When caring for the oral health of frail and functionally dependent older adults, it is important to understand their general health and oral health problems to make a diagnosis. There are multiple treatment strategies available to care for their needs; many may not be evidence based. Dental treatment planning for older adults is as much art as science and requires clinicians to understand how patients are functioning in their environments and how oral health care fits into their needs and lifestyle. This article discusses a variety of treatment planning techniques and illustrates the problem with a longitudinal case history.
Key points
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Frail and functionally dependent older adults include a diverse group of people with multiple disabilities, which are influenced further by their life experiences that complicate decisions related to clinical dental care.
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Furthermore, because they grew up prior to water fluoridation, most of them have maintained some of their teeth, but this puts them at higher risk for coronal and root caries, which complicates restorative care.
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The decision-making process, which has evolved, essentially has developed into a treatment planning philosophy that takes into account the best interests of the patient after evaluating all the modifying factors.
Introduction
In 2020, the total US population was approximately 330 million person and those aged 65 years and older made up nearly 16%, which is approximately 53 million persons. There is greater heterogeneity among people aged 65 years and older than in any other age group. Each older adult has a unique genome and has been influenced by a variety of environmental factors, such as social, cultural, economic, and cohort experiences, that have determined their lifestyle and health beliefs. The oral health of these individuals also is affected by these same factors, so, when planning dental treatment of older adults, dentists must take into account the social aspects, general health, and oral health conditions prior to delivering care.
In geriatric medicine, it is important to make a diagnosis, and, once a diagnosis is made, there usually is enough scientific evidence to support a treatment plan. In geriatric dental medicine, it also is important to make a diagnosis, but often there are multiple treatment strategies, which often are not evidence based. Also, dentistry is unlike internal medicine and more like surgery, in that dentists need to remove infected tissue and restore shape and function, which require operating equipment.
Therefore, if an older adult can drive or use public transport independently to access a dental office, this removes a significant complication associated with their treatment. These persons have been defined as functionally independent older adults and comprise approximately 70% of persons over the age of 65 years. In general, they live in the community without assistance, but many may have 1 or more chronic medical problems, such as hypertension, type 2 diabetes mellitus, osteoarthritis, and so forth, for which they are taking a variety of medications. To treat these older adults, dentists must take a thorough medical and drug history and understand how these diseases and medications influence patients’ oral health conditions and dental treatment. The treatment such patients accept depends on their own and their significant others’/family members’ perceptions of need for care as well as the amount of money they are prepared to spend on that care.
A smaller group of older adults (approximately 20%) can be designated as frail older adults, because they have lost some of their independence. They still are living in the community with the help of family and friends and may be using professional support services, such as Meals on Wheels, home health aides, visiting nurses, and so forth. These frail older adults can access dental services only with the help of others if they are provided with transport. To treat this population, the dentist needs a greater knowledge of medicine and pharmacology as well as the skill to evaluate a patient’s ability to maintain daily oral hygiene independently. Another important factor is the patient’s ability to tolerate the treatment that has been proposed.
The smallest group of older adults (approximately 10%) have been called functionally dependent older adults. These persons are unable to survive in the community independently and either are homebound (5%) or living in a long-term care institution (5%). A minority of these older adults can be transported to a dental office provided it is wheelchair accessible, and a dentist is willing to care for them. The majority need to be cared for at their home or in their institution. To care for them, the dental professionals need either mobile dental equipment or a dental office in the long-term care facility.
Treatment planning
Patient Interview
The initial contact between older adults and their dentist begins with telephone contact between the patient/caregiver and the dental office receptionist. Therefore, a receptionist needs to have been sensitized to eliciting important information from potential patients, especially if they are frail or functionally dependent. To treat these patients safely, there is a need to know whether a patient needs help with transportation, , any specific accommodations for wheelchairs or oxygen tanks, the availability to come for an appointment, the chief complaint, and current health issues, including questions about symptoms of 2019 Coronvirus Disease (COVID-19). The receptionist also ask the should patients/caregivers to bring a list of current medications or the medications themselves , ; a list of their health care providers; and dental radiographs if they exist. The receptionist needs to be empathetic to the age-associated sensory deficits of the patient, which can result in longer conversations to acquire the desired information and to schedule appointments.
Teledentistry
The COVID-19 pandemic has thrust teledentistry to the forefront of dental practices. Teledentistry may be beneficial particularly for those who are considered at high risk of severe illness or mortality associated with COVID-19 infection, because efforts are being made to minimize Severe Acute Respiratory Syndrome Coronovirus 2 transmission to this vulnerable population. The use of teledentistry, however, will transcend this pandemic as a useful tool for dentists, the public, and especially at-risk populations. This vulnerable population includes but is not limited to persons of any age with multiple comorbidities, those over age 65 years, persons who are immunocompromised, and those residing in nursing homes. A national survey has reported that older adults in the United States are interested in utilizing teledentistry but have expressed some concern with managing the technology needed to access virtual appointments. Teledentistry is particularly useful, however, in evaluating nursing home patients because it allows the dentist and the nursing facility resident to remain in their respective locations while nursing home staff manage the technology needed to complete the visit. Although these residents still may need an in-person dental appointment, the information gathered during these teledentistry visits can reduce the time in the dental office waiting room in order to complete forms and preappointment consent from the resident and/or person with power of attorney and, therefore, expedite treatment that minimizes the at-risk person’s exposure time to the public. Teledentistry similarly can be advantageous for older adults living at home, but efforts should be made to select a simple technology that is easily accessible and overcomes any sensory deficits, such as hearing loss, either via synchronous (live video) or asynchronous (forwarding a still photo to the dentist) methods. Instances in which dentists will find teledentistry immediately helpful is when triaging a new or existing older adult patient prior to entering the dental clinic, diagnosing and treatment planning for existing dental patients, and postprocedural management of those patients.
