On the right side of the grass

by Linda Niessen, DMD, MPH, MPP

About a month ago, a patient wheeled into the dental operatory for his oral exam. I greeted him and asked how he was doing. He answered, "Well, Doc, I'm on the right side of the grass." We laughed, but only later did I truly appreciate the significance of his comment. That 72 year-old, who suffered from diabetes and cardiovascular disease and had undergone bilateral, above-the-knee amputations, was completely serious!

As I reviewed and updated his medical history and medications, I noted that his medical history had changed and his medications were different. This was one of those days when his oral health seemed to be the least of his problems. His daughter was with him. Once again, we discussed the importance of daily oral self-care and the relationship between his periodontal disease and his diabetes. While the patient had heard my concerns before, it was new information to his daughter.

A week later, a 73 year-old woman came for an appointment. She was suffering from atrial fibrillation and was taking anticoagulants. As we discussed her medications and the effect of the anticoagulant on her dental treatment, she commented that she really appreciated my interest in her medical problems. I laughed and flippantly replied, "The last time I checked, the mouth was still connected to the rest of the body." However, she made think.

I love patient care because I learn from patients all the time. Their insight into what we do as dental professionals sometimes surprises me and occasionally disappoints me, but always makes me appreciate my chosen profession. These two patients reinforced the importance of the medical history review and medication update as critically important services that will only increase in salience as the population ages.

Dentists often fail to consider the patient medical history as a value-added service for our patients. The medical history and medication update contribute to the diagnostic component of our dental care. It is part of the information-gathering process that is critical to develop a patient's treatment plan.

We must also consider the patient's perception of this process. As patients age, the relationship between the mouth and the body becomes more evident. Patients are aging, and the dental team has a unique responsibility to help them understand the connection between oral health and overall health.

Demographic changes

Currently, about 12 percent of the American population is over the age of 65. The median age for those over age 65 is 73 years. Half of all the women who reach age 50 in 2000 will live to age 80. Their life expectancy will continue to increase as a result of better medical care, more preventive activities, and healthier lifestyles. In 2001, 79,000 Americans were over 100 years old. By 2050, this number is expected to increase to almost one million!

This increase in the oldest-old has led gerontologists to define the concept of "active life expectancy." Active life expectancy refers to that portion of life in which an individual can perform the activities of daily living with little or no help. Scientists have estimated that while a 65 year-old man may have an average of 15 years of remaining life expectancy, three of those years may be periods of dependency where the individual requires some type of care. Women who are age 65 can expect to spend 14 of their 19 remaining years functionally well.

Older adults want to experience these years of "active life expectancy" as fully and robustly as possible. They wish to maintain their health and they value preventive services. Oral health services that improve health and self-esteem may be of particular interest to this aging population.

While dental professionals may resent the increased time required for the history and physical examination for older adults, patients perceive it differently. Taking the time to complete a thorough medical history demonstrates the dental team's concern and care about patient health. Patients may recognize the changes in their health status, but they may be completely unaware of the connection between the mouth and body.

The medical history can be a significant factor when developing a treatment plan for an older adult. The most common chronic diseases seen in older adults include heart disease, arthritis, diabetes, osteoporosis, and senile dementia. Medical conditions must be identified and the stability of the patient's health status assessed. Medical history forms should provide an area for comments on the stability of a patient's medical condition. A medical history form that contains only a "yes" or "no" box for the question, "Do you have heart disease?" will not provide the dental team with sufficient information to gauge the patient's health. It is important to understand the nature of the patient's cardiac disease and any implications for dental treatment. Does the patient have a valvular heart problem that will require SBE prophylaxis? Is he taking anticoagulant therapy that may cause bleeding during scaling and root planing?

An older adult's medical history can change quickly, particularly medically compromised and/or nursing home residents. Incorporating a question about a patient's health before every dental appointment can be accomplished quickly and easily by any of the dental team. Be sure to listen to the answers! The history must include an assessment of any medication the patient is taking.

For new patients, the best approach for obtaining an accurate medication history is to ask them to bring all of their medications to the initial dental appointment. For patients of record, asking them at every dental visit if there have been any changes in their medications will help ensure a current record and identify risk factors that can affect oral health.

Salivary flow is much more likely to decrease as a result of multiple medication use. More than 400 medications can negatively affect salivary flow. Other medications, such as non-steroidal, anti-inflammatory medications, can negatively affect oral tissues. Antihypertensive and antiseizure medications can induce gingival overgrowth.

