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Preparing Patients for Future Oral Healthcare Decline: What Dentists Can Do Today
Elderly dental patients typically are challenging to treat due to their poor cognitive skills and manual dexterity. Clinicians need treatment-planning strategies specific to older patients, and should also be proactive in the oral healthcare of those who become residents of long-term care facilities.
What happened to Mrs. Jones? Clinicians have all had the experience of wondering what has become of an elderly patient who has been in the practice for 25 years or so. Because clinicians are frequently so busy running their practices, there often is no time to follow-up with these complex patients who no longer make their recall appointments because of cognitive decline, transportation issues, and other problems that typically accompany older age.
Dentists also often find it frustrating to treat elderly patients. These patients may develop poor oral hygiene secondary to declines in manual dexterity and cognition and/or develop a dry mouth and xerostomia because of their medication. No one wants to see their dentistry fail, but many of these patients are unable to maintain their oral health well enough to prevent decay.
The Coalition for Oral Health for the Aging (www.micoha.org) surveyed dentists in the state of Michigan who provide care for the elderly and found that they were willing to treat elderly patients who were able to come to the office and pay for services. But what about patients who can no longer make it to the dentist office? What should clinicians be doing now to prepare patients for their future decline in oral care?
Prepare for the Future: Patient Education
The discussion needs to begin now with 50- to 60-year-old patients regarding the need to prepare their dentitions for the future assault that aging brings. Like their medical colleagues do, dentists should establish a plan of action at the dental office. There should also be a discussion of current medications by all patients at all routine care visits.
Dentists should raise a number of issues with pre-retirement patients so they can be aware of such problems as xerostomia secondary to the use of medications, and make both financial and treatment-planning arrangements in anticipation of future challenges to their dentition. Recommended pre-retirement planning issues would include a plan that: protects the dentition from xerostomia and resultant root caries; spans the next 5 to 10 years, in which the patient’s dentition would be prepared for the future; works within the parameters of the individual patient’s insurance benefit package/health savings plan while funds are available, because after retirement, discretionary income is likely to be limited.
Dentists should bring to the operatory the scenario of what the future will hold for their patients. Let them know the importance of regular routine care not only for themselves but also elderly parents. Ask whether their parents are having their teeth cleaned regularly, and let them know about the importance and benefit of a 3- or 4-month routine care schedule. Discuss, too, polypharmacy and the use of fluoride products on a daily basis for their parents.
There are a number of commonly held myths in our culture about aging teeth, which dentists should discuss with their patients, including:
• If there is no tooth pain, there is no tooth problem.
• Teeth become softer with age and are more susceptible to decay.
• Tooth loss is a normal part of aging.
• If bleeding occurs with brushing, stop immediately.
•Teeth are not as important for an older person since they prefer to eat softer foods.
• Dentures, just like real teeth, stay in the mouth 24/7.
• Dentures are a great alternative to real teeth—simpler to clean, more cost-effective, and easier to function.
Prepare for the Future: Design for Longevity
Preparing patients for a future decline in their personal oral care includes dental treatment planning while the patients are in their 50s, 60s, and 70s. Dentists must design restorations to withstand the total failure of oral care that can occur as a result of the aging process. Designing crown margins subgingivally with adequate interproximal contacts and insisting on occlusal guards to minimize parafunction will adequately protect patients’ dentitions well into their 80s and 90s. Extraction and implant placement should be considered in situations where there is a guarded prognosis—ie, an endodontically treated tooth with a periapical radiolucency considered for re-treatment—or when a 10-year prognosis is not obtained after seeking endodontic consultation. Treatment planning 50- to 70-year-old edentulous patients for implant-retained lower dentures will allow adequate nutrition and prevent ill-fitting lower dentures and resultant ulcerations that accompany a severely resorbed mandibular ridge. Again, this level of restorative work needs to be accomplished when patients are healthy and able to have restorative dentistry completed, typically by age 70.
Focus on Prevention
Most of the dental care needed by the elderly in long-term care facilities (LTCFs) is not provided by a dentist. However, dentists need to be the healthcare providers advocating the recommended protocol for patients’ oral hygiene maintenance as outlined below—much of which applies to those who are not yet LTCF residents. Dentists also need to facilitate dental hygienists and staff in its implementation.
