Expanding Prosthodontic Services to the Older Patient in Dental Practices

Expanding Prosthodontic Services to the Older Patient in Dental Practices

Walter S. Warpeha, Jr., D.D.S., M.S.D., FACP:

A B S T R A C T
Numerous articles report on the unmet dental needs of the older patient, yet few have suggested strategies to overcome barriers to care for this unique demographic. At a  time when prosthodontic services, including dental implants, offer improved outcomes, the elderly remain the least served of all patient groups. Obstacles to treatment  include ageism, medical and dental complexity, financial limitations, and patients’ resistance to treatment. Expanding prosthodontic care of the elderly requires a departure from traditional patient management techniques. 
 
The attempt to reverse ageism in your practice must go beyond simple awareness. Those offices that can relate to, treat with respect, and fulfill the health aspirations of the older patient create the atmosphere where care is more readily accepted. A successful team approach to patient management depends upon the ability to listen and  respond to the elderly denture patient with information on denture maintenance and implant enhancements. An essential piece is encouraging regular recall for all denture  wearers by every staff member.
 
A well documented problem area in dental practice is the timely replacement of worn out or inadequate dentures. By using a simple assessment tool called the Satisfaction/Condition Score along with motivational interviewing, we have found increased treatment acceptance among our existing patients.
 
Use of these suggestions in a general dentistry practice is more likely to encourage the older patient to better accept enhanced prosthodontic services. 


Introduction
“Last scene of all… sans teeth, sans eyes, sans taste, sans everything.” Quoted from William Shakespeare’s As You Like It 
 
While the average lifespan has nearly doubled since Shakespeare’s time, societal attitudes toward the aging and the aged have changed little. Many dentists have questioned  why in the wake of great medical advances the loss of teeth and the accompanying disability continue to be an acceptable part of aging. 
 
We know that ageism — treating a group differently solely because of their age — exists in health care. Yet it is just one of the many obstacles in treating the older adult  dental patient. As people age, their dental and medical complexity increases, while their functional status and finances may be fixed or in decline. This is happening at a time  when seniors’ desire for an acceptable appearance, full function, comfort, and socialization over an ever-increasing life span remains at a level higher than previous  generations.
 
A well-known problem is that many full or partially edentulous patients are wearing old, worn out, or otherwise inadequate dentures. Dental communication coach Dr. Paul  Homoly explains that, in part, the older patient has a “perpetual lack of readiness” for treatment.1 When dentists use traditional methods of explaining the need for denture replacement, it lacks effectiveness for a several reasons. First, since tissue change under dentures is a slow process, the adaptable patient does not realize the extent of  deterioration that is occurring. In addition, studies show that patient satisfaction correlates poorly with oral-health-related quality of life (OHRQoL). Therefore, inadequate  dentures may be limiting food choices and enjoyment, or even causing discomfort, yet the patient does not perceive a reduced quality of life.2,3 Hence, advising these  patients that their dentures require replacement is met with skepticism.
 
Another common, but particularly unproductive, strategy is to wait for these patients to ask for treatment. People who may have lived through the tough times of the Great Depression or World War II are generally not complainers. These patients may also display a personal ageism, with reduced expectations of denture fit and function, often  coping with substandard performance and ongoing damage.
 
If a dental practice wants to expand prosthodontic services to the older patient, more than simply acknowledging the problem is needed.4 Proactive strategies must be put  into place that include appreciation of the uniqueness of this group, recognizing the care they take in making decisions, and understanding the things they value. 
 
I made some changes in my practice a number of years ago and found a significant increase in major prosthodontic services (rebase, replacement, or implant enhancement) for established patients — some who had been in our practice for 30 years or more. When I began to listen more carefully, enjoy their personalities, and appreciate their life  stories, it allowed me to empathize more readily with their health or dental problems. That understanding helped revamp the way we present treatment recommendations to  this practice demographic. 
 
I can recommend five strategies that may be a distinct departure from common practices for most dentists. I can attest to their effectiveness particularly for those patients  who resist a change in their present condition.
 
Keys to Expanding Prosthodontic Services
1. Correct even unconscious ageism in your practice. Whether from staff, your website, or even the doctor’s preference in continuing education, older patients are not going  to commit to treatment if they do not feel valued. 
 
A good start is to encourage your staff to show an active interest in the lives of these seniors. Be friendly and welcoming. Does your online presence portray vital seniors  with excellent oral health? Also, the dentist needs to stress to his or her team that every patient is to be given the opportunity for optimal dental health and that he or she  does not believe that oral disability is an inevitable consequence of aging. 
 
Lastly, if your capabilities in prosthodontics are weak, excellent course offerings presented locally by the University of Minnesota Continuing Education or, nationally, those  sponsored by the American College of Prosthodontists, can improve upon the basic skills you learned in dental school. This sends the message to your staff that the doctor  believes in quality prosthodontic outcomes for his or her patients. 
 
