Dental Care for the Aged: Role of the Private Practitioner

TW ELFTH N A T IO N A L DEN TAL H EA LTH C O N FE R EN C E .

. VOLUM E 64, FEBRUARY 1962 • 27/145

DENTAL CARE FO R THE AGED: ROLE OF THE PR IV A TE PRA CTITIO N E R

Sidney I. Silverman,* D.D.S., New York

Dental care provides nutritional and psy­ chological support for the aging patient. Such support means that the dentist’s re­ sponsibility is not confined to masticatory function but is related to the deglutitive, respiratory, speech and language func­ tions of the patient, and to the special senses of vision, hearing and taste, to head posture and ultimately, to the training and learning of vocational skills. This broad concept of dental care responsibil­ ity is relatively recent. It is substantiated by recent research experiences in studies in which the behavioral sciences have been coordinated with the biologic and clinical sciences. The management of dental care for the aging is thus related to both the social and medical aspects of their lives. The

socioeconomic experience of a patient and his prevailing medical condition are in constant interaction and together exist as a constellation of forces within which dental service is provided (illustration). The principal responsibility o f dentists toward the aging patients is to provide care for acute inflammatory conditions, to maintain and retain the residual oral structures and to restore teeth adequately for ingestion of food. Studies at several metropolitan hospitals reveal that many patients under supervision are served ade­ quate dietaries, yet do not ingest foods because of poor dental health. This re­ sults in a low protein, high fluid, high carbohydrate diet which undermines the health of an already sick person. The second major responsibility of

H e a l t h r e p r e s e n t s a s t a t e o f e q u i l i b r i u m b e t w e e n n o r m a l p h y s i o l o g i c a c t i v i t y a n d p a t h o l o g i c p ro c e s s e s o f d is e a s e ( F r o m S ilv e r m a n , S . I. O r a l p h y s io lo g y . S t, L o u is , C . V . M o s b y C o . , 1 9 6 1 )

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dentists is to improve the speech and language functions and to restore the facial appearance of the edentulous and partially edentulous patient. The im­ provement in speech and the improved esthetics of the face form lead to im­ proved social relations for patients who are seeking company, friends and social activity. The combined effect o f improved speech and appearance facilitates adjust­ ment to disability and to reduced func­ tion. The treatment most frequently needed for the aging relates to the management o f the residual dentoalveolar structures by periodontal and prosthodontic care as­ sociated with surgical, endodontic and restorative procedures. Thus, the aging patient requires all the skills which the dental practitioner must make available to the younger patient. There are, how­ ever, two important considerations of which the private practitioner must be cognizant in order to provide satisfactory dental care in private practice for these patients. They are (1) the increasing number of aged persons and increasing longevity, and (2) the high incidence of chronic disease and disability in patients o f this age group. These conditions dictate, in part, the diagnosis and treatment planning for dental care. The increased number of aged persons requiring and seeking care is adding to the critical shortage o f dental personnel trained to treat effectively the special clinical problems of such patients. The profession must, therefore, re-exam­ ine its diagnostic and therapeutic pro­ cedures to husband its personnel and physical resources. For example, tooth mobility in a young adult frequently has a different prognosis than does a similar disability in an older person; or, whereas a full complement of maxillary and man­ dibular teeth are restored for a mature adult, only the maxillary denture may be constructed for an older person; or fur­ ther still, whereas excessive keratinization o f the mucous membrane of a 50 year

old patient is viewed with considerable suspicion, in a 70 year old it is regarded with less anxiety. These clinical comparisons are not sharply delineated in practice according to age groups and the dentist must there­ fore view aging as a three dimensional phenomenon; namely, the chronologic age, the physiologic age and the psycho­ logic state of the patient. The processes are in constant interaction, and the den­ tist must assess their interrelationship for both the diagnosis and the treatment plan. This presentation will discuss these three processes and their effect on the clinician’s judgment. C H R O N O L O G IC AGE

