By Dorothy Garlough, RDH, MPA
Many progressive states and Canadian provinces recognize dental hygienists as self-regulated and allow for independent practice. Ontario is one such province and, like many other dental hygienists, I obtained my self-regulation status a number of years ago. The opportunity to be a business owner after being an employee for over 20 years greatly appealed to me. I knew there would be challenges in developing a business plan, implementing clinical protocol, and growing a client base, but the potential change excited me. By disrupting the traditional model of dentistry, I could expand my skills and create the tomorrow of my dreams.
Since I knew the demographics of older people is growing, I began to explore the possibility of delivering care to the elderly. With a natural affinity for enjoying older people, it held interest for me, and I was met with enthusiasm when I broached the subject with the administrator of a local nursing home and the director of an assisted living facility. The residents needed oral care, and there was no system in place to offer it. Could I offer my services to the residents and launch an independent dental hygiene practice?
The administrators wanted to help make this happen. They both offered me a dedicated room for the equipment that I would need to purchase. Additionally, they were willing to develop a system where the family of geriatric patients would give permission for the delivery of my services and then payment.
At that time, there was no dentist associated with either facility. As a result, my communication about complicated medical conditions would have been with medical doctors. This liaison was considered vital because of the multiple medications many elderly patients take.
In educating myself on how to go about setting up my business, I quickly learned specialized insurance was needed in order to take my services to others. This annual investment would be substantial. But it was necessary to protect both the nursing home and myself against unforeseen injuries and possible lawsuits.
The facility directors offered gloves, masks, and antiseptic cleaners. The equipment was the next challenge. Both facilities had suction devices that could be modified to work for dental care, but I would need to purchase a mobile chair for the patient, as well as instruments and an autoclave. In my research, I learned that secondhand equipment was available through companies that have supplied dental offices with upgrades. There was no question that setting up an independent dental hygiene business to work with geriatric patients was doable! In fact, with the growing demographics, it was a strong business model. Most importantly, it was needed.
The venture of my creating an independent practice never flew because I had a change of heart. Earlier in life, I had begun to pursue teaching in dentistry, but life happened and that dream was shelved. As I pondered this new era in my life, I recognized two things: First, I still harboured the desire to teach and, secondly, I am not best suited to work with the elderly and infirmed. Although I have always enjoyed older people, it takes a special person who can administer to the aged.
Dental hygienists are caring and empathetic people, as demonstrated by our entering a caring profession, but working with geriatric patients is a notch above. In my view, it takes someone with a calling: someone who is selfless and giving; someone whose purpose in life is to help those who cannot help themselves; someone who is kind and derives joy from doing for others; and someone who is a very special person indeed.
This type of caregiver has my utmost respect. I hope that dental hygienists who have this calling will step up to the plate, build an independent business, and shine their light on those in need.
The number of elderly patients is on the rise, and there is a propensity for them to retain natural dentition as compared to previous generations.1 According to The Federal Interagency Forum on Aging-Related Statistics, 20% of the U.S. population will be 65 or older by 2030. Of these, 18% will have untreated caries2 and 68% will have periodontitis.3
Consideration of the overall clinical and oral health context of aging patients is important in order to provide optimum dental care. This tsunami of elderly patients offers both opportunities and challenges to dental personnel. Arming professionals with knowledge on what is coming and how to meet the needs of the elderly dental patient is important for the care of the elderly. In addition, for many practices, treating the geriatric patient will be a significant source of income.
The new elderly, aged 65-74, tend to be relatively healthy, and elderly aged 75-84 range from being healthy to those who have chronic deterioration or diseases. The oldest (over 85) tend to be frail and is the fastest growing group.
At this time, in industrialized countries, almost 50% of these elderly persons are edentulous.5 However, with educated baby boomers getting older, the expectations of retaining their natural dentition is greater. They will likely reap the benefits of having taken better care of themselves over the years and having a higher awareness of the need for good oral health. This along with greater financial resources will change the landscape of the elderly in the coming generation.
A number of factors are inherent to being healthy in old age, and a number of conditions will contribute to dental health.
Nutrition-Good nutrition is key to offsetting declining physical and mental health, and poor home care can affect the elderly's nutrition. With reduced mobility resulting in a reduction of lean muscle mass and a lower basal metabolic rate, appetite often is reduced and inadequate nutrition is the result.
