Quality Resource Guide l Geriatric Dentistry: A Total Patient Approach 4th Edition 3 www.metdental.com Management of dental care Comfort in traditional settings For the dental treatment, there are many techniques to improve comfort during care. The clinician should offer frequent bathroom breaks for seniors with bladder or prostate conditions, or for those taking diuretic medications. Placing towels or pillows in the chair can ease pains associated with neck or back problems, leg cramps, arthritis, or musculoskeletal diseases. Many elderly patients seem to be acutely sensitive to cold or hot temperatures. Having fans available or blankets to offer demonstrate that the provider is concern about the patient having a comfortable experience. Office floorplans with wider hallways and open doorways more easily accommodate patients who are using walkers, wheelchairs, or scooters. Preventive strategies When treating the compromised geriatric dental patient, the clinician must look for methods to offer preventative care that targets their limitations. A patient who has suffered a stroke or has arthritis may present with low grip strength that does not allow them to properly hold a toothbrush. The dentist can suggest a mechanical toothbrush with a larger diameter handle or help modify a manual toothbrush by wrapping aluminum foil around the handle. Other potential toothbrush modifications include drilling holes and attaching vinyl or leather straps, using foam pipe insulation around the handle, or cutting a section of washcloth and securing it around the handle. Appropriate oral care aids to consider include water picks, floss holders, and interproximal brushes for those open embrasure areas that commonly develop when gingival recession occurs. The dentist may recommend xylitol products, such as mints or gum, for the patient with dry mouth or otherwise highly prone to developing carious lesions. Alcohol-free mouth rinses should be advised for patients that use rinses. A mirror at counter level should be recommended to clients in wheelchairs so they can more easily see and evaluate their oral hygiene performance. A relatively new therapy for preventive treatment is silver diamine fluoride (SDF) 38%. SDF was approved In 2014 by the US Food and Drug Administration for treating dental hypersensitivity. In 2016, the FDA gave a “breakthrough therapy designation” for SDF 38% as a caries arresting therapy agent for children and adults. Though it causes affected dentin to stain black, the SDF may be a viable option for older patients with nonrestorable teeth who are not ready for extraction. For patients who are not good candidate for dental prosthesis, have limited finances, limited “access to care”, or cannot cooperate during dental restorative procedures, SDF may allow otherwise nonrestorable teeth longer functional time. 11 Groups that can greatly benefit from SDF application include those residing in institutions, the medically compromised, patients with dementia or mental illnesses, and those needing palliative dental treatment. 11 Logistical challenges Dentists treating geriatric patients may face complicated logistical issues, financial concerns, and other factors that influence treatment planning. For example, getting the older patient, who no longer drives, to and from appointments might involve coordinating with their family, friends, or a transportation service. While many seniors are financially self-reliant, some are on fixed incomes and lack dental insurance coverage. Social Security can be a safety net. In 2021, the average monthly Social Security benefit was $1544 a month. 5 In 2017, Social Security benefits represented over 50% of total income for 50% of married couples, and 70% of single people. 5 For 21% of married couples and 45% of unmarried persons, social security was at least 90% of their income. 5 Even among patients who are financially secure, it is not uncommon for them to decline recommended treatments because - facing the possible end of their lives - some consider dental work an unnecessary expenditure. These factors present challenges for the dentist when planning treatment. Dentists should become familiar with local resources that may ease financial pressure, which is a deterrent for treatment. Adult Protective Services, Area Aging Councils, local charitable organizations that offer elder services, and hospital or institutional reimbursements in cases of lost dentures or partials may be resources to tap into. Even when a patient is willing and can afford major treatments, the dentist must weigh the patient’s expected life expectancy, quality of life issues, and ability to adapt to changes to present adequate information for an informed decision. (Table 2 summarizes issues that may deter an elderly patient from accepting a care recommendation.) Medical considerations in planning treatment Treating a geriatric patient will require more time. Investing the necessary time to obtain medical histories, research medications and consult physicians will demonstrate the dentist’s dedication to the patients and their caregivers. The time invested yields valuable insights into medical trends and will return dividends not only for the current patient, but also when future patients with similar conditions are encountered. Although conducting such due diligence is time consuming, taking shortcuts can pose serious potential problems if disease processes or medications are not adequately understood. Table 2 - Why the elderly might decline dental treatment • Perceived shortened remaining life span • Consider dentistry an unnecessary expenditure • Fixed income, limited finances • Transportation issues • Health care or medication costs are more priority expenses • Financially helping adult children or other family members • Functionally impaired (cognitively, physiologically, physically)