Older Adult

Case 1Older Adult

CASE STORY

A 73‐year‐old Hispanic female patient presents to the clinic with the chief concern of “I had a partial denture made back home in my own country and it does not fit well, because it rocks from side to side when I am trying to eat. I also have cold sensitivity when I am drinking cold beverages. My teeth are shorter and wearing down in the front of my mouth so I am self‐conscious when I talk to people.”

PROBLEM‐BASED LEARNING GOALS AND OBJECTIVES

• Describe the oral hygiene instructions necessary for a patient with removable prosthesis
• Describe best practices for treatment planning and scheduling of the older adult patient
• Demonstrate effective time schedule management of patients with osteoarthritis
• Explain best practices for effective biofilm removal for the older adult patient

Medical History

Patient was diagnosed with high blood pressure 10 years ago and is taking 50 mg of metoprolol succinate (Toprol) once a day. She also takes atorvastatin (Lipitor) 10 mg once a day. She was also diagnosed with osteoarthritis 10 years ago that affects dexterity of her hands and has limited mobility when walking. Patient is also taking over‐the‐counter 325 mg of aspirin as needed for the osteoarthritis. She has no known medication allergies.

Social History

Patient reports quitting smoking cigarettes about five years ago, and prior to quitting, was smoking one‐pack a day for approximately 50 years. She drinks three cups of coffee throughout the day. Patient also drinks alcohol socially. Patient also reports that she has a dry mouth, and tries to drink some type of liquid drink of water or juice during the day. Her daily diet consists of soft foods such as noncruciferous vegetables, fish, and dairy products, due to difficulty chewing while using her removable partial prosthesis. Patient snacks regularly on sugary candies and desserts, and does not brush during the day.

Patient currently lives alone in an apartment building, located within an older adult community. Patient is able to take care of her own dental needs and is able to travel independently to scheduled dental appointments by public transportation.

The patient’s current dental home care regimen involves brushing her own teeth once a day in the morning using a medium‐bristled manual toothbrush. Patient replaces her toothbrush infrequently, approximately once a year. Patient rinses her partial prosthesis under tap water on a daily basis. She does not brush the prosthesis daily or take out at night and soak. She does not use floss, interdental aids, or mouthrinses.

The patient reports that her last dental visit was five years ago back in her own country to make the removable partial prosthesis. She was not given any specific home care instructions or follow‐up care for the removal partial prosthesis.

Review of Systems

• Height: 5′ 4”
• Weight: 120 lbs
• Vital Signs
  • Blood pressure: 148/90 mmHg
  • Pulse: 64 beats/min
  • Respiration: 18 breaths/min

Extraoral Examination

Patient presents with bilateral clicking of the temporomandibular joint but does not express any discomfort. Her lips are dry and cracked. Patient presents with normal findings upon palpation of her lymph nodes, as well as the assessment of other facial features.

Intraoral Examination

Five intraoral pictures were taken.

• Soft tissues of the oral cavity:
  • Maxillary posterior ridges appear erythematous and tender upon palpation.
  • Tongue is enlarged and slightly coated on its dorsal surface.
  • Salivary output examination reveals hyposalivation of her major salivary glands.
• Occlusion Examination:
  • Edge‐to‐edge bite with attrition noted on all anterior teeth (Figure 9.1.1)
• Gingival examination:
  • Maxillary arch presents with localized recession with rolled margins, with erythematous and edematous gingiva on #6–7
  • Patient has generalized 3–4 mm probing depths, and localized areas of recession:
    • 4 mm recession on #6 facial
    • 2 mm recession on #8 facial
    • 3 mm recession on #9 facial
    • 3 mm recession on #11 distofacial
    • 3 mm on #23–26 lingual surfaces (Figure 9.1.2)
  • Generalized bleeding upon probing.
  • Patient has a diastema between #8 and #9, as well as open contacts on mandibular anterior teeth.
  • Gingival festooning on labial gingiva of #8 and #9.
• Dental examination:
  • Patient has crowns on #s 6, 7, 11, and 21
  • Patient has missing teeth #s 1–5, 10, 12–17, 31–32.
  • Patient presents with buccal surface abrasions on mandibular posterior teeth (Figures 9.1.3, 9.1.4, 9.1.5).

Figure 9.1.1: Front view.

Figure 9.1.2: Mandibular occlusal view.

Figure 9.1.3: Right side.

Figure 9.1.4: Left side.

Figure 9.1.5: Maxillary occlusal view.

Radiographic Examination

A panoramic radiograph was taken and, upon examination, a retained root tip was found in the area of tooth #31 (Figure 9.1.6).

Figure 9.1.6: Panoramic radiograph.

Dental Hygiene Diagnosis

Table 9.1.1 provides details of the problems and related risks

Table 9.1.1: Dental hygiene diagnosis.

