C o n s i d e r a t i o n i n Pl a n n i n g

D e n t a l Tre a t m e n t o f O l d e r
Adults
Ronald Ettinger, MDS, DDSc, DDSc(hc)a,
Leonardo Marchini, DDS, MSD, PhDb,*, Jennifer Hartshorn, DDS
c

KEYWORDS
 Aged  Frail elderly  Mental health  Root caries  Oral health  Oral hygiene

KEY POINTS
 Frail and functionally dependent older adults include a diverse group of people with mul-
tiple disabilities, which are influenced further by their life experiences that complicate de-
cisions related to clinical dental care.
 Furthermore, because they grew up prior to water fluoridation, most of them have main-
tained some of their teeth, but this puts them at higher risk for coronal and root caries,
which complicates restorative care.
 The decision-making process, which has evolved, essentially has developed into a treat-
ment planning philosophy that takes into account the best interests of the patient after
evaluating all the modifying factors.

INTRODUCTION

In 2020, the total US population was approximately 330 million person and those aged
65 years and older made up nearly 16%, which is approximately 53 million persons.1
There is greater heterogeneity among people aged 65 years and older than in any
other age group.2 Each older adult has a unique genome and has been influenced
by a variety of environmental factors, such as social, cultural, economic, and cohort
experiences, that have determined their lifestyle and health beliefs.3 The oral health
of these individuals also is affected by these same factors, so, when planning dental
treatment of older adults, dentists must take into account the social aspects, general
health, and oral health conditions prior to delivering care.4

a
Department of Prosthodontics, The University of Iowa College of Dentistry and Dental Clinics,
N-409 Dental Science, Iowa City, IA 52242, USA; b Department of Preventive and Community
Dentistry, The University of Iowa College of Dentistry and Dental Clinics, N337-1 Dental Science,
Iowa City, IA 52242, USA; c Department of Preventive and Community Dentistry, The University
of Iowa College of Dentistry and Dental Clinics, W327 Dental Science, Iowa City, IA 52242, USA
* Corresponding author.
E-mail address: leonardo-marchini@uiowa.edu

Dent Clin N Am 65 (2021) 361–376

https://doi.org/10.1016/j.cden.2020.12.001 dental.theclinics.com
0011-8532/21/ª 2020 Elsevier Inc. All rights reserved.
362 Ettinger et al

In geriatric medicine, it is important to make a diagnosis, and, once a diagnosis is

made, there usually is enough scientific evidence to support a treatment plan. In geri-
atric dental medicine, it also is important to make a diagnosis, but often there are mul-
tiple treatment strategies, which often are not evidence based. Also, dentistry is unlike
internal medicine and more like surgery, in that dentists need to remove infected tissue
and restore shape and function, which require operating equipment.5
Therefore, if an older adult can drive or use public transport independently to access
a dental office, this removes a significant complication associated with their treat-
ment.6 These persons have been defined as functionally independent older adults
and comprise approximately 70% of persons over the age of 65 years. In general,
they live in the community without assistance, but many may have 1 or more chronic
medical problems, such as hypertension, type 2 diabetes mellitus, osteoarthritis, and
so forth, for which they are taking a variety of medications.3 To treat these older adults,
dentists must take a thorough medical and drug history and understand how these
diseases and medications influence patients’ oral health conditions and dental treat-
ment. The treatment such patients accept depends on their own and their significant
others’/family members’ perceptions of need for care as well as the amount of money
they are prepared to spend on that care.5
A smaller group of older adults (approximately 20%) can be designated as frail
older adults, because they have lost some of their independence.3 They still are
living in the community with the help of family and friends and may be using pro-
fessional support services, such as Meals on Wheels, home health aides, visiting
nurses, and so forth.3 These frail older adults can access dental services only
with the help of others if they are provided with transport. To treat this population,
the dentist needs a greater knowledge of medicine and pharmacology as well as
the skill to evaluate a patient’s ability to maintain daily oral hygiene independently.
Another important factor is the patient’s ability to tolerate the treatment that has
been proposed.5
The smallest group of older adults (approximately 10%) have been called function-
ally dependent older adults.3 These persons are unable to survive in the community
independently and either are homebound (5%) or living in a long-term care institution
(5%). A minority of these older adults can be transported to a dental office provided it
is wheelchair accessible, and a dentist is willing to care for them. The majority need to
be cared for at their home or in their institution. To care for them, the dental profes-
sionals need either mobile dental equipment or a dental office in the long-term care
facility.5

