Taking Care There will be 74 million older adults
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Taking Care
How Dentists Should Prepare for Treating Aging Patients
By Frances Moffett
T
here will be 74 million older adults “It is important for the dental team well-educated and equipped for optimal
— those who are 65 years of age to understand the ‘graying’ of America,” oral health, even into old age.
and older — in the United States by says Katharine Ciarrocca, DMD, MSEd,
2030, according to Oral Health America’s assistant professor at The Dental College The Evolution of Treatment in Older
A State of Decay, Vol. III report (2016). of Georgia at Augusta University. “For Adults
Fourteen years from now, it is projected the first time in history, people aged 65 In the past, Ciarrocca says, geriatric
that one out of every five Americans will and older will soon outnumber children dental care was really geriatric denture
be age 65 or older — that’s 19 percent of under the age of 5.” care. The prevalence of edentulism has
the U.S. population. In 2010, this number With the “graying” of a dentist’s declined overall from 18.9 percent in
was about 13 percent. This shows a 46 patient base come a number of unique 1957–1958 to 4.9 percent in 2009–2012.1
percent increase in 20 years, and, accord- challenges an older individual may face Older adults are no longer living with
ing to A State of Decay, this population is — challenges that dental professionals the expectation that they will lose all of
expected to continue to grow. must be ready to address as well. These their natural teeth and enter old age with
So what does all of this mean? That include increased medical complexities, dentures.
with larger parts of the U.S. population lack of dental insurance, reduced mobil- “It’s not unusual for baby boomers
getting older, dentists will need to ity and cognitive function, and more. today to have grandparents who put
consider if they are prepared to properly Participation from the entire dental team their teeth in a cup at night,” says Linda
serve their aging patients. is necessary to ensure that patients are C. Niessen, DMD, MPH, MPP, dean
and professor at Nova Southeastern And, as Ciarrocca explains, with The Unique Challenges of Aging University College of Dental Medicine in advances in oral health care and medical Patients Fort Lauderdale, Florida. “Baby boomers, care, people are living longer and, thus, As the age of the general population however, are retiring with basically a full able to keep their teeth throughout the increases, so does the likelihood that complement of teeth, and there are two duration of their lifetime. dentists will be treating older individuals main reasons for that: better preventive “Advances in medicine and biomedical who are dealing with issues such as care and workplace dental insurance. It’s sciences have been major factors in the comorbidity and polypharmacy. much more common nowadays to see increase of life expectancy,” she says. “Older adults may be taking more a 65-year-old wearing braces instead of “Individuals who would have died 100 medications and have an increased dentures.” years ago due to infections, trauma, number of diseases and medical condi- Michael Helgeson, DDS, CEO and major organ diseases, or oncologic tions, such as diabetes, arthritis, or high cofounder of the nonprofit Apple Tree conditions, in many cases, now have blood pressure,” says Barbara Smith, Dental (which provides dental services treatment available that effectively Ph.D., RDH, MPH. “They have likely lost to those who are low-income, disabled, maintain life in most situations.” multiple teeth or have teeth that have and residents of nursing homes), says Ciarrocca says with changing been heavily restored. They might have that attitudes about the inevitability of demographics and improved medical arthritic changes that affect their ability tooth loss have shifted dramatically over management of the various health to take care of their teeth on a daily basis. the years; more people are asking about conditions older adults face, there are In the mouth itself, the teeth tend to be and choosing therapies that help sustain increasing demands on oral health care more brittle and may have decay around their teeth. providers for extensive knowledge of oral the root surfaces, which could also be “All adults, including seniors, are focus- manifestations of systemic disease. caused by the medications they take. ing on not just keeping their teeth, but “The individual who survives one or These are just a few of the things dentists actually having a brighter, whiter, and more more of these conditions often suffers and the dental team need to consider pleasing smile,” he says. “Emphasis on detrimental effects,” she says. “Therefore, when determining care.” looking good as you age will continue to patients are more medically complex, grow, particularly among older adults who so oral health care professionals need to are functioning well and have the financial be knowledgeable and comfortable in resources and the interest to do so.” managing these patients.”