The aging period is not clearly separated chronologically or physiologically from the preceding periods of adulthood. Table 1 demonstrates the increasing variability in the chronologic age in relation to bi­ ologic age. However, notwithstanding the variability, there is incontrovertible evi­ dence that the number and the longevity of older people are increasing. The lon­ gevity is increasing at a rate o f five years for every ten years so that it is apparent that every practitioner’s office will soon average one adult over 50 for every four patients. This represents a significant pro­ portion of his professional activity and related income. It then behooves the den­ tist to provide all the preventive and re­ storative practices that he makes.available to the children and the younger adult. The dentist who attempts to classify patients chronologically frequently may be shocked when he observes a 70 year old woman who can chew more vigorously with her few remaining abraded anterior teeth than can a young 35 year old man who has difficulty even chewing with an expertly fabricated fixed partial pros­ thesis. These contradictions arise when dentists direct their attention solely to the mechanical and restorative phase of tooth structure to the exclusion o f the biologic

TW ELFTH N A TIO N A L D EN TAL H EA LTH C O N FE R EN C E . . . VOLUM E 64, FEBRUARY 1962 • 29/167

T a b le 1 • In c r e a s in g v a r ia b ilit y o f c h r o n o lo g ic a g e in r e la t io n t o b i o lo g ic a g e * B io lo g ic la n d m a rk s

A v e r a g e c h r o n o lo g ic age a t onset E m b ry o n ic F e ta l

C o n c e p t io n

B irth

P e rio d

9 m o n th s +

2 w eeks

N e w b o rn In fa n tile C h ild h o o d

P u b e rty

12 y e a rs +

2 y e a rs

A d o le s c e n t^

F e r tility

16 y e a rs +

3 y e a rs

Y o u th Y o u n g a d u lt M a tu r it y

C lim a c te r iu m (fe m a le )

47 y e a rs +

5 y e a rs

O ld a g e

7 0 y e a rs +

1 0 y e a /s

- P e d ia tr ic p h a s e

A c t iv e a d u lt p h a s e

l a t e r m a tu r ity 1 r x S enescent S e n ile

> G e r ia t r ic p h a s e J

* F ro m S te ig litz , E d w a rd J u liu s . A fu tu r e f o r p re v e n tiv e m e d ic in e . C a m b r id g e , M ass., H a rv a r d 1945.

aspects o f tooth care in relation to the treatment of the periodontium, the bone and the muscle activity of the oral struc­ tures. These dental and oral structures depend directly on the systemic effects of the circulation, the endocrine, the neuro­ logic and the metabolic mechanisms of the body. The significant difference, therefore, in treating the aged is a shift in emphasis in diagnosis to an assessment o f the physiological state of the patient and in treatment planning to more bio­ logic considerations rather than to me­ chanical procedures. P H Y S IO L O G IC AGE

There is a general need for regarding aging as a normal life process and not as an illness. Also, it must be remembered that there is an interaction between the processes of health and those of disease. There are a number of changes which take place in aging people which may be accepted as physiologically normal for this group. These are gradual desiccation, retardation of cell division and capacity o f cell growth and tissue repair, lowering o f the basal metabolic rate, cellular atro­ phy, increased pigmentation and fatty

U n iv e rs ity Press,

infiltration, gradual decrease in tissue elasticity with ultimate degeneration of the elastic tissue, decreased speed and strength of neuromuscular reactions, and progressive degeneration of the nervous system. It is apparent, then, that the aging patient whose tissues are degenerating must suffer from many chronic diseases and disorders. In fact, the data in Table 2 reveal that from 56.9 per cent to 83.01 per cent o f the population over 45 years of age suffer from one or more chronic diseases. Thus dental care must be pro­ vided for these patients under conditions in which the physiologic processes of cells and functional organ systems are altered or deviate from the so-called norm. The most common clinical dental care prob­ lems o f aging relate to periodontal care and mobile teeth, prosthesis, tumors, and nutrition. M O B IL E T E E T H

The most significant clinical problem for the dentist in general practice is to evalu­ ate the mobile tooth. It is unfortunate that many aging patients are rushed into a completely edentulous state prematurely

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T a b le 2 •

H e a lth s ta tu s o f th e c iv ilia n n o n in s tlt u t io n a l p o p u la t io n o f th e C o n t in e n ta l U n ite d S ta te s *

A g e ly r.) (b o th se xe s)

A ll p e rs o n s

P e rs o n s w ith n o c h r o n ic c o n d it io n

A ll a g e s

1 0 0 .0

U n d e r 15 1 5 -2 9

P e rso n s w ith o n e o r m o re c h r o n ic c o n d it io n s !