Problems	Related to risks and etiology
Ill‐fitting removable partial prosthesis	Nutritional deficiency, traumatic lesions
Osteoarthritis	Limited dexterity, poor oral hygiene management
Bleeding upon probing	Periodontal disease, poor oral hygiene management
Localized abrasions	Aggressive toothbrushing with medium‐bristled toothbrush
Localized attrition	Bruxism
Coated tongue	Biofilm accumulation
Past history of smoking	Periodontal disease
Medication for hypertension	Xerostomia, biofilm accumulation

Planned Interventions

Table 9.1.2 provides details of the planned interventions

Table 9.1.2: Planned interventions.

Clinical	Education/Counseling	Oral Hygiene Instructions
Take blood pressure at every visitScaling and root planing with 4 to 8 week periodontal reevaluation of initial therapy.Refer to Doctor of Dental Surgery (DDS) or Doctor of Dental Medicine (DMD) for planned extractions, fabrication of crowns, and removable partial prosthesis	Encourage continued smoking cessationStress importance of routine primary care visits and scheduled dental recare visitsRecommend increased intake of fluoridated water for hydration, relief of xerostomia, remineralization of hard tooth surfacesNutritional counseling for increasing calcium and/or Vitamin D intake	Soft‐bristled toothbrush usage with modified Stillman techniqueToothbrush with tongue scraperRecommend use of fluoride toothpastesRecommend use of lubricating mouthrinse for xerostomiaDesign of adaptive aids for effective brushing and functional controlInstruction of proper removable partial prosthesis cleaning and care

Discussion

The number of adults over the age 65 in the United States continues to increase, as people are living longer – 13% of the United States population is aged at least 65 with 7% of the population between 65 and 74 years, 4% between 75 and 84 years of age, and 2% older or equal to 85 years of age (Oong and An 2014; “Quick facts, United States” n.d.). Older adults are retaining more of their natural dentition because of increased access to dental care during their younger years (CDC 2010; LaSpina and Towle 2016). However, this population continues to need proper home care regimens, including preventative measures to maintain their dental health. Medicare, which provides healthcare insurance for adults 65 and older, provides no basic dental coverage. This population of adults who do not have supplemental insurance are at the greatest risk of having unmet health‐care needs (Cohen et al. 1997). The lack of access to care is compounded by many other factors, such as: a shortage of skilled health‐care providers for the older adult, limited transportation options to appointments, and lack of financial resources (Dolan et al. 2005).

Due to the complex needs of this aging population, older adult patients can often present with multiple medical and periodontal conditions. A thorough review of the patient’s medical and dental history, including periodontal examination, must be completed to facilitate proper diagnosis. As a person ages, metabolic changes occur, and the adverse effects of long‐term pharmaceutical usage will have an impact on the oral cavity (Yellowitz and Schneiderman 2014).

The dental hygienist needs to be prepared and be competent in treating this aging population – they must remain current in their knowledge of pharmaceutical products, while providing preventive and therapeutic services in all types of dental practices. For example, xerostomia is a very common side effect of many medications and is one of the factors of an increased caries risk in older adults (Moore 2016). Interprofessional communication needs to be improved among all health‐care providers in order to manage and maintain the older adult patients’ quality of care and medications – especially among dental and medical health‐care providers.

Patients in this aging population frequently present with degenerative joint disease (DJD), or osteoarthritis, and this can affect their motor function. Manual dexterity and the timing of the appointment are important to consider when treating these patients. Considerations of limited manual dexterity from DJD or osteoarthritis should include: the design of adaptive aids that are easier to grip and are of enlarged and wider size to promote grip strength and functional control (Muzzin 2014). It is recommended that these patients have shorter appointments, and be scheduled during the late mornings or in the afternoons (LaSpina and Towle 2016).

In many cases, the older adult patient may require a fabrication of a removable prosthesis. This can be the result of periodontal disease, trauma, and/or decay. Removable prosthesis can restore the aesthetic appearance of the older adult, as well as their quality of life and dental function (Yellowitz and Schneiderman 2014). In order to maintain the integrity of the removable prosthesis, it is recommended that it be cleaned daily using a dedicated removal prosthesis toothbrush with soft end‐rounded filaments. Proper cleaning, along with daily removal of the prosthesis overnight will prevent denture stomatitis and other related oral infections (Donnelly 2014; Swecker 2016).

Take‐Home Hints

1. Daily care of removable prosthesis should include: nightly removal of the prosthesis with rinsing, immersing, and brushing with a designated partial denture toothbrush for proper biofilm removal.
2. Degenerative joint disease or osteoarthritis can influence the patient’s dexterity required for effective biofilm removal. Adjunct aids should be introduced and custom‐designed for the patient’s individual needs.
3. Scheduling/dental appointment times for older adult patients with degenerative joint disease or osteoarthritis
4. Patients presenting with periodontal disease should be regularly scheduled for recare appointments at three‐month intervals to ensure periodontal maintenance.
5. Considerations for improved access to dental care for the older adult patient; transportation, finances, scheduling of appointments, and interprofessional teamwork.