According to the World Health ized or localized periodontal disease. for Medicare by 2035. (In some states,
Organization, common ailments older The National Institute of Dental and Medicaid may pay for limited dental
adults experience include hearing loss, Craniofacial Research reports that services for low-income adults, including
cataracts and refractive errors, back 17.2 percent of older adults have older adults.)
and neck pain, osteoarthritis, chronic this condition. Additionally, African Niessen says, “What this means is that
obstructive pulmonary disease, diabetes, American and Hispanic seniors, as the dental team will often become the
depression, and dementia. In treating well as those who smoke and have insurance management/benefits counsel-
these conditions, patients can be taking lower incomes and less education, ors, so to speak, for patients. The office
a number of medications that can affect are more likely to have periodontal managers should be communicating with
their oral health. According to the disease. patients who are close to retirement age
2015 Journal of the Canadian Dental Another common infection, particularly and asking them when they’re planning
Association study, Pharmacotherapy for when caring for palliative patients, is oral to retire and ensuring that they’re aware
the Elderly Dental Patient, elderly adults candidiasis. As many as 70–85 percent of how their dental coverage is going to
are prescribed the highest number of of these individuals suffer from it.4 In change.”
medications — sometimes taking up to addition, Niessen says that dentists
four or five prescription drugs in addi- should conduct a thorough oral cancer Limited Mobility and Lack of
tion to two or three over-the-counter examination with older adults, checking Transportation
medicines. It is estimated that by 2040, for lesions and other symptoms, because As older adults become less independent,
they will consume 40 percent of all the risk for developing the disease daily self-care and access to transporta-
prescriptions used. increases with age. tion become more difficult, especially
There are multiple common oral for frail adults who live in facilities
conditions that dentists should be aware Lack of Dental Insurance such as nursing homes, says Helgeson.
of when treating older adults who are Many of today’s older adults have had According to National Caregivers
taking numerous medications, such as: the opportunity to benefit from health Library, 8.4 million seniors depend on
• Xerostomia (dry mouth). Dry insurance provided through their others for their transportation.
mouth affects 30 percent of patients workplace, which, in comparison to In addition, conditions such as osteo-
who are 65 years old and older, up generations past, has led them to enjoy arthritis, which is the most common
to 40 percent of those older than age better oral health. Yet what most of them form of arthritis, or rheumatoid arthritis,
80, and is considered one of the most don’t realize is that once they retire, they the second most common, can affect
common oral health issues in older will likely lose their health insurance and an older person’s ability to maintain
adults due to medication intake (this have to enroll in Medicare, which doesn’t optimal oral health, due to the inability
condition is more likely to occur in cover routine dental care. to properly hold a toothbrush or floss.
those who take more than four daily “What a lot of baby boomers don’t Along with frequent cleanings and
prescription drugs). Dry mouth can realize is that when they retire, their dental exams, modification of manual
lead to other ailments such as muco- workplace health insurance switches to toothbrush handles with the addition
sitis, caries, cracked lips, and fissured Medicare, and then they’ve just lost their of Velcro® straps, etc., or use of an
tongue.2 dental coverage,” Niessen says. “Some electronic toothbrush with a wide handle
• Root caries (or root decay). About baby boomers may not know this is that’s easy to grip, can help with loss of
50 percent of elderly individuals who coming.” mobility; floss holders or interdental
are older than age 75 have root caries According to A State of Decay, cleaners/brushes can help as well.2
affecting at least one tooth. This 52 percent of people older than 50 — According to Beth Truett, president
population is at a higher risk for root regardless of their income or education and CEO of Oral Health America, lack
decay because of increased gingival level — either did not know or believed of transportation, inability to pay for care
recession that exposes root surfaces, that Medicare covered routine dental or find a provider who accepts Medicaid,
as well as increased use of medica- health care. Yet less than 1 percent of etc., are common challenges for older
tions that produce xerostomia.3 Of dental services are, in fact, covered. patients, but dentists should also be
patients ages 75 to 84, 10 percent are (Medicare will pay for dental services aware that they may have language
affected by secondary coronal caries, that are medically necessary for another diversity (i.e., the inability to find a
likely because of the prevalence of covered procedure; Medicare Advantage dentist who speaks his or her primary
restorations in these individuals.2 plans cover some dental services.) language) or they may suffer from fear
• Periodontal disease. According to In 2015, the Centers for Medicare & and embarrassment, which may keep
Niessen, periodontal disease occurs Medicaid Services reported that more them from visiting the dental office.
more frequently in older adults, so it’s than 55 million Americans were covered There are ways to combat this,
important that dentists do a complete by Medicare. And with the aging popula- though. “Depending on the size of the
periodontal evaluation and measure tion growing at a faster-than-ever rate, community, dentists can work with local
probing depths to ensure that patients Eligibility.com says that approximately transportation companies to offer trans-
don’t have areas of either general- 80 million individuals will be eligible portation at affordable rates,” she says.
