Chapter 7
Treatment Planning and Oral Rehabilitation for the Geriatric Dental Patient
Peter Y. Kawamura1 and Mary R. Truhlar2
1 Department of Veterans Affairs Medical Center, San Francisco, CA, USA
2 Department of General Dentistry, School of Dental Medicine, Stony Brook University, Stony Brook, NY, USA
Introduction
Many patients, including the elderly (or their families) will seek dental care because something in their mouth changed. It is not uncommon to hear a functional complaint from an older patient such as “My tooth broke,” “My denture doesn’t fit anymore and it hurts,” or “My mom/dad isn’t eating well and we think that her/his teeth don’t fit right …”. Due to a number of reasons; finances, lack of dental insurance, overwhelming medical care issues, inconvenience of transportation; the older patient more frequently than their younger counterpart is likely to not have regular dental care for an extended period of time (Dolan et al., 2005; Kiyak & Reichmuth, 2005). The clinical picture is disheartening: missing nonreplaced teeth; moderate–severe gingival inflammation; multiple carious lesions frequently at the margins of crowns and on root surfaces; ill-fitting and poorly maintained prosthesis; retained roots; moderate oral debris and calculus; and malocclusion secondary to lack of oral maintenance and rehabilitation. The dismal appearance of the patient’s clinical situation is frequently compounded by: a complex medical presentation with multiple diagnoses and polypharmacy; families who share the financial and social burdens of care and want “only what is really necessary” and “nothing complex”; and a providing dentist who has a limited available skill set in the management of the medically complex frail elderly.
As daunting as it may seem, providing dentistry for the older patient really relies on some fundamental clinical skills and tasks, that are in the repertoire of most dentists. The providing dentist also needs to possess additional skills in geriatric patient assessment and be comfortable managing the associated medical, physical, cognitive, and social findings. The clinical dental procedures for restoring individual teeth do not change from patient population to patient population; what does change is the approach to overall case management.
Diagnostic studies to facilitate planning and treatment
Diagnostic casts mounted in maximal intercuspal position (MIP) or centric occlusion (CO) is a fundamental and necessary step for any patient needing more than operative dentistry and single crowns within an existing dentition. Any time bridges, implants, partial, or complete dentures are contemplated, an accurate, three-dimensional, replica of the dentition and occlusion, i.e., diagnostic casts, will enable proper planning, temporization, and definitive restorations to be done. The mounted casts serve as a medico-legal record of the initial presentation of the patient and should not be altered or marked. Additionally, the patient who allows you to make two alginate impressions and an occlusal record during the early stages of diagnosis and treatment planning probably will allow you to work in his or her mouth. So in addition to diagnostic value, study casts also have predictive value in terms of the ability of patients to comply with treatment requirements.
A full intraoral set of photographs (front face (no smile), front face (smiling), profile view, front view of teeth in occlusion and lips retracted, left side view with intraoral mirror, right side view with intraoral mirror, maxillary occlusal view with mirror, and mandibular occlusal view with mirror) is invaluable to document various clinical conditions and provide a solid medico-legal record of the patient’s initial presentation. Tooth shades and positions can be determined from photographs and incorporated in future prostheses. Be sure to obtain a signed informed consent to photograph the patient.
An assessment of the patient’s temporomandibular joints, maximal intraoral opening, and number of functional pairs of occluding teeth should be made. Popping, clicking, crepitus, tendency for dislocation, and deviations in movements need to be recorded. Maximal intraoral opening, along with patient cooperation, is important in evaluating access to the posterior teeth. The number of functional pairs of teeth is critical to establish, as these are the teeth the patient has been functioning with and will continue to habitually use whether or not they wear prostheses.
Besides the radiographic data that panoramic and bitewing images provide, the process of obtaining images yields invaluable information about the patient’s ability to follow directions, remain still for prolonged periods, and to endure the discomfort of intraoral films/sensors. Especially with the use of rigid digital sensors, the patient who tolerates the imaging procedure will probably tolerate the dentist probing, manipulating and working in his or her mouth. Cone beam computerized tomography (CBCT) imaging should be considered for a definitive three-dimensional radiographic assessment of the patient who has more complex restorative needs, anatomical deviations, or head and neck pathology concerns.
Planning for dental treatment in the older adult
In a general dental practice, the focus is on restoring dentition and function in healthy ambulatory patients. When an older patient presents with multiple health issues, the focus shifts to maximizing function and esthetics while managing the patient safely within his or her physiologic limitations.
Following are some key questions focusing on oral function that can facilitate the assessment and planning process.
Can the patient chew foods of the desired consistency?
Much of the joy of eating and joy of life comes from eating the variety of foods one wants. Patients often talk about looking forward to biting into “that juicy steak” or “cob of corn” once their teeth are fixed or they get their new dentures. While foods can be ground or pureed to facilitate swallowing, the natural consistency of the food will provide the most satisfying eating experience. Oral rehabilitation should be directed at maximizing the patient’s masticatory efficiency.
