Are we ready to care for advanced periodontitis in an aging America?
The baby boomers have taken over America! The largest growing age group of all sociological groups studied are persons over age 65. In 2012, 77 million Americans will reach retirement age. Many geriatric patients will also lose their dental insurance coverage after retirement. Currently only 20% of the geriatric population seeks out dental care. Advances in health care have increased the number of healthy seniors. However, many of these seniors are taking an average of eight medications. Often at least one of these medications causes a diminished salivary flow. Many medications enlarge gingival tissues or change other normal conditions of the oral cavity. One in two geriatric patients will be debilitated by Alzheimer's disease, causing them to rely on others to provide their daily oral care. Twenty-five percent of the geriatric population in America has advanced periodontal disease.
Most geriatric dental patients have part or all of their natural dentition. Many have previously been treated for advanced periodontitis and have numerous areas of root exposure due to recession after healing or periodontal surgical procedures. Because these advanced periodontitis patients are being placed in assisted living or managed care facilities, a new category of dental hygienist or dental hygiene practitioner will be needed. Currently very few managed care and retirement facilities have on-site dental centers. Many dental schools cannot get graduates of dental or dental hygiene programs to focus on this group because the age bracket for new graduates to gain the most return financially is 35 to 45. Most states require an annual dental exam as part of the standard of care in nursing home facilities, and most nursing homes do have a dentist of record on staff. However, few patients actually receive dental care unless family members initiate it.
Since 2002, many private research groups, including large studies in Japan and America, have studied the connection between oropharynx bacteria that cause pneumonia and anaerobic oral bacteria such as those found in periodontal pockets. Research shows that daily removal of biofilm improves the patient's risk of not contracting pneumonia, the most common cause of death in geriatric patients in long-term care, by aspirating bacteria from the oral cavity.
Our responsibility as clinical dental hygienists should be to help all our patients understand the increased risk they will have as they advance into geriatric health. How should we educate? What special needs care should we be ready to provide?
Not only am I discussing risk factors (see related sidebar) with my geriatric patients, I am advising even the 20-something patients that have placed themselves in a high-risk category by consuming too much soda, or who have a history of decalcification and hypoplastic enamel associated with previous orthodontic care. Their gingival health is also a major factor in long-term oral health as they age.
As a clinical dental hygienist responsible for providing my patients with the most up-to-date 21st century dental hygiene care, I need to understand what aspects of care are needed for the long-term health of their periodontium. Not only are we responsible for monitoring gingival health, but root health is another factor that impacts individuals that have some form of advanced periodontitis.
Products that have been on the market long enough to have solid research to back them, such as MI Paste Plus, are one of the major items I promote for home care to all patients with xerostomia, decalcification, or root exposure. Stressing immaculate plaque removal and explaining the connection between oral health and systemic health to all patients helps prepare those that will become high-risk geriatric patients. The better their oral home care is now, the healthier their hard and soft oral tissues will be when their abilities to remove plaque daily are diminished by systemic conditions. Stroke, Alzheimer's, Parkinson's, and severe arthritis are just a few of the conditions that may force people to rely on others to maintain their oral health.
Patients that achieved average to immaculate oral health during their teen and young adult life will most likely have some areas of periodontal disease to maintain. Once they reach a systemic state that compromises their daily abilities of good oral health, those areas will progress faster than normal, even with regular six-month visits. This could place them in the category of advanced periodontitis, and in a lifestyle that prohibits quality daily oral care.
If we educate all patients of these risks, we will help them understand the importance of oral health related to systemic health in geriatrics. The more we educate our patients about the connections of systemic and oral health, perhaps the public will demand that medical care include oral health care. This is an area dental hygiene needs to embrace and promote for our future as well.
It's important to develop a focused approach with your geriatric patients to understand the direct impact the condition of their oral cavity has on their systemic health. A detailed discussion each visit to review their prescription medications should be standard of care, and don't forget the over-the-counter herbal and supplemental medications. In most cases, these affect the oral conditions quicker than prescription medications.
Many geriatric patients with advanced periodontal disease ease may have teeth that are so compromised with diminished oral care that extraction is the best and most conservative option. Knowing the history of medications containing bisphosphonates is important to avoid the risk of osteonecrosis-related complications. Many patients have taken oral bisphosphonates for more than five years, putting them in a high-risk category for BRON (bisphosphonate-related osteonecrosis).
Other geriatric patients at risk are those receiving IV-bisphosphonates to reduce bone pain associated with hypercalcemia and skeletal complications with multiple myeloma, those with breast, lung, and other cancers, and those with Paget's disease of the bone. These geriatrics may be high risk but have not been told of dental related complications by their physicians. They must rely on our professional standard to ensure we will inform them of any risk factors, monitor these high-risk complications, and make sure that any oral surgeons they are referred to are aware of their risk category.
The geriatric patients in your practice are part of a population that have hip and knee replacements. Over 700,000 of these surgeries are done each year. There is currently a heated debate between the American Heart Association and the American Academy of Orthopedic Surgeons on the standardized prophylactic premedication for joint replacement patients receiving dental care. Once considered a two-year postsurgical requirement, the AAOS now wants their patients premedicated with antibiotics before dental visits for life, especially therapeutic and maintenance care for advanced periodontitis. The AHA stands by its two-year post-surgical recommendation. We must protect ourselves and our patients legally and follow the AAOS standard.
What else can we do to maintain a high standard of care for geriatric patients? We can attend continuing education lectures that focus on geriatric health, oral pathology, and the most current updates on bisphosphonates.
We can do our own research via the Internet to gain information about Alzheimer's treatment, data concerning systemic conditions and oral plaque associated with pneumonia in geriatrics, and treatment for dry mouth conditions associated with medications containing calcium channel blockers and phenytoin.
Identifiers for targeting future high-risk patients:
- History of previous periodontitis and surgery that exposed root surfaces.
- Recession associated with hard toothbrush use or loss of attachment due to high frenum attachment.
- Abfraction exposing dentin and creating crevices that harbor bacterial colonization.
- Furcation-involved molars, especially areas that the patient cannot access.
- High caries risk due to poor plaque removal or high acidic and sugary intake.
Karen Donaldson, CDA, RDH, BS, has worked as a dental hygienist since 1989 when she graduated from the University of Southern Indiana as a nontraditional student. She graduated magna cum laude in 1990 with a bachelor's degree in health sciences with a geriatrics and social services emphasis. She also holds certification from DANB as a Certified Dental Assistant and has had expanded functions training. Karen practices clinical dental hygiene in Northwest Arkansas.
References
Calhoun Karen H, Eibling David E. Geriatrics Otolaryngology. New York: Taylor and Francis Group, LLC, 2006.
Rehiman Abdu M, et al. "Geriatrics and Oral Health." Dentaires Revista, Vol. II No 1, Jan-Mar 2010: 29-32.
Yoneyama Takeyoshi, et al. "Oral Care Reduces Pneumonia in Older Patients in Nursing Homes." JAGS 50 2002: 430-433.
