Taking Care There will be 74 million older adults

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Taking Care There will be 74 million older adults
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
Taking Care There will be 74 million older adults
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.”
Taking Care There will be 74 million older adults
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
Taking Care There will be 74 million older adults
“[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

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cognitive 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 2016
with 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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