September 2017
Volume 13, Issue 9

Protecting Your Elderly Patients

Best practices for addressing geriatric treatment challenges

By Ellen Meyer, MBA

Chronic illnesses, cognitive decline, and physical challenges can affect the treatment and self-care of patients at any age, but there’s no denying that advanced age increases the likelihood that these concerns will be present. Given the impact of oral health on overall health, it is especially important that this segment of the patient population be treated comprehensively—even while medication side effects, compromised cognition, limited dexterity, and other issues make it more challenging.

As several members of the dental profession and industry explained to Inside Dentistry, although there are significant concerns (especially in treating those deemed to be medically complex), a wide range of “geriatric-friendly” approaches, materials, and methods are available to help facilitate treatment when these issues arise.

The Geriatric Patient Identified

Domenica Sweier, DDS, PhD, is specifically trained in hospital dentistry focused on geriatric and special needs adults. At the University of Michigan’s School of Dentistry, she is a clinical associate professor in the Department of Cariology, Restorative Sciences & Endo­dontics. According to Sweier, they refer to the geriatric population as those who are 65 years of age and older, “but we break them into subcategories in recognition that there are issues—such as cognitive decline, chronic disorders, and physical disabilities—that become increasingly prevalent as they progress from being ‘young old’ (age 65 to age 75) to ‘old’ (age 76 to age 85) to ‘old old’ (age 85 and older).” She notes that the age 85 and older bracket is “the fastest growing subgroup of them all.”

There are “normative processes” in physiology, primarily degenerative disorders (eg, osteoarthritis, diminished sight and hearing), that occur at an expected rate and ultimately add up to physical disabilities—all of which not only affect patients’ ability to care for themselves, but also their access to professional care, she explains. However, despite obstacles such as high cost and the need for transportation and physical assistance, Sweier emphasizes that prevention, maintenance, and timely intervention remain crucial for this population.

Where Medical Complexity Comes In

Sweier is quick to add that—age brackets and normal wear and tear aside—it is the patients considered to be medically complex who raise the greatest concerns regarding treatment. “Chronic comorbidities can contribute to serious consequences.”

Sweier observes that things can unexpectedly “go south” with such patients, including the presence of hypoglycemia during long appointments, cardiovascular manifestations, or uncontrolled bleeding in a patient on an anticoagulant. Oftentimes, such patients are best cared for in a hospital setting, because “general practitioners may not feel that they have the training to be able to address the comorbidities that place these medically complex patients at risk for complications,” she explains.

For example, conditions that are commonly present in elderly patients affect a clinician’s ability to render dental implant treatment. Seattle, Washington, prosthodontist Dean Kois, DMD, MSD, explains, “Some of the more common concerns when treating an elderly patient surgically for dental implants are polypharmacy, tolerance for surgical procedures, sedation concerns, and general systemic risk factors, which include smoking, diabetes, periodontal issues, autoimmune diseases, and even history of radiation treatment—all of which can add risk to the procedure and impact survival probabilities of dental implants.” In addition, he says that oral imbalances from medications can make patients more susceptible to bacterial infections and fungal manifestations, and deficiencies due to changes in diet as a result of tooth loss can affect the oral mucosa and therefore impact wound healing. Diabetes, which is present in roughly 25% of those who are 65 years of age or older, is undiagnosed in almost the same percentage, Kois says, and is especially problematic when uncontrolled. “Uncontrolled diabetes is a risk factor for predictable wound healing and implant survival.”

Patient History

All of the interviewees agreed that the best way to determine whether and how to treat any patient is to start with a comprehensive medical history. However, this is especially important for geriatric patients. Even those who appear to be healthy and high-functioning may have conditions that could affect their care.

“A thorough new patient medical history is critical,” says Roger P. Levin, DDS, a practice management expert who is CEO of Levin Group, Inc., and also a third-generation dentist. “An aide or family member may need to accompany the geriatric patient and provide the information to the dentist. It can also require communication with the patient’s physician, both for information and to receive clearance before performing certain procedures.”

This history, Sweier adds, should include specific diagnoses and a complete medication and social history. Access to this information can have a significant impact on the choice and success of a treatment plan. Like Levin, she stresses the value of communication with other healthcare professionals. “Interprofessional comprehensive care is important to improve success.”

As an implant surgeon, Kois is especially cognizant of issues that threaten surgical outcomes as well as a patient’s health. “Some of the more common medication interactions involve anticoagulant and antiplatelet medications that can create bleeding risks during surgery if not controlled,” he notes. “In addition, with xerostomia caused by many commonly prescribed medications, the teeth and oral mucosa can be severely affected. Saliva is not only the mouth’s primary lubricant, it also aids in digestion and contains proteins and minerals that combat bacteria and protect tooth enamel. These patients may be more susceptible to peri-implant mucositis as well, and chronic inflammatory responses can lead to more substantial disease.”

During the patient history, Kois says, “We spend a good amount of time listening to patients so we can really understand their needs and expectations for treatment and then explain what options are available to improve their oral health and quality of life.”

