Geriatric restorative care - the need, the demand and the challenges

Roopa R Nadig, G Usha, Vinod Kumar, Raghoothama Rao, and Anupriya Bugalia
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Abstract
He, who is born, has to go through childhood, youth and old age. If aging is inevitable, let's be
graceful and serene about it and lead a disciplined quality life.
Bhagvad Gita.
To lead a quality life in old age, one needs teeth not only for the enjoyment of food but also for
proper nutrition and pleasant looks. There is also evidence that oral diseases impact
cardiovascular, endocrine and pulmonary health particularly in the elderly, which will certainly
provide additional stimuli for the elderly to seek dental care.[1] Therefore retention of teeth can
have an impressive value on the overall dental, physical and mental health of an elderly individual.
This review is based on a Pub Med data base search published in the period from 1990 to 2010 in
various dental journals. The World Health Organization (WHO) documents that although the
global population is growing at a rate of 17% annually, the aged population is galloping at a rate of
30% which implies that people over 60 years of age are outrunning young children below 15 years
of age.[2] These demographics suggest that there is an explosion in the population of the elderly.
This improved life expectancy is as a result of greater health awareness, accessibility, affordability
and acceptability of improved medical care. This in turn implies that the need and demand for
dental care is expected to upsurge tremendously in the coming years. Do we possess the required
knowledge, skill, patience, empathy, sympathy and time to treat this special group of patients?
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INDIAN SCENARIO NEED VS DEMAND
Currently the old age population in India is around 8%[3] amounting to over 80 million and
expected to reach 12% in 2025. The world population of elderly individuals is expected to reach
830 million by 2025, of which India alone will contribute to 110 million,[2] which means one out
of every 7 aged persons in the world will be an Indian. Unfortunately, geriatric dental care in India
is still in its infancy. Dental treatment is considered the last priority owing to lack of awareness
and poor socio-economic status. Moreover, there is a non-availability of proper dental services in
many rural areas. Therefore the need far exceeds than the demand. In addition the dental
curriculum of both under-graduate and post-graduate courses in India covers geriatric dentistry
with a particular focus only on prosthetic dentistry and there is insufficient emphasis on restorative
care and endodontics. Therefore, many practitioners are reluctant to treat the elderly for fear of
being not fully equipped in managing them. Changing this scenario is still a daunting task for all
the oral health professionals in India.
The term geriatrics stems from a Greek word GERON meaning, old man and IATROS means
healer. It is cognate with JARA in Sanskrit which also means old. Three groups of older
subjects are identified. (1) Young old (65 74) (2) Older old (75 -84) (3) Oldest old (greater than