T o ta l

W ith n o lim ita tio n o f a c t iv it y

W i t h p a r t ia lj; lim ita tio n o f a c t iv it y

W it h m a j o r ! lim ita tio n o f a c t iv it y

5 8 .6

4 1.4

3 1 .3

8 .0

2.1

1 00 .0 1 00 .0

8 2 .5 65.1

17.5 3 4 .9

16.0 3 0 .3

1.2 4 .0

0 .2 0 .5

3 0 -4 4 4 5 -5 4

1 00 .0 1 00 .0

5 0 .8 43.1

4 9 .2 5 6 .9

4 1 .2 4 3 .9

7 .2 11.3

0 .8 1.7

5 5 -6 4 6 5 -7 4

1 0 0 .0 1 00 .0

3 4 .6 2 4 .4

6 5 .4 7 5 .6

4 3 .4 3 8 .4

17.6 2 7 .8

4 .4 9 .4

75

1 00 .0

16.9

83.1

2 8 .2

31.1

2 3 .7

*F ro m U n ite d S ta te s P u b lic H e a lth B u lle tin N o . 5 8 4 -B II, W a s h in g to n , D. C ., U . S. G o v e r n m e n t P rin tin g O ffic e . {C h r o n ic c o n d itio n s : a s th m a , a n y a lle r g y , d e n ta l d ise a se , tu b e rc u lo s is , c h ro n ic b ro n c h itis , re p o r te d a tta c k s o f sinus tr o u b le , rh e u m a tic fe v e r, h a r d e n in g o f a rte rie s , h ig h b lo o d p re ssure , h e a rt tr o u b le , s tro k e , tr o u b le w ith v a ric o s e ve in s, h e m o rrh o id s o r p ile s , g a llb la d d e r o r liv e r tr o u b le , s to m a c h u lc e r, a n y o th e r c h ro n ic s to m a c h tr o u b le , k id n e y stones o r o th e r k id n e y tr o u b le , a r t h r it is o r rh e u m a tis m , p ro s ta te tr o u b le , th y r o id tr o u b le o r g o ite r , d ia b e te s , e p ile p s y o r co n v u ls io n s o f a n y k in d , m e n ta l o r n e rvo u s tr o u b le , re p e a te d tr o u b le w ith b a c k o r sp in e,' tu m o r o r c a n c e r, c h ro n ic skin tr o u b le , h e rn ia o r ru p tu re . fL im ite d in a m o u n t o r k in d o f m a jo r o r o u ts id e a c tiv itie s . § U n a b le to c a rry o n m a jo r a c tiv it y .

because of cost factors or because the value of retaining one or more mobile teeth for the retention of a transitional partial denture is not fully appreciated. The patient who has never worn a pros­ thetic appliance should have the benefit o f a simple inexpensive partial denture, even if only for a few months, in order to learn how to use a prosthesis. It takes longer for an older than for a younger person to learn to wear dentures because o f the changes in the nervous system and in the control over the musculoskeletal function. This learning period is essen­ tial, and the dentist must develop insight into the neurophysiologic and psychologic mechanisms associated with learning the skills which the patient must acquire in order to use dentures with reasonable suc­ cess. Furthermore, it has been observed clin­ ically that whereas an individual mobile tooth may have a very guarded prognosis, several mobile teeth which collectively support a partial denture can have more than just an additive life expectancy. They appear to support each other be­ yond the time they could be retained