TREATMENT PLANNING
Patient Interview
The initial contact between older adults and their dentist begins with telephone con-
tact between the patient/caregiver and the dental office receptionist. Therefore, a
receptionist needs to have been sensitized to eliciting important information from po-
tential patients, especially if they are frail or functionally dependent. To treat these pa-
tients safely, there is a need to know whether a patient needs help with
transportation,7,8 any specific accommodations for wheelchairs or oxygen tanks,
the availability to come for an appointment, the chief complaint,9 and current health
issues,9 including questions about symptoms of 2019 Coronvirus Disease (COVID-
19).10 The receptionist also ask the should patients/caregivers to bring a list of current
medications or the medications themselves5,9; a list of their health care providers; and
dental radiographs if they exist. The receptionist needs to be empathetic to the age-
 Planning Dental Treatment of Older Adults 363

associated sensory deficits of the patient, which can result in longer conversations to
acquire the desired information and to schedule appointments.11

Teledentistry
The COVID-19 pandemic has thrust teledentistry to the forefront of dental practices.
Teledentistry may be beneficial particularly for those who are considered at high
risk of severe illness or mortality associated with COVID-19 infection, because efforts
are being made to minimize Severe Acute Respiratory Syndrome Coronovirus 2 trans-
mission to this vulnerable population. The use of teledentistry, however, will transcend
this pandemic as a useful tool for dentists, the public, and especially at-risk popula-
tions. This vulnerable population includes but is not limited to persons of any age
with multiple comorbidities, those over age 65 years, persons who are immunocom-
promised, and those residing in nursing homes.10 A national survey has reported
that older adults in the United States are interested in utilizing teledentistry but have
expressed some concern with managing the technology needed to access virtual ap-
pointments.12 Teledentistry is particularly useful, however, in evaluating nursing home
patients because it allows the dentist and the nursing facility resident to remain in their
respective locations while nursing home staff manage the technology needed to com-
plete the visit.13 Although these residents still may need an in-person dental appoint-
ment, the information gathered during these teledentistry visits can reduce the time in
the dental office waiting room in order to complete forms and preappointment consent
from the resident and/or person with power of attorney and, therefore, expedite treat-
ment that minimizes the at-risk person’s exposure time to the public. Teledentistry
similarly can be advantageous for older adults living at home, but efforts should be
made to select a simple technology that is easily accessible and overcomes any sen-
sory deficits, such as hearing loss, either via synchronous (live video) or asynchronous
(forwarding a still photo to the dentist) methods. Instances in which dentists will find
teledentistry immediately helpful is when triaging a new or existing older adult patient
prior to entering the dental clinic, diagnosing and treatment planning for existing
dental patients, and postprocedural management of those patients.14
As patients come for the initial appointments, usually they are handed multiple
forms about patient registration, finances, and health history. It is assumed that pa-
tients are literate, cognitively not impaired, and can understand the information being
sought. The National Adult Literacy Survey reported, however, that 59% of the US
older adult population had basic or below proficiency in health literacy, which means
they would have difficult interpreting health-related printed materials.15 Patients’ age-
associated impaired vision and slower cognitive processing of information exacerbate
the problem of understanding printed materials, which often can slow the usual pace
of a dental office.15
Consequently, when interviewing an older adult patient, the dentist should use the
completed forms to begin the conversation with the patient/caregiver but extend the
interview to include an evaluation of all the potential modifying factors. Good commu-
nication with patients and their significant others requires investigative interviewing
when assessing patients with complex social and medical/mental conditions, in order
to understand the hidden meanings of their complaints.5 If dentists are not sensitized
to understand the true nature of the implications of the chief complaint, they may miss
important clues. For instance, a 72-year-old patient from a practice returns because
she has lost the crown on her central incisor. Previously, she had returned for routine
care regularly every 6 months, but she has been missing her appointments for more
than 2 years. On careful questioning, she reported that 2 years ago her husband
died unexpectedly, and her children live in distant states. Her health and overall
364 Ettinger et al

grooming have deteriorated visibly as has her oral hygiene. It is clear that she is
suffering from severe depression associated with sustained grief due to the loss of
her husband and her own health and mobility. She urgently needs counseling and
mental health care. Merely treating her current dental problems does not address
her essential needs. Therefore, focusing only on her current dental problem can
lead to continuous oral deterioration or even more life-threatening consequences.
In assessing patient health histories, it is important to interpret the information pro-
vided by careful questioning. For example, if a patient reports a has a history of angina
pectoris, what does this really mean? Does the patient experience spontaneous chest
pain or by walking from the car to the office or by going up a set of stairs, or did the
patient have chest pain 6 months ago and no episodes since then? Each of these sce-
narios requires the dentist to modify the management of the patient, due to the risk of
precipitating potential medical problems. Possible modifications might range from us-
ing a stress-reducing protocol to postponing elective treatment until patients have
been assessed by their physician.

