Geriatric Patient Competency by Sarah Coulter Introduction MD is a 71–year–old Vietnamese-American female who lives with her sister in Mountain View, where she has lived most of her life. She is retired after owning a coffee shop in San Jose for 10 years. She enjoys playing piano and listening to classical music. She also enjoys going for walks. Her active lifestyle and daily walks add up to more than the 150 minutes recommended for her age. Standing at 5 feet, 3 inches and 125 pounds, MD’s BMI is 22.1, which is normal. She has been a patient at Foothill Dental Hygiene Clinic for many years and is interested in improving her oral health. She is in the involvement stage on the learning ladder because she is actively improving her oral health and nutrition. She is a kinesthetic learner and learns best from tactile learning techniques. Her diet consists mainly of fruits and vegetables but she eats chicken and fish about twice per week. Assessments MD is in good overall health. She is under the care of her physician to manage her cholesterol levels. Her cholesterol levels are currently at healthy levels. She also gets a checkup every year and a breast exam. She was hospitalized in 2011 at El Camino Hospital to remove fat under both armpits after a suspicious breast cancer exam. There were no complications during or after the surgery. She is currently taking Simvastatin to manage her cholesterol levels. Her vital signs at all appointments were within normal limits. There are no dental implications for this medication. On the day of her third appointment MD took a sinus decongestant called phenylephrine hydrochloride. She stated she was experiencing slight cold symptoms such as a stuffy, runny nose. The dental considerations for this medication are xerostomia and increased blood pressure. Epinephrine is contraindicated while taking this medication. During her third appointment, her teeth were hand scaled with no anesthesia. Her last medical exam was June 2014 for a breast exam. There were no significant findings. Her last dental appointment was in 2013 to remove #3 and 30 due to decay. There were no complications. Her last dental hygiene visit was November 2013 at FHC for a cleaning.
Transcript
Geriatric Patient Competency
by
Sarah Coulter
Introduction
MD is a 71–year–old Vietnamese-American female who lives with her sister in Mountain
View, where she has lived most of her life. She is retired after owning a coffee shop in San
Jose for 10 years. She enjoys playing piano and listening to classical music. She also enjoys
going for walks. Her active lifestyle and daily walks add up to more than the 150 minutes
recommended for her age. Standing at 5 feet, 3 inches and 125 pounds, MD’s BMI is 22.1,
which is normal. She has been a patient at Foothill Dental Hygiene Clinic for many years and
is interested in improving her oral health. She is in the involvement stage on the learning
ladder because she is actively improving her oral health and nutrition. She is a kinesthetic
learner and learns best from tactile learning techniques. Her diet consists mainly of fruits and
vegetables but she eats chicken and fish about twice per week.
Assessments
MD is in good overall health. She is under the care of her physician to manage her
cholesterol levels. Her cholesterol levels are currently at healthy levels. She also gets a
checkup every year and a breast exam. She was hospitalized in 2011 at El Camino Hospital
to remove fat under both armpits after a suspicious breast cancer exam. There were no
complications during or after the surgery.
She is currently taking Simvastatin to manage her cholesterol levels. Her vital signs at all
appointments were within normal limits. There are no dental implications for this
medication. On the day of her third appointment MD took a sinus decongestant called
phenylephrine hydrochloride. She stated she was experiencing slight cold symptoms such as
a stuffy, runny nose. The dental considerations for this medication are xerostomia and
increased blood pressure. Epinephrine is contraindicated while taking this medication.
During her third appointment, her teeth were hand scaled with no anesthesia.
Her last medical exam was June 2014 for a breast exam. There were no significant findings.
Her last dental appointment was in 2013 to remove #3 and 30 due to decay. There were no
complications. Her last dental hygiene visit was November 2013 at FHC for a cleaning.
Suspicious caries were noted on teeth #3 and 30 on her dental referral letter. Her last x-rays
were taken in 2013 at Foothill Dental Hygiene Clinic for bitewings and 2 periapical films.
There were no radiographic caries found. After these radiographs were taken, her DDS
extracted #3 and 30 due to decay. Her vitals were generally within normal limits. Over the
course of her appointments her blood pressure ranged from 110/70to 120/78. Her pulse
ranged from 70–72, respiration was between 14 and 18. She was classified as ASA 1.
