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Senior Oral Care: Restorative Challenges When Treating Older Patients
By 2030, projections put the number of people in the US over age 65 at over 73 million. Will you be ready to treat them in your practice? We look at restorative challenges when treating older patients.
Many of your current and potential patients are over 65. The 2020 census revealed that over 56 million people in the US are 65 and older, representing almost 17 percent of the population. In 2030, that population segment jumps to 73 million and nearly 86 million by 2050.
Moreover, more people kept their teeth than in previous generations. The number of people that had full-mouth extractions between 2012 and 2020 dropped by 17 percent to 13.4 percent (compared to 16.1 percent).1
So, when some of these older patients find their way into your chair, will you be ready to treat them?
While many things are no different when treating a senior patient, some things are. We look at restorative challenges when treating older patients and how you can prepare to handle them in your practice.
The Need is High for Oral Health Management
Older adults need oral care. At 96 percent, almost all people this age have had a cavity, and 20 percent have untreated tooth decay.2 Most of them also have gum disease, at 68 percent,3 and this age group is often diagnosed with severe cases.4 In addition, the median age for diagnosis of oral cancer is 62.5
Many people in this age group go to the dentist. In 2017, nearly 66 percent in this age group had gone to the dentist in the last 12 months. However, you can see that this percentage declines as patients age. For example, nearly 68 percent of patients under 74 had been to the dentist in the past 12 months, but the rate drops to 64 percent from ages 75-84, and then to 58 percent for those 85 and older.6
The Challenges When Treating Older Patients for Restorative Cases
There are a few reasons for this decline as patients age. Some are age-related, others are financial, and a few are societal. However, they affect how often you see your older patients in the chair.
For example, many adults in this age group do not have dental coverage. Much of this population is retired, so they no longer have employer-sponsored health and dental care. Also, Medicare does not cover most of the dental care they need regularly.7 In 2017, the CDC reported that only 29.2 percent of adults 65 and older had dental insurance.8
This age group also has complicated health histories. They have higher rates of obesity (29.3 percent) than previous generations at this age. Plus, they have reached a time when inflammatory conditions like cardiovascular disease, diabetes, and Alzheimer's disease have settled in, requiring medications to manage them. In the 65 to 74 age range, 46 percent had multiple chronic conditions.9 The medicines for these conditions can lead to complications with their oral health, stemming from Xerostomia, which contributes to tooth decay and root caries. Moreover, older adults have high rates of gum disease and candidiasis at this age.10
Past dental decisions might also affect their oral health in older age. Their teeth may appear darkened from consuming foods and drinks that stain the dentin and thinning enamel that allows it to show through. Some may suffer from an uneven jawbone because of not replacing missing teeth, allowing their teeth to shift. Older edentulous patients wearing a removable prosthesis might also have stomatitis from their dentures, which inflames the tissue underneath.11
Social norms play a role here, too. Women were more likely than men to see a dentist and retain their natural dentition. Highly educated older adults were also more likely to have better oral health than those without as much formal education. Isolated adults, due to separation or divorce or death of a spouse, were also more likely to have poor oral health than those with a support system.12
In addition, adults in this age group can't always get to dental appointments at the practice. Many no longer drive or live in nursing homes, so getting where they need to go depends on caregivers. Some have difficulties in taking care of themselves, too, which leads to poor home care habits that exacerbate declining oral health conditions.13
How to Prepare to Serve This Population
So, with so many obstacles to care, what should clinicians do to prepare to serve this population? Jeffrey Hoos, DMD, FAGD, a private-practice dentist in Stratford, Connecticut, says that gray hair or a number on the birthdate line do not always define the patient sitting in the chair. The restorative challenges you have with one older patient might not be the same with a different older patient that enjoys better overall health.
Instead, Dr Hoos considers overall health, systemic disease presence, and medication regimen. With women, he would want to know if they have reached menopause or are taking estrogen replacements or anticholinergics drugs. Each patient, he says, should be assessed on where they are in their life and what is possible in terms of their home care.
For example, Dr Hoos never cleaned his mother's teeth in 30 years because she was so thorough in her oral care. She didn't require professional cleaning. He also has some patients with zero plaque on their teeth after 6 months and others that need their teeth cleaned every month because they don't brush and floss the way they should.
"You have to have a customized health care plan," Dr Hoos says.
Lifestyle is an essential part of this customized health care plan, Dr Hoos explains. What patients eat has a lot to do with their oral health. Regarding an older population, their diet during the day and how often they brush have a lot to do with managing their plaque. For example, having cookies and tea, drinking coffee with lots of sugar, or sucking on hard candy all day bathes the teeth in sugar, feeding the plaque that then attacks the teeth.
"So, it's not your teeth; it's what you do with them," Dr Hoos says. "So, you could do the best restoration with the best margins in the world, but without proper home care, nothing will stand up."
Dr Hoos thinks the restorative material you choose for your decay-prone older patients is essential, particularly regarding marginal breakdown. He likes Kuraray Noritake Dental's CLEARFIL™ SE Protect to give his restorations the most significant bond strength and keep his restorations in place while protecting against decay.
"If you don't have a good bond in your restorations, the bacteria leaches where it is warm, wet, and dark, a perfect nidus for tooth decay to start," Dr Hoos says.
Also, Dr Hoos says you should openly discuss getting plaque under control with patients. He says showing patients with a mirror is all it takes to show them the problem and talk about solutions together. Dr Hoos says technology is also great for this, but many patients appreciate the analog device.
"We practice patient-centered dentistry. Patient-centered dentistry means patients diagnose with us what they need us to do. It's a conversation you have with your patients," Dr Hoos says.
However, it isn't that he lets patients control what treatments they need. Instead, he listens to what they object to and doesn't insist they move forward with treatment if the answer is "no." This tactic gives Dr Hoos another chance to talk to the patient about the treatment in the future rather than losing them with his insistence upon treatment plan acceptance. He compares it to choosing your battles with teenage children.
"There are patients that come in that require different levels of care, not different levels of quality of care, but different levels of interaction," Dr Hoos explains, adding that he employs the transactional analysis model or adult-to-adult communication. "You never speak to anyone unless they are at eye level with you so that you can have an adult conversation."
Moreover, Dr Hoos never wants to embarrass a patient but instead elevate them. For example, many dentists present treatment plans that cost tens of thousands of dollars but have no idea where the patient is in life or what the patient can afford.
"We have no problem presenting treatment plans that are $30,000, $40,000, and $50,000, but if someone earns $100,000 or $200,000 a year, can they afford $50,000 worth of dentistry? Maybe they can. So, you must understand where the patient is before talking to them about dentistry. You need to have a relationship before you ask if they want to do this."
Dr Hoos says this approach means you get a chance to have the next conversation where you can try to meet them where they are. Then, you can get them to the best possible oral health that they are open to right now. By allowing that goal to guide your actions, you can overcome some of these restorative challenges inherent with an aging patient population.
"That interaction that you have with that patient,” Dr Hoos says, “allows you to provide the highest quality care for the greatest number of patients while maintaining a balance between your personal and professional life.”