As patients come for the initial appointments, usually they are handed multiple forms about patient registration, finances, and health history. It is assumed that patients are literate, cognitively not impaired, and can understand the information being sought. The National Adult Literacy Survey reported, however, that 59% of the US older adult population had basic or below proficiency in health literacy, which means they would have difficult interpreting health-related printed materials. Patients’ age-associated impaired vision and slower cognitive processing of information exacerbate the problem of understanding printed materials, which often can slow the usual pace of a dental office.
Consequently, when interviewing an older adult patient, the dentist should use the completed forms to begin the conversation with the patient/caregiver but extend the interview to include an evaluation of all the potential modifying factors. Good communication with patients and their significant others requires investigative interviewing when assessing patients with complex social and medical/mental conditions, in order to understand the hidden meanings of their complaints. If dentists are not sensitized to understand the true nature of the implications of the chief complaint, they may miss important clues. For instance, a 72-year-old patient from a practice returns because she has lost the crown on her central incisor. Previously, she had returned for routine care regularly every 6 months, but she has been missing her appointments for more than 2 years. On careful questioning, she reported that 2 years ago her husband died unexpectedly, and her children live in distant states. Her health and overall grooming have deteriorated visibly as has her oral hygiene. It is clear that she is suffering from severe depression associated with sustained grief due to the loss of her husband and her own health and mobility. She urgently needs counseling and mental health care. Merely treating her current dental problems does not address her essential needs. Therefore, focusing only on her current dental problem can lead to continuous oral deterioration or even more life-threatening consequences.
In assessing patient health histories, it is important to interpret the information provided by careful questioning. For example, if a patient reports a has a history of angina pectoris, what does this really mean? Does the patient experience spontaneous chest pain or by walking from the car to the office or by going up a set of stairs, or did the patient have chest pain 6 months ago and no episodes since then? Each of these scenarios requires the dentist to modify the management of the patient, due to the risk of precipitating potential medical problems. Possible modifications might range from using a stress-reducing protocol to postponing elective treatment until patients have been assessed by their physician.
How do dentists make decisions?
When examining how dentists make decisions, it should be that considered a majority of oral diseases are chronic plaque-associated diseases, such as caries and periodontal disease, which cause irreversible damage. Some diseases of the oral mucosa and pulp can be cured, whereas a few, such as oral neoplasms, are life-threatening. , A majority of oral health needs in older adults are treating the exacerbations of caries and periodontal disease. , ,
Clinical geriatric dentistry requires problem solving and decision making to develop an appropriate treatment plan. In younger adults, the factors that influence the decision making related to treatment planning are simpler; for instance, Does the patient have the will and the time to accept the care? Does the patient wish to pay for the care? and Does the dentist have the resources and skills to carry out that care? In older adults, the factors may become more complex, and the dentist needs more skills and experience in decision making to develop an age-appropriate treatment plan. This treatment plan should take into account the multiplicity of modifying factors, which include but are not limited to patient’s socioeconomic, psychological, and medical problems; side-effects of their medications; and the cumulative effects of dental diseases as well as the iatrogenic effects on the dentition due to previous dental care. ,
The knowledge base to manage the treatment planning process for older adults does not require the development of new technical skills but rather the development of thought processes to understand the patient’s modifying factors and how they may influence treatment. The aim of treatment is to understand how patients are functioning in their environment and how their dental needs and treatment fit into their lifestyle. When making these decisions, the benefits of treatment must outweigh the risks of adverse events. The thought processes that are required to develop this treatment protocol were developed by Ettinger and Beck, and have been called, “rational treatment planning.”
To make these decisions requires the gathering of information from and about the patient, in order to be able to make a diagnosis and a treatment plan. There have been several systems suggested in the literature on how to gather and process this information. One of the most used systems is a modification of the American Society of Anesthesiologists evaluation scheme to assess patients’ ability to tolerate treatment. This system has been used as a reference to modify therapy and patient management and provides guidelines for the dental treatment of medically compromised patients, especially those who need anesthesia. This system was modified by Kamen into 4 broad categories ( Fig. 1 ). Gordon and Kress identified some of the faults of this system by stating, “when applied to specific situations, the system is somewhat simplistic, in that many patients fall between categories and many choices remain even within one category.”
