Monday, August 19, 2013

Oral health care for the elderly: It's about more than dentures

"She laughs at everything you say. Why? Because she has fine teeth." -- Benjamin Franklin.

Making informed health care decisions aren't easy at any point in one's life but when you're over 90, situations are more complex, the trade-offs less obvious. On a recent routine dental visit, my 98-year-old mother learned that her lower front teeth are infected (abscessed). Her regular dentist was adamant that they should be extracted. If left untreated, there could be swelling and infection that could become a medical emergency.
My mother's response -- "So what."
In a younger person, say under age 85, standard procedure likely would prevail. The chance of inflammation, pain and even bone involvement is high. Antibiotics, effective in the short term, won't solve the problem, he said. So over the past two weeks my mother has been worrying about what to do.
The extractions would trigger a cascading number of follow-up challenges. First there's the procedure itself, which would be tricky since my mother takes the blood-thinner Coumadin. That would have to be managed. Secondly, the physical stress of the extractions on a 100-pound 98-year-old body could be profound with days of recovery, never mind the mental stress. Mother's primary dentist will then build a false tooth "partial" that must be anchored to her lower remaining side molars using Fixodent denture adhesive every day.
Mother has trouble keeping the upper partial in place that she already wear. It's sad (and kinda funny) to watch her talk with the upper partial flopping loose in her mouth. For God's sake, she's in a wheel chair, can't see very well and has minimum strength, so let's not get too cheery about how she's going to manage all this.
Today's consultation with an oral surgeon was the first indication that things might go my mother's way. She does not want to have her lower front teeth pulled, if she can help it.
"It just doesn't make sense to do all this when I'm not going to live that much longer," she said plaintively. "He told me that this was up to me. I told him that I'd think about it."
In a follow up conservation, the oral surgeon told me that since my mother isn't in pain that there was no real harm in waiting. "Worst case, we have to take them out at the point it starts hurting," he said. "I told her that it was her decision. We can hold off."
Wow, a doctor who seemed to consider how the extractions might affect my mother's 98-year-old quality of life, her self image, her ability to continue to live in the assisted-living care center and her sense of control over her life.
Health care professionals would classify my mother as among the "frail elderly" because of her weakened physical condition. However, she's anything but mentally frail. She's grateful to her oral surgeon for giving her time to come to terms with what the next steps might be concerning her teeth.
According to  a report, "Dental Considerations of the Frail Elderly" it is the cumulative effects of both oral and systemic diseases that account for the extensive pattern of oral disease among the elderly". Some people, the report said, are able to stay well, maintain their own teeth throughout old age. "For the frail elderly the situation is quite different."
In my mother's case, things began to deteriorate when she fell stepping onto a curb and knocked out a couple of upper front teeth and broke a knee cap at age 93. She got an upper partial to replace the teeth. Her knee cap healed after several weeks in a thigh-to-calf brace. The fall certainly contributed to her overall physical decline because she lost strength and endurance. The experts say, loss of one or more teeth can predispose to further tooth loss, to destruction of bone surrounding the teeth and dependence on dentures. All this in turn may interfere with chewing food and nutrition.
"Geriatric diagnosis and treatment planning are complex," said the report. "Aging has an impact on oral tissues just as it has on other tissues throughout the body."
Older teeth are more brittle, less resilient, less soluble and less permeable. The pulp chamber, where blood vessels and nerves of the teeth are located, also under go significant changes.
If 20 or 30 years ago, most frail elderly people or elderly in general, were without their own teeth and wore a set of dentures things are different now. The good news is that there now is an array of procedures and treatments...implants, veneers, partials and other treatments that were not available even a few years ago. And there is more awareness of the importance of good dental hygiene by the aged themselves and caregivers.
However, "the caregiver, particularly a spouse or other family member, may be so burdened with other needed care that oral concerns are not recognized," the report said.
At 98 my mother faces numerous disabilities every day...her speech has been affected by a stroke, her eyesight is marginal also because of the stroke. She's weak and works to raise herself up and out of a chair and into her wheel chair. She struggles to dress herself and undress at night, one leg at a time while sitting.
She was caught by surprise by this latest indignity of old age...bad teeth.
For more about oral health in the elderly:
"Senior Dental Problems and Taking Care of Elderly, click here.
"Dental Considerations in the Frail Elderly, click here.
Osteoporosis of the Elderly & Risks with Oral Surgery, click here.
Should Your Parent Risk an Anesthesia Disaster or Forgo Surgery? - click here.
"Oral Health Care for the Elderly: More than Just Dentures, click here.
Abscessed teeth, what to do, click here.
 

 

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