Growing Wiser

Publication
Article
Dental Products ReportDental Products Report March 2023
Volume 57
Issue 3

Products, Services, and Strategies to Help Improve Access to and Enhance the Quality of Dental Care for Older Patients.

OLEKSANDR / STOCK.ADOBE.COM

OLEKSANDR / STOCK.ADOBE.COM

As your patients age, their needs change. Elderly patients may struggle to get to the office for care, and once they do, they may find the experience uncomfortable for a variety of reasons, from patient chairs that cause body aches to loud instruments that interfere with hearing aids. They also have more complicated health issues to manage. Many are taking multiple medications, leading to dry mouth and recurrent caries that they just can’t seem to get under control.

Declining dexterity and arthritis pain can negatively impact their home care habits, fueling problems with caries and periodontal disease. Some elderly patients are also dealing with cognitive issues and may struggle to remember and then follow through with your recommendations. Educating patients and their caregivers is critical to helping them maintain their oral health, as is focusing on prevention.

Quality of life becomes an issue for many of these patients, and although some see the value of investing in their oral health to change that, others simply don’t. They expect to lose their teeth, to have pain as they age, and to wear dentures just as their parents and grandparents did. Many are on fixed budgets and don’t have the money to pay for expensive treatments and aren’t aware that there might be other more affordable options.

Older patients come to your practice with different concerns and perceptions of dental care that are difficult to change. They often require extra care and a different approach to treatment than your younger patient base. Unfortunately, many dental offices simply aren’t prepared to meet that challenge, which simply must change—and fast. The number of older adults who need access to high-quality dental care will only continue to grow, with the Federal Interagency Forum on Aging-Related Statistics projecting that there will be 72 million adults aged 65 or older in the United States by 2030, making up nearly 20% of the total population. That’s almost double where we were in 2000.

To provide this patient base with the best care possible, it’s critical to start investing in products that promote prevention and equipment that enhances comfort, as well as to provide treatments that can enhance their quality of life. There’s also a greater need for mobile dentistry, as many of these patients will be living in nursing facilities or will be unable to easily leave their homes to get to a dental office.

Of course, training is crucial; dental teams must understand how to effectively talk to senior patients about their treatment options and have the skills to provide the care they need. Then there’s the human element. Many of these patients are struggling financially or with their health (or both) and are frustrated when the same dental problems keep coming back. Showing them compassion is important and will go a long way in earning their trust.

“Get down to their level. Sit, don’t stand, when you’re talking to them. Lower or raise your voice as needed and make eye contact,” William Paveletz, DMD, clinical educator for VOCO America, says. “Really listen to them and realize they might need extra time. Put that time in the schedule—just an extra 5 or 10 minutes. That interaction could make the biggest difference in their day, whether you’re just being human or you’re providing dental care.”

In 2020, the American Dental Association (ADA) recognized access to care for the aging population as a national health care concern, and supports developing policy at the federal, state, and local levels for the “fair, equitable, choice-driven provision of dental care to promote improved health and well-being in elderly patients.” There’s a lot you can do to help ensure the elderly patients in your community have access to dental care, and it starts with properly preparing your practice to treat them.

Making Them Comfortable
There are many ways to create an exceptional experience for your senior patients. You can help them feel a connection to the practice by asking about their day and educating them about their treatment options. Take the time to build rapport. You also can show them you care by focusing on their physical comfort.

It may take these patients longer to get from the reception area to the operatory, for example, and once they do, they may struggle to get into the chair, says Lisa Thompson, CDA, RDA, CDIPC, manager of dental clinical services for Midmark Corp. She suggests making space in the room for items such as canes, walkers, and wheelchairs and to look at flexible patient chair configurations that are easier for patients to navigate. Flexible headrests can ease discomfort for patients who have arthritis, and adding heat and massage can also help them relax. Midmark offers a variety of chair configurations, Thompson says, and the company’s designers can work with you to ensure the chair you invest in creates a comfortable space.