Another such system uses the mnemonic, subjective findings, objective findings, assessment, and plan (SOAP). For older adults, subjective findings must include information on functional status, such as activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Objective findings include an oral examination, radiographs, and other intraoral and laboratory findings. Using these findings leads a dentist to an assessment of the patient’s expectations and needs, which evolves into a treatment plan.
Shay has proposed another mnemonic, which he called OSCAR, especially designed for older adults. The O stands for oral factors, the S for systemic factors, the C for capability, the A for autonomy, and the R for reality. The oral factors include the condition of the dentition, restorations, periodontium, coronal and root caries, tooth loss, salivary function, mucosal health, oral hygiene, and the occlusion. Systemic factors should include an assessment of general health, available laboratory findings, the impact of medications, and communication between the dentist and the patient’s physicians. Capability addresses the patients ADLs and IADLs as well as issues, such as incontinence. Autonomy relates primarily to a patient’s ability to provide informed consent independently and maintain oral hygiene, which might be impaired as a result of stroke, dementia, or other diseases that affect cognitive function. Reality takes into account life expectancy and a patient’s ability to access care and pay for the required treatment.
A similar but somewhat different conceptual model was suggested by Berkey and colleagues. They proposed that decision making for older adults requires clinicians to take into account 4 domains, which are function, symptomatology, pathology, and esthetics. Function relates to the ability of the patient to chew and eat an adequate diet. Symptomatology assesses the amount of pain or discomfort when chewing and having adequate amounts of saliva to speak, to taste and to swallow. Pathology evaluates oral discomfort and the presence of lesions in the mouth. Esthetics focuses on the patients’ expectations to improve their appearance or smile. In order to achieve these assessments, the investigators suggested that clinicians need to ask older adults the following questions:
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What are the patient’s desires and expectations with regard to dental treatment?
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What are the type and severity of dental needs?
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What is the impact of dental treatment on quality of life?
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What is the probability of positive outcomes of dental treatment?
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What are reasonable dental treatment alternatives?
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What is the ability of the patient to tolerate the stress of dental treatment?
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What is the capability of the patient to maintain oral health?
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What are the patient’s financial and other resources to pay for dental treatment?
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What is the dentist’s capability of achieving the planned dental treatment?
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Are there any other issues?
Using the answers to these questions, the dentist then could determine what level of care was achievable for the patient, which could be very extensive care, extensive care, intermediate care, limited care, or very limited care. Very extensive care includes complex rehabilitation, such as fixed prosthodontics and implants. Extensive care may be a combination of fixed and removable prosthodontics. Intermediate care requires a modification of traditional therapies, such as an interim prosthesis. Limited care suggests that patients cannot tolerate extensive treatment time in the dental chair and require short appointments and simplified treatment. Very limited care focuses only on pain relief and infection control.
Various other models have been proposed to aid the clinician in decision making, especially with regard to the medically at risk and frail and functionally dependent older adults , . Recently, a teaching tool was created to provide a structured process to guide novice students when caring for frail and functionally dependent older adults. This teaching tool helps the students to process the overwhelming amount of information gathered from their patients and helps them to develop a decision-making process that would lead them to rational treatment planning. This concept, which has been called rapid oral health deterioration (ROHD) risk assessment, also may be useful for the practicing dentist.
The concept was developed because more older adults are keeping their teeth into older age, which has complicated dental treatment. There is evidence that as they age the risk of oral disease, which negatively affects their dentition or results in the deterioration of their general health, increases. ROHD has been based on evidence based risk factors, which have been classified into 3 categories: (1) general health conditions, (2) social support, and (3) oral health conditions. Briefly, in the first category, there are multiple diseases, which influence a patient’s ability to maintain oral hygiene, which would increase their risk of ROHD. Some of the concepts included in the social support category are lack of income or dental insurance, dependency on caregivers, transportation barriers, being institutionalized or homebound, and being able to access adequate nutrition as well as having had the benefit of lifelong community water fluoridation. The oral condition category encompasses factors, such as dry mouth and xerostomia associated with disease and polypharmacy, lesions of the oral mucosa, level of oral hygiene, number of heavily restored teeth, amount of coronal and root caries, degree of periodontal disease, and presence of fixed and removable prosthesis. Box 1 presents the detailed steps used for treatment planning based on the concepts of ROHD risk assessment.
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Step 1. Gathering information concerning ROHD risk factors
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General health conditions
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Social support
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Oral health conditions
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Step 2. Prioritizing the information and developing an appropriate communication plan
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What matter most for disease progression and treatment planning?
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What will happen if the patient does not receive dental care?
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An appropriate communication plan includes but is not limited to explaining the findings, the prognosis, the treatment alternatives, and the maintenance plan to the patient and care personnel.
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Step 3. Categorizing the risk for ROHD
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Risk factors are not present; therefore, ROHD is not occurring.
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Risk factors are present; however, ROHD currently is not occurring.
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Risk factors are present, and ROHD currently is occurring.
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Risk factors are present, and ROHD already has occurred.
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Step 4. Identifying possible treatment alternatives compatible with rational treatment planning
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Comprehensive care
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Limited care (maintenance and monitoring)
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Emergency care (pain and infection control)
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No treatment
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Step 5. Developing a maintenance plan
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