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Presentation at the workshop on ‘Facing the challenges of the aging society’ held at the King Fahad Medical City Small Auditorium on February 2, 2016, by Prof Omar Hasan Kasule Sr. Chairman of the Human and Medical Ethics Committee. Professor at the Faculty of Medicine and Chairman of the Ethics Committee at Fahad Medical City Riyadh Saudi Arabia.
HOLISTIC
VISION
·
Holistic care requires that dental
needs are considered alongside other health problems.
·
Dental problems like other health
problems increase with age. Systemic diseases are correlated with dental
conditions in the elderly[1].Tooth loss for example was
found associated with artherosclerosis[2].
·
The elderly are heterogenous. Oral
quality of life is associated with personality traits of the elderly[3] so we need to
individualize.
·
Treatment of oral conditions in the
elderly is associated with many medical, social, psychological, and financial barriers that have
to be overcome[4].
Barriers to dental care of the elderly exist in the protected environment of
the care homes[5].
·
ADOH index measuring dental
functioning of the elderly[6]
ACCESS
TO DENTAL CARE
·
Oral health of the elderly is poor[7] with a high need for
dental care[8] as well as unmet need for
oral health and dental dare[9].
·
Cognitive impairment in the elderly
means they are less able to take care of their dental health which results in
dental problems[10].
·
The elderly in residential homes
may not have access to dental care due to a shortage of staff and facilities[11]. Elderly abuse by the neglect
of their dental needs[12].
·
Doctors in rural areas assessed the dental needs of the elderly less often than their urban counterparts[13]. The Elderly admitted to ED
because of lack of community dental care resources[14].
·
The elderly in Senegal face many
dental problems with extraction being the only treatment available[15]
CONSENT
·
Dental treatment like all medical
procedures must respect the patient’s autonomy by means of informed consent[16].
·
The elderly are not able to make
decisions on dental care because of cognitive impairment[17] [18] [19] and Alzheimer’s[20].
·
Measures may have to be taken to
enhance decision-making capacity[21]
·
When the elderly lack the competence to
make independent decisions regarding their dental care and proxy decision
makers may have to make decisions for them.
·
When not sure a formal test of
competence must be undertaken[22].
RISK
vs BENEFIT CONSIDERATIONS
·
Dental interventions carry higher risks for the elderly because of
other concomitant problems.
·
Conservative minimal intervention strategies are needed[23].
·
Dental interventions for cosmetic effects may have to be limited.
Simple measures such as rinsing may improve the dental health of the elderly[24] [25]
·
Professional dental care improves
elderly dental health in the short term[26].
·
Functionally oriented treatment was
more cost-effective than tooth replacement with artificial prostheses[27].
·
Education of home health care
nurses on dental care improves their care for the elderly[28]. The elderly need
education about oral health and oral diseases[29].
·
Concept of expected remaining life
span?
CASE
SCENARIO #1
An elderly patient with severe
painful periodontal disease that prevents him from eating resulting in severe
malnutrition refuses treatment for fear that doctors will pull out his teeth.
All attempts at explanation to convince him to consent fail. Assessment by the
psychologists shows that he is competent. The dentists decide to sedate and
treat him against his wishes after obtaining consent from his wife.
CASE
SCENARIO #2
An elderly dental patient able
to eat properly and in good nutritional status came to the dental clinic and
asked for cosmetic oral surgery. The doctor refused to say that resources were
limited to those whose life in danger.
CASE
SCENARIO #3
An oral surgeon examined an
elderly patient and got permission to extract a dead tooth under heavy
sedation. She discovered during the procedure that there was an extra tooth
that needed extraction but he had not got consent for the procedure
REFERENCES
[1]
Dent Clin North Am. 2014 Oct;58(4):797-814
[2]
J Dent Res. 2015 Mar;94(3 Suppl):52S-58S.
[4]
Dent Clin North Am. 2014 Oct;58(4):739-55..
[5]
Community Dent Oral Epidemiol. 2014 Apr;42(2):113-21.
[6]
Spec Care Dentist. 2001 Mar-Apr;21(2):63-7.
[7]
N Z Dent J. 2014 Dec;110(4):131-7.
[8]
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[9]
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[10]
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[11]
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[12]
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[13]
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Community Dent. 2015
May; 5 (Suppl 1):S20-4.
[14]
J Mass Dent Soc. 2013 Summer;62(2):24-8.
[15]
Odontostomatol
Trop. 1991 Mar;14(1):7-12.
[16]
Br Dent
J. 2006 Jan 14;200(1):18-21..
[17] Tex Dent J. 2009 Jul;126(7):582-9
[18]
Tex Dent
J. 2009 Jul;126(7):582-9.
[19]
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Dentist. 1992 Sep-Oct;12(5):202-6.
[20]
Tex Dent
J. 2009 Jul;126(7):582-9
[21]
Am J
Geriatr Psychiatry. 2007
Feb;15(2):163-7.
[22]
Aust Dent J. 2015 Mar;60 Suppl 1:64-70..
[23]
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[24] Clin Prev
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[25]
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[26]
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[27]
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[28]
Community Dent Oral Epidemiol. 2014 Feb;42(1):88-96.
[29]
J Am Dent Assoc. 2015 Jan;146(1):17-26..