HOW DO DENTISTS MAKE DECISIONS?

When examining how dentists make decisions, it should be that considered a majority
of oral diseases are chronic plaque-associated diseases, such as caries and peri-
odontal disease, which cause irreversible damage.16 Some diseases of the oral
mucosa and pulp can be cured, whereas a few, such as oral neoplasms, are life-
threatening.5,16 A majority of oral health needs in older adults are treating the exacer-
bations of caries and periodontal disease.5,17,18
Clinical geriatric dentistry requires problem solving and decision making to develop
an appropriate treatment plan. In younger adults, the factors that influence the deci-
sion making related to treatment planning are simpler; for instance, Does the patient
have the will and the time to accept the care? Does the patient wish to pay for the
care? and Does the dentist have the resources and skills to carry out that care? In
older adults, the factors may become more complex, and the dentist needs more skills
and experience in decision making to develop an age-appropriate treatment plan. This
treatment plan should take into account the multiplicity of modifying factors, which
include but are not limited to patient’s socioeconomic, psychological, and medical
problems; side-effects of their medications; and the cumulative effects of dental dis-
eases as well as the iatrogenic effects on the dentition due to previous dental care.19,20
The knowledge base to manage the treatment planning process for older adults does
not require the development of new technical skills but rather the development of thought
processes to understand the patient’s modifying factors and how they may influence
treatment. The aim of treatment is to understand how patients are functioning in their envi-
ronment and how their dental needs and treatment fit into their lifestyle. When making
these decisions, the benefits of treatment must outweigh the risks of adverse events.
The thought processes that are required to develop this treatment protocol were devel-
oped by Ettinger and Beck,21 and have been called, “rational treatment planning.”
To make these decisions requires the gathering of information from and about the
patient, in order to be able to make a diagnosis and a treatment plan. There have
been several systems suggested in the literature on how to gather and process this
information.5 One of the most used systems is a modification of the American Society
of Anesthesiologists evaluation scheme to assess patients’ ability to tolerate treat-
ment. This system has been used as a reference to modify therapy and patient man-
agement and provides guidelines for the dental treatment of medically compromised
patients, especially those who need anesthesia.22 This system was modified by
 Planning Dental Treatment of Older Adults 365

Kamen23 into 4 broad categories (Fig. 1). Gordon and Kress24 identified some of the
faults of this system by stating, “when applied to specific situations, the system is
somewhat simplistic, in that many patients fall between categories and many choices
remain even within one category.”
Another such system uses the mnemonic, subjective findings, objective findings,
assessment, and plan (SOAP).25 For older adults, subjective findings must include in-
formation on functional status, such as activities of daily living (ADLs) and instrumental
activities of daily living (IADLs). Objective findings include an oral examination, radio-
graphs, and other intraoral and laboratory findings. Using these findings leads a
dentist to an assessment of the patient’s expectations and needs, which evolves
into a treatment plan.
Shay26 has proposed another mnemonic, which he called OSCAR, especially
designed for older adults. The O stands for oral factors, the S for systemic factors,
the C for capability, the A for autonomy, and the R for reality. The oral factors include
the condition of the dentition, restorations, periodontium, coronal and root caries,
tooth loss, salivary function, mucosal health, oral hygiene, and the occlusion. Sys-
temic factors should include an assessment of general health, available laboratory
findings, the impact of medications, and communication between the dentist and
the patient’s physicians. Capability addresses the patients ADLs and IADLs as well
as issues, such as incontinence. Autonomy relates primarily to a patient’s ability to
provide informed consent independently and maintain oral hygiene, which might be
impaired as a result of stroke, dementia, or other diseases that affect cognitive func-
tion. Reality takes into account life expectancy and a patient’s ability to access care
and pay for the required treatment.
A similar but somewhat different conceptual model was suggested by Berkey and
colleagues.27 They proposed that decision making for older adults requires clinicians
to take into account 4 domains, which are function, symptomatology, pathology, and
esthetics. Function relates to the ability of the patient to chew and eat an adequate
diet. Symptomatology assesses the amount of pain or discomfort when chewing

