The life expectancy has steadily increased over the years. With increased life expectancy we see
increased wear and tear on teeth. The goal for the elderly population is to retain as many teeth as
possible to improve the quality of life and nutrition. Chronic dental diseases, such as dental
caries and periodontal disease are quite common in the elderly population. In a recent review
published in January 2019 in the journal Gerodontology explored the use of minimal intervention
dentistry to control and reduce caries and tooth loss in partially dentate older adults. 1
In a systematic review of the global burden of disease, untreated dental caries was found to be
the most common non-communicable disease worldwide. Additionally, this study reported three
peaks of disease burden, these peaks were at 6, 25, and 70 years of age. It was reported that
caries incidents were as high as three surfaces every three years in adults over age 65. This
burden is multifactorial, as patients age, they begin to take medications that induce
hyposalivation. Hyposalivation reduces the patient’s natural ability to reduce caries risk with the
buffering effects of saliva leading to, not only increased caries risk but also an increased risk for
periodontal disease and tooth loss.
There is also an increased concern for dependent frail elderly patients living in nursing homes.
These patients often lack basic dental care and there are many barriers preventing dental care in
residential settings. This lack of dental care has been associated with increased risk of respiratory
illnesses as well as dental disease. From a public health standpoint, it is important to find a way
around these barriers to better serve these patients in residential settings.
Minimal intervention dentistry (MID) concepts focuses on management of oral biofilm and
preservation of tooth structure. The goal for partially dentate adults is to provide “limited, but
acceptable, level of oral function”. This may also be a more cost-effective way to manage dental
disease in the elderly population, which will be helpful from a public health view.
MID includes tailored treatment by using risk assessment. When determining risk assessment, it
is recommended to assess not only the patient’s risk of disease, but also their ability to properly
care for future restorations. If there is a concern for the patients ability to care for the ideal
restoration, an alternate more simplified, easier to maintain restoration should be considered.
As previously mentioned, biofilm control is a huge factor in MID. Simple modifications may
help patients in their efforts to control biofilm for instance, patients with limited dexterity may
need a larger handle toothbrush or a mechanical toothbrush that reduces the need for proper
technique. Also, root exposure and sensitivity are common in elderly patients, recommending or
providing toothpaste to reduce sensitivity may encourage better oral hygiene and better biofilm
management. The idea is to shift from “treating” patients to “caring” for patients by empowering
them to take control of their oral health.
Root caries are especially frequent in the elderly population. There are multiple
chemotherapeutic agents that have been shown to be effective for preventing or arresting root
caries. These agents include sodium fluoride, silver diamine fluoride, chlorhexidine, and casein
phosphopeptide-amorphous calcium phosphate. For patients with high caries risk and multiple
root caries evidence suggests including a professionally applied fluoride varnish every 3-6
months in addition to specific oral hygiene instructions would be beneficial. Arginine has been
suggested to help reduce caries risk, however there are no long-term studies to confirm the
effects and a recent systematic review indicated insufficient evidence of a caries prevention
effect.
Atraumatic restorative treatment (ART) is a technique supported by MID. ART involves
removing carious lesions with hand instruments only, no rotary instruments. Then restoring with
an adhesive restoration material such as a glass ionomer. This technique saves time and has
shown to be just as successful as conventional treatment.
Another technique embraced by MID is the shortened dental arch concept. This concept suggests
providing a functional (shortened) dentition by “providing 3-5 contacting pairs of posterior teeth
with an intact and aesthetically acceptable anterior dentition”. There is evidence patients treated
with this technique instead of removable partial dentures have a lower incidence of dental
disease.
The review concluded that care for older patients needs to be tailored to circumstances, such as
medical and social circumstances. Heavy emphasis should be applied to “risk categorization and
minimizing the burden of maintenance to a manageable level”. Providing care to patients that is
affordable and acceptable with improved access to care for the aging population is also an
important part of the equation of MID.
Do you practice MID? Do you feel as if MID could improve treatment acceptance? Do you
believe with the proper tools and guidance elderly patients could improve biofilm control? What
are some of the tailored oral hygiene instructions you have provided to elderly patients? Do you
have a favorite “tool” you recommend for patients with limited dexterity?
1. Allen PF, Da Mata C, Hayes M. Gerodontology. 2019;36(2):92–98.
doi:10.1111/ger.12389
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