Inadequate sunlight may result in developing osteomalacia. Women are often lacking in calcium, and they generally need supplementation (1900 calcium a day) by the time they are 80 years old. Vitamin needs are similar as when they were younger. Other nutrients required for optimum health are ascorbic acid, potassium and iron.5
Dentition-The elderly often have a compromised dentition with either fewer teeth or being edentulous. In addition, there is progressive atrophy of the buccal, labial, and masticatory musculature as the patient ages. This is accelerated further in the edentulous and cannot be corrected.
It is important to educate the elderly on how they can obtain proper nutrition with this new reality. This affects their mastication ability and, as a result, their ability to absorb nutrients. Combine this with a lessened saliva flow and the breakdown of food is compromised even further. Lack of properly functioning teeth may force the elderly to eat soft foods. These foods may predispose the patient to root caries because they are often highly fermentable carbohydrates.5
For the dentally compromised older patient, it is important to advise the person on how to attain an adequate diet that is easy to chew. Additionally, the professional needs to also provide the aged patient with resources to clean properly after eating.
Attitude of Dental Professionals
A number of questions come to mind as to dental professionals' attitudes towards the elderly. Why is there a comparatively low utilization rate for dental care of the elderly despite the high needs? Why has this market not been targeted? Why aren't graduating dental students more willing to fill this void?
Some possible answers to these questions include:
- Lack of experience in dealing with geriatric challenges
- Fear of treating geriatric patients
- Belief that finances are lacking
- Transportation problems if working from a dental office
- Transportation problems for homebound and institutionalized patients;
- Negative attitudes toward the elderly's need for dental care
- Poor oral health status of the elderly
- Difficulties in dealing with debilitating and life-threatening illnesses
- Challenges of acquiring informed consent from family members
- Residential facility staff members with negative attitudes21
Root and coronal caries-Gingival recession exposes root surfaces to a higher risk of caries and approximately 50% of people over 75 years old have at least one tooth affected by root caries6,7,8 and 10% have coronal caries.9 There is a prevalence of restorations in the older population,9 which also contributes to ongoing restorative needs.
Good oral hygiene is imperative to prevent caries. Suggesting oscillating and rotating toothbrushes with enlarged handles for grasping with arthritic hands goes a long way in helping the geriatric patient. However, caution should be taken with those who have congenital heart disease or other conditions affecting the heart valves because of the danger of subacute bacterial endocarditis caused by the improper use of electrical devices.31 Fluoride-Fluoride application to the geriatric patient in the form of rinses, gels or varnishes will help prevent caries in three ways: developing enamel in the form of fluorapetite; remineralizing carious lesions; and acting as an antibacterial agent.10 The use of topical fluoride (such as daily mouth rinses, high fluoride toothpaste, and regular fluoride varnish application), as well as attention to dietary intake is also recommended.9,11
Xerostomia-A dry mouth (xerostomia) affects almost one-third of patients over 65. A dry mouth can lead to mucositis, caries, cracked lips, and fissured tongue11 and periodontitis. Xerostomia increases to 40% in those over 89 years old. The root cause of this reduction of saliva production is usually attributed to side effects of medication, although conditions such as Alzheimer's, diabetes and Parkinson's disease can also exacerbate it.9,11,12
Geriatric patients who ingest more than four medications have a higher incidence of dry mouth syndrome than those who take fewer medications.12 Recommendations for individuals with dry mouth include drinking or at least sipping water throughout the day5,8 and limiting alcoholic beverages and beverages high in sugar or caffeine, such as juices, sodas, teas or coffee (especially sweetened). 11 Additionally, there are commercial products geared to relieving dry mouth syndrome. Root caries are also more prevalent in the elderly who suffer from xerostomia.
Aging and periodontal disease
As health professionals, we know that the greater amount of plaque is directly related to the health of the periodontium. Greater indices are present in the elderly, perhaps because of gingival recession and their inability to clean their mouths thoroughly. Greater severity of periodontal disease in the elderly is also a condition of the individual's cumulative oral history. As well, the susceptibility is increased by specific health problems of the aging patient.13
Wear and attrition are inherent in the elderly. The teeth look flat because the imbrication lines are lost, resulting in teeth having less detail than in teeth that have recently erupted. The effect causes an altered pattern of the reflection of light giving the appearance of a change in color. Transparency is further diminished because the dentin is thickened. In addition, anatomical defects and poor oral hygiene may affect the tooth coloration.14 Enamel becomes more brittle and less permeable with time and the nitrogen content is greater.
