Dental treatment concepts for elderly and medically compromised individuals focus on restoring mastication in order to reestablish nutrition and thereby improve the oral health-related quality of life (OHRQoL).1–5 This goal should be achieved with treatment concepts that are minimally invasive and reduce the treatment burden (Fig 16-1). This can be accomplished by adopting procedures that promote preventive measures, simplify restorative procedures, and avoid surgeries.6–14 However, the need for minimally/optimally invasive rehabilitation in age-advanced and/or medically compromised patients can be questioned. Would it be better if tooth loss in such individuals could be prevented, in order to avoid rehabilitation?
Aging is inevitable; the associated sequelae to this phenomenon are hence unavoidable, but may be preventable. Dental treatments, either for maintaining the natural teeth or for restoring the lost dentition, are an expensive and complicated affair in dependent and medically compromised individuals.
Maintaining oral health and adopting preventive strategies are cardinal measures that must be considered as prerequisites when planning oral health care for medically compromised or elderly individuals.
Population demographics for the year 2017 reveal that there are approximately 962 million people aged 60 years or over worldwide, and this is expected to double by 2050.15 There are an estimated 137 million people aged 80 years and over, and this is likely to rise to approximately 425 million by 2050 (Fig 16-2).15,17 By then, 35% of Europe’s population will be aged 60 years or over. Switzerland alone is currently estimated to have 18.4% of its population who are 65 years or over, of which 5.1% are above 80 years; it is expected to increase to 28.7% and 11.7% by 2050, respectively.15,18
An aging society has an impact on a socioeconomic as well as on a biologic front. Age-related changes cause functional and structural changes in the body and affect all systems.19 The systems degenerate,20,21 along with a diminution of the oral and perioral structures.22–27 Irreversible degenerative changes are evident in the skin and the musculoskeletal system.28–31 These musculoskeletal changes are pertinent when treating elderly adults as it potentially limits the overall mobility of the individual. Metabolic capacities and responses to drug treatments are also affected,32 making the therapeutic doses of the drugs administered fairly complicated.
In elderly and medically compromised pa-tients, multimorbidity is often a common presentation.33,34 Due to this, polypharmacy is an associated feature and, as a consequence, xerostomia and drug-induced hyposalivation are frequently a common finding in these individuals.35 Moreover, these individuals usually present with a loss of functional autonomy with/without cognitive decline, with dementia being very common in age-advanced institutionalized dependent elders.36,37
Cognitive decline is one of the biggest health risks in elderly people, with Alzheimer disease (AD) occurring in almost 50% of those 85 years and over.38 Furthermore, functional and nutritional status is poor in institutionalized elders.39
Poor oral hygiene is a very common finding in such institutionalized dependent elders,40 and this is further deteriorated in those with cognitive impairments and dementia.41 Poor oral health and untreated oral infections can be precursors for developing cognitive impairment and clinical manifestations of AD.41,42
Physiologic age-related changes and complications have a direct clinical impact on oral health and the dental team. The treatment rationale, therefore, migrates towards a more preventive approach, with the focus on an attempt to delay some of the age-related changes.18
Along with advancing age, another demographic trend that has been witnessed in developing nations is the retention of natural teeth to an advanced age.43,44 This trend can be attributed to the advancements in dental treatments, success of the preventive treatment programs, and provision of, as well as access to quality dental care. The “domino effect” predicted a decline in edentulism almost two decades ago.45–47 Current demographic trends show this prediction to be true.43,48 A factor to consider is that the retention of teeth to an older stratum might be beneficial, but the risk of caries and periodontal infections is augmented.49–53 Problems with dental health start occurring in this advanced age due to age-associated chronic disease and/or disability. Tooth loss eventually presents itself in a much older and, more frequently, in a frail dependent older population segment.
Periodontal disease is one of the most prevalent diseases known to man that affects both the young and elderly adult population.48,54 Recent reports indicate that this condition has undergone a demographic shift, in the direction of the advanced age strata.48 This shift is more evident in high-income countries. Possible explanations are that the younger adult population lead a healthy lifestyle, are better educated, and hence more aware of preventive measures, as well as the increasing affordability of dental treatments along with relatively good access to quality dental care.55 While these factors may be considered common denominators for the older population, it is difficult to draw and predict the same inferences for this older age group. The age-advanced individual is relatively more at risk for periodontal disease. Hence periodontal treatment needs will become more age-specific, isolated to the advanced age groups.48
A similar trend observed is in the incidence of caries, and in particular, root caries. Root caries prevalence has steadily increased in elderly adults, and increases even more as age advances.48 Root caries is a growing problem in medically compromised subjects because of the comorbidities, such as drug-induced hyposalivation, cognitive decline, and loss of physical and functional autonomy.
Prevention of root caries and its management with minimally invasive techniques are essential in this vulnerable patient cohort.