Some older patients simply can’t lean back all the way, which can make treating them challenging, says John Flucke, DDS, chief clinical editor and technology editor for Dental Products Report ®.

He suggests offering Tempur-Pedic lumbar neck pillows to give them more support when they’re reclined, and to invest in cordless products such as prophy handpieces. Hygienists then have the freedom to move around patients as needed without cords getting in the way.

The technology you invest in can also add comfort. For example, Thompson says intraoral scanners eliminate the need for polyvinyl siloxane impressions, making the process faster and goop free. Using electric handpieces can also create a more comfortable experience, as they reduce unpleasant noises and vibrations that can be even more intense for elderly patients.

Some handpieces use ultrasonic sound waves that may be bothersome to patients with hearing aids, Paveletz says, so you might have to turn them down or use another type of instrument.

It’s also important to remember that older patients may not be able to tolerate procedures that require them to keep their mouth open for long periods, says Tina Saw, DDS, CEO and clinical director of Oral Genome. Take their tolerance level into consideration when recommending treatment and make adjustments as needed.

“Keep in mind the materials you choose may help reduce treatment time. Let’s say you’re working on a Class V restoration for a geriatric patient. A single-shade composite like Admira Fusion x-tra from VOCO offers a chameleon-like behavior that allows it to match the entire range of tooth shades, allowing your restoration to blend right in without the shade matching step. This simplifies and speeds up the procedure process which in turn reduces chair time,” Dr Paveletz says.

Older adult patients will also feel more at ease in your practice if they’re involved in their care, Dr Saw says.

Addressing Budget Constraints

Many older patients are on a tight budget and naturally have concerns about the cost of treatment. Phasing treatment can certainly help, according to Lisa Thompson, CDA, RDA, CDIPC, manager of dental clinical services for Midmark. You can prioritize and present what needs addressed first so they don’t become overwhelmed with the price tag. This is a difficult skill to develop, but it is one that will help ensure patients get the care they need most without being strained financially, and it allows dentists to add other services down the road.

Third-party financing is also an option, Indraneel Kanaglekar, senior vice president and president of ZimVie’s Dental Business says. The treatment plan can be adjusted based on what the patient is able to pay, for example placing implant-supported overdentures instead of a completely fixed denture.

John Flucke, DDS, a practicing dentist from Lee’s Summit, Missouri, often offers senior discounts, but when finances are really an issue, he’ll perform some procedures for free. “You don’t have to charge for everything,” he says. “As a doctor, you can [decide to say], ‘You know what, I’m doing this filling for nothing, or for 50% just to cover my costs.’”

“They want to have a sense of control, so it’s important to go at a pace they can handle. Independence is really important to them,” she says. “It also helps with their mental health. Often older adult patients bring in a caregiver, maybe a son or a daughter, but it’s important for the caregiver not to take over.”

And of course, it’s important to listen. Give these patients a reason to entrust you with their care. Remember, many are juggling different doctors and appointments, and they need to feel like you understand their concerns and can help. “Sometimes there’s quite a lot of past dental experiences in the patient’s history that may be stressful to them, and sometimes they are guarded, especially about change,” Amy Varshock, Licensed Denturist, DPD, says. “Listening is an easy way to understand them better, thereby making it easier to educate them on newer materials or processes that may meet their needs.”

Dealing With Dry Mouth
Dry mouth can be a big problem for your older patients, Dr Saw says. They typically have more health issues and take more medications than younger patients, and that often results in xerostomia.

Elevate Oral Care’s Allday line

Elevate Oral Care’s Allday line, which includes a spray, gel, and prescription-strength toothpaste, is designed to provide long-lasting treatment for dry mouth.

Not only is dry mouth uncomfortable for patients, it can lead to rapid caries progression, Dr Saw says, with problems developing in a matter of months. Some patients may resort to chewing on candies for temporary relief, which helps with saliva production but also becomes a constant source of sugar—only adding to problems with recurrent caries.