The blood supply to the teeth in the elderly is diminished substantially from when they were younger. When viewed through an electron microscope, the tooth shows degeneration of both the myelinated and unmyelinated nerves resulting in a compromised ability to heal the pulp. It is not uncommon to have pulp calcifications and also the narrowing of the root canals. Although cementum continues to be deposited throughout the life of a tooth, the rate of the deposit is greatly reduced as people age.
The oral mucosa acts as a protective barrier to the host. Degeneration of this barrier can expose the elderly patient to a myriad of pathogens. Both the connective tissue and epithelium with its stratified cells interferes with toxic substances and microorganisms. This layer of cells also synthesizes keratin and lamina.15 In a healthy adult, there is a natural turnover of the epithelial cells. But with the thinning of the membrane in the elderly there is a loss of elasticity and stippling. The tongue becomes smooth with a reduction of filiform papillae. In addition, there is a susceptibility to Candida infections and a decreased rate of wound healing.14
Medication Considerations in Elderly
With the use of multiple prescription drugs and also many over-the-counter medications, geriatric patients are susceptible to error, side effects, and adverse reactions. A study by NHANES revealed that 90% of people 65 years or older have taken prescription drugs in the past 30 days during 2011 and 2012.16 In addition, 39% have taken five or more prescription drugs in the past 30 days during this same time.16 Adding to complications are the two or three over-the-counter medications that are being taken.17
Dental professionals need to review regularly all prescribed and not prescribed medications along with supplements18,19 that their elderly patients are taking.12
With so many pharmaceuticals ingested by older people, there is a higher risk of medication errors, inappropriate drug reactions, and side effects.12,17 Medications most often prescribed for the geriatric patient are statin drugs17 for hypercholesterolemia; antihypertensive agents; analgesics; drugs for endocrine dysfunction, including thyroid and diabetes medications; antiplatelet agents or anticoagulants; drugs for respiratory conditions; antidepressants; antibiotics; and drugs for gastroesophageal reflux disease and acid reflux.17 Analgesics, laxatives, vitamins, and minerals are the over-the-counter drugs most frequently ingested by the aging population.17
The central nervous system declines naturally with age and this complicates the response to these drugs in the elderly. The American Geriatrics Society has published a 2015 update to the Beers Criteria for potentially inappropriate medication use in older adults.8,20 Beers Criteria suggests that potentially inappropriate medications have been found to be associated with poor health outcomes, including confusion, falls, and mortality. This degeneration often limits the elderly person from acquiring new muscle memory, and they therefore have difficulty in adapting new patterns for prosthetic treatment.
Anesthetic and cardio patients
Because cardiovascular disease is common among older individuals, it has been suggested by the authors of "Pharmacotherapy for the Elderly Dental Patient" some researchers (Ouanounou and Haas) that the dose of epinephrine contained in anesthetics should be limited to a maximum of 0.04 mg.17 The authors recommend that even without a history of overt cardiovascular disease, the use of epinephrine in older adult patients should be minimized because of the expected effect of aging on the heart. They recommend monitoring blood pressure and heart rate when considering multiple administrations of epinephrine-containing local anesthetic in the older adult population.17
Rinses-Dental professionals know that therapeutic rinses contain agents that are beneficial to the tooth surface or oral environment. They may contain chlorhexidine, sodium benzoate, sanguinaria, a fluoride, or other remineralizing agents. When implicated to be of value, they should be promoted to the elderly.23
Chlorhexidine is primarily indicated for gingivitis. However, it is also effective against a variety of plaque bacteria and can help with plaque control. This is especially important for patients with physical and mental disabilities. Additionally, chlorhexidine can help with patients who have undergone intensive chemotherapy who now have a suppressed immune system. It has been shown to reduce oral mucositis and candidiasis.
Patient education-Patient education includes a discussion of the causes of oral disease and the means of intervention and prevention. Discussion of etiology should be tailored to the level of understanding of the elderly patient but also should be comprehensive.