Certain adults are more prone to periodontal disease than others because of genetic and/or microbial influences. It is important to understand that the progression of periodontal disease is not a continuous entity but occurs over periods of recurrent acute episodes.56,57 In older adults, the general health status plays a crucial role in the disease progression. This does not imply that periodontal disease occurs because of the underlying health condition, but rather that the underlying condition makes the medically compromised elder more susceptible to it.57 The actual disease onset may have occurred at an earlier age and before the elder became dependent and/or medically compromised. The progression, however, becomes more pronounced in elders who require more care.57,58 These institutionalized dependent elders have usually poor oral health in comparison with elders living independently. Elevated levels of dental biofilms/plaque in the oral cavity lead to an increase in the oral bacterial load that could make the institutionalized dependent elder more susceptible to various systemic diseases, and augment the risk of death due to aspiration pneumonia.40,50,51,53,59
An important aspect to consider is the disease propensity. In a study with a mixed age cohort (age range 28 to 75 years) that induced experimental gingivitis and experimental peri-implant mucositis, the authors concluded that the inflammatory responses could be reversed at the biomarker level, soon after resuming plaque control.60 Clinically, however, the restoration of gingival and peri-implant health to pre-experimental levels took longer than the stipulated time period. Furthermore, it was observed that the inflammatory responses were stronger around the implants.60 Another study that had included only an elderly cohort (mean age 77.0 years) demonstrated similar findings in elders. In this study, the inflammatory response around the implants was again stronger than around the natural teeth.61 Although a distinction between the peri-implant mucosal and gingival responses existed, the bacterial profiles in the submucosal/subgingival sulci were similar.62 A longer healing period was required clinically to reverse the induced effects.60–62 This demonstrates that periodontal disease must be contained or arrested before the effects of aging set in.
Although old age is not a contraindication to periodontal therapy in medically compromised institutionalized dependent elders, it is a general consensus that treatments that prevent disease progression are recommended.63,64 Preventive strategies to minimize periodontal diseases in young or middle-aged adults are cardinal. This will limit the progression of the disease to an advanced age, thereby reducing the potential susceptibility as well as preserving the natural teeth. It has been documented that institutionalized dependent elders receiving regular oral care will retain more teeth when compared to elders not receiving regular care. However, routine care received by dependent elders does not have the same outcome as in younger adults.65 Therefore, the preventive care should focus more on improving and maintaining oral hygiene. Factors such as manual dexterity, access to care, the knowledge and skills of the care providers, reluctance in providing care by the providers, and/or the reluctance of the elders themselves to accept or perform the required care all play an important role in preventing the disease progression.
The strategy for oral prevention in elderly or medically compromised patients should be individualized based on patient needs, and tailor-made (Fig 16-3). Provision of appropriate tools for oral care (manual or electric toothbrushes, flosses, floss-handles, interdental brushes, tongue scrapers), and modifying them based on the elders’ disabilities or for the ease of use may dramatically help to improve oral hygiene.66
Primary prevention strategies such as routine biofilm removal and professional mechanical plaque removal reduce gingivitis and help decrease the prevalence of mild/moderate periodontitis.67–69 Routine professional mechanical plaque debridement as supportive therapy restricts the progressive attachment loss and prevents further tooth loss.70 Additionally, careful monitoring of risk factors, such as diabetes mellitus, can further prevent disease progression. Periodic recalls to assess the progress of the therapy are important. If during recall, the treatment benefits are not evident then a referral to the periodontist would be mandatory. Professional elimination of both supragingival and subgingival plaque deposits either by surgical or nonsurgical interventions is key to achieving success.71 A successful therapy would result in the following70:
- reducing the sites of bleeding on probing and restricting them to below 15%
- restricting probing pocket depths to less than 5 mm
- eliminating active infections (absence of suppuration/pus).
It is empirical that there is complete compliance with home care, from both the patient and the caregiver, involving efficient plaque removal, and that scheduled recall visits are maintained.
Preventive strategies for coronal caries are well documented in children and young adults, and these srategies are relatively similar for elderly patients. This section focuses on the preventive strategies for root caries in particular for elderly/medically compromised patients because of its increasingly high prevalence in this cohort.
- periodontal disease and associated recessions
- xerostomia, hyposalivation
- impaired manual dexterity
- cognitive decline
- poor oral hygiene, a high Plaque Index
- high carbohydrate diet
- mobility issues with a lack of access to quality dental care.
Although root caries can be treated with traditional restorative procedures, this is not always possible, due to procedural difficulties or logistic reasons. Therefore, therapeutic strategies for root caries predominantly focus on prevention. Prevention of root caries can be primary, secondary, or tertiary. Primary prevention aims to prevent the initiation of root caries, whereas secondary and tertiary methods take place after the caries has occurred.
Tertiary prevention of root caries comprises invasive restorative procedures that constitute the conventional “drill and fill” and atraumatic restorative therapy (ART) (Fig 16-4) techniques.