2. Establish a firm policy of regular recalls for all dentate, edentulous, and implant patients. Once a denture is made, the health of the oral tissues depends upon good  maintenance. Detecting a deteriorating fit and making a timely correction minimize damage to supporting tissues. Along with routine teeth or implant prophylaxis, dentures  need to be adjusted periodically so a proper relationship between the jaws is maintained. Thereby the face is supported, and a look of premature aging is prevented. The  opportunity for early detection of oral cancers allows conservative treatment and avoids devastating therapies or fatal outcomes. 
 
Make it a priority that all staff be able to verbalize the importance of regular recall and periodic maintenance. 
 
3. Making the case for retreatment or enhancement. I have mentioned that the soft and hard tissues of the mouth change slowly under a full or partial denture so that many  patients adapt to a deteriorating function and appearance. All patients need to hear at the time of new construction (repeated in a treatment conclusion letter), and at  recalls or repairs, that maintenance is required and periodic retreatment is inevitable. As the oral condition changes or as adaptation lessens, there is opportunity for offering  implant enhancement. Although denture quality is not directly correlated to OHRQoL,5 implant support dependably increases patient perception of wellbeing and satisfaction.6  In fact, in a ten-year multi-center study, all aspects of denture function showed improvement by the addition of implant support.7 
 
Other than denture enhancement, techniques like the shortened dental arch8 using dental implants to reduce tooth mobility9 or using implants with natural teeth to support a   partial denture,10 all are minimalistic procedures providing particularly cost effective treatments for the older patient. 
 
4. Motivational Interviewing and the S/C Score. The older prosthodontic patients may think they don’t have a problem, may exhibit lowered expectations, and may not easily  be motivated for any change. These are people who have spent a lifetime developing sales resistance. For all of the above reasons, the typical “case presentation” seldom  produces a commitment to treat. 
 
I explained in a previous article** how an undisciplined communication by the health provider could hinder health decision-making.11 The approach of giving direct advice commonly fails because the older patient reacts negatively to being told what he or she “should do”. As a result, the then battered health care professional retreats to the  mistaken belief that the patient does not want better health. 
 
A technique called motivational interviewing can lead even a resistant patient to a more healthful outcome.12 The approach is based on empathetic listening followed by  reflective response from the provider — devoid of any judgment or blame. Rather than telling these patients what is best for them, I want to put them into a situation where  the information they provide me and the information I return enables them to rationally analyze their own health choices. 
 
I have developed and tested my personal adaptation of motivational interviewing specifically targeting the prosthodontic patient for several years. It is a simplified screening method I call the Satisfaction / Condition Score (S/C Score). 
 
This screening is not meant to be a comprehensive tool such as the Prosthodontic Diagnostic Index produced by the American College of Prosthodontists.13 Yet it is a useful adjunct to involve the patient in treatment decision-making. Avoiding conflict and lowering the stress level of decision-making allows the patient to make better choices and  be more satisfied with the result.14 
 
During a recall appointment, my hygienist assists in a cooperative assessment of the adequacy of the patient’s prosthesis. She begins by saying, “Our job is to maximize your oral health by caring for the fit, function, and appearance of your dental appliance(s). Can we have a discussion on how well your denture(s) meet your needs?” Rather than direct questioning, the patient is guided by lead-in reflections to talk about their denture experience, while we carefully note patient-reported limitations or difficulties with  their dentures. Supportive responses are returned, such as, “Let me make sure I understand what you are saying”, or “It sounds like you think …” 
 
To conclude the  satisfaction part of the score, the hygienist asks these patients to rate their happiness with each denture they wear on a scale of 1-5. A score of 1 would  indicate a denture that is unwearable. A score of 5 would indicate a denture that is fully satisfactory. 
 
Then the dentures are removed, cleaned in the ultrasonic bath, rinsed, closely inspected, and cleaned manually when necessary. With denture in hand, they are examined together with the patient. The hygienist points out wear, fractured or missing teeth, discoloration, or deterioration of the base. Similar to the satisfaction score, a condition  score is recorded for each denture, where one point is deducted for each major deficit. A patient with an upper and a lower denture would have four numbers recorded —  i.e., a satisfaction and condition score for each denture. 
 
When the dentist comes in to complete the intraoral exam, the condition score can be discounted if the denture displays a defect in the occlusion, instability due to  inadequate base extension, or signs of tissue trauma. In general, scores less than 3 indicate that the denture either has deteriorated substantially or satisfaction is lessening.  After the dentist reviews the scores with a patient, moving that individual toward a change could include asking, “What would make your satisfaction score higher?” Their response may be an opening to offer options focused on areas where the patient places importance. 
 