85).[4] This definition and grouping of the elderly is based on chronological age rather than
biological age, although the latter makes more sense. Geriatric dentistry is the delivery of dental
care to older adults involving diagnosis, prevention and treatment of problems associated with
normal aging and age related diseases as part of an inter - disciplinary team with other health care
professionals.[5]
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A MULTI-FACETED CHALLENGE
In the course of one's life, teeth would have been subjected to various physiological wear and tear,
as well as pathological disease conditions leading to a compromised dentition. Old age is
associated with several risk factors, both general as well as those specific to the oral cavity.
Managing compromised dentition amidst multitude of risk factors is indeed a multi-faceted
challenge.
The general risk factors include various medical problems, medication induced side effects and
psychological problems. Those risk factors related specifically to oral cavity are gingival
recession, presence of restorations, removable partial dentures and age related odontometric
changes.
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MEDICAL PROBLEMS
More than 50 % of patients over 60 years of age are medically compromised and are on
medication. Most commonly seen medical conditions are diabetes, hypertension, cardiovascular
diseases, arthritis and neuromuscular problems like Parkinson's disease and Alzheimer's. The
above clinical conditions can even trigger emergency situations during dental treatment if proper
considerations and precautions are not taken. Therefore all health care providers should be familiar
with the course and the complications associated with these disease conditions and the
prophylactic guidelines provided for various medical conditions.[6] For example, patients with
some form of cardiovascular disease are vulnerable to physical or emotional stress that may be
encountered during dental treatment. Treatment plan should include low stress protocols and
shorter appointments. Vasoconstrictors should not be administered to patients with unstable
angina, uncontrolled hypertension or people with recent myocardial infarction and coronary
bypass graft. Prophylactic antibiotic may be necessary for patients with history of high risk cardiac
conditions while undertaking endodontic therapy.[7] Likewise appointments for diabetic patients
should be scheduled with consideration given to patients normal meal and insulin schedule. In the
presence of acute infections, hypoglycemic control needs to be altered in consultation with a
physician. Drug interactions and adverse drug reactions are more likely in aged patients as many
of them are under multiple drug therapy. Therefore, careful evaluation of patient's medical /
medication history, followed by consultation with the concerned medical professional is
imperative to optimize patient care.[8]
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PSYCHOLOGICAL
Many elderly patients suffer from endogenous depression on account of loneliness or feeling of
neglect. Senile dementia is a common phenomenon seen amongst the elderly that can cause
memory loss, confusion, difficulty in making decisions, comprehension and alter ability to learn
new tasks associated with the treatment modality.[9,10] Hearing and vision impairment can further
worsen the situation.
Psychological problems in the elderly differ in each country depending on the social infrastructure.
May you lead a long life is a common phrase used as a blessing in Indian culture where the aged
are still looked at as a source of pride and joy in most Indian families.
The life span of any civilization can be measured by the respect and care given to the elderly.
Those societies that treat their elderly with contempt have the seeds of their own destruction.
A. Toynbee
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DRY MOUTH
Saliva plays a major role in oral homeostasis and is very much necessary to prevent oral disease.
Although there is some conclusive evidence with regards to salivary hypo function due to aging, it
is not a simple sequel to growing old. It is usually associated with use of medications such as antidepressants, antihypertensive, anti-cholinergic and anti-asthmatics etc commonly taken by the
elderly. There is also evidence that older adults are more susceptible to medication induced anticholinergic effect than younger individuals. This condition can significantly result in both local
and systemic consequences to the host including caries, periodontal disease, dysphagia etc. In
order to overcome this dryness they resort to chewing lozenges containing sugar which further
worsens the situation.[11]
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GINGIVAL RECESSION
Leads to food impaction and plaque accumulation on the rougher cemental surface, rendering
maintenance of oral hygiene difficult and leading to dental diseases
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RESTORATIONS
Old dentition generally has many restorations with faulty margins. This coupled with poor oral
hygiene and dry mouth increases risk of secondary caries.
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REMOVABLE PARTIAL DENTURES
The retention clasps and junction of removable prosthesis and teeth can also act as retention sites
for food and plaque.

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AGE RELATED ODONTOMETRIC CHANGES
Tooth tissue and supporting structures undergo a number of well recognized changes many of
which are not fully age related but are as a result of incremental effects of wear, disease and
habits. There is considerable reduction in density of odontoblasts. Reparative capacity of the pulp
following injury (tooth preparation, micro leakage etc) is also reduced.[12] Compensatory changes
occur as a result of aging or disease. The greater thickness of dentin and the reduced volume of
pulp in the elderly may compensate to some extent for the compromised response of the pulp by
allowing the preparation to be deeper. Attrition is a compensatory change that acts as a stabilizing
factor between loss of bony support and excessive leverage from occlusal forces imposed on the
teeth. In addition, a reduction in the overjet of the teeth may be seen manifesting as an edge to
edge contact of anterior teeth due to the proximal wear of posterior teeth. An increase is seen in
the food table with loss of sluiceways.[12,13]
All the above risk factors together with dry mouth and reduced physical ability of older
individuals hinder the maintenance of oral hygiene, often encouraging the development of
diseased conditions such as dental caries, periodontal disease, tooth wear etc.
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TREATMENT PLANNING FOR ELDERLY-THE DECISION MAKING DILEMMA
Adding life to years rather than years to life, expresses the state of geriatric care model
Philip. J. Clark
Both uncertainty and complexity is inherent in the treatment planning of the elderly making
treatment decisions difficult.[14] Prior to any clinical treatment planning, the following
determinants need to be considered:[15]
1. Patient desires and expectations.
2. Type and severity of patients dental problems after evaluating the four domains of need
such as function, symptoms, pathology and esthetics.
3. Impact on patient's quality of life in terms of ability to eat, comfort level and esthetics that
could affect self-image.
4. Probability of positive treatment outcome (prognosis).
5. Availability of reasonable and less extensive alternatives.
6. Ability to tolerate treatment stress.
7. Patients capability to maintain oral health, whether he or she is well motivated and can
carry out independently or require assistance.