“We have to educate our senior population on the appropriate ways to address dry mouth,” Dr Saw says. “They don’t see it as a medical or a health issue; it’s more of an annoyance to them.”

Elevate Oral Care offers a variety of products to properly treat dry mouth through its Allday line, which includes a spray, gel, and prescription-strength toothpaste. Each product has a 44% xylitol content, which offers a huge benefit for patients with root caries, says Arika Luskin, product and business development manager at Elevate Oral Care. The gel and spray feature an adhesive that holds xylitol in the mouth, providing long-lasting relief.

Elevate products offer a neutral pH of 7. Xerostomia leaves patients with a naturally acidic mouth that’s ripe for caries formation, Luskin says, and the products they use to treat it shouldn’t add to that (though many others do). The prescription-strength toothpaste features a mild surfactant, which patients with dry mouth appreciate because their tissue tends to be sensitive, Luskin says.

Patients need various treatment options for conditions like dry mouth, as they’re more likely to use a product if it comes in a form they’re comfortable with, says Brooke Crouch, RDH, professional education specialist for Elevate Oral Care. Some may prefer the spray, whereas others who have caregivers helping with their oral care routine might find the gel easier to use, for example.

“It comes down to provider knowledge and how the hygienist or dentist talks to patients,” Crouch says. “If providers tell patients they may need to use the Allday spray or gel multiple times a day, that helps with [adherence] and sets appropriate expectations.”

Overcoming Recurrent Caries
As patients age, they tend to have more exposed root surfaces, Flucke says. Dexterity issues that make it difficult for patients to brush properly and the lack of saliva production from dry mouth create an environment where teeth break down easier and faster. These areas are difficult to restore because the roots are curvy and are in places that are hard to reach, Flucke says. He puts glass ionomer restorative materials on roots because they offer fluoride release. He also recently began using Infinix by Nobio, a new universal composite that contains a bacteria-killing molecule.

Staying on top of Recall Visits

Brooke Crouch, RDH, professional education specialist for Elevate Oral Care, says high-risk elderly patients should come in every 3 or 4 months for recall visits. This allows you to recognize and address issues earlier.

“When you restore root caries for older patients, because of dry mouth, they [often] can’t [it] keep clean, so it breaks down again,” Flucke says. “If bacteria gets in, Infinix will kill it, so the incidence of break down is much less.”

Having older patients switch to an electric toothbrush with a large grip may help improve their oral hygiene and slow the spread of caries, as will using a water flosser at home and addressing dry mouth with appropriate products, Flucke says. He also sometimes prescribes chlorhexidine to help control bacteria.

Dealing with recurrent caries can be disheartening. Restorations don’t last nearly as long as they should, so senior patients find themselves in the dental chair way more often than they’d like. And if money is tight, it just adds to the stress. Helping them find products that can address dry mouth and caries while also keeping a positive outlook are critical elements of their care.

“No patient likes walking into the office and always getting diagnosed with a cavity, but because of medicine-induced dry mouth issues, we see a lot of caries and periodontal disease in elderly populations. Add poor dexterity and poor oral hygiene habits, and it just compounds,” Thompson says. “A lot of patients feel like they can’t get ahead of it, so you almost have to overcome their feeling of ‘I’m never going to have a good checkup.’ We become coaches. We’re dental health care providers who offer solutions, but we also have to be that morale coach, saying, ‘You can do this. You can get ahead of this.’”

Focusing on Prevention
Because of the elderly population’s high risk for root caries and recurrent decay, it’s critical to focus on prevention, Crouch says. There are plenty of products available to do that, and most of them contain fluoride.

Flucke is a big believer in fluoride and now offers varnish to every patient, whether insurance covers it or not. After he explains the benefit, most patients will pay for it out of pocket. If it’s for an elderly patient he knows is on a fixed income, then he’ll apply fluoride for free.