Fig. 1. Full mouth view of Mrs LL’s dentition, showing multiple root caries lesions as well as
generalized gingival recession. Plaque levels are limited to the lower one-third of the teeth,
with relatively little gingival inflammation.
366 Ettinger et al

and having adequate amounts of saliva to speak, to taste and to swallow. Pathology
evaluates oral discomfort and the presence of lesions in the mouth. Esthetics focuses
on the patients’ expectations to improve their appearance or smile. In order to achieve
these assessments, the investigators27 suggested that clinicians need to ask older
adults the following questions:
1. What are the patient’s desires and expectations with regard to dental treatment?
2. What are the type and severity of dental needs?
3. What is the impact of dental treatment on quality of life?
4. What is the probability of positive outcomes of dental treatment?
5. What are reasonable dental treatment alternatives?
6. What is the ability of the patient to tolerate the stress of dental treatment?
7. What is the capability of the patient to maintain oral health?
8. What are the patient’s financial and other resources to pay for dental treatment?
9. What is the dentist’s capability of achieving the planned dental treatment?
10. Are there any other issues?
Using the answers to these questions, the dentist then could determine what level of
care was achievable for the patient, which could be very extensive care, extensive
care, intermediate care, limited care, or very limited care. Very extensive care includes
complex rehabilitation, such as fixed prosthodontics and implants. Extensive care
may be a combination of fixed and removable prosthodontics. Intermediate care re-
quires a modification of traditional therapies, such as an interim prosthesis. Limited
care suggests that patients cannot tolerate extensive treatment time in the dental chair
and require short appointments and simplified treatment. Very limited care focuses
only on pain relief and infection control.
Various other models have been proposed to aid the clinician in decision making,
especially with regard to the medically at risk and frail and functionally dependent
older adults9,28. Recently, a teaching tool was created to provide a structured pro-
cess to guide novice students when caring for frail and functionally dependent older
adults. This teaching tool helps the students to process the overwhelming amount
of information gathered from their patients and helps them to develop a decision-
making process that would lead them to rational treatment planning. This concept,
which has been called rapid oral health deterioration (ROHD) risk assessment, also
may be useful for the practicing dentist.4
The concept was developed because more older adults are keeping their teeth into
older age, which has complicated dental treatment.29 There is evidence that as they
age the risk of oral disease, which negatively affects their dentition or results in the
deterioration of their general health, increases.18 ROHD has been based on evidence
based risk factors, which have been classified into 3 categories: (1) general health
conditions, (2) social support, and (3) oral health conditions. Briefly, in the first cate-
gory, there are multiple diseases, which influence a patient’s ability to maintain oral hy-
giene, which would increase their risk of ROHD. Some of the concepts included in the
social support category are lack of income or dental insurance, dependency on care-
givers, transportation barriers, being institutionalized or homebound, and being able
to access adequate nutrition as well as having had the benefit of lifelong community
water fluoridation. The oral condition category encompasses factors, such as dry
mouth and xerostomia associated with disease and polypharmacy, lesions of the
oral mucosa, level of oral hygiene, number of heavily restored teeth, amount of coronal
and root caries, degree of periodontal disease, and presence of fixed and removable
prosthesis.4 Box 1 presents the detailed steps used for treatment planning based on
the concepts of ROHD risk assessment.
 Planning Dental Treatment of Older Adults 367

RATIONAL TREATMENT PLANNING

After gathering and processing the data from the clinical assessment of the patient,
the dentist needs to develop viable treatment alternatives that are compatible with a
patient’s lifestyle and modifying factors. The rational treatment planning philosophy
can guide the development of these treatment alternatives, by using evidence-
based data, where available, to make decisions.21
Caries is prevalent among frail and functionally dependent older adults who have
teeth that have been treated and retreated over the years,14 which makes restoring
this dentition complex. Rational treatment planning evaluates the modifying factors
to offer a realistic treatment plan that has the best potential outcome for the patient.
For instance, the tooth may need to be extracted, the recurrent caries could be exca-
vated and the existing restoration repaired with a glass ionomer, the whole restoration
may need to be replaced, or the tooth may need to be crowned. The decision would
depend on the patient’s access to care, the systemic health of the patient, the extent
of the carious lesion, and patient’s ability to tolerate treatment and to maintain oral hy-
giene as well as ability to pay for care. A principle that could guide the decision is mini-
mally invasive dentistry (MID), which contends that caries is a chronic infectious
disease and should be treated using a medical model rather than a mechanistic
one. The primary components of MID are assessment of the risk of disease, with a
focus on early detection and preservation of dental tissue, external and internal remi-
neralization, and using a range of materials with surgical intervention only when the
disease has been controlled.30,31
Some of the alternatives to the treatment of caries in frail and functionally dependent
older adults, especially those with severe cognitive impairment, that derive from MID is
the use of silver diamine fluoride (SDF) only to arrest caries.32 If the patient is relatively

