The daily review of the schedule often brings many challenges, as well as patients that you look forward to seeing every few months. Frequently, the joy and challenges are wrapped up in one package and presented to us as our geriatric patients. This generation often presents us with health concerns and an array of oral care challenges.
As a dental clinician, it is of utmost importance to recognize the risks as well as the ways to help maintain oral and overall health with elderly patients. According to the U.S. Department of Health and Human Services, more than 10,000 people celebrate their 65th birthday every day in the United States. In addition, by the year 2030, Americans age 85 and older are expected to grow to 9.6 million residents.
More of the elderly have retained their natural teeth than in past generations. In turn, clinicians are presented with more complex treatment plans for our elderly patients. Americans over 65 years of age are the consumers of 30% of prescribed medications, and studies show the average elderly person in America takes two to seven medications per day, not including over-the-counter medications. Medications may be necessary to control chronic and acute medical conditions in the general population, not just the elderly. As a result, dental clinicians must be aware of the potential oral side effects.
One common cause of xerostomia is medication. It is a frequently known side effect of more than 400 commonly prescribed medications. Patients taking multiple medications or one medication may exhibit symptoms of xerostomia at a dental visit, and not even be aware of the oral changes. Common signs of xerostomia may include cheilitis, a painful or fissured tongue, or trouble speaking and eating. Saliva may appear thick or ropy upon oral examination. The parotid gland may be enlarged, and the patient may complain of halitosis. Oral candidiasis is one of the most common opportunistic infections related to xerostomia, and may or may not be painful.
A patient may not notice any difference in symptoms, but suddenly may have an increased incidence of dental caries, which may be atypical for that particular individual. Reduction in salivary flow likely results in the increase risk of caries, especially root caries (and they can quickly progress into large cavities). As oral care providers for the elderly population, we have to look at the individual as a whole, and target our questioning and treatment plans more so than for the average patient.
Managing xerostomia can be a challenge for both the clinician as well as the patient. Elderly patients frequently are plagued by some degree of arthritis, with limited or painful movement as a result. The dexterity to brush and floss may become a daily challenge, and home care may not be optimal. With subpar home care, or the inability to brush or floss properly, the patient is more susceptible to dental caries as well as periodontal disease.
How many times have we seen elderly patients who require us to spend longer than usual debriding the calculus or plaque, only to expose rampant caries? I have personally experienced this in patients who are living independently as well as those who are in group home care, all of whom have decreased dexterity due to arthritis or other physical impairment.
There are many dental aids to assist in home care that we can recommend to our patients. These include floss aids with long handles. Oral irrigators and power toothbrushes are my favorite recommendations for elderly patients. Power toothbrushes have larger handles than manual toothbrushes and provide the patient with the ease of letting the brush do the work. For many of my patients, this has been one of the best tools for improving home care.
I have a patient who was once a strapping elderly man and then suffered a stroke about a year ago. He is now nonverbal and is cared for by his wife. Although he is very cooperative for her, the challenge of daily care has been daunting. She has been entirely responsible for his care for the past year and has been concerned about his oral care. He had been through periodontal therapy prior to his stroke, but had not been treated for about eight months since. During his dental visits, the wife explained she has to brush and floss for him as he has lost the ability to provide any self-care. He did allow me to perform periodontal maintenance at subsequent visits and was very cooperative, just as he is for his wife with home care. In conjunction with his loving wife, we were able to devise a home-care plan utilizing a power brush and other interdental aids to ease the access to daily oral care.
A saliva substitute or stimulant may provide much needed relief as well as caries prevention for patients with xerostomia. Saliva is necessary to lubricate as well as wash away bacteria. Many people suffering from a dry mouth will often turn to candy or chewing gum to try to stimulate salivary flow and get some relief, increasing risk of caries. Suggesting a gum or mint that contains xylitol can help combat the increased caries risk that xerostomia brings.