8. Patients financial resources.

9. Life span.
10. Family support physical, psychological or financial.
While treating the old, one should integrate their needs (functional, psychological, perceived and
normative.) into a holistic approach to demonstrate the benefit, taking into account the impact of it
on the patient's quality of life.[16] When conditions prevent the achievement of an ideal treatment
plan, the dentist should focus on each problem and then distinguish between ideal, realistic
alternatives and an interim plan.[17] Bannet and Cramer have suggested staged treatment
planning.[18] If the treatment is carefully staged, the requisite care can be delivered in increments
that are appropriate to the resolution of the immediate problems. Once a critical dental problem is
stabilized, consider providing more elaborate and comprehensive care.
Staged treatment plan

Stage I Emergency care

Stage II Maintenance and monitoring: Includes management of chronic infection, Root canal
therapy, Root planing and curettage, restoration of carious lesions, work related to dentures,
Patient education to improve oral health. A further period of evaluation is required before one
proceeds further
Stage III Rehabilitation phase: Includes Implants, Surgical endodontics, Surgical periodontics,
esthetic rehabilitation, reconstruction of occlusal plane and restoration of vertical dimension
Care of institutionalized or home bound patient: (Functionally dependent older adults)

These patients require assistance even for their normal day to day activities. The objective should
be minimum treatment required to maintain physical and psychological comfort. Mobile dental
services should be made available. Physician's presence may be necessary in patients who are
severely diseased. If it involves medical risk it is better to hospitalize and do the necessary
treatment. Atraumatic Restorative Techniques may prove useful in these cases for restorative
management
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RESTORATIVE MANAGEMENT OF COMMON ORAL DISEASES IN THE ELDERLY
Dental caries

The prevalence of dental caries in older adults is said to be more than 50-60%. While the
incidence of coronal caries in the old is more or less similar to the young, root caries incidence is
much higher (40-70%).[19,20] In the elderly, proportion of secondary caries predominates over
primary caries and repairs and replacements make the major operative work in today's practice.
[21] 93% of recurrent caries are associated with silver amalgam occurs at gingivo-proximal
locations of class II restorations or crowns.[22]

As a first step it is imperative to evaluate the risk factors involved as it plays a major role in
treatment planning. A thorough history of medical conditions and medication has to be analyzed.
Diet history with specific information on sucking candies etc has to be elicited. Salivary volume
and buffering capacity tests can also help make decisions. Taking into consideration the various
determinants, treatment can be instituted in two phases.

Restorative phase

Maintenance phase

Restorative considerations for coronal caries

The selection of restorative techniques in older adults is more or less similar to that in younger
population. However, permissible direct plastic restorative materials are preferred in the former as
these restorations can be readily and inexpensively repaired or replaced. Owing to the presence of
several risk factors, caries activity is quite high and therefore requires frequent maintenance which
might not be easily done in an indirect restoration.[23,24]
Restorative considerations for root caries

Root carious lesions are mostly situated subgingivally or gingival to the proximal surface making
visibility, accessibility and isolation extremely difficult. The process of mineral loss in root caries
can be twice as fast as that on enamel.[25] Billings et al. in 1984 had categorized root caries into
several grades and outlined the treatment plan that holds good even today [Table 1].[26]

Table 1
Billings classification for root caries
Glass Ionomer Cement (GIC) is the choice of restorative material due to the it's adhesive property
allowing minimum preparation, fluoride release, reasonable esthetics, biocompatibility and less
technique sensitivity as compared to composites.[27] New and alternative caries management
strategies have been suggested by many. Holmes demonstrated reversal of leathery root caries
(grade I and II non cavitated sites) on exposure to ozone.[28] Exposure of the lesion to ozone for
10-40 seconds is said to be anti-microbial, eliminates the ecological niche, and removes acidity
allowing remineralization. Use of carisolv[29] and lasers for caries excavation has also been
suggested especially for those who dont tolerate local anesthetics.[30]
Maintenance phase