individually. It also appears that the m o­ bile tooth in the aging responds favorably to moderate periodontal management and occlusal adjustment. I am suggesting here only that the simple management o f sin­ gle or few remaining periodontally in­ volved teeth of an older patient be explored by the general practitioner with the objective in mind o f retaining them long enough for the wearing of a transi­ tional partial denture. This denture may be worn from several months to several years. It also has been noted that many aging patients fare better with one partial denture retained by several mobile teeth than they do with expertly made com­ plete maxillary and mandibular dentures which they do not learn to wear. The management of periodontally in­ volved teeth is eagerly undertaken by the profession when the prognosis is favorable and when there are a substantial number of teeth remaining. However, the profes­ sion has been remiss in extending the benefits of periodic care to the needs of the few remaining teeth of the aging. T o achieve the best clinical climate for the mobile tooth, the denture base should be

TW ELFTH N A TIO N A L DENTAL H EALTH C O N FE R EN C E . . . VO LU M E 64, FEBRUARY 1962 • 31/16»

extended as far as possible and as few clasps as possible should be used. These teeth are hardy indeed and can provide years of service to the patient if only the profession could accept the philosophy that it is also good dentistry to achieve short-term objectives in therapy; it is not necessary to consider only services which last a lifetime. D E N T U R E P R O S T H E S IS

The physiologic changes which occur nor­ mally during the life cycle and affect the occlusion should be included in the verti­ cal dimension and the centric relation record when complete dentures are con­ structed for an older patient. For exam­ ple, the vertical dimension should provide the freeway space that 60 to 70 year old persons would have and not the idealized 2 to 4 mm. measured on a young 30 year old adult with a full complement of teeth. In truth, the 60 year old with a 6 to 8 mm. space presents a more attractive ap­ pearance than does the “ toothy” appear­ ing, patient who has too little freeway space. The facial appearance should be evaluated during the functions of speech, swallowing, smoking and in states of emo­ tional changes from laughter, fear and anxiety, with the patient in both standing and sitting positions. It should not be evaluated solely during the passive, static state when in the dental chair. The occlusal relationship should be such that the arch form is not contracted too far by placing the teeth over the “ crest” of the ridge. These patients usu­ ally have suffered extensive loss of the alveolar bone so that the ridge crest is considerably contracted. When the teeth are placed over the ridge, the face is not adequately supported and the tongue is crowded so that it interferes with res­ piration. Such injudicious placement of the arch results either in a collapsed facial appearance because the lip and face con­ tours have lost muscle tonus even though the patients can wear the denture, or in

a strained uncomfortable look of the pa­ tient who can only wear the dentures for very brief intervals before a state of suffo­ cation and anxiety compels them to re­ move the denture. Generally there is associated with these denture problems a considerable change in the physical and chemical characteris­ tics of the dietary intake. The patients change, some slowly, others suddenly, to a high carbohydrate, low protein, nonde­ tergent diet which impairs the nutritional state of the patient and creates the loss of muscle tone so necessary for good face form and the maintenance of the func­ tional configurations of the philtrum, the modiolus and the lip form. The patients therefore require careful dietary advice to maintain good health, otherwise all the medical conditions can be exacerbated. In a recent study of 300 patients with chronic disease who were wearing com­ plete dentures, it was observed that many patients function very well with mobile denture bases. It is concluded that move­ ment in the denture base is not neces­ sarily a failure or to be criticized if the denture base remains stable during func­ tion. One of the critical phases of treat­ ment related to stability when movement occurs has been demonstrated in the management of the postpalatal region and the distal extension of the lower den­ ture. Denture bases should be extended as far as possible in the posterior region of the soft palate providing, however, that the depth of the posterior seal is minimal (1 to 2 m m .). In the lower den­ ture, the retromolar pad extension is es­ sential for good stability of the denture. Many unstable mandibular dentures can be salvaged by extending them over the retromolar pad when the denture is un­ derextended. S E N S O R Y F U N C T IO N

There are many neurologic changes in the aging which affect dental treatment. They are associated with the perception

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of the general senses o f touch, pressure and pain and of the special senses of vision and hearing.

o f dentures and should continue intermit­ tent follow-up examination on a regular basis.