The mouth can be a window into our patients’ overall health, with signs of chronic disease and deficiencies showing in the oral cavity sometimes prior to a diagnosis. Diabetes may appear orally as poor healing or uncontrolled periodontal disease. Poor glucose control generally will affect the ability to heal quickly, especially if there are other underlying medical conditions. Oral manifestations of diabetes may include candidiasis, periodontal disease, and salivary dysfunction.
The CDC states that 29 million Americans are affected by diabetes while an estimated 86 million American adults are considered prediabetic or glucose intolerant. The rate of seniors in our country affected by diabetes is near 11.8 million, which is nearly 26% of the population age 65 and older. Studies have found the risk of cardiovascular disease and stroke to increase 1.5 to 2 times higher for those with diabetes. By being aware while we are seeing our elderly patients, we may be able to recognize signs that may be part of the bigger puzzle, and can alert the patient and their physician to investigate further and potentially save a life.
Dental clinicians often see patients who return to us after cancer treatment. Treatments include chemotherapy, surgery, and radiation. The importance of updating the medical history at each visit is crucial. Radiation to the head and neck can greatly affect the oral health. The results of radiation can affect salivary production, consistency, and flow.
When xerostomia is induced by radiation, it is usually permanent; when caused by chemotherapy drugs, it can often be a temporary condition. But even a short-term bout of xerostomia can cause rampant caries and increased incidence of periodontal disease, as well as opportunistic infections due to a disruption of normal oral flora. Many senior cancer patients experience oral sores in conjunction with cancer treatments. To prevent rampant caries, home fluoride may be recommended to help maintain oral health.
While we usually don’t see patients who are undergoing cancer treatments, we may see them for a dental emergency during that period of time. Always consult with the supervising dentist and possibly the oncologist prior to administering any treatment to these patients due to a compromised immune system.
More than one million Americans have joint replacements each year, thus requiring premedication prior to dental treatment. For the first two years, or until the patient’s surgeon recommends it, a preventative prophylaxis regimen is recommended to prevent potential bacteremia infection and failure of the artificial joint. Patients with an increased risk due to other systemic conditions or a compromised immune system may require the antibiotic treatment for longer than two years. When in doubt, always consult with the supervising dentist and patient’s physician for a recommendation.
Many in the senior community did not grow up with preventive dental care and only saw a dentist for a problem. They may be missing teeth and have dentures, partials, or implants in addition to large restorations. Having extensive dental restorations to clean around can be a great challenge for someone already affected with arthritis. Creating a customized care plan, being mindful of the patient’s challenges and strengths, can greatly motivate and improve the outcome.
In conjunction with a power toothbrush, an oral irrigator for those with limited dexterity may be helpful. A chlorhexidine rinse can be a valuable part of the oral routine. In addition, home fluoride or a prescription strength fluoride paste or fluoride trays can help slow down the caries rate. Even a basic review of home-care instructions can serve as a great reminder. Written instructions can be beneficial for anyone, especially individuals afflicted with memory loss.
While many of our geriatric patients are able to walk back with us to our treatment rooms, we also have some who are in wheelchairs and require special considerations. Some can be transferred to our dental chair, and others cannot be moved. I have had my share of senior patients who cannot lean back more than 45-degrees in the chair before they say it is enough, and I spend the next hour standing up and bent over sideways to see. By the end of the appointment, I am ready to schedule a massage, but it is the only way these patients are able to comfortably receive dental treatment. When you find yourself in this position, although not ideal ergonomically, be sure to take frequent breaks to align yourself and stretch often.
For many of the elderly, a dental visit provides an opportunity to get out of the house or care facility. They have lived and seen things that many of us will never experience, and the outing to the dental office is the highlight of the day or even the week. I have had many patients bring in photos from their youth and tell stories of great adventures, or just wanting someone to listen. Taking the time to oversee not only the dental care and concerns, but also providing a social outlet, can be rewarding for both the elderly patient and clinician. RDH
Jamie Collins, RDH, CDA, resides in Idaho with her husband, Cory, and their four children. She currently works as a full-time hygienist as well as an educator at the College of Western Idaho. In addition, she acts as a content expert and contributor in multiple upcoming textbooks. She can be contacted at [email protected].