Box 1
Steps in treatment planning using the rapid oral health deterioration assessment

Step 1. Gathering information concerning ROHD risk factors

a. General health conditions
b. Social support
c. Oral health conditions
Step 2. Prioritizing the information and developing an appropriate communication plan
a. What matter most for disease progression and treatment planning?
b. What will happen if the patient does not receive dental care?
c. An appropriate communication plan includes but is not limited to explaining the findings,
the prognosis, the treatment alternatives, and the maintenance plan to the patient and care
personnel.
Step 3. Categorizing the risk for ROHD
a. Risk factors are not present; therefore, ROHD is not occurring.
b. Risk factors are present; however, ROHD currently is not occurring.
c. Risk factors are present, and ROHD currently is occurring.
d. Risk factors are present, and ROHD already has occurred.
Step 4. Identifying possible treatment alternatives compatible with rational treatment
planning
a. Comprehensive care
b. Limited care (maintenance and monitoring)
c. Emergency care (pain and infection control)
d. No treatment
Step 5. Developing a maintenance plan
368 Ettinger et al

uncooperative, then atraumatic restorative technique can be used to hand excavate

the caries and restore the tooth with a glass ionomer.33,34 Less cognitively impaired
patients may tolerate the use of more traditional restorative techniques. Topical appli-
cation of fluoride varnish on a regular basis is recommended for all patients.35
Although edentulism has declined, tooth loss still is a major oral health problem,
especially among older adults.29 Evidence-based guidelines to replace a missing
tooth are virtually nonexistent.5 Answering the problem, however, requires evaluating
patients’ dentition and determining several factors,5 such as
1. How long has the tooth been missing? If the extractions are recent, then it is impor-
tant to look at the occluding pairs of teeth, which determines the stability of the
occlusion.
2. Is the extracted tooth an antagonist and has it moved? If there is an antagonist and
if the extraction is recent, then a replacement may be necessary to preserve the
occlusal plane.
3. Is there an esthetic problem? If the missing tooth is in the anterior of the mouth and
the patient is severely cognitively impaired, replacement of that tooth with a pros-
thesis needs to be evaluated carefully. The decision requires a discussion with pa-
tients and person with power of attorney in terms of the risk of a prosthesis
increasing plaque retention as well as on the preservation of the rest of the dentition.
4. Can the patient chew comfortably and effectively? Are there adequate numbers of
occluding pairs of teeth, as suggested by Käyser.36
5. Is there any temporomandibular joint pain? If patients report temporomandibular
dysfunction pain, they may need posterior support of the occlusion provided by
a prosthesis.
When considering replacing posterior missing teeth, it should be kept in mind the
concept of the shortened dental arch introduced by the studies of Käyser,36 who
showed that patients had sufficient adaptive capacity to maintain adequate oral func-
tion if they had at least 4 posterior occlusal units remaining, preferably in a symmetric
position. They have been several studies that have supported the shortened dental
arch concept, functionally,37 financially,38 and as it relates to quality of life.39
The maintenance of remaining teeth in older adults becomes important, especially
for older adults with a variety of systemic diseases. Persons with neurodegenerative
diseases, such as Parkinson disease, tardive dyskinesia, stroke, and dementia, are
unable to adapt to complete dentures, especially on the mandibular arch. Therefore,
the maintenance of some mandibular teeth is critical to maintain adequate oral func-
tion. Some of these teeth become more valuable than others, and these teeth have
been described as key teeth (Box 2).
The available options for dental treatment have increased dramatically over time. As
the total number of dental journals indexed by Journal Citation Reports available on
the Institute for Scientific Information Web of Knowledge database has increased
from 46 in 2003 to 83 in 2012, in the same time period, the number of publications
in dental journals more than doubled, from 4727 to 10,102.40 This number of publica-
tions is equivalent to more than 27 articles per day. These options include new restor-
ative and preventive materials as well as new techniques, such as implants and digital
dentistry. Treatment planning, however, still remains as much as art as science.