Extraoral/Intraoral exam and Periodontal exam
The extra and intraoral exams were WNL with no significant findings. The periodontal exam
revealed generalized 2-4 mm pockets with some areas of 6-9mm pocketson teeth #2, 15, 18,
24, 25, and 31. She had generalized recession ranging from 1-5mm. She had furcation
involvement ranging between class 1-2 on all furca on # 15 as well as class 1-2 furcation
involvement on buccal and distal furca on #2. She also had class 1 furcation involvement on
buccal furca of #19.She had generalized moderate bleeding on probing and suppuration
upon probing on lingual of #2. She had no mobility on the maxilla but she had class 3
mobility on #24 and + on 23, 25, 26 and 31. She had smooth, pink attached gingiva and
firm, blunted, pink papillae. Her gingiva had generalized firm consistency, light
inflammation, and receded margins. Her plaque was moderate and her hygiene was fair. Due
to generalized moderate subgingival calculus, MD was placed as calculus class 4. She was
placed as AAP type IV due to more than 50% bone loss, mobility and furcation
involvement.
Dental Charting
Over the last 2 years, MD had several teeth extracted due to caries involvement. There were
no complications upon removal. Teeth #3 and 30 were extracted in 2013and #14 was
extracted in 2012. Her 3rd molars were extracted over ten years ago. MD wears a partial
denture to replace teeth #3 and 14.She had amalgam restorations on #4 MOD, 5 MOD, 12
DO, 18 O, 29 O and 31-MO. She had composite restorations on #2 MO, 19 MO, 19 B, 20
MO, and 24 L5. She had porcelain crowns on #13 and 15. She had generalized attrition and
a defective restoration on #12 O. During her appointments, MD requested #24 to be left
alone due to sensitivity and mobility. #12 O and #24 were noted on her dental referral letter
to be checked by her DDS.She had class 1 occlusion with an open bite on # 13 and 20. Her
overbite measured 3mm, her overjet measured 5mm and her midline was even.
Plaque Index Score
MD was disclosed with a two-toned solution that shows plaque present for less than twenty-
four hours as pink and more than twenty-four hours as purple. These areas of plaque biofilm
accumulation were pointed out to MD. Heavy plaque was found on the distals of all
posterior molars and her plaque index score as 2, which is poor. Her DMFT was 13.
Update Assessments, CHX, scale using hand instruments.
4 Revaluate Bass technique and c-‐shape flossing technique.
2-‐5 Update Assessments, CHX, scale using USS, hand instruments. Apply 20% Benzocaine as topical, 4% Citanest Plain: infiltration #2, R MSA. Selective polish, 5% NaFl varnish.
Referral Recommendations: Based on the assessment evidence, the following indicate evaluation by a dentist Restorative DDS-‐ check #24 for mobility, sensitivity; #12 O defective restoration Periodontal 3 month recall– periodontal maintenance
Patient Education
The OHI evaluation was performed during the second appointment. MD brushes her teeth
three times per day with a soft bristled manual toothbrush and Pepsodent or Aquafresh
fluoridated toothpaste. Every night she gargles with salt water and flosses. Bass brushing
technique was chosen since there were areas she was missing at the gingival margin with her
current brushing method. Her plaque index score was 2, which is considered poor oral
hygiene. MD is in the involvement stage on the learning continuum since she is interested in
improving her dental hygiene and keeping her remaining natural teeth.
Since MD wears a removable partial denture, her denture was cleaned in the ultrasonic
cleaner for her. She was very grateful and said she cleans it every day but can never get it as
clean as it gets after being put in the ultrasonic cleaner. She brushes her denture with a
denture brush and Pepsodent cleaner at night. Since she had heavy plaque buildup around
areas of her denture, these areas were pointed out to improve brushing.
Plaque biofilm was explained to her as a sticky coating that constantly forms on teeth
immediately after eating. There are bacteria that produce acid, which eats away at enamel, the
outer surface or teeth, causing cavities. To protect enamel, this plaque needs to be removed
twice per day by brushing and flossing. Brushing alone cannot remove plaque from in
between each tooth, making it necessary to floss. MD was asked to point out the pink and
purple spots in her mouth showing where the plaque was in spots that were missed during
brushing. MD demonstrated in her mouth how she brushes. She showed excellent manual
dexterity. Afterward, proper Bass brushing was demonstrated inside MD’s mouth as she held
the mirror to watch. Proper 45–degree angulation technique was demonstrated, emphasizing
the importance of angling the brush so it’s aimed at the point where the teeth meet the gums
to remove plaque from pockets and all surfaces. Also emphasized was to hold the
toothbrush vertically for the labial surfaces of anterior teeth. Simple language was used to
avoid confusion. MD demonstrated what she learned in her own mouth. It was explained
how nutrition is important in preventing caries and she was praised for doing well in the
fruit and veggies groups. She was encouraged to drink more soymilk, since it contains
calcium to help strengthen her teeth and bones. MD was counseled on the importance of a
nutritious diet with the suggestion of decreasing her daily acid bath by drinking water after
each meal. She was asked if she was willing to try this new method of brushing everyday as
well as modify her dietandshe agreed that she was definitely willing to comply. She was
surprised by all of the purple areas in her mouth. My instructor said I did a wonderful job at
explaining everything.
