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What Can Be Done to Improve Their Oral Health?
Improved oral health will lead to improved quality of life through increased personal dignity, improved nutrition, better appearance, greater cleanliness, and greater comfort or relief from pain. But meeting the oral health needs of frail elderly adults requires new approaches to dental treatment planning that take into account the special needs of the elderly. Berg, Garcia, and Berkey have described a process called “spectrum of care treatment planning.” This model emphasizes essential steps in clinical decision making for both patient and dentist. The process begins with an interview of the patient to determine his/her concerns and perceived needs. This process addresses four domains of subjective and objective needs: function, symptoms, pathology, and esthetics. Eliciting this information may require considerable geriatric skills. Older patients are less likely than younger patients to report symptom complaints, and often they are completely unaware of pathology that would create dramatic symptoms in younger patients. In one study of older adults, more than half of 20 potentially serious medical symptoms were never reported to a health professional. These data contrast with a popular misconception that the elderly are prone to exaggerate their health care complaints. The next step in treatment planning is the objective assessment of the patient by the dentist. Because elderly patients have generally lost significant numbers of teeth, assessment of function can be difficult. Many older adults have complicated patterns of missing teeth together with fixed and removable prosthodontic devices (full and partial dentures). The effectiveness of the few remaining teeth on the patient’s ability to chew and to speak must be assessed carefully, and the alternative treatment options explored fully. In older adults, this planning process is generally much more involved than in younger individuals. A thorough medical history must be integrated with the dentist’s oral health findings while dental treatment options are developed. In addition, the dentist must assess the patient’s ability to tolerate the potential stress of treatment. The ability of an older adult to tolerate stress is highly individualized, so it is important for the dentist to be comfortable with geriatric medicine and the need to consult with the physician and others when necessary. In addition, the dentist must evaluate the patient’s functional capability and resources for maintaining oral health. According to Berg, Garcia, and Berkey, “The functional capability of the patient to maintain restorations, prostheses, and periodontal health successfully is a critical element in treatment planning, as are the financial resources the patient and/or family are able to dedicate to treatment.” If the patient is functionally impaired and unable to carry out brushing and flossing, then the family and caregivers’ ability to help with daily oral care must be assessed. Other risk factors that could cause treatment failures need to be assessed, including the history of recent decay and periodontal disease, presence of xerostomia (dry mouth), the presence of failing older restorations, drifting or tipped teeth, bruxism (teeth grinding habit), alveolar bone loss (shrinkage of the ridges following tooth extraction), loss of host resistance due to medical problems, and a variety of factors effecting the patient’s manual dexterity.
Once the medical and dental information has been collected and processed, the dentist must begin to formulate treatment options that are often extensive. In geriatric treatment planning, the focus should be on identifying levels of care and seeking a level of care that is optimal for the patient, given all the factors that have been assessed. Levels of care range all the way from “none” to “very extensive.” In planning care for older adults, it is not appropriate to equate an optimal level with the “highest level technically possible.” Instead, the goal of geriatric treatment planning is to seek the highest level of care that is appropriate and necessary to maintain the individual patient’s oral and general health.
The final step in treatment planning is reviewing the treatment options with patient and/or their caregiver. Although the dentist generally recommends the highest appropriate level of care with the best long-term prognosis, it is important to offer reasonable alternatives along with their costs and risks. The principles of informed consent and patient autonomy must be clearly understood by the dentist, and agreement must be reached before treatment is started. Because the course of
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