The ‘Sunset Age’ patients…Let’s know more about Geriatric patients!

– Dr Smita Athavale

The world is ‘Graying’ fast & so is India! Currently 10% of the population is more than 60 years old & it will be 22% by 2050. (1) That would mean a large number of Geriatric patients coming to dental clinics for treatment in the near future!

Geriatric patients, due to the age-related physical, physiological, psychosocial & dental problems, need special attention & care. Hence, it is extremely important for all the clinicians to know how to take care of our senior citizens in the dental chair.

What is Geriatric Dentistry?

Like pediatric dentistry, geriatric dentistry is also emerging as a speciality branch of dentistry.

Geriatric Dentistry can be defined as a science, that deals with diagnosis, management & prevention of all types of oral diseases in elderly population.(2)

Scope of Geriatric Dentistry

• Geriatric Dentistry emphasizes on dental care for the elderly population & focuses upon the elderly patients with chronic physical, physiological &/ psychological changes or morbid conditions / diseases.
• It is a speciality in dentistry that involves multi-disciplinary approach in evaluation of oral health, diagnosis, prevention & treatment planning for senior citizens (60 years and above)
• It involves dental treatment for elderly & / or medically compromised patients.
• It deals with providing palliative treatment and symptomatic relief from oral health problems like mucositis, xerostomia, dental caries and chronic periodontal problems.

The Elderly Age Segments

All geriatric patients can be divided into different categories depending on age and physical health status.

Categorization of elderly population according to age:

• The Young Old – 65 to 74 years old
• The Old Old – 75 to 84 years old
• The Oldest Old – 85 years old & above

Categorization of elderly population according to physical health status (3):

• Functionally independent elderly – 70% of the elderly patients. They are able to get to the dentist for treatment.
• Frail elderly – 14% of the elderly patients. They may have chronic conditions with impaired mobility.
• Functionally dependent elderly – 5% & the rest of the elderly patients. They may be homebound/ institutionalized.

Medical Problems of the Geriatric Patients (4)

Geriatric patients are hounded by various different medical health issues, and multiple medical issues in a single patient is also not uncommon. These medical problems include:

• Hypertension

• Ischaemic Heart Disease

• Constipation

• Chronic Obstructive Airway Disease

• Dyspepsia

• Diabetes Mellitus

• Cataract

• Osteo-arthritis

• Benign prostatic Hypertrophy

• Depression

• Cancers

• Parkinson’s Disease

• Osteoporosis

• Hearing Loss

• Degenerative Spine Disease

• Recurrent falls and Syncope

• Stroke

• Dementia

• Heart Failure

• Glaucoma

• Incontinence

Oral & peri-oral Problems in Geriatric patients.

Degenerative changes occurring in elderly population may lead to:

• TMJ Problems
• Attrition & Abrasion of teeth
• Root caries V/S Coronal caries
• Periodontal Degeneration
• Loss of Teeth

The ‘Giants’ of Geriatric Medicine ….(5)

The same medical issue found in the younger population can be more complex to manage in the elderly patient. This is because with increasing age, inherent obstacles block the way to good recovery. These include:

• Multiple Pathologies

• Atypical Presentation of Disease

• Immobility

• Instability ( Falls )

• Incontinence

• Intellectual Impairment ( Confusion )

• Late Presentation of Disease

• Silent Presentation of Disease

• Polypharmacy

Challenges in Geriatric Dentistry

1) Socioeconomic Challenges –

• Financial inability & physical disabilities/ limitations act as barriers for geriatric patients to undergo dental treatment.
• Older individuals in low socioeconomic strata have severe financial problems, making dental treatment difficult to obtain.
• Primary care-givers of dependent / disabled / vulnerable patients are overloaded with the overall responsibility, hence the dental treatment tends to take a back seat.
• Increase in per capita cost of healthcare has made dental treatment go beyond reach of an average Indian elderly patient.
• Patients who are dependent on social / government healthcare system may sometimes get delayed treatment.

2) Medical issues & Health challenges –

• Various diseases / systemic disorders could pose great difficulties in treating a patient in the dental chair.
• Status of public health & sanitation problems make things further difficult for dental health professionals working for government hospitals.
• Existing diseases / co-morbidities eg. diabetes, hypertension, cancer, cardiovascular diseases, neurological disorders etc. can cause complications during the dental treatment of the elderly.
• Most of these patients have at least one chronic health problem & ongoing medication (causing increased burden on the care givers & health care system)
• Diagnosed, undiagnosed & misdiagnosed health problems further complicate the treatment planning, management & treatment outcome.

3) Oral Health challenges –

a) Diseases of stomatognathic system

• Loss of multiple teeth causing esthetic & functional problems.
• Poor health status of remaining teeth (Increase in DMFT index)
• Increased requirement of dental treatment due to deterioration of oral health.
• Degenerative changes in the oral & peri-oral hard & soft tissues.
• Temporomandibular Joint dysfunction & disorders.

b) Oral manifestations of systemic disorders & diseases.

Some systemic disorders & diseases can have oral manifestations eg.

• Diabetes Mellitus
• HIV
• Anaemia
• Bleeding disorders etc.

We need to keep these in mind during oral examination of the patient & in case of doubt, always consult the patient’s general physician.

Checklist for your Geriatric Patient before starting the dental treatment

• Detailed medical history – confirm it with patient’s physician
• Socioeconomic history & family background – always call a relative / friend to accompany the patient
• Recent blood / radiological / other investigations – should not be older than 3 months
• Existing medications – Discuss their effects on the dental treatment with the physician

Interdisciplinary Approach for successful outcome of Dental treatment for Geriatric patients.

Since geriatric dental treatment may need involvement of experts from various specialities in dentistry, an interdisciplinary approach in diagnosis, treatment planning & execution is the best way for successful outcome of the treatment. One needs to take into consideration all the following treatment aspects:

1. Preventive treatment
2. Oral surgical treatment
3. Periodontal treatment
4. Restorative & endodontic treatment
5. Prosthodontic treatment
6. Oral hygiene Maintenance
7. Regular Follow-ups & Recalls

Please remember!

• Be thorough with the medical history & records of the patient. In case of doubt, always consult the physician. Take physician’s consent during major dental treatments. Take informed written consent from the patient & the care-giver.
• Explain the treatment planning, cost, risks & limitations in details to the patient & the care-giver before starting the treatment. Encourage them to list down their doubts / queries. Address them satisfactorily & only then begin the treatment.
• Considering the age of the geriatric patient & physical limitations, as far as possible, always schedule morning appointments of short durations. Avoid complicated & lengthy treatments for physically &/or mentally compromised patients.
• A responsible accompanying person – care-giver, friend or relative – should always be present during the treatment.
• Emphasize on meticulous oral hygiene maintenance, preventive/prophylactic measures & regular recall appointments.

Aim of Geriatric Dentistry is Complete Rehabilitation – Not just the Oral Cavity, but also Functional, Social, Psychological well-being of the Geriatric Patient!!

References

1) World Health Organization – Aging & Health – 5 Feb 2018

2) Talwar M. Chawla S., Geriatric Dentistry – Is rethinking still required to begin undergraduate education? Indian J Dent Res 2008;19:175-7

3) Ettinger RL et al (1984), Leon J et al (1990)

4) A Handbook of Geriatric Care – Edited by Dr. O. P. Sharma 2019

5) Management issues in Geriatric Care – Drs. O. P. Sharma, P. S. Shankar, Anand Ambali