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The dental treatment needs of the elderly differ from those of younger adults, and newer cohorts of elderly have significantly different needs than older cohorts. Shay reports that in 1957, 70 percent of adults over age 75 were fully edentulous, while today the number has dropped to less than 40 percent. This means that 40 years ago, most dental treatment for older adults involved making and repairing full dentures. Today the picture has changed dramatically, with far more natural teeth present, and significantly different attitudes towards oral health and dental care among newer cohorts of the elderly. The elderly now receive a full range of dental services from examinations and preventive services to complex restorative and periodontal services. Aging has an impact on oral tissues just as it has on other tissues throughout the body. As teeth age, the enamel, dentin, and pulp undergo progressive changes. The enamel becomes less hydrated and may gain fluorine superficially if fluoride toothpastes, rinses, or drinking water are used. In addition, the thickness of the enamel decreases as enamel is lost from abrasion and attrition. Dentin changes more profoundly over a lifetime. The dentin volume expands into the pulp chamber as secondary dentin forms in response to decay and mastication. Many dentinal tubules narrow and others close altogether, forming sclerotic dentin. These changes make the older tooth more brittle, less resilient, less soluble, less permeable, and darker in color. The pulp chamber, where the blood vessels and nerves of the teeth are located, also undergoes significant changes. The volume of the chamber declines as secondary dentin is deposited. The blood vessels and nerves in the pulp decline with a loss of myelinated nerve fibers and a gain of dystrophic calcium.
All these changes in the teeth have implications for many dental restorative procedures. Acid etching and bonding materials and techniques, for example, need to be modified. The aging of the teeth affects the design of cavity preparations, the choices of restorative materials, and the anatomy and esthetics of the final restorations. Pulpal sensitivity is diminished in older teeth, and normal symptoms of dental decay or pulpal infections are reduced, altered, or eliminated. The radiographic appearance of teeth is also affected by aging, requiring modified interpretations and diagnosis.
It is not just the teeth and other oral tissues that change with age and have an impact on the special needs of the elderly. With increasing disability, functional impairments, and declining cognitive functions in the frail elderly, the dental team is faced with important ethical issues that have an impact on dental diagnosis, treatment planning, and how dental care is actually provided. Shuman reviews a number of these key ethical concerns and offers guidelines for addressing them. Securing informed consent when the cognitive function of an older adult is impaired requires interaction between the clinician, the patient, and the guardian. The clinician must be able to make mental status assessments and to form judgments about a patient’s capacity to understand and act upon choices. In addition, the clinician must be knowledgeable about the legal and ethical responsibilities placed on those providing geriatric care to vulnerable adults. In situations where the patient is incompetent to make treatment decisions, the clinician must be familiar with two alternative care standards, the substituted judgment standard and the best interest standard. The best interest standard suggests that the dentist should plan care that reflects what other reasonable people would do under similar circumstances, while the substituted judgment standard suggests that the dentist should plan care that the patient would have chosen if he or she could have expressed their wishes.
Other important special care issues for the frail elderly involve knowledge about the use of sedation, behavior management and restraint in cognitively impaired patients, issues related to death and dying, and issues related to elder abuse.