MRS LL CASE

For example, the authors were contacted by the director of nursing from a local
nursing home about a 77-year-old woman (Mrs LL), who was avoiding certain foods.
 Planning Dental Treatment of Older Adults 369

Box 2
Characteristics of key teeth

A key tooth
1. Is one that can support itself or other teeth
2. Is one, which, if lost dramatically, changes the treatment plan, such as
 From no prosthesis to a fixed partial denture
 From a fixed partial denture to a removable partial denture
 From a tooth supported partial denture to a distal extension removable partial denture
 From a removable partial denture to an overdenture/complete denture
3. Is one that is required to maintain an adequate chewing pair

The patient had not seen a dentist in at least 2 years, and the staff were concerned that
she might have some “dental problems.” An appointment was arranged for the pa-
tient, who was wheelchair bound. Transportation and an escort were provided by
the nursing home, who brought the patient’s medical record and a list of her medica-
tion. The record showed that Mrs LL’s son lived in a distant state and had power of
attorney, but visited his mother several times a year. On contacting her son for permis-
sion to examine Mrs LL, he told the authors that he was financially responsible for her
dental care. The escort told the authors that Mrs LL loves ice cream but recently has
refused to eat it.
Medical History
The patient is allergic to dimenhydrinate (Dramamine). She has a history of hypothy-
roidism that was diagnosed 10 years ago, history of Parkinson disease with mild
tremors (3 years ago), history of gastroesophageal reflux (3 years ago), dementia
(2 years ago), depression (2 years ago), and insomnia (10 years ago). She also has
chronic pain and muscle weakness.
Daily Medications
Mrs LL was taking multiple medications for her illnesses, many of which had significant
systemic and oral side effects, as shown in Table 1.
Oral Health Findings
The patient was not concerned about esthetics; although she did not complain about
any discomfort, the staff told the authors that she always loved ice cream and recently
was avoiding it. On oral examination, Mrs LL is fully dentate, except for third molars
and first premolars, which had been extracted for orthodontic purposes. A majority
of teeth were covered with plaque at the gingival margins; however, there was little ev-
idence of inflammation and no significant pocket depths. There was gingival recession
and root surface caries on multiple teeth in both arches (see Fig. 1). The radiographic
evaluation showed some bone loss in the mandibular anterior region. There was evi-
dence of root canal treatments on teeth #9 and #10, with no visible periapical radiolu-
cencies (Fig. 2). Although the patient did not complain of a dry mouth and the clinical
examination did not suggest a lack of moisture, multiple root surface lesions suggest
that there may be a change in the quality of the saliva. Mrs LL was able to follow di-
rections, was able to cooperate during the oral examination, and had minimal tremors
of the head and neck.
After examining the patient and gathering data (Box 3), the question was how
should Mrs LL’s oral health needs be approached? One approach would be to prior-
itize the risk factors that are more important for disease progression and treatment
planning (see Box 3). When evaluating medical and social history, the impact of her
 370
Ettinger et al
Table 1
Daily medications

Commercial/
Drug Dosage Generic Name Use Side Effects
Bisacodyl 5 mg qd Dulcolax Laxative Gastrointestinal discomfort, cramps, semi-supine chair position
Diphenhydramine 25 mg q6h Benadryl Antihistamine Somnolence, dizziness, hypotension, sedation, dry mouth, nose
and throat
Guaifenesin 2 mg q4h Robitussin Expectorant Dizziness, headache, nausea, gastrointestinal pain
Hydrocodone/ 5 mg q6h Vicodin Opioid analgesic Dizziness, sedation, bradycardia, risk of psychological and
Acettaminophen physiologic dependence, orthostatic hypotension
Levothyroxine 50 mg qd Synthroid Thyroid hormone Hair loss, dry skin
Loperamide 2 mg qd (prn) Imodium Antidiarrheal opioid Dry mouth, somnolence, semi-supine position
Miconazole 200 mg bid Monistat- Imidazole antifungal Rash, itching, dizziness, can increase bleeding with warfarin
Derm
MiraLAX 17 g qd Polyethylene Laxative Bloating, dizziness, blood in the stool
glycol 3350
Mirtazapine 7.5 mg hs Remeron Tetracyclic Somnolence, dry mouth, constipation, weight gain. dizziness,
antidepressant semi-supine position
Nystatin ointment 1000 U 4/day Mycostatin Fungistatic antifungal Rash
Omeprazole 20 mg qd Prilosec Proton pump inhibitor Headache; nausea, cough, dry mouth
Quetiapine 25 mg bid Seroquel Antipsychotic Headache, somnolence, dizziness, dry mouth, constipation,
tachycardia, orthostatic hypotension, tardive dyskinesia,
frequent recalls
Risperidone 2 mg bid Risperdal Antipsychotic Agitation, anxiety, insomnia, constipation, rhinitis, orthostatic
hypotension, dry mouth, extrapyramidal movements, limit
vasoconstrictors, semi-supine position
Sinemet 0.5 mg bid Carbidopa/ Antiparkinsonian Uncontrolled body movements, nausea, anorexia, depression,
levodopa anxiety, confusion, dry mouth, orthostatic hypotension,
photophobia (dark glasses)
Trazadone 25 mg hs Desyrel Antidepressant Somnolence, dizziness, nausea, blurred vision, light headache,
orthostatic hypotension, dry mouth
Tylenol 650 mg q6h Acetaminophen Nonnarcotic analgesic Hypersensitivity, liver damage with dosage of 3000 mg/d
 Planning Dental Treatment of Older Adults 371