Does the patient choke or have swallowing problems?
Choking and swallowing problems (dysphagia) while eating can indicate that the patient has not masticated and moistened the food bolus sufficiently to swallow safely. Patients tend to have a set number of chewing strokes before they swallow, so if there is an abrupt change in their ability to grind the food bolus into a “swallowable” mass, they can potentially have problems in the initial oral phase of swallowing. In addition, residual effects of strokes and neuromuscular diseases of movement such as Parkinson’s disease and multiple sclerosis, can affect the swallowing process. Special attention needs to be directed to fabrication of prostheses, as well as insuring that these patients have a protected airway when receiving dental treatment. One way to protect the airway is to place an opened gauze pad that drapes over the oropharynx and extends out of the mouth. The patient may need to be positioned in a semi-reclined position instead of a more fully reclined position. The saliva ejector will need to be positioned in the most dependent position in the mouth to collect fluids. The high volume suction needs to be used to catch all aerosols and large volumes of fluids as they are generated to minimize choking and swallowing issues during treatment.
Can the patient manage a prosthesis?
Inserting and removing a removable denture requires the dexterity and coordination to correctly position, seat, and remove the prosthesis. Patients will often bite the denture into place and, if it is not correctly positioned, they will break or bend denture clasps or connectors. Removing the denture can be a problem if a patient is arthritic or can only use one hand and cannot unseat retentive clasps. In addition, care needs to be exercised with the patient with tactile sensory deficits, as they may be unable to sense where the prosthesis is in their mouth. If the patient cannot demonstrate that he or she can manage a prosthesis, then caregivers need to become involved in placing, removing, and cleaning the prosthesis and also insuring that the patient’s abutment teeth are properly debrided and maintained. It is important to include appropriate and timely caregiver training and education in insertion, removal, and cleaning of prostheses, as well (see the “Can the caregiver(s) manage prosthesis?” section later in this chapter).
Can the patient tolerate the prosthesis?
Wearing dentures is a skill that is developed over time and requires a certain amount of patience, endurance, and tolerance. The following obstacles need to be overcome for successful denture use: adjusting to lack of tooth proprioception to enable the patient to know where the food bolus is; tongue, cheeks, and lips must develop coordinated and restricted movements to effectively hold the dentures in place; chewing efficiency/force is drastically reduced compared to natural teeth; speech and swallowing need to be re-learned or modified; there is a tendency to gag if the dentures extend over sensitive tissues; the mucosa is easily traumatized by uneven denture surfaces. There is no boilerplate way of designing the prosthesis to ensure patient tolerance and acceptance. A thorough examination of intraoral anatomy and identification of factors that will impact denture use will allow for the design of a prosthesis that best adapts to the patient’s functional limitations. Examples include:
- “I” bar clasps may not work for the patient with arthritis who cannot get their fingertips under this type of clasp and may benefit from the use of a bulkier Akers/circumferential clasping.
- Flanges may need to be modified for the patient learning to tolerate a new prosthesis and acrylic can be added slowly to gradually accustom the patient to the bulk and extensions of the denture.
- Denture adhesive can be used to assist in controlling the retention and stability of the new denture. As the patient becomes more skillful in tolerating the dentures less of the adhesive may be needed.
- Gaggers may not tolerate the palate of a maxillary denture and can do well with a palate-less prosthesis retained by two or more dental implants.
Can the caregiver(s) manage prosthesis?
When the patient cannot manage the denture, the caregiver needs to be involved in the insertion, removal, and care of the prosthesis. The caregiver needs to be instructed in the various tasks that need to be done and must be able to demonstrate back these skills. Teaching the caregiver to manage the prosthesis is important but more important is the process of empowering the caregiver to become involved with the oral care for the patient. Often the caregiver wants to help the patient but feels powerless to do so because the patient “wants to do it themselves”. Discussions with the patient and caregiver should be together and the caregiver can be “assigned” a role in helping the patient. In this setting, the patient may be more willing to allow the caregiver to assist because the doctor has “authorized” the caregiver to participate in oral care.
Which teeth are most strategic for patient to maintain?
When treating the medically frail elderly, inevitably a circumstance will arise in which the provider is prioritizing the retention and restoration of teeth. All teeth are important to the patient’s function and/or esthetics; however, treatment planning should give priority to retaining and preserving the following teeth, with accompanying rationale:
Teeth in occlusion
These are the teeth the patient uses for chewing and incising food and have adapted their jaw movements to maximize their contact.
Teeth structure that can provide proprioception
These teeth/roots enable the patient to know where they are masticating and to more selectively position the food bolus for mastication.
At least one tooth on either side of each arch, preferably in same coronal plane
These teeth provide cross a/>
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