Treating More Dental-Savvy Seniors

Some of your senior patients know exactly what they want and can afford treatment, and you need to be prepared for them, too. They don’t just want a partial denture, they’re interested in solutions like implants, says William Paveletz, DMD, clinical educator for VOCO. They’ve done their research and are ready to get their smile back, or to once again be able to eat pain free. Some are even interested in orthodontic treatments, such as clear aligners, and want the confidence boost that a beautiful smile will bring. It’s important to know how to talk to these patients about their treatment options and to draw more of them to your practice by offering the services that interest them most.

“VOCO’s Profluorid 5% sodium fluoride varnish is among the options and comes in 7 flavors—with options like Cola Lime and Pina Colada geared more toward older populations. While many individuals think of fluoride varnish as a necessity for adolescent patients (and it is) it is even more beneficial for older patients trying to ward off recurrent decay,” Dr Paveletz says. “Profluorid varnish contains xylitol, has a high immediate fluoride release, and sets in seconds after contact with saliva.”

Elevate offers FluoriMax fluoride varnish, which Crouch says should be applied at least every 6 months on high-risk patients, but every 3 months if possible. The company’s 38% silver diamine fluoride, Advantage Arrest, is another option that can be used to arrest caries. It should be applied at 2 separate appointments for best results.

“If a patient comes in and has root caries or a cavity under a crown or bridge that can’t be replaced, this can be used to slow the progression of the cavity,” Crouch says. “This is used frequently in older populations, because cost is [often] a big concern for these patients. If an 80-year-old [patient] comes in with decay under a 3-unit bridge, the cost to replace it could be $4000. This option only costs whatever the provider sets the fee at.” The provider cost is approximately $0.80 per drop; however, most offices’ charges vary quite a bit, Crouch adds.

High fluoride toothpaste can also help protect teeth from caries, which is why Flucke typically prescribes it to patients who are susceptible to decay. There are many toothpaste options available, including FluoriMax 5000 from Elevate, which is for patients who are high risk for caries but don’t have dry mouth.

“A product like Remin Pro [VOCO] is another way for older patients to get the fluoride they need,” Dr Paveletz says, “as they can actually brush with it. The tooth cream contains 1450 parts per million of fluoride, xylitol and nano-hydroxyapatite, which together stimulate saliva production without any abrasiveness and helps to restore the mineral balance.”

“Any sort of proactive treatment we can do like applying fluoride and having older patients come in for additional cleanings will help,” Dr Saw says. “I’m also a really big believer in saliva testing because as we age, our saliva changes.”

Dr Saw believes in this so much so she’s started her own company, Oral Genome, and is developing saliva tests for early oral disease detection. The tests will help dentists bring comprehensive, connective care to their patients, pairing a proprietary computer vision algorithm with spit test cards to analyze saliva. With the results, dentists can create more personalized treatment plans.

“The computer vision we’re developing will help make predictions and take into account all those different risk factors,” Dr Saw says. “We’re decoding the mouth.”

Test cards will be made available at dental offices as well as nursing facilities for patients who can’t come in for appointments, Dr Saw says. One goal is to engage in remote monitoring at nursing homes, and to improve care coordination with the staff for better diagnosis and care recommendations.

The test measures a variety of health indicators, Including acidity, buffering capacity, enzymes and inflammatory markers that can indicate caries and periodontal disease, Dr Saw says. Based on test results and known health conditions, treatment recommendations can be better tailored to patients while allowing for more collaborative care between the dental and medical communities.

“I like to address the whole picture, not just dental health,” Dr Saw says. “There are other health conditions like diabetes and high blood pressure that might impact oral health. When patients with periodontal disease have high blood pressure and diabetes, we need to treat them in conjunction with their physicians.”

The Case for Implants
Implants can be life changing for anyone who has lost teeth, but particularly for older patients who may not realize that this is a viable treatment option. Many may not understand that poor chewing function impacts their overall health, according to Indraneel Kanaglekar, SVP and President of ZimVie’s Dental Business. Kanaglekar also explained that implants will not only give patients a confidence boost, but they will also allow them to chew comfortably again, improving their nutrition. Education is key to changing that perception so more patients can benefit from this treatment.