Fig. 2. Full mouth radiographs, including bitewing radiographs made at the initial appoint-
ment, showing multiple caries lesions and root canal treatment of teeth #9 and #10.

developing dementia and Parkinson disease suggests that she will need increasing
help with her daily oral hygiene over time and dietary changes to reduce her sugar
intake. An electric toothbrush has been shown to be beneficial in this population, pro-
vided patients can tolerate it.41 Additional preventive measures will be needed, such
as the use of topical fluoride varnish, a prescription for high-concentration daily fluo-
ride toothpaste, and a return dental visit every 3 months.42
If the necessary preventive measures and treatment are not accepted, there will be
further progression of root surface caries, with fracture of the teeth with possible local
pain and infection, resulting in periapical lesions and loss of function. Consequently,
there could be a possible deterioration of Mrs LL’s systemic health and quality of
life and the potential for aspiration pneumonia, which can be life threatening. There-
fore, Mrs LL is presenting with multiple ROHD risk factors, and ROHD currently is
occurring (see Box 3).
Considering the extensiveness of the current caries lesions and the patient’s ability
to cooperate, it is possible to choose multiple options to treat Mrs LL’s dentition (see
Box 3). For instance,
1. Comprehensive care, such as excavating the lesions to determine their depth. If
they are shallow, complete caries removal is possible. If a lesion is deep, then

Box 3
Modified American Society of Anesthesiologists classification for frail and functionally
dependent older adults23

Class I. Comprehensive dental treatment, including all necessary surgical, operative, prosthetic,
and preventive services
Class II. Intermediate dental care, emphasizing preservation and maintenance of the existing
dentition and prevention of further deterioration. This can range from restorative dentistry to
a simple prophylaxis.
Class III. Emergency dental care only. This includes alleviation of pain, infection, and/or
swelling. This is palliative care, applicable even for terminally ill patients.
Class IV. No dental treatment, a decision based on physical and mental contraindications for
care, when treatment would do more harm than good.
372 Ettinger et al

partial caries removal should be considered, with glass ionomer applied to the
deepest areas. The use of a sandwich technique may be appropriate, or, if the
lesion is very large or very deep, it may be necessary to do a root canal treatment
and/or to crown the tooth.
3. Limited care might include
a. The use of atraumatic restorative technique to hand excavate the lesions and
restore with glass ionomer, associated with home preventive measures and
6 month recalls
b. The use of SDF to arrest the carious lesions and 6-month recalls with SDF
reapplication
c. The use of fluoride varnish in the office followed by the daily use of high-
concentration fluoride toothpaste and recalls every 3 months
3. Emergency care (pain and infection control)
Emergency care may be the first step in a comprehensive care plan, or it could be the
choice of a patient who seeks only comfort for the problem. If the patient presents with
odontogenic pain or a dental abscess, however, it is important to define the source and
treat the offending tooth or extract it. It may be necessary to support this treatment with
oral antibiotics. If the pain is from a nonodontogenic source, then it is important to define
the cause and treat the problem appropriately. It may be necessary to refer the patient
to an appropriate medical or dental specialist for care.
4. No treatment.
If a patient seeks a consultation, is offered a treatment plan, and refuses treatment,
the dentist needs to document this encounter in detail. If patients are so impaired that
they cannot tolerate transfer to a dental office or any procedure in their mouth, how-
ever, a caretaker may help to reduce the bacterial burden by spraying chlorhexidine in
the mouth on a daily basis.43
At this point, Mrs LL’s son was contacted to inform him of his mother’s oral health
status and her treatment needs. In order to get informed consent (either verbally or in a
signed document) to allow the authors to treat Mrs LL, the authors informed him about
the different treatment options and their costs and suggested a rational treatment
plan. This rational treatment plan included an evaluation of Mrs LL’s cognitive status
and ability to cooperate with the amount of dental treatment she needed as well as the

