February 2012, Volume 8, Issue 2
Published by AEGIS Communications
What dentists need to know about the aging population requires a better understanding of medically complex conditions and comorbidities than ever.
By Ellen Meyer
While geriatric dentistry is not yet a designated specialty, there are many who think it should be, largely because of the complexity of the issues involved in treating this segment of the population. Specialists in this field continually struggle to define “geriatric dentistry.” Prominent dentists interviewed by Inside Dentistry generally agreed that the traditional “over 65” definition is inadequate and that function more than chronology describes patients covered by the term “geriatric.”
Linda C. Niessen, DMD, MPH, vice president, chief clinical officer at DENTSPLY International and clinical professor in the department of Restorative Sciences at Texas A&M Health Science Center Baylor College of Dentistry in Dallas, says, “Rather than thinking about a geriatric patient, we need to think about and talk about medically complex patients—those with cancer, chronic diseases, hypertension, depression, arthritis, etc.—who visit their dentist. These patients come in all ages, and their medical history is a significant part of their oral healthcare, no matter what the patient’s age.”
Marsha A. Pyle, DDS, dean of the University of Missouri–Kansas City School of Dentistry, also avoids defining the geriatric population in terms of age. “It’s easy to start with age as a qualifier, but it’s best to consider how people function in their lives to describe different levels of impairment and activity and independence among the elderly.”
Teresa Dolan, DDS, MPH, professor and dean of the University of Florida College of Dentistry, notes that while there are psychological, social, physical, and mental definitions as well as chronological, “I tend to consider the chronological definition to be the one with the least merit because we know there are under-65-year-olds with a lot of special needs and 90-year-olds who may have no special considerations in their dental care.” She turns to the American Dental Association (ADA) term “vulnerable elders,” which defines “a population that needs special consideration or adjustments in their needs.” With that in mind, she says, “I would consider a geriatric patient to be an older person whose special needs require some modification—either in diagnosis and treatment planning or the conduct of treatment.”
Dolan sees the largest part of the problem as being the accumulation of chronic conditions in older adults and the side effects of the medications they take, although she notes a smaller subset who need special consideration in their dental care due to the difficulty posed by cognitive challenges, dementia, chronic illnesses, and physical challenges that impede their ability to maintain their oral health. “The dental team needs to be aware of these chronic conditions, such as hypertension, arthritis, and diabetes because there are a lot of potential implications for oral health,” she says.
Eliciting the Information
To be prepared for special issues, Niessen believes it is crucial that dentists recognize the importance of the patient’s medical history. “The message that the mouth is connected to the rest of the body is a message not just for patients, but also for dental professionals, and as the patient population gets older, we see this connection more clearly,” she maintains. “The patient who has rheumatoid arthritis may not be able to hold a toothbrush because her hands are disabled, and even if you put a toothbrush in the hand of a patient with Alzheimer’s disease, he might not know what to do with it. A patient undergoing cancer treatment may have oral stomatitis associated with cancer treatment. The point is that all of these conditions require that the dental team first ask for and take a thorough medical history, understand the implications, and then modify either home care or office treatment as necessary,” she says.
As for the oral examination, Niessen suggests combining it with the Caries Management By Risk Assessment (CAMBRA) questionnaire, which is available on the ADA website. “That questionnaire combined with the oral examination can give you a sense of whether a patient is at high risk for caries because of various health conditions or medications.”
Here Come the Baby Boomers
ADA President William R. Calnon, DDS, is especially concerned about the oral healthcare needs of the aging baby boomers. “Every day, 10,000 of them turn 65, and by 2030, there will be 65 to 70 million in this population. Among them, there’s a tremendous amount of dental caries; probably one third of older adults have untreated dental caries, including a rising incidence of root caries, which is very devastating.” Calnon says it is especially disheartening to see oral health decline in those with a history of diligent self-care. “One of the hardest things we’ll ever see is someone who has taken good care of their teeth and mouth over the years but as they age—for many of the reasons mentioned, changes in dexterity, cognition, illnesses, and medication side effects—we’ll see the development of caries and the need for a tremendous amount of work in their mouths.”
Meeting the Challenge to Maintain Dentition
All agreed that the trend toward maintaining teeth is an important contributor to total health and well-being, and that the baby boomers are leading the charge, intent on becoming the first generation in history to die with nearly all their natural teeth.
