160202P - ETHICO-LEGAL ISSUES IN GERIATRIC DENTAL CARE

Presentation at the workshop on ‘Facing the challenges of the ageing 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

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. Tooth loss for example was found associated with atherosclerosis. 
• The elderly are heterogeneous. Oral quality of life is associated with the personality traits of the elderly 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. Barriers to dental care of the elderly exist in the protected environment of the care homes. 
• ADOH index measuring dental functioning of the elderly 

ACCESS TO DENTAL CARE

• The oral health of the elderly is poor with a high need for dental care as well as an unmet need for oral health and dental dare.
• Cognitive impairment in the elderly means they are less able to take care of their dental health which results in dental problems.
• The elderly in residential homes may not have access to dental care due to a shortage of staff and facilities. Elderly abuse by the neglect of their dental needs. 
• Doctors in rural areas assessed the dental needs of the elderly less often than their urban counterparts. The Elderly admitted to ED because of a lack of community dental care resources. 
• The elderly in Senegal face many dental problems with extraction being the only treatment available 

CONSENT

• Dental treatment like all medical procedures must respect the patient’s autonomy by means of informed consent. 
• The elderly are not able to make decisions on dental care because of cognitive impairment and Alzheimer’s. 
• Measures may have to be taken to enhance decision-making capacity 
• 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. 

RISK VS BENEFIT CONSIDERATIONS

• Dental interventions carry higher risks for the elderly because of other concomitant problems. 
• Conservative minimal intervention strategies are needed. 
• Dental interventions for cosmetic effects may have to be limited. Simple measures such as rinsing may improve the dental health of the elderly   
• Professional dental care improves elderly dental health in the short term. 
• Functionally oriented treatment was more cost-effective than tooth replacement with artificial prostheses. 
• Education of home health care nurses on dental care improves their care for the elderly. The elderly need education about oral health and oral diseases.
• 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.