In the elderly, not only are the risk factors are many and co - exist; many of them cannot be
eliminated. Therefore caries activity will continue to remain high and unpredictable which might
even increase with advancing age. So maintaining low caries activity amidst increasing risk
factors for the rest of their life is challenging and many a times frustrating. With the mechanism of
caries being the same in the young and the old, preventive strategy also remains the same with
minor modifications to suit the elderly. Daily use of fluoride dentifrices and fluoride rinses along

with periodic topical fluoride application regime is advisable. Fluoride varnishes may be preferred
over other forms.[31,32] Automated toothbrushes may be of some value in people with reduced
dexterity. Chlorhexidine gel/mouth rinses/varnishes are advised. 10 % varnish is preferred over
rinse/gel once a week for four weeks.[33] New remineralization products containing casein
phosphopeptide-amorphous calcium phosphate (CPP-ACP), casein phosphopeptide-amorphous
calcium phosphate fluoride (CPP-ACPF) , may also be of some benefit.[34] Xylitol containing
candies help not only in getting over the dryness but also prevents caries.[35,36] All possible
measures should be taken to prevent further loss of gingival tissue attachment which is most
crucial to prevent root caries.
Preventive regimen for elderly with dry mouth

If it is drug induced and is causing major discomfort, modifying the medication can be considered
in consultation with the attending physician (substituting the drug with one having lesser anticholinergic effect or altering the time of medication). Symptomatic relief could be obtained by
asking the patient to sip water frequently throughout the day and reduce caffeine containing
beverages. Instruct the patient not to use sugar containing lozenges and candies; instead replace
them with Xylitol containing gums and candies. In patients with severe salivary gland dysfunction
artificial saliva can be prescribed that is available in the form of gels, sprays and liquids.[24]
Non carious tooth tissue loss

Tooth wear is one of the most common problems in the older dentate population. The mechanisms
by which teeth wear include attrition, abrasion and erosion, that are rarely ever seen isolated. It is
for this reason that the more general term tooth wear was introduced by Smith and Knight in
1984.[37] In addition to long term wear and tear, several factors contribute to this phenomenon.
Xerostomia results in the loss of buffering action of saliva making the teeth more susceptible to
acid erosion of teeth. Exposed cementum is susceptible to abrasion and erosion. Lack of proper
posterior support is another factor that gives rise to attrition. Consequences of tooth wear in the
elderly include unsightly appearance, possible development of caries in the exposed cemental /
dentinal surfaces, sensitivity and reduction in clinical crown height. Reduction in the height of the
crowns of teeth is usually accompanied by progressive eruption so that teeth continue to migrate
incisally or occlusally together with the alveolar bone, resulting in long bulky alveolar processes
that helps to maintain the occlusal vertical dimension. For problems concerning tooth wear, the
need for treatment is decided on the degree relative to the age of the patient, symptoms, patient's
perceived needs and motivation. Generally, the treatment is directed towards eliminating
etiological factors and strengthening the modifying factors. As suggested by Davies, treatment
may be either passive or active.[38]
Passive treatment consists of monitoring and prevention. Monitoring helps in knowing whether
tooth surface loss is progressive or static. Periodic checkup, study casts, photographs etc. made at
different time intervals help in assessing the progress. Preventive treatment is to ensure that there
is no further tooth tissue loss and depends on predominant etiological factors. For e.g. if erosion is
on account of excessive citrus fluid consumption, dietary modifications along with fluoride
regimen can be suggested.[39] Most patients can be successfully managed only by passive
treatment. Active treatment may be required for the following reasons such as sensitivity,

aesthetics, functional difficulty and space loss in vertical dimension. Localized defects due to
attrition, abrasion or erosion can be restored by using composite resin materials or glass ionomers
depending on the location, occlusal load and esthetic needs. Very few patients need advanced
rehabilitative therapy. Careful selection of cases is essential after taking into consideration
tolerability to stress and the time involved in the treatment process as well as the motivation and
the financial status of the patient.[40] With the advent of newer improved composite resin
materials, small increase in vertical dimension not more than 1-2 mm can be achieved by
reconstruction using direct composite build-up.[41] If it is more than that or if it involves more
than one or two surfaces, it is better to go for extensive crown and bridge work, after establishing
centric relation with stabilization splint, prior to restoring the existing facial height.[42]
Esthetic rehabilitation of the elderly

