Dentistry for seniors

dentistry for seniors

Silver fluoride treatment is among the many ways dental practices can prepare for the coming surge in elderly patients. By James Gallaway

We’re getting older and more and more of us are keeping all our teeth. In a little over a decade, one fifth of the Australian population will be over 65—well outnumbering those under 20—and success for a dental practice in this ‘grey new world’ will require dentists to think differently about treatments and surgery fit-outs, if they want their business to thrive.

“Eliminating stairs and creating roomier treatment facilities are definitely a good start,” according to Dr Alan Deutsch, principal at Bondi Junction Dental, and formerly the senior clinical tutor at Sydney University’s Faculty of Dentistry.

“But,” he says, “dentists should also look at treatments that have a specific relevance to the elderly particularly, by way of example, the minimally invasive use of silver fluoride, for elderly patients generally but even more so for those that present with complications and conditions that can sometimes include any combination of higher levels of anxiety, dementia, hypertension or Parkinson’s and other distortions in cognitive function.

A far as the topical application of silver fluoride for the aged is concerned, Dr Deutsch believes it provides an ideal treatment that does not require complex training and may have the potential to prevent and arrest carries in all teeth and all surfaces.

Of the the two preparations of silver fluoride available for treatment—aqueous silver fluoride with stannous fluoride or ammonia-based silver diamine fluoride—he prefers the former because of its flexibility, and has published extensively on the clinical aspects related to the treatment.

Both treatments, he says, turn caries black (a compromise the elderly more usually accept) but the stannous form is non-threatening to patient safety because it leaves no gingival burn.

“It’s no longer possible to use a small space. Those days are gone. Older people will attend in wheelchairs and with walking frames.”—Dr Alan Deutsch, principal, Bondi Junction Dental

Dentists ready to incorporate this and other treatments in elderly patient groups should also, Dr Deutsch believes, move to outfit surgeries with an increasingly older clientele in mind. “Surgeries that do not adapt to an ageing patient load will fall behind,” he says.

“If you look at older patients born before 1950,” Dr Deutsch says, “50 per cent of them had no teeth. From then onwards, that figure drops to five percent, and from 1975 onward, it’s closer to zero. So, new methods of delivering treatment will need to be developed for the elderly, particularly those living in residential care.

“It’s no longer possible to use a small space,” he continues. “Those days are gone. Older people will attend in wheelchairs and with walking frames. Often, where the chairs have a reclining function, [older patients] can be treated without having to work through the difficulties of moving them across to the surgery chair.”

For treatment in these circumstances, practices should look to change fit-outs to add longer arms on lights and X-rays and, beyond the environment of the chair, they should also consider access ramps and handrails that are easy to grip and see, along with wheelchair access and disabled toilets and parking. Older people also prefer quiet in the waiting rooms because of hearing difficulties and problems understanding and retaining information in distracting noisy environments.

For patients who are in the 65+ age group, only five per cent are confined to home and five per cent are in residential care. This means that 90 per cent of patients in this age group are mobile to some degree and have a reasonable level of self-care when it comes to dental hygiene, but this is likely to fall away as they age.

“With the aged,” Dr Deutsch says, “a higher incidence of polypharmacy, which depresses salivary function, produces a more acidic environment in the mouth. This higher level of acidity can dissolve teeth to the root stumps within two years.”

“If you look at older patients born before 1950, 50 per cent of them had no teeth. From then onwards, that figure drops to five per cent, and from 1975 onward, it’s closer to zero. So, new methods of delivering treatment will need to be developed for the elderly.”—Dr Alan Deutsch, principal, Bondi Junction Dental

Cognitive impairment also negatively impacts on dental health in the aged. Dr Deutsch cites a 2014 study in Melbourne nursing homes that found 67.9 per cent with untreated coronial caries and 77.4 per cent with untreated root caries. Significant increases are also observed in people with Alzheimer’s and dementia, creating circumstances where older Australians will have a greater impact on dental services as ‘the absolute numbers of inadequately maintained mouths increases’.

Dr Deutsch says it is important that dental practices come to terms with the fact that the number of elderly patients they see will increase over time. Ignoring this inevitability, he says, will harm the practice.

In part, this can involve a process of making small changes and adapting slowly. These small adjustments are then re-evaluated at monthly intervals by monitoring patient and dental team member’s levels of satisfaction. Success stories should be shared throughout the practice as changes become more permanent.

Dr Deutsch’s experience in aged care dentistry saw him set up a clinic for the elderly at Randwick Montefiore Home in Sydney. The facility is one of the first purpose-built dental clinics in an aged care facility in Australia that provides dental programs directed at the elderly.

“We wanted the clinic to be self-sustaining, financially, which meant there were a lot of challenges involved in presenting elderly residents with treatment options,” he says. Issues relating to cost, for example, were resolved when incoming residents were told that they would only need to pay annually the equivalent of one dollar a day for dental treatment.

“As older people lose cognitive capacity,” Dr Deutsch adds, “the responsibility for attending dental check-ups and their health in general often devolves to their children.”

Which is why when discussing getting older and expectations about their longer-term dental care with patients in their 40s and 50s, Dr Deutsch suggests dentists also ask patients about their intentions on behalf of their ageing parents.

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