Daily Oral Care
1. Every resident should have a daily oral care plan.
2. Supervised toothbrushing should occur twice daily—after breakfast and before bedtime—with a regular toothbrush and fluoride toothpaste, not a toothette or sponge.
3. An accountability system with regular evaluation should be established.
4. Yearly oral health education of staff should be provided via in-servicing.
Daily Fluoride Application
1. First, a decay risk assessment should be performed to determine fluoride need.
2. An assessment of resident pharmacy formularies should be performed to determine fluoride prescription coverage and availability.
3. Appropriate fluoride application should be administered depending on the level of decay risk: fluoride toothpaste, fluoride rinse, fluoride gel.
4. Staff training should occur annually for proper administration of fluoride toothpaste, fluoride rinse, fluoride gel.
Regular Professional Cleanings
1. The last cleaning and due date for the next cleaning should be documented in the resident’s medical record upon admission.
2. Assessment and identification of barriers to obtaining regular professional cleanings should be performed (ie, funds, transportation, behavior challenges).
3. Confirmation and documentation that the facility dental provider offers regular professional cleanings (ie, every 3 to 6 months) for the residents should be secured.
Provide Practical Dentistry That Doesn’t Fail
In the elderly population, acceptance and understanding of the failure of restorative dentistry is a necessary component to proper treatment planning. It is essential to have a completely different treatment-planning mindset when working with this population as opposed to patients in private practice settings.
Dentists need to understand that it is entirely acceptable to extract teeth. It is acceptable to remove the four lower anterior incisors, if ravaged with root caries, and fabricate a 6-unit bridge supported by the canines. It is acceptable to extract grossly decayed posterior teeth with the goal of strategically preserving what can be restored and maintained, paying close attention to occlusion and function. It is also acceptable to extract retained roots and fabricate overdentures or Valplast partial dentures that are easily inserted and removed, again with the primary goal of function and occlusion.
Assist patients in using their monetary resources wisely. If insurance is in the mix, it should be used for two prophylaxis visits per year; for the recommended 3-month routine care schedule, the patient must agree to pay out-of-pocket for two of the visits.
Once the initial treatment plan has been completed, the option of combining a minor restorative need with a 3-month prophylaxis visit is common. For example, an area of buccal cervical decay detected at the most recent prophylaxis visit can be planned to be restored at the next 3-month prophylaxis visit. Understanding the lack of urgency in planning a visit to restore a single area of decay as well as combining visits for increased production for the patient is wise treatment planning.
Esthetic concerns become secondary in this population, given the many medical challenges they face. The primary treatment goal is comfort and practical function, eliminating infection and decay.
Navigating Foreign Territory
General dentists must play an active role in the oral healthcare of geriatric patients, including those who become residents of LTCFs. Because few dental schools provide extensive clinical experience in geriatric dentistry in their undergraduate curriculum, and since there are very few graduate programs nationwide, geriatric dentists available for referrals are scarce.
It is clear that there is a need for continuing education for the general dentist. Those interested in more comprehensive continuing education related to the topics covered in this article can contact the authors. Seminar topics include: Treatment Planning and Treatment Techniques for Geriatric Patients; Patient Education and Prevention to Help Aging Patients Maintain Their Dental Investment; and Providing Care in a LTCF and Identifying Community.
For Healthcare Professional:
Michigan Department of Community Health Oral Health Program; Beyond the Dental Office: Dental Care Needs in Michigan’s Nursing Homes.
Smiles for Life: Training Modules in Oral Health for Across the Life Span: Course 8 Geriatric Oral Health.
Geriatric Education Center of Michigan; Oral Health in the Elderly.
American Dental Association. Oral Longevity.
Elisa M. Ghezzi, DDS, PhD
Dental care provider to residents of nursing and assisted-living facilities in the metropolitan Detroit, Michigan area; Adjunct Clinical Assistant Professor, Department of Cariology, Restorative Sciences, and Endodontics, University of Michigan
School of Dentistry, Ann Arbor, Michigan
Mary M. Fisher, DDS
Dental care provider to residents of nursing and assisted-living facilities in the metropolitan Detroit, Michigan area; Private Practice
West Bloomfield, Michigan