I watched ‘Logan’ recently-it was a fairly emotional affair illustrating the slow demise of both Wolverine and Doctor X. The former slowly succumbing to the poisonous adamantium (rhymes with stuff we use!) and the latter to alzheimers and dementia. Wolverine attended to Doctor X throughout the film in tasks such as bathing and going to the toilet, this was humbling to see. It reminded me of a time when I provided domiciliary dentistry in Essex care homes where the level of self care and support to provide oral hygiene was very limited. The elderly population, as much as toddlers with new teeth, need attention too.
In 2009 the ‘Steele’ review into NHS dental services was published outlining areas for improvement in oral health and identifying cohorts needing increased access. At the time one area that received significant attention was a group of patients aged between 30 and 65 who had extensive restorative dentistry with metal ceramic crowns and bridges. This cohort was nicknamed the ‘heavy metal’ generation due to their significant amount of fixed prosthodontics, which may or may not be failing but clearly in need of maintenance.
Did we know this previously ?
The short answer is yes ! The BDA published a policy paper in 2003, Oral Healthcare for Older People: 2020 Vision, and highlighted the impending changes in demographics of patients and the likely problems they can present with. As life expectancy increases so the restorations we place will either need longer success rates OR will be replaced more often. In the report they identified a population increase in the over 65’s to approximately 20%-essentially one in five patients. This is also on a backdrop of patients who may have previously accepted the need to have extractions but are now less keen to loose teeth or be provided with removable prostheses.
The adult dental health surveys, conducted on a 10 yearly basis since 1968, illustrated a gradual reduction in the number of completely edentate patients with an obvious increase in those partially/fully dentate. This has some significant repercussions, bearing in mind the increase in the population.
Patients are living longer but not necessarily in complete health. Patients on polypharmacy may have significantly dry mouths with increased associated decay and periodontal susceptibility. Other systemic problems such as the development of obesity and the associated increased risk of Diabetes impacts upon the prevalence and incidence of periodontal disease. The development of oral cancer is also something that needs consideration, middle aged to elderly patients may undergo significant treatment involving surgery, radiotherapy and chemotherapy that will impact on their mouths. The latter, ideally, should be seen and treated by a restorative dentistry consultant in good time prior to oncology treatment and in the long term due to the chronic issues they are likely to develop.
“I’d like to keep it…”
The paternalistic approach to dentistry has diminished. Patients may want to retain their teeth despite our advice to the contrary. This is now being felt in areas outside of the diagnosis of unrestorable teeth in orthodontics where premolar extractions may be more likely challenged than they were twenty years ago. Despite societal change the remuneration for complicated procedures in insurance systems here and around the world may not actively feed this ethos. This can be very challenging where the minds eye envisions what we would like to provide but our hands may be tied together.
“How long will it last ?”
If a crown is placed in someones 20’s the refurbishment and replacement of that unit may, at an estimate, need to be provided at least 4/5 times during a lifetime depending on failure intervals. This could be every ten years or potentially longer as and when problems arise. Imagine removing a crown, with baited breath, to find a significant lack of tooth tissue, unrestorable caries or a fracture. Unfortunately although crown removal is not “invasive” per se it could commit the patient to treatment or even the need to have a tooth removed if nothing can be salvaged from the underlying remnants.
No restoration is permanent-like wheels on our cars the apparatus driving the implement is still functioning but the tyre will inevitably need replacement. Patients may request a ‘permanent’ solution to their problems-it is the skill of the clinician that helps them realise that can’t be the case. This is ever more apparent with the ‘heavy metal’ generation. The more intricate the initial prosthesis provided the more likely you are to have issues and the less likely they are to be remedied. Deconstructing bridgework can be difficult and we have to be mindful there was a reason why the bridge actually failed which may make like for like replacement less viable.
Dentine is softer and dissolves at a higher pH than enamel. As periodontal disease is age related there is a higher likelihood that dentine is exposed in the ‘heavy metal’ cohort. Root caries in a dry mouth can be supremely difficult to manage optimally, the decay encircling the tooth, where manipulation of the material is difficult in and around the cervical area. This coupled with the potential reduction in manual dexterity can result in a problem that is only ever going to get worse with time. Of course this generation of patient are more likely to have lived in a time when smoking was considered healthy if not medicinal !
Mental well-being and manual dexterity
Mental health conditions such as Dementia are on the increase. This will further complicate and confound the already difficult oral health issues identified above. The management of oral hygiene in this cohort can be difficult to administer and the responsibility may fall on carers or family members to contribute their time twice a day. Prevention initiatives amongst this cohort are seldom instigated unlike the young.
One aspect that is more and more worrying is the presence of implants among the elderly. Not only are these implants at a greater risk of peri-implant disease due to systemic deterioration but also due to a reduction in net manual dexterity where more complicated restorations can be impossible to cleanse. Indeed if locator systems are too retentive they may never be able to remove the prosthesis for cleaning due to physical weakness or conditions such as arthritis. AA
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