Smile has no age bar. Most of the elderly lead an independent social life and are therefore
conscious about their appearance. The esthetic treatment for elderly could range from simple
recontouring procedures to bleaching, laminates and crowns. Any major esthetic rehabilitation
should be undertaken only after proper occlusal and esthetic analysis to achieve predictable
results.
Endodontic considerations in the elderly

Although there are no absolute contraindications for root canal treatment in the elderly, there are
certain situations that post limitations such as in patients who are unable to sit on the dental chair
and tolerate lengthy course of treatment or in patients with severe Parkinson's disease, tremors etc.
There are many technical challenges encountered during the root canal treatment of the elderly
starting from diagnosis to various stages in the therapy. Increased bulk of dentin and increased
pulpal fibrosis may diminish the response to traditional vitality testing. Hence, it will be wrong to
assume that the pulp is non vital and carry out the treatment without other supporting evidences.
[43] Certain systemic conditions may preclude the use of epinephrine reducing the duration of
anesthesia warranting re-injections.[44]. Isolation is often difficult because of sub-gingival caries
or defective restorations. Special techniques may be necessary to hold the dam in place.
Access and canal negotiation probably presents the greatest challenge in geriatric endodontics.[45]
The physiological reparative and degenerative changes in the pulp space, could be analyzed in the
preoperative radiograph in order to prevent catastrophic overcutting.[46] The pulp stones can be
visualized often with additional light and magnification.[47,48] Ultrasonic troughing tips are
especially useful in cutting through the calcifications that covers the canal orifices. Proper
planning is required for over erupted, tilted and teeth with reduced clinical crown height.[49]
During canal preparation, use of half sized files may help gain path for the enlarging tools to
follow. Unlike in young patients where the cemento-dentinal junction is situated usually around
0.5 to 1 mm from the outer surface of the root, in geriatric cases this distance becomes greater
because of continued cementum formation at the apex.[50] Since the canals are much narrower, it
takes more time, effort and care to prepare the root canal and reduce the risk of binding and
separation.[51] When it comes to the number of sittings, functionally independent patients who
can tolerate stress can be treated in a single sitting. For patients who cannot tolerate prolonged

mouth opening, shorter multiple appointments would be required. Use of a rubber bite block
placed may help to solve this discomfort to some extent.[52]
In conclusion, successful endodontics can be achieved for the elderly, if proper attention is given
to the diagnosis, good quality radiographs and adapting techniques that overcome the challenges
posed by calcification of the root canal system. As long as the tooth has a strategically important
role to play, endodontic therapy is indicated and justified in any patient.
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CONCLUSIONS

Increased life expectancy is causing an explosion of the aging population that will continue
now and in the foreseeable future.

Although old age population in India is expected to increase at a rate much higher than the
rest of the developed parts of the world, the demand for restorative care is far less than the
need. The need of the hour is to create awareness, improve availability and accessibility of
dental services to people of all sections of the ageing population. In addition, scope of
health insurance should be widened to include oral health care services.

Improved quality of life at old age will demand tooth retention and consequently the need
for restorative care. Retaining teeth disease free and maintaining them amidst multitude of
risk factors associated with old age is a multi - faceted challenge. Due diligence and
interdisciplinary co-ordination among the dental and the medical professionals is crucial in
providing safe, effective and appropriate care.

The curriculum of Undergraduate and Post graduate programmes should expose the
dentists to the physiological, psychological, social and special medical needs of the elderly.
There is a strong need to focus on research encompassing all aspects of aging, age related
Medical and Dental problems and its appropriate management.

It should be the endeavor of dental professionals to be conscious of the needs of the elderly
patient, provide necessary infrastructure, comprehend their psychological demeanor, offer
them empathetic care to ensure satisfaction, augment graceful dignity and inculcate a sense
of well - being as age advances.

While wrinkles and graying are inevitable with age, tooth loss is not. So let's gear up to cater to
the need, the demand, and the challenges of geriatric restorative dentistry.
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Footnotes
Source of Support: Nil
Conflict of Interest: None declared.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3198545/