18 | AGD Impact | August 2016
“[With regards to Medicare], we need to “The OSCAR approach is an excellent, before treatment; and they have more
advocate on a national level for inclusion, systematic approach to evaluate the complex needs, such as completing a
and with state legislators to include whole geriatric patient,” she says. plan without multiple return visits, espe-
adult dental coverage in Medicaid and The acronym OSCAR stands for: cially if they have physical limitations. “A
for better reimbursement rates, so that Oral and dental needs revised protocol may be needed, which
more dentists will be willing to take Systemic factors extends the time the dentist spends with
these patients. [For language barriers], Capability the patient, or planning for other health
work with local schools who may have Autonomy workers to spend one-to-one time with
English as a Second Language teachers Reality the older adult to complete their plan
and students who may want to volunteer with fewer visits,” she says.
as translators.” This approach, according to Clinical Helgeson says that dentists should
Practice of the Dental Hygienist (10th also bear in mind that older adults tend
Considerations for Treatment edition), outlines the dental, medical/ to transition through three stages as they
Planning pharmacologic, functional, ethical, and age: independent, semi-dependent, and
Ciarrocca says that when treatment fiscal factors that dentists should analyze fully dependent.
planning for a geriatric patient, it is when treatment planning for older “During those different phases,
important to consider how they function individuals or those with disabilities. patients will have different treatment
in their environment, what type of social Caring for older adults will also likely needs,” he says. “Having a dialogue early
support systems they have, what their take more time than caring for younger with older patients about their plans
diverse sociologic variables may be, how patients, says Truett, because they move for ‘retiring’ their mouth can help them
oral health care fits into their environ- less quickly; they are challenged by the make appropriate treatment decisions
ment, and if they are able to maintain the physical environment; they will likely while they’re independent, because as
care you provide. prefer a conversational relationship they become semi-dependent, their
What Can You Do to Better Serve Aging Patients?
1. Have a discussion with your patients about future planning, the potential need for a
caregiver, and their long-term goals for their teeth. Documenting this information early
will show your patients you care and help you avoid conundrums later on.
2. Collect detailed health histories, including a list of all medications, and provide coaching
on how to mitigate dry mouth.
3. Evaluate the cognitive function of elderly patients. Always ensure that they understand
the information that’s being presented and can provide informed consent.
4. Talk about changes in insurance. Discuss options to make their care affordable and practi-
cal over time.
5. Emphasize the importance of preventive care. Prevention works at every age, so don’t
give up on saving teeth prematurely.
6. Don’t treat vulnerable adults like children. No matter what people’s age or disability, if
they’re an adult, they need to be treated like one.
7. Train staff to be senior-friendly and create a senior-friendly dental office. Consider things
such as lighting and space that allows for proper patient safe-handling.
8. Be wary of stereotypes about older patients. Don’t assume that just because someone is
older that you know what their needs and preferences are. And don’t limit their options
based on their age. Be open to their preferences and honest with them about the
benefits, risks, and costs of various treatments.
— Michael Helgeson, DDS, and Barbara Smith, Ph.D., RDH, MPH
| agd.org | 19cognitive and economic status, as well a similar process for each patient. The long-term care in a nursing facility,
as their mobility, may change. For difference with the older patient is that hospice care at home, etc.
independent seniors, though, most of the when you document the medical history, “Many of the seniors who are in that
treatment planning will be similar to how you’re going to have a lot more positive population end up losing their savings
you would plan for any other adult.” answers. They’re going to say ‘yes’ to because of the high cost of nursing
Niessen agrees, saying that gener- having heart disease, ‘yes’ to arthritis. facilities, and they become dependent on
ally, there are more similarities than They’re going to say ‘yes’ to taking Medicaid at a certain point during their
differences when preparing treatment multiple medications.” stay,” he explains. “For those patients,
for an elderly patient. “Our procedure According to Helgeson, when there’s a combination of having medical,
for care should be the same for every treating fully dependent elders, dentists dental, and nursing care needs overlaid
patient,” she says. “How we do our should be aware that this population with loss of resources to be able to pay
dental exam, how we document medical typically has cognitive or physical for dental coverage.”
