ByRDH, BSDH, MSDH
Baby boomer patients have been a fixture in dental operatories in general and specialty dental practices since the late 1950s, and they're getting closer to retirement. The first of the boomer generation reached age 65 in 2011. By 2030, older adults will account for roughly 20% of the U.S. population.
Boomers, for the most part, have enjoyed economic success, low taxation, and full employment. As they approach retirement, they are making their presence felt in a number of ways, and they are taking the phrase "growing old gracefully" to a whole new level. Overall, boomers are healthier, wealthier, and better educated, but they will eventually experience the physical and cognitive changes, including sensory and motor impairments, as their parents did.
Baby boomer overload has already been noticed by many health-care disciplines. In my case, not only have I observed that my schedule contains many boomer patients, I'm a boomer myself, and I'm growing old in tandem with many of my favorite loyal patients!
Other articles by Lynne Slim:
- Cochrane's review of triclosan toothpastes
- Educating patients about the biofilm phenotype
- Dental Implant Assessment
It's important for dental hygienists to explore disease prevention/maintenance strategies with this particular age group, because these patients are concerned about what they can do about their health and staying healthy. Boomers love detailed explanations during dental hygiene appointments, and they're eager to listen when you make appropriate suggestions.
Many of my boomer and older patients (I have been in my current practice for about six years) who were accustomed to six-month recare and "prophy" status (D1110) are being transitioned to three- to four-month recare and supportive periodontal therapy (SPT). Studies indicate that older people have the highest rates of periodontal disease, and 70% of Americans 65 and older have chronic periodontitis.1,2
In my recent experience, I am noticing increased clinical attachment loss in many boomers. What I concentrate on with razor-sharp focus is root morphology/biofilm removal, as well as pH imbalance as it pertains to prevention and management of root caries and periodontitis. In addition, I discuss with each patient lifestyle/environmental factors that will impact their health as they age and ways to minimize risk of chronic health conditions that are mostly preventable (or can be delayed) such as type 2 diabetes. Not only do I discuss the prevention/delay of type 2 diabetes with boomers, but I also talk about the history of diabetes worldwide, so they can educate their children (Millennials) and their grandchildren, too (Generation Z).
In the past, type 2 diabetes was commonly considered a relatively mild ailment associated with aging -- "just a touch of sugar." Today we know that type 2 diabetes is one of the major contemporary causes of premature disability and death.
According to the Centers for Disease Control and Prevention, 60% of boomers (aged 50-64) suffer from at least one chronic health condition.3 Fifty percent of Americans aged 55-64 years have hypertension (a major risk factor for heart disease and stroke), and two in five are obese. One in three self-report no exercise and about 40% of baby boomers have cardiovascular disease.3
Last week, I treated three boomers in succession who presented for recare. Two were periodontal maintenance patients (who I had never seen before), and one was scheduled for a regular prophylaxis. All three patients were in their late sixties, and I discovered root caries on all three.
I would like to walk you through some of my treatment considerations and suggestions for these patients. I take vertical bitewings on older adult patients and adults with periodontitis, and technique really does matter. I use the appropriate sensor holders for direct digital imaging with the ring, and it helps me be more consistent with quality of films.
All three patients reported xerostomia, and the condition was related to medication. So I knew I would be spending a lot of time discussing pH dysfunction in biofilm and recommending products. I'm a big advocate of CAMBRA and have been following this caries risk assessment protocol since 2007. A relatively new product that I am now using on high-risk patients is the GC Tri Plaque ID Gel. I apply it with a microbrush in localized areas and use it to distinguish between fresh and mature plaque and strong acid-producing plaque. It's a great way to open up conversation with boomers about pesky biofilms around the CEJs and in root concavities/furcas, etc.
My boomer buds (that's my nickname for them, but I keep it to myself) love to be educated about different devices they can use to maximize biofilm removal, and I especially want them to focus on the cementoenamel junction (CEJ) and entrances to furcations. The TePe compact end-tufted brush and other brand end-tufted brushes are ideal for difficult-to-reach areas along the gingival margin and line angles.
High-end powered toothbrushes with unique brush heads such as Philips DiamondClean, Rotadent, and Oral-B Professional are safe and appeal to many boomers who are serious about fine-tuning their brushing techniques. The superiority of different modes of powered toothbrushing has not yet been established, according to the Cochrane Oral Health Group, and cost/dependability is another factor to consider.4 Selection of a toothbrush for most boomers is a personal preference and often based on affordability. But they are open-minded about new products, and many of my patients love a high-tech approach to self-care, including powered toothbrushes.
Two manual toothbrushes that are easy to "wiggle" around the CEJ and line angles are the Colgate Slim Soft and Sunstar's GUM Summit.