As Dolan observes, “A generation ago, it was commonly accepted that when you got old, you lost your teeth and wore dentures. The baby boomers have a different set of expectations. They intend to keep their teeth, and are learning what to do to maintain their oral health.” This, she says, is a good thing. “We also have a better understanding of how maintaining natural dentition contributes to overall health and well-being, and there’s new science that substantiates that as well. Given a choice, people would always prefer to have their natural teeth in terms of function and proprioception and being able to chew your food and enjoy it.”
Pyle, too notes the trend, but points out the downside of keeping the natural dentition intact. “If you ask people if they’d prefer to have their natural teeth or a denture or partial denture, they’d say they’d prefer their natural teeth, but it’s a little bit of a liability in that by having teeth, they are at risk for disease, especially caries and periodontal disease, and, depending on risk factors, such conditions as oral cancer.” She adds that many of these patients have already had a significant amount of dental treatment. “These restorations don’t last forever; they’re subject to needing repair and replacement.”
To rise to the challenge of maintaining dentition, Pyle says, “Dentists need to address prevention, making sure there are systems in place to address patients’ needs as they become increasingly compromised and frail. We need to understand the value of preserving their oral health through their illnesses for the remainder of their life.”
Pyle also points out that it is becoming increasingly clear that more than oral health is at stake. “There’s continuing support for the notion that there’s an association between oral health and general health. Those studies leading us toward a better understanding of what that relationship really is suggest that we need to preserve oral health as we age. As patients become more medically compromised, understanding the impact that oral health has on those diseases is critical,” she says.
Ira B. Lamster, DDS, MMSc, a professor of dental medicine and dean of the Columbia University College of Dental Medicine in New York City, believes that dentists should do more to make themselves aware of health issues—including those that are suspected but not diagnosed— because of their impact on general health as well as oral health. Just as it has been recently recognized that inflammation associated with periodontal disease has the potential to exacerbate serious medical conditions, he points out that undiagnosed underlying conditions or dentists’ lack of awareness of such conditions can impact patients’ ability to tolerate treatment— possibly resulting in dangerous high blood pressure, hypoglycemic shock, or bleeding issues. He insists that attempting to treat periodontal disease in a patient with untreated diabetes is counterproductive. “Even if you treat that periodontal disease properly, if the diabetes mellitus is not managed, your periodontal therapy will fail.”
“Dentists may be able to do more than just treat dental disease; they may in fact be able to contribute to the health of the patient and that is particularly relevant for the geriatric patients in whom chronic diseases such as diabetes mellitus, cardiovascular disease, and cognitive impairment are so commonly seen,” he says.
Creating a Senior-Friendly Practice
Modifying the Office Environment
To have a sense of the kinds of accommodations a practice might make for its older patients, Dolan suggests clinicians try “walking in the shoes of an older patient.” An article she wrote nearly 20 years ago, she says, still has relevance in its point that “sometimes it’s the little things—small considerations in the treatment experience—such as having a desk in the waiting room where they can fill out forms, pillows to support the neck, spine, or limbs affected by stroke, or having forms with large clear type on non-glare paper that can make a difference.” (Dolan TA. Is your practice “senior friendly”? Today’s FDA Scientific. 1993;5:1C-2C.)
She notes the special challenges faced by seniors in the dental office, such as impaired vision, hearing, and cognition, as well as physical limitations imposed by use of wheelchairs and conditions such as arthritis.
Calnon, too, emphasizes the importance of making the elderly comfortable, with additions to Dolan’s list that includes providing ramps so they can go where they need to, seating that is not too low with arms on chairs that are firmer so they can push themselves up, large-type reading material, and good lighting.
Modifying Treatment Approaches
To compensate for difficulties some patients have in maintaining oral healthcare at home, Dolan suggests creating treatment plans that address prevention and frequent recall visits to the dentist and thinking creatively. “Knowing that oral health is already compromised or will likely become compromised, we need to think of ways to help the individual patient,” she says. She suggests taking what she calls “a kind of team approach,” which is a therapeutic approach plus occupational therapy ideas and tools to help them function better. “The oral professional can think about ways to improve the daily oral hygiene in addition to the actual physical brushing of the teeth,” she explains.”