history, our diagnostic and treatment impairments — or, most often, a combi- Another part of treating semi- and
planning procedures — we should have nation of both — and may be receiving fully dependent older adults is ensuring
that they fully understand the informa-
tion they are being presented with and
can give informed consent.
Properly Treating Aging Patients Is a Team Effort “It’s always a challenge identifying
Each member of the dental team must be forward-thinking in their approach to senior semi-dependent older adults — some-
patient care. Michael Helgeson, DDS, and Barbara Smith, Ph.D., RDH, MPH, highlight the body who has some level of impaired
unique roles each team member plays, in addition to providing optimal care. cognitive ability, but it’s not clear how
extensive it is,” Helgeson says. “When
in doubt, that’s a good time to involve
spouses or adult children, with consent
from the older adult, of course.”
If this is the case, a dentist should talk
to patients and ask for their help identi-
fying a caregiver, letting them know that
you want to be able to help in the event
that they need assistance in making
Dentist Dental Hygienist treatment and/or financial decisions
• Educates patients about the • Encourages daily self-care and the relating to their oral health. “Asking,
oral-systemic link need for frequent professional visits for ‘Is there someone who you would like
• Evaluates cognitive status of a patient cleanings and exams to have involved in decision-making
• Develops short- and long-term treat- • Manages preventive care such as about your care?’ helps. Setting that up
ment plans that fit changing needs and fluoride use, etc. in advance is a little like having a will or
financial status • Establishes daily mouth care routines establishing their end-of-life priorities.”
• Leads team in creating a senior- and caregiver assistance coaching for Helgeson cautions that if a dentist
friendly office environment semi-dependent patients is working with a vulnerable adult who
is losing cognitive function, then the
consent received from that person is
not valid. He advises that, if available,
dentists take advantage of the informed
consent training materials and guidance
provided by most malpractice insurance
carriers, and that they become comfort-
able with discussing this topic with their
older patients. He also says that tools
Dental Assistant Office Staff such as the Mini-Cog™, a mental status
• Ensures patient safety and • Communicates well and understands assessment test, can help dentists quickly
safe-handling the scheduling challenges that many evaluate a senior’s cognitive function.
• Accompanies patients and observes seniors face (coordination with
any changes in well-being caregivers, transportation issues, etc.) Communicating with Older Patients
• Reinforces post-op patient • Detects signs of declining health and What should dentists keep in mind when
communications cognitive status early communicating with elderly adults?
• Acts as ambassador with family Smith says, “One of the challenges in
members/caregivers dentistry is that we have, over time,
created an environment that interferes
20 | AGD Impact | August 2016with communication with face masks and lation is also less likely to understand contribute to the unmet dental needs
goggles, etc., which we use for a perfectly how medication can affect the health of of older adults, according to A State
reasonable thing — infection control. This their mouth. of Decay, is a lack of programs that
can make communication with patients “The dental team needs to emphasize support oral health prevention and
difficult, but it becomes particularly criti- that mouth health is related to overall education for this population. Though
cal with older adults if their sensory input health, with particular emphasis on there have been advances in preventive
is not as good as it once was.” heart health and diabetes,” Helgeson education over the years, Helgeson
She offers the following tips: says. “Inflammation and infection in the and Smith say there is still a need for
• Always face the patient, make eye mouth may aggravate heart conditions this consistent messaging among older
contact, and unmask. and make diabetes harder to control. adults.