The S/C score is done at every recall, and the score is documented on a sticker kept with the hygiene notes (Figure 1.). Patients can see the change in the number as their dentures age. Successive motivational interviewing sessions (similar to our scoring sessions) have been used in health care to increase the effectiveness in changing a wide  range of behaviors.15I have witnessed a steady decrease in the age of dentures that my patients have been willing to refit (high S, low C score) or replace (low S score,  low C score), as well as a substantial interest in retrofitting certain dentures (low S score, high C score) with dental implants. Recognize that a poor satisfaction score on  one denture may implicate the opposing denture when worn teeth or improper occlusal
plane decreases overall performance.
 
5. Association with a Prosthodontist.
Finally, as general practitioners do more prosthodontic dentistry, there is an increased chance that the dentist will uncover challenging cases. A relationship with a  prosthodontist can be beneficial for selecting an appropriate treatment plan, or as a resource when difficulties are encountered during treatment. 
 
Conclusion
Every dental practice has patients that could benefit from refitting, from new construction, or from implant prosthodontics. These predominantly older patients have  obstacles not found in other demographic groups. Yet few practitioners have a proactive stance to address those things that leave these individuals underserved. 
 
Five strategies are offered to reduce barriers in general practices and overcome obstacles in treating the fully or partially edentulous elderly. The dental staff needs to see the dentist’s conscious commitment to the oral health of patients of any age. They should be willing and able to communicate the importance of  regular recalls for all  patients, the health benefits of replacing worn or defective dentures, and enhancements possible with implant prosthodontics. 
 
Motivational interviewing skills, along with a unique satisfaction/condition scoring method, are designed to include the patient in decision making and encourage the older  patients to seek treatment. 
 
Finally, an association with a prosthodontist can be a valuable asset in expanding prosthodontic services among your existing dental patients. 
 
 
References
1. Homely P. Personal Communication, March, 2010.
2. Stober T, Danner D, Lehmann F, Séché AC, Rammelsberg P, Hassel AJ. Association between patient satisfaction with complete dentures and oral health-related quality of  life: two-year longitudinal assessment. Clin Oral Investig. 2010;Nov 3. [Epub prior to print]
3. Allen PF, McMillan AS. A longitudinal study of quality of life outcomes in older adults requesting implant prostheses and complete removable dentures. Clin Oral Implants  Res. 2003 Apr;14(2):173-9.
4 . Moreira AN et al. Knowledge and attitudes of dentists regarding ageing and the elderly. Gerodontology, 09/13/2011. 
5. Gray SA, Inglehart MR, Sarment D. Dentures and quality of life – a longitudinal analysis. J Dent Res 2002, 81(Spec Issue A):#267:60.
6. Naito M, Yuasa H, Nomura Y, Nakayama T, Hamajima N, Hanada N. Oral health status and health-related quality of life: a systematic review. J Oral Sci. 2006 Mar;48(1):1-.
7. Doundoulakis JH, Eckert SE, Lindquist CC, Jeffcoat MK. The implant-supported overdenture as an alternative to the complete mandibular denture. J Am Dent Assoc 2003   134(11);1,455-1,458.
8. Witter, DJ, VanPalstein Helderman WH. The shortened dental arch concept and its implications for oral health care. Community Dentistry and Oral Epidemiology August 1999  27(4);249-258.
9. Walton TR. Changes in the outcome of metalceramic tooth-supported single crowns and FDPs following the introduction of osseointegrated implant dentistry into a  prosthodontic practice. Int J Prosthodont. 2009 May-Jun;22(3):260-7.
10. Ohkubo C, Kurihara D, Shimpo H, Suzuki Y, Kokubo Y, Hosoi T. Effect of implant support on distal extension removable partial dentures: in vitro assessment. J Oral Rehab 34(1);Jan 2007:52-56. 
11. Warpeha W, Jr. Pitfalls in full mouth implant dentistry. Part Two: Effectively communicating costs and outcomes as a patient advocate in prosthodontic treatment  planning. Northwest Dent. 2011 Mar-Apr;90(2):27,9,37-40. 
12. Miller WR, Rose GS. Toward a theory of motivational interviewing. Am Psychol. 2009 September;64(6):527–537. 
13. McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH. Classification system for complete edentulism. J Prosthodontics 1999;8:27-39. 
14. Schwartz, B. The Paradox of Choice: Why More Is Less. Ecco, 2004. 
15. Scales R, Miller J, Burden R. Why wrestle when you can dance? Optimizing outcomes with motivational interviewing. J Am Pharm Assoc 2003 Sept-Oct;43(5 Suppl 1):S46-7. 


*Dr. Warpeha is a board certified prosthodontist in private practice in Minneapolis, Minnesota. He is a panel member of the Cleft Palate Clinics at the University of Minnesota  School of Dentistry and Children’s Hospital/Minneapolis, and is a prosthodontic consultant to the Minnesota State Board of Dentistry. Email address is rebecca@warpeha.us.
 
**“Pitfalls in Full Mouth Implant Dentistry”, Parts One and Two, January-February, 2011, pages 27-32; March-April, 2011, pages 37-40.