Research
Geriatric patients have oral health care needs specific to those age 65 and older. Since MD
wore a removable partial denture and complained of not being able to get it as clean as she
wanted it, the research willdiscuss oral hygiene amongremovable denture wearers. This
includes proper cleaning methods for removable dentures. It will also show how partial
dentures affect the health of the geriatric patient and the prevalence of endentulism in the
geriatric population.
Edentulism is the complete loss of teeth. It can also be one of the most important indicators
of oral health. Edentulism significantly affects quality of life, self-esteem, and nutritional
status. Over the past several decades, endentulism has dropped in the U.S. A survey
conducted by the National centers for Health Statistics (NHANES) showed the prevalence
of edentulism dropped from 34% in 1999 to 27% in 2004 in those aged 65 and older.
According to a study titled “Oral status in home-dwelling elderly dependent on moderate or
substantial supportive care for daily living: prevalence of edentulous subjects, caries and
periodontal disease”, endentulism has decreased from 56% in 1983 to only 5% in 2003 in
Sweden. This decline in edentulism can be attributed to advances in oral health care and
treatment. This means the proportion of adults retaining their natural teeth much later in life
has grown significantly.1, 2, 3, 4
Despite the decline in prevalence of total tooth loss in the U.S., there is a slight increase in
demand for complete dentures. This demand is due to population shifts as the geriatric
demographic is increasing in size. The most common treatment for total loss of teeth in a
dental arch is a complete denture. Proper care for dentures is important for overall health,
especially among older individuals. In general, effects of oral diseases caused by unclean
dentures can be more profound on a frail elder than on a younger, healthier person.4
It’s important for dental hygienists to teach geriatric patients how to not only clean their
teeth and gums but to clean their dentures properly as well. Failure to remove the buildup of
biofilm on dentures can lead to pulmonary infections and pneumonia according to a study
titled “The needs of denture-brushing in geriatrics: clinical aspects and perspectives.”This
study claims that elderly often have poor oral hygiene because the patients and nursing staff
are not given proper instructions on how to care for dentures. This problem is made worse
by xerostomia suffered by many geriatric patients caused by numerous medications.3, 5
According to a study titled, “A survey assessing modes of maintaining denture hygiene
among elderly patients”, the older the patient gets, the less frequent they tend to clean their
dentures. In this study 500 subjects were given a questionnaire. Of the total sample size, 130
were over age 65.Graph 1 shows that most (19.10%) used water and brush to clean their
denture. Only 9.23% use cleansing tablets along with water. Of the sample, 60% of the
dentures were considered to be in poor condition. 6
Table 1shows only 11.1% of the 65 and older demographic clean their dentures once or
twice in a week. The majority (64.7%)of this geriatric age group cleaned their dentures
occasionally, which is even less frequently. 6
Fig. 1 (Graph 1) Fig. 2
The results in this study can be attributed to irregular cleaning habits and not using cleansing
solutions. Most of these patients were unaware of proper methods of cleaning. These
patients may have decreasing manual abilities due to older age. Another possibility for these
results could be that they were given improper instructions from the dental office when their
denture was given to them. This study showed the need for increased awareness among
denture wearers. Conducting educational and motivational meetings could increase
awareness. 6
Without proper denture hygiene, the patient is susceptible to flabby ridges, oral carcinomas,
denture stomatitis, angular cheilitis, traumatic ulcers and denture irritation hyperplasia. The
patient could also experience acute or chronic reactions to microbial denture plaque,
reactions to denture base material, or mechanical denture injury.6, 7
For routine cleaning, mechanical methods, such as toothbrushes are recommended. This
may cause undesirable surface abrasion. The use of toothpaste on the denture may cause
denture pigmentation. Patients should rinse their dentures and mouths with water whenever
possible. The tongue and mucosal surfaces of residual ridges should be brushed daily with a
soft brush. According to a study title “Examination of denture-cleaning methods based on
the quantity of microorganisms adhering to a denture” a denture brush and denture cleanser
should be recommended toeffectively reduce the amount of microorganisms on dentures.