The Root of Common Problems

In particular, two issues plague geriatric patients either as a direct result of the aging process or the medications that make it possible for them to live longer, better lives despite chronic conditions: gingival recession and xerostomia. Steven Jefferies, MS, DDS, PhD, Associate Dean for Research and Graduate Education/Professor, Restorative Dentistry, Kornberg School of Dentistry, Temple University, notes that gingival recession and resultant root exposure is often associated with advanced age and factors such as gingival trauma, soft tissue and osseous considerations, and gingival inflammation-associated periodontal disease. “Whether or not it’s due to an inflammatory process, such as periodontal disease and its treatment, or trauma involving aggressive brushing or occlusal factors, with geriatric patients, there appears to be an increased risk and incidence of gingival recession and exposed root surfaces. Recession exposes the underlying root dentin and cementum, both of which can be more susceptible to demineralization due to the caries process.”

Root exposure associated with gingival recession can also be linked with another problem, he adds: tooth sensitivity. Recession-associated tooth sensitivity can make ingesting certain liquids (especially hot or cold beverages) and certain foods, as well as undergoing routine hygiene to debride and clean the root surface, especially uncomfortable in certain patients.

Another problem, xerostomia, can also be a significant predisposing factor in the development of root caries. The connection between xerostomia and the increased risk of root caries is attributed to the fact that saliva contains a number of protective elements (eg, enzymes, antimicrobial/protective molecules, buffering compounds and agents) that provide natural defense mechanisms against caries. While the etiology of xerostomia is multifactorial, it remains a common side effect of many medications. Xerostomia not only causes a change in the quantity of saliva produced, but also can alter the quality of saliva, leading to a reduction in efficacy of salivary protective factors.

This modified oral environment, in combination with gingival recession, makes the oral cavity more vulnerable to caries, explains Ithaca, New York, private practitioner John C. Comisi, DDS, MAGD. “As more tooth structure is exposed in the oral cavity, the softer dentin, which is found on the root surface of the tooth, becomes more susceptible to decay. The dentin will start to demineralize at a pH of approximately 6.2 to 6.5, which is very close to neutral (ie, pH 7); however, enamel will not start to demineralize until the pH is approximately 5.5. Therefore, root caries are a significant problem among the geriatric population, because it doesn’t take a lot of acid to create damage.”

As Sweier observes, xerostomia can have devastating effects beyond caries, including difficulty in swallowing, inability to wear prostheses, and problems with speaking. It can also make treatment difficult. “With severe xerostomia, everything sticks to the mucosa—the gauze, the mirror, even my gloved hands,” she explains. “Patients also can feel an increased need to cough or clear their throat.” She uses lubricating jelly in such patients, because it doesn’t interfere with dental material and can be easily washed away with water. Issues that commonly affect the the dental care of elderly patients are presented in Table 1.

Treatment Challenges/Considerations

Treatment planning for geriatric patients should not be based on age per se, but the context of the individual patient. Patient selection, Sweier says, is crucial to the success of treatment. “What has the best prognosis given the patient’s context medically, cognitively, and socially? As with other patients, they must meet appropriate criteria for success physically (eg, have an adequate amount of bone for implants), but they must also be able to cooperate with treatment, cognitively give informed consent, and care for the prosthetic.”

To that, Kois adds, “While age is not a primary determining factor in creating a treatment plan, overall patient health, presenting anatomy, and the patient’s goals are.” Although the full range of treatments are available to geriatric patients who meet selection criteria, he notes that certain adjustments may be advised. “In elderly and medically complex patients, we tend to minimize grafting needs by utilizing shortened dental arches, angling implants, or selecting more removable implant options that allow us to overcome site-specific anatomical concerns by treating entire arches. Our plans often include multiple implant-retained or -supported solutions that focus on functional longevity with great esthetic outcomes.” For example, he says, when reduced salivary function impacts the oral mucosa that some restorations use for support, these tissues can become extremely fragile. In such cases, restorations that do not directly load the mucosa can be more beneficial for the patient.

Ease of servicing and home care are also critical to outcomes. “As we age, we may lose dexterity in the hands, which is needed to properly keep up with necessary oral hygiene maintenance,” Kois adds. “Restoration design becomes very important to allow good access without compromising lip support or impacting phonetics.”

Kois also points out that impaired neurologic function in elderly patients can hinder their adaptive abilities to transition to changes in their occlusion or adjust to a new prosthesis, emphasizing, “Patients who suffer from dementia can have difficulty chewing and swallowing, regardless of the restoration.”

Geriatric-Friendly Prevention and Treatment Materials

To facilitate the dental healthcare of geriatric patients, dentists can dispense a variety of products for home use as well as provide treatments in the office to prevent and treat caries (including root caries) and address sensitivity, xerostomia, and other discomforts related to aging and the natural dentition. For example, Kois describes how technology, new material options, and designs are now converging to enable the fabrication of better fitting and more affordable dentures—including implant supported restorations—more quickly than ever before. “Laboratories are now moving away from traditional casting techniques and progressing towards CAD/CAM techniques. Using a digital workflow has the ability to minimize the visits and costs associated with fabrication, and decreased chair time can be optimal for elderly patients.”