• Extinguish external noise sources, Also, aspiration pneumonia in nursing “Historically, the use of fluoride
such as suction units, handpieces, facility residents is an issue that isn’t often treatments for prevention has been
etc. discussed but can be a cause of hospital- focused on children, but it is equally
• Speak distinctly, not louder, in a izations and death, due, in part, to poor effective in older adults and just as
lower pitched voice. oral health, leading to increased bacteria important in preventing cavities,”
• Support verbal messages with writ- in the mouth. Keeping the mouth clean Helgeson says. “Treatment of root caries
ten communication that clearly and healthy is simply a good, preventive is a big issue in older adults. Periodontal
outlines treatment plans, cost of measure for overall health.” and endodontic care are still important
services, etc. Written/typed com- Niessen adds that since most patients as well.”
munication should not be smaller aren’t knowledgeable about how oral In addition to the push for prevention
than a 12-point font. health affects systemic health, it’s easy in older adults, Niessen encourages
• Use everyday language and avoid for them to misconstrue certain symp- dentists to collaborate with their health
jargon and overly technical terms. toms or illnesses they might have. profession colleagues — physicians,
• Be mindful of the patient’s pride “Sometimes they don’t realize that nurses, pharmacists, etc. — in order to
and dignity. Elderly patients are the pain they are having in their top educate them about oral health and its
adults and, as with all patients, teeth could really be a sinus infection relationship to overall health.
should be treated with dignity. instead of a toothache,” she explains. “I’ve done a lot of in-services for
Dentists and their teams should also “Patients who have diabetes may not physicians and nurses in nursing homes
keep in mind that even though senior realize that if their diabetes is uncon- or in hospital settings, and I’ve lectured
patients may need more assistance, trolled, they’re much more likely to for physicians as well,” she says. “For
independence is still important to them. get periodontal disease. Or, if a patient dentists in private practice, maybe
Truett says, “Kathy Greenlee, assistant comes in with fruity-smelling breath, there’s a physician or a medical group
secretary for the Administration on that could be a sign of diabetes. There in the same building as your practice.
Aging at the U.S. Department of Health are patients who have angina or heart Introduce yourself and get to know
and Human Services, once said that disease who present with jaw pain. them. Ask if they’d be interested in
independence is what older adults value Many medical conditions can present learning more about oral health during
and fear losing the most, so anything the with symptoms in the mouth.” a lunch meeting, etc. Sometimes, these
dentist can do to reinforce a sense of self- Niessen also says that dentists should meetings can happen in serendipitous
efficacy will engender a ‘grateful patient.’” try to get a full picture of a patient’s ways; for instance, while you’re at a
health conditions. “If a patient has a his- social event. We should take every
Talking about the Oral-Systemic Link tory of heart disease, the dentist needs opportunity to educate our health
According to Truett, family caregivers to understand the nature of the heart profession colleagues and alert them
told Oral Health America (in a two-day disease and what type of medicines to the importance of good oral health
online focus group survey) that in they’re taking, because if that patient at any age, particularly at an older age.
regards to their older-adult neighbor or suddenly loses consciousness, the dental Oral health doesn’t need to decrease as
loved one, they are concerned for the team must be prepared to stabilize chromological age increases.” F
health of the whole person — especially him or her until the EMTs [emergency
when it comes to nutrition, falls, chronic medical technicians] arrive. If a patient Frances Moffett is managing editor of AGD Impact.
diseases, and oral health. has a hip joint replacement, the dentist To comment on this article, email impact@agd.org.
“Taking a whole-person approach and the orthopedic surgeon should be
could be valuable in compassion- talking. If the patient has a cardiac con- References
ately treating the individual and gaining dition, the cardiologist and the dentist 1. Slade, G.D., A.A. Akinkugbe, and A.E. Sanders. “Projections
of U.S. Edentulism Prevalence Following 5 Decades of
the family’s business,” she says. should be talking to make sure that the Decline.” Journal of Dental Research 93.10 (2014): 959–965.
PMC. Web. 30 June 2016.
A State of Decay reports that older treatment is appropriate.” 2. Oral Health Topics — Aging and Dental Health. Center for
Science Information, ADA Science Institute.
patients who have lower income and 3. Public Health and Aging: Retention of Natural Teeth Among
Older Adults — United States, 2002. Morbidity and Mortality
are less educated are most likely to The Importance of Prevention and Weekly Report. Centers for Disease Control and Prevention.
4. Dental Care in the Frail Older Adult: Special Considerations
misunderstand the connection between Multidisciplinary Collaboration and Recommendations. California Dental Association
Journal. July 2015.
oral health and overall health. This popu- One of the significant factors that
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