Among those who used a denture cleanser daily or 3–4 times a week, the quantity of
microorganisms was found to be significantly lower in the dentures of patients than in those
who used one once or less per month. The cleansers used in this study were “Enzyme-
containing Polident” and “Toughdent”. Also in this study, it was determined that using a
denture brush was more effective than a toothbrush to clean the denture. There were no
reported differences in effectiveness between the brands of denture cleansers used.8, 9
According to an article called, “Evidence on the most effective method of cleaning dentures
is inconclusive” enzyme cleaners were more effective at removing plaque than effervescent
tablets over a longer period of time (8 hours) but not in a short period of time (15 minutes).
Enzyme cleaners were found to be as effective as brushing to remove plaque. 10
A study titled, “The effectiveness of chemical denture cleansers and ultrasonic device in
biofilm removal from complete dentures” compared 4 different methods of cleaning. The
control group was brushing with water. The other three groups compared were effervescent
tablets, ultrasonic device and a combination of effervescent tablets and ultrasonic device. All
groups used the same type of denture brush and water to clean their dentures 3 times a day
before applying their treatments. The results showed all methods were equally effective at
removing biofilm and superior to the control method of brushing with water. According to
mouthhealth.org, it is recommended to choose cleansers with the American Dental
Association seal of Acceptance. Denture brushes tend to fit the shape of the denture,
however a soft bristled toothbrush is also acceptable. Hard bristled brushes can damage the
denture. 11, 12
In conclusion, the geriatric population is living longer, keeping their teeth longer, but are
unaware of how to properly care for their remaining teeth and dentures. The research shows
the necessity of removing biofilm from dentures in order to keep their natural teeth longer,
prevent further tooth loss, denture stomatitis and other denture related conditions. As life
expectancy continues to increase, so do the needs of these aging individuals. The growing
population of geriatric patients requires dental hygienists to be aware of their unique needs
and teach them how to care for dentures. Dental hygienists need to instruct their geriatric
patients to remove their dentures each night, brush with a denture brush and soak in an
enzymatic cleaner over night. They need to be instructed to rinse their mouth and denture
frequently with water throughout the day. In addition, geriatric patients in nursing homes
and hospitals need the same instructions. The nursing staff needs to inform their patients
these same instructions or perform these duties for them if the patient is unable to.
Reflection
Due to MD’s recent extractions, I wanted to educate her on the importance of flossing her
remaining teeth to prevent them from needing extraction. I showed her proper c-shaped
flossing and had her demonstrate it back. I also made sure she could reach the distals of her
molars since this was where the majority of plaque was accumulating. After showing her the
plaque I found during the appointments, I noticed a significant decrease in plaque by her last
appointment. I made sure to praise her and encourage her to continue the plaque removal. I
told her that what she does everyday at home to clean her mouth and her denture is far more
important than what a hygienist can do in an office during one visit. I told her the cleaner
she keeps her teeth and gums, the more likely she will be able to keep her remaining teeth
healthy and intact. I instructed her to soak her denture in an enzymatic cleaner all night and
brush it with a denture brush or the soft bristled toothbrush I gave her. I also made sure she
understood it was important to rinse her mouth and denture out often through out the day.
She said she would definitely do this because wants to keep all of her remaining teeth.
Overall, I know I made a difference in MD’s home care because she her mouth increasingly
got cleaner at each visit before I even began each cleaning session. I felt good knowing that I
had made a difference in her life as far as her health is concerned. She even said she would
be at my graduation ceremony. I had never had a patient say that to me, so I was very
touched. After completing this geriatric patient, I feel more prepared for my next geriatric
patient because I was able to use some advanced instrumentation techniques. I used my 7/8
Gracey horizontally over line angles and I used my extended shank instruments in the deeper
pockets, especially in furcas. My instructor showed me new techniques that strayed from
what is consideredthe standard “textbook techniques”. I found these to be extremely helpful
in developing a more advanced tactile sense, which I was definitely lacking. Simple things
such as sitting at a different clock position meant the difference between feeling the calculus
and not feeling the calculus.
References
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and older adults in the United States: comparison of five racial/ethnic groups.
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Geriatr Soc. 2011 Mar;59(3):512-8
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effectiveness of chemical denture cleansers and ultrasonic device in biofilm removal