Keep in mind placing implants for this population is more complicated than when working with younger patients. These patients likely have experienced bone loss, Kanaglekar says, and much of the remaining bone is weakened because of higher instances of osteoporosis. And in some cases where patients have been wearing dentures, the bone has possibly receded and could require bone augmentation.

It's critical for trained healthcare professionals to enhance their skills so they can properly treatment plan these advanced cases, Kanaglekar says. Clinicians can stay sharp through ZimVie’s different educational offerings, including web, Institute, and field-based learning opportunities. Additionally, ZimVie’s Smile Today program provides clinicians with turnkey marketing tools to educate patients on the benefits and risks of implant therapy and full-arch restoration to help support patient acceptance.

Investing in the right education and the right products will help make even more complex implant procedures seamless, Kanaglekar says. ZimVie offers an end-to-end solution with a range of products, including implants, abutments, bone grafting materials, overdentures and surgical guides—basically, anything you need for successful implant cases.

The company’s RealGUIDE software suite makes it quick and easy to plan an implant case and design the guide, Kanaglekar says, but if the healthcare professional would rather not be involved with the planning, they can send all the data collected for the case to the company’s Implant Concierge. This service will develop the plan and, once approved, send the guide and everything needed for surgery.

Of course, you will have patients who prefer to go with traditional dentures because that’s what their parents had, Varshock says. If you show them pictures of what porcelain denture teeth can do to the alveolar ridge without implants, they will better understand the benefit of going with implants instead.

Keeping Implants and Other Appliances Clean
Once patients have their new implants or implant-supported dentures, remind them they must be cleaned by a hygienist, even if they’re fully edentulous, Varshock says. “A lot of patients are surprised to learn that,” she says. “I explain [that] the calcium and plaque that would have to get removed from [the] lower front teeth will now try to collect on the dentures and the implants, so maintaining the implants with regular cleanings with the hygienist and a deep cleaning of the prosthesis followed by a polish should be part of their semi-annual routine for the best long-term benefit.”

Poor eyesight and arthritis can also make it difficult for patients to clean implants and removable appliances at home, Varshock says. Removables, such as partials and occlusal guards, don’t get fully clean in an oscillation denture cap, and the tablets simply don’t remove the plaque that collects on the lingual of the lower appliance and the buccal flanges of the upper appliance.

Varshock uses the Sympro from Renfert USA to clean these appliances in-office. “In 15 minutes, I can get any prosthesis, occlusal guard, or retainer looking new,” she says. “It’s exactly enough time to explain why it’s important to come in and have us decontaminate the prosthetics any time the patient has an illness, such as candidiasis, pneumonia, or even COVID-19, for example.”

Communication and Education
Educating elderly patients about their condition and the various causes behind it can help get them to accept recommended treatments such as bridges, implants, and crowns. The more they know about the benefits these treatments can provide, the more likely they are to move forward. However, it’s also important to educate them about changing their home care habits and to recommend products to help them find better success.

For example, instead of telling patients to look for a dry mouth spray or gel at the store or online, which can be quite overwhelming, consider offering them in your office, Luskin says. If it’s easy for patients to buy the products, they’re more likely to do it.

Check for Drug Interactions

Because older patients often take so many medications, you have to make sure any pain medication or antibiotic you prescribe won’t interact with them. John Flucke, DDS, chief clinical editor and technology editor for Dental Products Report®, a practicing dentist from Lee’s Summit, Missouri, uses an app called Lexicomp, which is an online drug database that will tell you whether it’s safe to add a certain drug to what the patient is already taking.

“Remind the patient that you know their medical history,” Dr Paveletz says, “and it’s best to come to you when they’re ready to purchase a tooth cream or a sonic or motorized toothbrush, rather than buying a product over the counter that may do them more harm than good. Another benefit? Your team members can explain exactly how to use the products and why you recommend them over others.”

