과구강건강수준의연관성을고려할때, 신체적으로취약한노인들의건강관리및만성질환관리에구강건강관리가포함되어야한다. 이런측면에서치과의사와의사 ( 한의사 ), 관련업종간의팀어프로치를통해포괄적으로건강을관리하도록하는제도의내실화는매우중요하다하겠다. 현행치과촉탁의제도는진료범위가매우제한적이고, 치과촉탁의선정이의무조항이아닌선택사항으로되어있어, 전신질환관리가상대적으로중요한노인요양시설에서의활동이매우제한되어있다. 이를개선하기위해서는진료범위를현행제도가허용하는한많이늘리고치과촉탁의지정을의무로하는방안을검토하여야할것이다. 노인인구의증가와더불어치과의료의패러다임도변화하고있다. 고가의장비와시설이있는병원에내원하지않더라도적정한치과진료를받을수있는방문치과진료에대한심도있는고민이필요한때이다. 이를위해학계, 대한치과의사협회, 정부가공동으로진료수요조사와새로운프로토콜의보급, 모니터링체계의구축을위한공동의노력이요구된다. 고령화를대비한다양한의료정책을개발하고변화에대응하기위해, 치과의사의역량강화가우선되어야한다. 더불어구강에한정하지않고환자의 삶의질 을유지하고증진시키는것을최종적인목적으로하는치과의료인의새로운인식변화가요구된다. Acknowledgements This study was supported by a research fund from Chosun University, Conflict of Interest The authors declare that they have no competing interests

7 The role of dentist under long-term care insurance ORCID Jung-Min Kwag Inn-Im Park Mee-Kyoung Son References Statistics of Senior Citizens, Statistics office, Jeong JW. The Aging Era and Long-term Care Insurance Scheme. Dae Yong Publishing, p Enforcement Regulation on Welfare of the Aged Act Article 22 (Revised Aug. 31 st. 2016). 4. Korean Dental Association. Provided by Culture and Welfare Commission, Life Table, Statistics office p Reference on Announcement of WHO Jeong KH. Survey on the Elderly Life Condition Ministry of Health and Welfare, Korea Institute for Health and Social Affairs Current State of Welfare Facilities for Senior Citizens, Ministry of Health and Welfare Sung SC Statistic Annual Report on Long-term Care Insurance for Senior Citizen. National Health Insurance Corporation Big Data Operations Center/ Statistical Department The First Korea and Japan Social Policy Ordinary Forum: The shock and respond to low birth rate and aging population. Korea Institute for Health and Social Affairs, National Social Security, Japan s Population Research Institute. 11. Jeong JU. Aging Era and Long-term Care Insurance Scheme for Senior Citizens. Dae Yong Publishing, p Dental Institute for Dental Policy: Survey on Dental Care Service Implemented in Japan s Long-term Recovery Institute for Senior Citizens. Korean Women s Dental Association, p Korean Academy of Dental Science for Senior Citizens: Gerodontics. Ji-seong Pulisher, p De Visschere LM, van der Putten GJ, Vanobbergen JN, Schols JM, de Baat C; Dutch Association of Nursing Home Physicians. An oral health care guideline for institutionalised older people. Gerodontology 2011;28: doi: /j x. 15. Office of Population Policy-Office of Senior Citizen s Policy Management Office: Division of Health Care Insurance: Research on Introducing the Entrustment of Dental Service in Nursing Care Facilities. Ministry of Health and Welfare, p

서론 34 2

서론 34 2 34 2 Journal of the Korean Society of Health Information and Health Statistics Volume 34, Number 2, 2009, pp. 165 176 165 진은희 A Study on Health related Action Rates of Dietary Guidelines and Pattern of