Mark Heiss, DDS, Director, Regulatory Affairs & Academic Affairs, GC America Inc., notes that a public health objective of the Japanese government—and one that might well be adopted in this country—is for its 80-year-old citizens to have at least 20 teeth, which is associated with better health. He notes that GC America has led the market in products focused on prevention. MI Paste™ and MI Paste Plus™, he says, are the only products for professional use containing the active ingredient RECALDENT™ (CPP-ACP), a special milk-derived protein that has a unique ability to release bioavailable calcium and phosphate (and fluoride in MI Paste Plus) to tooth surfaces.

“We have a wide array of preventive products that address the needs of the aging population, including GC Dry Mouth Gel, which is designed to ease the symptoms of dry mouth for patients who may be suffering from impaired production of saliva due to medications, radiation treatment, or diseases that damage the salivary glands. GC America is also launching a next-generation, brush-on version of MI Paste named MI Paste® ONE, which contains 20% more fluoride. Its two-in-one application can simultaneously clean and remineralize teeth while relieving sensitivity. All are for home use, but are dispensed by the dental office,” says Linda Bellisario, RDH, BS, Senior Manager, Marketing Communications, at GC America Inc.

Although they are commonly used to prevent caries in children, Comisi notes, varnishes are the first line of defense against decay and are useful for older adults as well. Larry Clark, Director of Marketing & Clinical Affairs at Pulpdent, agrees. “The advantage of a varnish is that it can be easily applied and can help deliver the minerals the tooth needs as well as the fluoride that binds the minerals so they are more acid resistant.” He says that because Pulpdent’s varnish, Embrace™, is hydrophilic, it can get into pit and fissures easily without the challenge of a hydrophobic resin, which can feel gritty. The company, he says, also makes restorative materials that are similarly beneficial to tooth structure. “Pulpdent has created a complete family of products from beginning to end that can help protect, preserve, rebuild, and restore tooth structure in whatever situation the clinician might encounter.”

Although the company hasn’t specifically targeted the geriatric market for its products, Shofu Dental Corporation has recognized that this generation of senior citizens is unique. Lynne Calliott, Vice President of Marketing, Americas, explains, “Due to better healthcare, patients today—especially aging baby boomers—have more retained teeth than they did in the past. They are accustomed to going to the dentist, and they take care of their teeth and themselves in general.” Among Shofu’s preventive products that are useful for patients who are home bound or in long-term care facilities are pit and fissure sealants and a varnish product that is light cured for desensitization. “We think of these products for young patients, but they work well on elderly people too. They can be applied to the gingival area—sealing dentinal tubules, preventing sensitivity, and creating a barrier that protects the tooth.” In recognition of patients’ esthetic concerns, Calliott adds, Shofu introduced a pink composite with antiplaque and acid neutralization characteristics to mimic the appearance of healthy gums in teeth restored using its core restorative material.

Prevention and restoration materials continue to improve; however, the “ideal restorative material for the geriatric circumstance” is still in the future, according to Jefferies. “Selection of preventive products and restorative materials that release fluoride as well as remineralizing factors, such as calcium ions or compounds, is optimal. In addition, materials with self-adhesive properties, such as conventional or resin-modified glass ionomers, not only release fluoride and have some potential for remineralization, but their adhesive properties also reduce the need remove sound tooth structure to achieve retention. In treating root caries, preservation of tooth structure can also reduce the chance of tooth fracture associated with compromising the amount of remaining root structure.”

Special Treatment for Geriatric Patients: Good Dentistry and Good Business

Levin recognizes that geriatric patients may require modified approaches, but says it is both good business and good medicine to reach out to this population segment. “Elderly patients come with a variety of medical and dental complications. There is a certain level of expertise required in order to properly diagnose and treat these patients.”

Some of the many ways practices can cater to the needs of the elderly (and even make this part of their brand) include accommodating their need for more time, spreading treatment over several appointments, helping with physical challenges, and even arranging special hours and transportation. “A practice has to be dedicated, flexible, and motivated to provide a high level of care to geriatric patients. For example, there are some patients who cannot lean back in a chair, while others may have difficulty transitioning from a wheelchair into a dental chair. All of these issues are easily overcome if the practice has the right training and experience.”

Practices that treat geriatric or special needs patients should establish certain protocols to make the dental visits easier, more convenient, and enjoyable. This includes special hours that are more suitable for seniors, slightly longer appointment times to accommodate the physical needs of the patient or any breaks that might be necessary, information to educate elderly patients about their specific dental considerations, and assistance in potential transportation issues, such as sending an Uber driver to pick up patients who are mobile but no longer able to drive. “There are many considerations that can be evaluated with respect to elder care that are beneficial to both the practice and the patients.”

Levin says dentists who welcome and accommodate geriatric patients should make all patients aware of their elder care expertise, because they may have elderly relatives and friends in need of dental care. “The practice can build a brand around the care of geriatric patients, increasing the number of patients served and creating a win-win for both the patients and the practice.”

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