Keeping team members on the same page is also critical, Paveletz says. During your morning huddle, go over that day’s patients and talk about any special needs they might have. Maybe one of your elderly patients is coming in for an extraction and you know it will take them a little extra time to get to the chair. Beyond the physical limitation, the patient is nervous and could benefit from a more gentle approach. Make sure your team members know when a little extra compassion is required.

Nutrition also can be an issue, especially if it hurts to eat, Dr Saw says. The way they’re chewing food could lead to digestive issues, so be sure to educate them on how to adjust their eating habits both before and after treatment.

It is important for dental companies to provide top-notch education to not only trained healthcare professionals but also patients. ZimVie, for example, offers patient education materials through its Smile Today program, Kanaglekar says, including clinic-customized marketing materials that review the benefits and risks of full arch rehab, including better chewing function and enhanced esthetics.

“This is a population that’s really high risk [and] needs more attention as far as what we’re offering and what we’re recommending for them,” Crouch says. “If there’s a caregiver with an older patient, we have to make sure we give them the same home care instructions we give the patient, because the patient may not be able to relay it back. It’s so important to educate the patient and anybody helping with their oral health.”

Consider Offering Mobile Dentistry
Transportation can be a challenge for seniors, which means they often go without treatment that can make their lives better. The dental industry has to find a way to reach these patients, many of whom live in nursing homes.

“There’s a tidal wave coming because our health care system is so good [that] people are living a lot longer,” Flucke says. “You can take a pill no matter where you are, but dentistry doesn’t have a way to work with elderly patients unless they’re in our offices. We [must] figure out a way to do that, because a lot of [patients] out there need our help.”

 ASI’s portable self-contained dental equipment

ASI’s portable self-contained dental equipment comes in various models and can be customized. It can help with offering care outside of dental offices.

Teledentistry can fill in some of the gap, and sending auxiliaries to nursing homes to gather images is another step forward. But mobile units, such as the ones from ASI Dental Specialties, make it possible for dentists to go to patients and provide treatment anywhere, even in their homes. The equipment contains its own internal vacuum and compressor and can plug into any standard electrical outlet.

ASI’s portable self-contained dental equipment comes in various models and can be customized, according to Dana Kjerstad, director of corporate development at ASI. The units provide the same instrumentation you would find in a traditional dental office and can be set up to include high- and low-speed handpiece connections, saliva ejectors, instrument trays, curing lights—whatever you need to provide optimal care. Sales consultants will sit down with you to determine the best configuration, whether you’re looking to set up dental suites in a mobile van or visit nursing homes with a unit a few days a month.

“It overcomes the challenge of elderly patients having to find transportation to a dental office or having to be lifted from a wheelchair into a patient chair,” Kjerstad says. “It can also decrease the fear some patients have about going to a dental clinic, reducing patient anxiety and allowing for better treatment outcomes. It makes dental care more accessible to the elderly population, which can improve their health and significantly improve their quality of life.”

Show Them What’s Possible
Patients are living longer, but that also means they’re likely dealing with multiple health issues, such as diabetes and high blood pressure. They’re taking more medications to manage these conditions, which can lead to dry mouth and problems with recurrent caries. Many have accepted dental pain and, eventually, dentures as just part of aging. But of course, you know that isn’t true, and it’s time for the dental industry to focus on showing these patients what’s possible.

As the elderly make up more and more of the patient base, dental teams must be prepared to properly care for them. That not only means getting advanced training, focusing on educating them about how to care for their oral health as they age, and offering the services they need most, but it also means investing in the right products and technologies, from preventive fluoride varnish to digital technologies that streamline appointments and make patients more comfortable.

“Adding a knowledge base in specific procedures that improves the quality of life for this age group or helps with pain management is beneficial,” Thompson says. “We know we’re living longer and have patients on medications that might affect the oral environment. We all need to stay up to date, advance our skills, and learn to better serve this patient population.”

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