There is a direct correlation between increasing probing depths and the increasing presence of residual biofilms and calculus.5 Thirty- to 40-minute recare intervals for boomers and older adults does not ensure adequate time for biofilm/calculus removal. As periodontal disease progresses, leading to destruction to the periodontal ligament and adjacent alveolar bone, CAL increases over time, and it is more time consuming and challenging for hygienists to debride these areas during recare.
One common area to find biofilm/calculus, especially in post-SRP patients, is the CEJ, and this is an area that is easily accessible.5 Why is the CEJ such a biofilm/calculus trap? There is a wide variability concerning the relationship between enamel and cementum, which is part of the problem. Sometimes the enamel overlaps cementum, or the cementum overlaps enamel. Cementum may meet enamel end-to-end, and there may be a gap between the enamel and cementum that results in exposed dentin.
In addition, abfraction lesions harbor biofilm and calculus. Structurally, the varied contours of the CEJ (which are usually irregular) lead to biofilm development, and the CEJ is often in close approximation to restoration margins that may be overcontoured or have overhangs at the gingival margin.5 Hygienists should also keep in mind that aggressive instrumentation may also contribute to biofilm and calculus retention in these areas.5
I've modified a short take-home educational sheet for boomers that Sarah McMonigle, RDH, shared with me (see Table 1). Our collective version isn't perfect, nor is it conclusive, but it includes some of the educational messages that are important to convey to this particular age group. When communicating with boomers, consider framing messages that provoke a sense of self-efficacy and empowerment.
SELF-CARE: HOW TO PREVENT DENTAL DISEASE
- Eliminate sugars in foods and beverages with the exception of xylitol.
- Eliminate refined and processed carbohydrates from your diet to reduce bacterial growth.
- Reduce frequency of eating- baking soda rinse after eating raises pH and a more basic pH promotes remineralization of teeth.
- Two Basic Bites ™ chews a day help to support healthy pH levels. www.basicbites.com
- Dry mouth decreases oral pH and greatly increases the development of tooth/root decay.
- Adoption of healthier diets, better exercise habits and maintaining a wellness attitude can result in a higher quality and length of life. Healthy lifestyle practices can reduce your risk of chronic illnesses like diabetes, hypertension, heart disease, cancer and stroke.
- Remove 100% of biofilm every evening.
- Use a soft or high-end powered toothbrush. Wiggle the bristles in between your teeth and along the gumline. Your hygienist will customize an over-the-counter or prescription toothpaste depending on your risk for dental decay or gum disease.
- Clean in-between your teeth. Ask your hygienist to make suggestions about different devices available to maximize biofilm removal in these areas. Biofilm forms nests in-between teeth and along the gumline that creep below the gumline and cause chronic inflammation (bleeding) of gums.
- If you have poor dexterity or arthritis or a lot of mineral buildup on your teeth or a lot of diseased areas, biofilm removal will take longer than just a couple of minutes at nighttime. At first, it will be uncomfortable and your gums will bleed. Rinse frequently with warm salt water until discomfort goes away.
- If you have gum recession, always use an end-tufted toothbrush to clean along the gumline. Your hygienist will show you how to use one and give you online resources for purchasing one.
- Use over-the-counter fluoride toothpaste twice a day or a prescription fluoride product as recommended by your hygienist.
- For fresh breath, select breath mints that are 100% xylitol.
- If your hygienist recommends a daily mouthwash, ask him/her to customize a suggestion for you based on your unique needs. If you have dry mouth, use an alcohol-free mouthwash.
- Take a free online self exam for a personalized dental score report if you are interested in knowing more about your risk for three oral diseases: tooth decay, gum disease and oral cancer.
2. Grossi SG et al. Assessment of risk for periodontal disease. I. risk indicators for attachment loss. J Periodontol 1994 Mar; 65 (3): 260-7.
4. Deacon SA et al. Different powered toothbrushes for plaque control and gingival health. Cochrane Database Syst Rev. 2010 Dec 8;(12): CD004971. doi: 10.1002/14651858.CD004971.pub2.
LYNNE SLIM, RDH, BSDH, MSDH, is an awardwinning writer who has published extensively in dental/dental hygiene journals. Lynne is the CEO of Perio C Dent, a dental practice management company that specializes in the incorporation of conservative periodontal therapy into the hygiene department of dental practices. Lynne is also the owner and moderator of the periotherapist yahoo group: www.yahoogroups.com/group/periotherapist. Lynne speaks on the topic of conservative periodontal therapy and other dental hygiene-related topics. She can be reached at firstname.lastname@example.org or www.periocdent.com.
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