General Senses • The older patient fre­ quently has altered pain, touch and pres­ sure perception which results in extensive ulceration associated with circulatory changes. The pressure often is not per­ ceived until the ulcer is infected and in­ flamed. On the other hand, circulatory changes often cause unusual pain after the slightest pressure on the mucous membrane. There are also proprioceptive changes which disturb the patient’s abil­ ity to use muscular mechanisms with great precision. As a result, these patients require more interocclusal space, teeth with shallow cusps and the replacement of fewer teeth than customary. Also there is a need to create greater freedom of movement from centric occasion to the acentric positions of the mandible. These patients, furthermore, should be in­ structed to select food which they can chew effectively, to ingest small morsels of food, and to take more time when chewing. The net result o f such treatment will be to create reduced masticatory forces which the patient can use effec­ tively. The sensory input stimuli arising in the oral structures are continuously sent to the brain to control the direction and magnitude of the masticatory muscula­ ture. When the sensory stimuli are defi­ cient, as they frequently are in the aging, the muscles have very aberrant activity. Sometimes they contract excessively and not in synchronous patterns. Thus fre­ quently excessive forces are generated which cause teeth to become mobile and results in the loss of alveolar bone. There are also associated with the al­ tered sensory experiences, circulatory and metabolic changes which create difficul­ ties in denture function. These disorders are the most common o f all the chronic conditions. Patients therefore should have frequent adjustments after the insertion

Vision • There are degenerative changes both in the lens and in the optic nerve function which affect the patient’ s capac­ ity to evaluate color, form and distance. It is important, therefore, to compare the patient’s ability to see objectively with what he perceives subjectively. It is rec­ ommended that the dentist use colored yarn to determine the extent o f a patient’s color perception; determine visual acuity by having the patient identify shapes of common objects at near and far distances, and observe the extent o f the field of vision o f adult patients. This latter is especially important in relation to the patient’s movement in and out of the dental chair. A poor field of vision may be the cause of an accident which results in serious injury to the patient. The ex­ amination of the aging patient’s vision should be routine. It does not have to be overt, but it should be done or the dentist may have a serious problem in accept­ ance of the color and size o f tooth re­ placement after the dentures are com­ pleted. When the patient’s vision is very poor, another person should accompany him if a judgment is to be made about the esthetics of the denture. The patient may require the services o f a physician and possibly an ophthalmologist and the appropriate referral should be made by the dentist. Hearing • There is almost a universal hearing change in all patients over 45. The earliest changes are the slight degen­ erative modifications in perceiving high frequency sounds (especially the conso­ nants) . In normal speech, the aging adult generally hears well enough for ordinary verbal communication. However, under the stress and anxiety o f dental treatment, or in the presence of the noises associated with treatment, the patient may not hear ordinary conversational voice levels. The

TW ELFTH N A TIO N A L DENTAL H EA LTH C O N FE R EN C E . . . VOLUM E 64, FEBRUARY 1962 • 33/171

dentist should therefore assess the pa­ tient’s hearing function by simple tests such as speaking first with a low voice and then with a high voice, noting the difference in responsiveness. The dentist should then speak from behind the pa­ tient and from the left and right side with low and high voice levels. The re­ sponsiveness will again reveal the state of hearing effectiveness when there are deficiencies in hearing in either the right or the left ears of the patient or in both ears. The evaluation of hearing is impor­ tant to the dentist because dental care depends on the voluntary responses of patients to verbal instructions. If the pa­ tient does not hear the instructions for appropriate treatment procedures and those required for postoperative and home care treatment, the dental care may re­ sult in failure. The dentist must there­ fore speak loud enough for the patient to hear and understand. He should rein­ force the hearing perception by standing in front of the patient so the latter can see his lips and face; that is, see the den­ tist talk. It must also be noted that high-speed instrumentation with its high frequency sounds and auditory analgesia should be used very cautiously and for only short periods of time on older people who give evidence of auditory malfunction. These patients may suffer additional in­ sult to the hearing structures and we would do well to be careful in this area of activity. It is apparent from this brief discus­ sion of sensory experience that older pa­ tients must have a carefully controlled environment, especially in relation to vi­ sion and hearing, if dental care is to be most effectively achieved. This environ­ ment sets the condition for the correct muscle and neuromuscular responses of the patient. The older patient, however, has an additional factor which affects dental care considerably; namely the per­ sonality factor.