“Some patients have difficulty with dexterity, so it helps to consider what kind of options are there for those patients with the ability to independently maintain their oral hygiene,” she says. Such therapies might include the use of fluoride applications at home, therapeutic mouthrinses, and probiotics. She points out that adjunctive aids for those at risk who have difficulty with daily oral hygiene or are dependent on others to provide that care can be purchased through occupational catalogs. However, she also describes what she calls “do-it-yourself ways” to help those with impaired fine motor skills remain able to be independent in their oral healthcare. These include modifications to a typical toothbrush such as “putting a ball of tinfoil around the bottom of a toothbrush or putting a slit in the bottom of a tennis ball and inserting a toothbrush, so that they can have a larger, easier way to grip the toothbrush.”
Calnon emphasizes the importance of communication and suggests a top-down approach that includes staff training that ensures that older patients feel valued, understood, comfortable, and free to express their needs and desires. “The line of communication in both directions has to be very important,” he says, adding, “Clinicians in medicine as well as dentistry must understand that the communication you have with an elderly or vulnerable person can tend to be a little different. Sometimes you need to take a little more care to see that that person really does understand because a lot of older patients tend not to report symptoms or complaints to the same degree that a younger person might.”
To try to ensure that “you’re hearing them and they’re hearing you,” he says. It is sometimes helpful to ask the same question in different ways, to see if the answer is the same. He notes, too, that older patients are often reluctant to ask questions and may be too willing to “put the clinician on a pedestal,” and accept the explanation of the treatment modalities. “It can be hard to know if they understand, but it’s very important that they do. They may be nodding but not really hearing or comprehending.”
Calnon says many older adults need someone to advocate for them. “It can be someone they trust within the practice or a friend or family member who accompanies them and is present for the explanations they need to understand,” he says.
Eliminating the Fear Factor
Calnon says that fear is not an inconsequential factor among all dental patients, but it is especially problematic in older patients. “Patients’ fear of the dentist is something that must always be taken into account, as is their shame about being fearful, so it’s especially important to put them at ease.”
With older adults, he says, the relationships they build internally with the dentist and the dental team are especially critical. “If they feel comfortable, like they have a built-in advocate in the practice, it helps allay their fears. They need to believe the dental team is acting in their best interests, that they understand them, their needs and desires and fears, and are advocating for them. When patients are comfortable enough to tell exactly what they need, then the treatment modalities go much better,” he explains.
What More Dentists Can Do
Lamster believes dentists, who may see patients more frequently than physicians, are in a unique position to do much more for the total health—not just the oral health—of their patients. “There is an important need to define dentistry in the context of healthcare. While Americans typically think of physicians as the gatekeepers of primary healthcare, that is too narrow a concept in today’s healthcare environment,” he maintains.
He says it is important that clinicians understand the patient’s medical status—the diseases they have and how they are being treated. “We need to know if the patient is taking a medication such as Plavix or Coumadin that will cause them to bleed following surgery. If they have teeth that need to be removed, will that patient be able to clot?”
He advocates assessing patients for conditions that complicate dental treatment in particular. “If you can identify undiagnosed diabetes mellitus in the dental office, and that patient is properly treated, his/her response to the periodontal disease therapy will be better. Likewise, if you take and measure blood pressure, you’ll find that the patient whose blood pressure is well-controlled will be a better candidate for dental therapy, while a poorly controlled one—eg, someone who is hypertensive—would be at risk should something stressful occur in the dental chair,” he says.
Lamster also believes dentists, as primary healthcare providers, can become more involved in using their access to the face and neck, as well as the mouth of the patient, to server the larger health needs of their patients. “There are a variety of other medical conditions where dentists should be involved. For example, dentists should understand and be familiar with the appearance of skin lesions such as BCCs, SCCs, and melanoma on exposed skin surfaces. The face is a prime location, and skin lesions disproportionately affect the geriatric patient,” he says, suggesting that the dentist offer to examine the patient’s scalp, ears, face, and neck before examining the mouth. He also says clinicians’ involvement in smoking cessation efforts would be in keeping with both oral and general health. “We know that periodontal disease and oral cancer are two important diseases that have been linked to smoking, so it would be appropriate for dentists to become involved with smoking cessation programs,” he says.
“There are many ways that dentists can do more than they are now doing. These things will improve overall health, but they’ll also improve oral health,” he concludes.