Know that education of preventive measures by dental staff will not be enough to maintain optimum oral health. There needs to be a therapeutic alliance with other health professionals, family members, and also the patients themselves. If the elderly patient is cognitively sound, they need to realize that ultimately only they can ensure that the recommended preventive measures are taken to help them achieve good oral health. 30
Mental health-Cognitive acuity may also be affected, ranging from not at all affected to dementia.12 This condition, if severe, interferes with everyday functioning.5,14 Those who suffer from poor cognitive health have difficulty in managing medical conditions, including dental hygiene.21,27
Patients who have mental disorders complicate the outcome of suggested home care because of their inability to perform their own self-care.21 The elderly are at a greater risk for caries, periodontal disease, and oral infection and need individualized education in order to manage their dental care.12,21 Better results will be produced with the cognitively challenged patient if noises are reduced and distractions minimalized.
If someone has dementia, it is prudent to have a trusted caregiver in the operatory with you.22 Speak slowly, smile, make eye contact, and keep instructions short.22 Clinical personnel need to ensure that sutures and socket preservation techniques be self-maintaining prior to dismissal.14
Home care should be stressed and the mechanisms for it followed.21 Instructions to caregivers need to be explicit for both home care and the removal and cleaning daily of any removable prosthetic device.21 A battery-operated toothbrush should be considered and the same oral routine should be established.
Communication with patients with cognitive challenges should be at eye level with eye contact and the clinician smiling.22 Begin the conversation by introducing yourself and keep instructions simple, such as "Please open your mouth."22
Yellowitz in "The ADA Practical Guide to Patients with Medical Conditions"21 advises the following in communicating with patients with hearing loss and/or hearing aids: "If a patient reads lips, face the patient while speaking, speak clearly and naturally; and make sure your lips are visible (remove mask). Be at the same level as they are and you may need to gain their attention with a light touch."
Elderly patients who have visual impairment often have difficulty in processing visual cues of communication.22 Ensure the patient can clearly see demonstrations and read written materials, including appointment cards and instructions.14 Suggestions21 that can assist visually impaired older adults in the dental office or any location where care is given (home, institution, etc.) include a magnifying glass available to the elderly, educational materials with large printed; and bright lighting throughout the office or facility.
Many elderly patients suffer with osteoarthritis or rheumatoid arthritis in the hand, fingers, elbow, shoulder, and/or neck, resulting in compromised oral self-care. Velcro straps can be attached to manual toothbrush handles or the use of a bicycle handle may help accommodate for lost mobility. Battery powered brushes as well as floss holders can aid in oral self-car as well as increasing the frequency of dental cleanings and examinations.21
The researchers Penchansky and Thomas14 define the issues in delivering geriatric dental care barriers as availability, accessibility, accommodation, affordability and acceptability, financial considerations, previous patterns of dental utilization, lack of education, and fear.19,20 The vast majority of elderly patients, edentulous or not, do not believe they have the need for dental care until they develop pain or eating difficulties, or suffer from social embarrassment.16,17 Institutionalized elderly have a higher normative need and a lower perceived need than less dependent groups.18 The dental professional's challenge is to educate the aging population on ongoing dental needs before health deteriorates.
Changes need to be made to accommodate the growing demographic of elderly patients. Dealing with the elderly requires an understanding of and sensitivity to the medical, psychological, and financial states of these patients. The traditional educational and practice structures currently in place are based on serving the needs of a healthy and affluent population.22 Encouragingly, in the United States, infrastructures are starting to be put into place to address these issues, but more needs to be done. Coordinating ongoing medical support with pharmacists, physiotherapists, and caregivers is vital,30 as is support from the various dental specialties. Communication with family members and nursing home staff is key as well, but the most important factor to orchestrate change is to educate all dental professionals and the general public on the growing number of the elderly and their unique dental needs.
More information on the care for the elderly can be found at the South Texas Geriatric Education Center, which serves as the National Repository for Geriatric Dentistry. RDH
Dorothy Garlough, RDH, MPA, is an innovation architect, facilitating strategy sessions and forums to orchestrate change within dentistry. As an international speaker and writer, Dorothy trains others to broaden their skill-set to include creativity, collaborative innovation, and forward thinking. She recognizes that engagement is the outcome when the mechanisms are put in place to drive new innovations. Connect with her at [email protected] or visit innovationadvancement.ca.
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