AGIN G P E R S O N A L IT Y

The aging person’s personality is the sum total of his ideas, emotions, and behavior. It depends in part on his life’s experi­ ences and his state of health. Since most aging people have reduced sensory func­ tion, their responses are slower, they take longer to respond and to learn. They are frustrated quicker and make greater de­ mands on themselves than they can pos­ sibly fulfill. Hence, anxiety, depression and hostility generally accompany dental care for the aging. These patients may suffer keen disappointment, be very sus­ picious, and even be blunt and abusive. Some of the strange behavior charac­ teristics o f the older patient reveal great dependency— some are overdependent, almost childlike— demanding, urgent and repetitious. They want immediate atten­ tion, they are garrulous and are not re­ sponsible about wasting the dentist’ s time. Others exhibit pseudo-cooperation, which is deceiving indeed. The patient comes on time, prepays for the service, is friendly, but somehow cannot learn to wear a simple denture. The key to this personality is that the patient is “ too cooperative.” He listens carefully to in­ structions for home care of the periodon­ tal tissues but never really carries them out. There is also the perfectionist who makes unrealistic demands with veiled threats and makes suggestions about the diagnosis or treatment plan. These pa­ tients interpret their own symptoms, ad­ just their own dentures, and otherwise force the dentist to overadjust and mu­ tilate a denture. Still another character­ istic of the perfectionist is that he tries to chew bread crusts or foods he could not manage when he had natural teeth. With patients who have definite traits of anxiety, dependency or hostility, there should be limited goals in their dental care programs. The decision which dentists frequently must make concerning personality and physiologic activity is related to differ­

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ential diagnosis. Is the sensation o f pain which a patient describes psychologically induced by an altered personality or is it caused by physiologic or structural defi­ ciencies? Whatever the cause, the dentist must proceed with caution and restraint in order not to overtreat or overadjust. The dentist must be very aware that the older patients take longer to adjust to changes in occlusion and take longer to learn to use dentures; also, such pa­ tients should be advised that when fa­ tigued they should remove one or both dentures from the mouth pr whenever they are irritable. The removal of den­ tures for “ resting” should be part of the prescription and not a second best rec­ ommendation to relieve a problem. It is also important to recognize the person­ ality pattern of each patient. Some older patients can be treated best in the morn­ ing, others in the afternoon, still others only on certain days. Older people also have a longer recovery period, so that adjustments to dentures should be slight and should be done more frequently. Otherwise very satisfactory dentures will

be destroyed by the dentist through exces­ sive adjustment. Finally, the older patients should not be left to their own judgment as to when to return for re-examination. T h ey should have early recalls, 3 to 6 months, and ' should have a prophylactic service for ex­ amination of the oral mucosa, the residual teeth and the denture prosthesis. C O N C L U S IO N

The major considerations in the treat­ ment of the aging patient in private prac­ tice are namely, the chronologic, the physiologic and the personality status of the patient. These factors are in constant interaction and the practitioner must always hold them in balance if he is to provide satisfactory clinical care. 80 Park Avenue P re se n te d b e fo re th e T w e lfth N a tio n a l D e n ta l H e a lth C o n fe re n c e , A m e ric a n D e n ta l A s s o c ia tio n , C h ic a g o , A p r i l 26-28, 1961. • D ir e c to r a n d a s s o c ia te p ro fe s s o r, g r a d u a t e a n d p o s t­ g r a d u a te p ro s th o d o n tic s , N e w Y o rk U n iv e rs ity C o lle g e o f D e n tis try ; a s s o c ia te c lin ic a l p ro fe s s o r, p h y s ic a l m e d i* c in e a n d r e h a b ilit a t io n , N e w Y o rk M e d ic a l C o lle g e .