Physicians prescribe these drugs but rarely explain the side effects or adverse reactions that can affect oral health. By identifying a potential problem and educating the patient about it, you demonstrate your concern for your patient's overall health.

Dependency and chronic diseases

Dependency usually results from chronic systemic diseases that cause disabilities. Some examples are chronic hypertension that leads to a stroke and resulting paralysis, or arthritis that impairs an individual's ability to walk. Dementia is yet another disease that impairs a patient's ability to function cognitively. These medical, mental, and physical disabilities put patients at greatest risk for oral diseases.

These disabilities can prevent patients from practicing proper oral hygiene. Sjogren's Syndrome patients have inadequate salivary flow and thus an increased risk of caries. The diabetic patient will be at increased risk for periodontal infection because of systemic illness. The hypertensive patient has an increased risk of gingival overgrowth secondary to the anti-hypertensive medication. For dental professionals, the medical and medication review is an opportunity to educate patients about the risks to their oral health, the link between oral health and overall health, and strategies for prevention.

An adult's period of dependency may result in a nursing home admission or require home health care. Only 1.5 million adults over age 65 reside in nursing homes at any given time, but adults over age 65 have a one in four chance of spending some time in a nursing home. When personal care is impaired, it is essential for dental professionals to educate nursing home staff, families, and/or caregivers about the patient's daily oral hygiene needs.

Treatment planning

When preparing a treatment plan for older adults, give them the opportunity to "say yes." They have seen their children and grandchildren benefit from modern dental materials and techniques and they may be interested in those same procedures. Don't assume that the 78 year-old woman isn't interested in whitening her teeth or replacing her worn amalgam restorations with new, tooth-colored filling materials. Older adults in the United States are seeking orthodontic treatment in far greater numbers than any previous generation of this age group. Many adults with missing teeth also are interested in trading their removable prostheses for implant-supported prostheses.

As long as patients continue to "own" their dentition, making assumptions about their oral health expectations or finances is patronizing and disrespectful. Oral health services are not contraindicated for patients with chronic diseases. However, the dental team should educate the patient on the effects of systemic diseases and medication use on dental care and subsequent home care.

Family members sometimes question clinical recommendations. Why should my 82 year-old mother whiten her teeth? What if she has to enter a nursing home a year from now? Clinical decisions, such as tooth-whitening and anterior veneers, that seem appropriate today for a healthy 80 year-old may seen inappropriate 12 months later after the patient has had a stroke and can no longer brush her teeth sufficiently to maintain the dental work. It is normal for patients, families, and even dental professionals to question the original treatment-planning decision. Was this the correct treatment? Would the patient have been better off with his natural, malposed teeth rather than crowns? Would the old amalgam restorations have held up better against the constant plaque attack than the newer composite restorations? Is the implant and crown at greater risk than simply a missing tooth when the patient is in a nursing home? These questions can only be answered retrospectively. Dentists make the best decision they can with the information they have at the time. We should also take into account the joy and comfort the patient receives from improvements in his or her oral health, wellness, and self-esteem prior to any catastrophic health event.

Preventive care

Perhaps the most important aspect of oral health care for patients with chronic illnesses is incorporating a preventive dental plan into any treatment plan. By emphasizing a rigorous preventive program, you implicitly say to a patient that you care about his or her future and that you want it to be a healthy one. This is a powerful message for anyone, but it is often far more appreciated by older adults! Helping patients and/or their caregivers understand the importance of risk factors and then eliminating those factors that predispose patients to oral diseases can improve the quality of life for both healthy and medically compromised older adults.

Conclusion

Older adults provide a unique challenge for practitioners. They present a wide array of social, medical, and economic conditions, and maintaining their oral health is essential as they seek to stay healthy and manage an array of chronic diseases. Our diagnostic abilities will play a greater role in the dental care provided to this demographic. We no longer can take the medical and medication history for granted; moreover, it must become a consistent, value-added component of regular care.

Dental visits, diagnosis, and treatment planning provide an opportunity to educate patients about the link between systemic and oral health and the role of prevention in maintaining oral health for a lifetime. Given dentistry's past successes, I'm optimistic about its ability to meet the challenges of an aging population and make the remaining years on the "right side of the grass" dentally healthy.