What are the treatment planning considerations in older adults?
Ella M. Oong, DMD, MPH and Gregory K. An, DDS, MPH
- As U.S. population increasingly ages, older adults have retained more teeth than ever before.
- In recognition of treatment needs, older adults continue to seek dental care: from 2000 to 2011, dental utilization among older adults increased from 38% to 42%. 1
Purpose of the Review
This article briefly describes the profile of older adults in the United States, and discusses the dynamic process of treatment planning and obtaining informed consent. As well, various models for formulating alternative treatment plans are described.
- Treatment planning for geriatric care is a dynamically informed process culminating from comprehensive diagnostic evaluation and informed consent.
- Geriatric patients presenting with multiple chronic conditions, medications, and complex socio-behavioral histories require a strategic, stepwise plan for disease treatment and oral health maintenance.
- Flexibility and good communication with the patient and other involved parties during treatment planning for older adults may attenuate uncertainties and lead to successful outcomes.
Models of Geriatric Dental Treatment Planning
Mnemonic SOAP (Subjective findings, Objective findings, Assessment, and Plan)2
- In geriatric patients, the subjective findings include additional information concerning functional status as described by the ability to carry out ADLs and instrumental activities of daily living.2
Mnemonic Oral factors, Systemic factors, Capability, Autonomy, and Reality (OSCAR):3
- Oral factors take into consideration the current dentition and restorations, periodontium, oral hygiene and root caries, salivary secretions, tooth loss, mucosal tissues, removable prosthesis, and occlusion. Systemic factors encompass normal changes related to aging and comorbidity, effect of medications, and communication between the dentist and physician(s) in managing the geriatric dental patient with a medically compromised health status.
Rational treatment model:
- Considers the influence of modifying factors on primary factors, which in turn alter the biofilm and, consequently, the development of oral diseases and conditions. 4, 5
- Modifying factors, such as lifestyle, socioeconomic status, medications, cognition, disability, and medical and dental history alter the balance of diet, saliva, and genetics, and affects chemotherapeutics and oral hygiene.
- This model, adapted from a caries risk model, explains how etiologic factors affect the development of caries, periodontal disease, tooth loss, and mucosal lesions.
- Risks and benefits of treatment also influence whether no treatment, emergency care, limited treatment, or comprehensive care is planned.
- The patient’s desires, expectations, dental needs, quality-of-life expectations, stress tolerance, financial status, and oral hygiene capacity, along with the dentist’s experience and skill level, direct the treatment-planning process.6, 5
Clinical reasoning sequence in decision making and resolution of dental problems:5
- Three action sequences are presented in resolving dental problems:
- Determine the cause,
- Choose an action, and
- Implement the plan.
- To determine cause, the problem must be defined, other possible causes considered, and possible causes tested.
- To help choose an action, goals in consultation with the patient must be established, alternatives examined, and adverse consequences considered.
- Implementation of the plan involves anticipating potential problems, taking preventive actions, and setting up contingency plans.
Complexity and uncertainty in treatment planning in elderly patients:
- It provides a basis for prioritizing and weighing factors affecting the treatment-planning process.7
- Important factors include:
- Reliance on biological age rather than chronologic age;
- Consideration of the useful life of dental interventions, such as fillings and prosthetics in the context of life expectancy for older adults; and
- Reconciliation of expectations between the patient, other involved parties, and the dentist through effective communication.
- To address uncertainties inherent to treatment planning, clear decisions should be made and treatment progress monitored.
- Careful documentation from evaluation to implementation protects from uncertainty.
Geriatric care model intended to account for the factors precipitating successful treatment in any setting:
- Interplay between 4 broad domains: dental/oral, medical, psychosocial, and behavioral.
- Dental/oral: Examination findings, influence of systemic disease, physician consult, dental specialty referral, treatment plan modifications, and selection of appropriate treatment options.
- Medical factors include: systemic conditions; medications, including adverse effects and drug-drug interactions; laboratory values; special issues; and medical referral.
- Psychosocial factors influencing treatment plan include: informal assessment; basis of functioning such as cognition, recognition, reasoning, and commitment; and support system from the societal to the personal.
- Behavioral factors include: decision-making style; ability to cooperate with treatment; sedation involving feasibility and need; understanding of one’s own limitations; need for personal assistance; home-care capability; and adherence potential. This model guides the clinician in attenuating psychosocial, medical, and behavioral barriers.
A more specific approach to treatment planning addresses dementia and its role in planning:8
- In the early stage of dementia, when changes in cognitive function are minimal, changes to the treatment-planning process are minimal as well.
- If there is an accompanying degenerative disease diagnosis, such as Alzheimer disease, the treatment plan should be designed to anticipate future loss of cognitive function, include aggressive prevention, and restore function with celerity.
- Treatment plans for middle and late stages of dementia may require considerations, such as modifying appointment length, using sedation, and increasing the frequency of recalls.
- In the middle stages of dementia, it is suggested that limited treatment plans are designed with minimal changes, and should include aggressive prevention along with communication of prevention strategies with caregivers.
- Treatment of those at advanced and terminal stages may be basic, with palliative and emergency care aimed at maintaining the dentition.
- Throughout the treatment-planning process the patient’s desires continually influence clinical decision making.
- Nasseh, M. Vujicic Dental care utilization continues to decline among working-age adults, increases among the elderly, stable among children Health Policy Resources Center Research Brief American Dental Association, Chicago (IL) (2013) Available at: http://www.ada.org.myaccess.library.utoronto.ca/sections/professionalResources/pdfs/HPRCBrief_1013_2.pdf
- M. Laudenbach Treatment planning for the geriatric patient. In Clinician’s guide to oral health in geriatric patients (3rd edition) American Academy of Oral Medicine, Edmonds (WA) (2010), pp. 7–8.
- Shay Identifying the needs of the elderly dental patient. The geriatric dental assessment. Dent Clin North Am, 38 (1994), pp. 499–523.
- L. Ettinger Meeting the oral health needs to promote the well-being of the geriatric population: educational research issues. J Dent Educ, 74 (2010), pp. 29–35.
- B. Berkey, K. Shay, P. Holm-Pedersen Clinical decision-making for the elderly dental patient P. Holm-Pedersen, H. Loe (Eds.), Textbook of geriatric dentistry (2nd edition), Munksgaard, Copenhagen (Denmark) (1996), pp. 319–337.
- L. Ettinger Rational dental care: part 1. Has the concept changed in 20 years? J Can Dent Assoc, 72 (2006), pp. 441–445.
- E. Johnson, S.K. Shuman, J.C. Ofstehage Treatment planning for the geriatric dental patient. Dent Clin North Am, 41 (1997), pp. 945–959.
- C. Niessen, T. Wetle, G.P. Wirthman Clinical management of the cognitively impaired older adult P. Holm-Pedersen, H. Loe (Eds.), Textbook of geriatric dentistry (2nd edition), Munksgaard, Copenhagen (Denmark) (1996), pp. 248–257.