Box 4
Classification of patients with chronic unstable medical problems

Type I
Patients with chronic existing problem(s), for example, post–cerebrovascular accident,
asthma, chronic bronchitis, coronary artery disease
These diseases progress but usually at a slow rate.
Time is not a problem, because treatment can be phased in a little at a time to keep stress low.
Type II
Patients with progressive medical problem(s), for example, dementia, cardiomyopathy,
myasthenia gravis, scleroderma
These diseases progress at a relatively faster rate, and patients deteriorate with time:
 Need to maintain and preserve key teeth
 Need to remove questionable teeth
 If necessary, need to crown teeth
Time is a problem, because patients need to be treated while they are able to tolerate
treatment.
 Planning Dental Treatment of Older Adults 373

Fig. 3. Full mouth view of Mrs LL’s dentition, showing the completed glass ionomer restora-
tions. Tooth #30 has been extracted, because it was deemed unrestorable.

authors’ ability to deliver this care. An assessment of her chronic medical problems
will help determine the need for phasing of her treatment, as shown in Box 4. Another
important consideration was the nursing home staff’s ability and willingness to commit
to carry out daily oral hygiene in order to keep the appropriate maintenance regimen.
The treatment plan suggested and that her son accepted was as follows:
1. Scaling, cleaning, and polishing with fluoride varnish application, followed by
customized oral hygiene instructions, including information for the nursing staff
on how to maintain Mrs LL’s daily care
2. A prescription for 5000 parts per million fluoride toothpaste, which should be so-
dium lauryl sulfate–free
3. Systematic restoration of the carious lesions using incomplete caries removal to
determine restorability
In the maxilla: from teeth #2 to #4, #6 to #11, and #13 to #15: cervical glass ion-
omer restorations
In the mandible: from teeth #18 to #20, #23 and #27, #29 and #31: cervical glass
ionomer restorations. Tooth #22 was deemed to be able to be remineralized
with topical application of fluoride varnish
Teeth #24 to #26 did not require any restorations.
Tooth #30 was deemed unrestorable and was extracted.
The completed dental treatment of Mrs LL after 4 weeks is shown in Fig. 3.
4. Patient was put on 3-months’ recall and has returned consistently for the past
2 years, and recurrent caries occurred on tooth #14.

SUMMARY

The case of Mrs LL history presented illustrates the significant changes that have
occurred in the aging population, that is, the maintenance of a natural dentition into
old age. It also illustrates the problems and risks this presents for the patient and those
374 Ettinger et al

who care for them. The chronic medical problems of the patient, especially the de-
mentia and Parkinson disease, which are progressive diseases, will cause limitations
in the patient’s ability to cooperate and follow instructions over time and put this pa-
tient’s oral health at risk. Therefore, it was important to involve the family (son) and the
care staff at the nursing home in the patient’s restorative care as well as in the main-
tenance of her oral health.
In addition, modern restorative techniques need to be used, such as minimal inva-
sive dentistry, including incomplete caries removal and sealing the lesions with glass
ionomer, followed by a high concentration of topical fluoride to prevent further demin-
eralization. The treatment followed the overall ethical principles, which are to do no
harm and to do treatment that benefits the patient. This treatment was well tolerated
and should improve the quality of her life (eg, allow her to enjoy her ice cream) and
maintain function.
It is the authors’ belief that the successful treatment of frail and functionally depen-
dent older adults must include an understanding of how patients are functioning
(medically, socially, and emotionally) in their environment and how the art and science
of dental medicine fit into that environment.

CLINICS CARE POINTS

 Teledentistry should be considered when triaging new or existing older adult patients prior
to their entering the dental clinic. Teledentistry also can be used for diagnosing and
treatment planning for an existing dental patient as well as for postprocedural
management.
 Good communication with patients and their significant others requires investigative
interviewing when assessing patients with complex social and medical/mental conditions.
 In assessing patients’ health histories, it is important to interpret the information provided by
careful questioning.
 The aim of treatment is to understand how patients are functioning in their environment
and how their dental needs and treatment fit into their lifestyle.
 Rational treatment planning philosophy can guide the development of treatment
alternatives, by using evidence-based data, where available, and selecting alternatives that
are compatible with a patient’s lifestyle and general health-modifying factors.
 Some of the alternatives to the treatment of caries for frail and functionally dependent older
adults, especially those with severe cognitive impairment, are incomplete caries removal
followed by sealing the lesions with glass ionomer. SDF also can be used to arrest caries in this
population.

DISCLOSURE

The authors have nothing to disclose.

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