Aspects of Polypharmacy in Dental Treatment of Seniors

Abstract

Background:

Due to demographic changes, the task of dental treatment for older patients is increasing. The aim of this study was to record polypharmacotherapy in elderly patients undergoing dental-prosthetic treatment. In addition, it was hypothesized that patients with removable dentures have a higher polypharmacy rate than patients with fixed dentures.

Methods:

In a prospective and observational study, 103 patients aged 70 years and over were included. Age, gender, and the type of denture were recorded. Daily medication was charted using a questionnaire and patients’ medication plan. The medication was recorded according to the anatomical-therapeutic-chemical classification system of the World Health Organization. In addition, a patient-related medication analysis was carried out.

Results:

Of the 103 study participants, 59 were female and 44 were male. The average age was 80.7 years. Twenty-six patients were fitted with fixed restorations (PFR) and 77 patients with removable dentures (PRD). Polypharmacy (more than 5 medications taken) was equally common in both patient groups (62% in PFR and 61% in PRD; P = 0.964). The number of medicaments (4.8 ± 2.8 in PFR and 6 ± 4.3 in PRD; P = 0.318) and the number of medication groups (1.6 ± 0.9 in PFR and 2 ± 1 in PRD; P = 0.053) did not differ significantly. Considering the medication groups PRD group took anti-diabetic drugs significantly more frequent (4% in PFR and 25% in PRD; P = 0.021). Of the medications taken, 24% belonged to the group of anticoagulants/platelet inhibitors, 12% to the group of psychotropic/neurological drugs, 11% to antidiabetics, 1% to bisphosphonates/monoclonal antibodies, 1% to cytostatics, and 51% other medications. The patient-related analysis showed that 47% of the study participants took anticoagulants/platelet inhibitors, 25% psychotropic/neurological drugs, 19% anti-diabetics, 3% cytostatics/angiogenesis inhibitors, and 2% bisphosphonates/monoclonal antibodies. In addition, 93% of the patients took other medications, while only 6% of the study participants received no drug therapy.

Conclusion:

On average, the majority of patients requiring prosthetic treatment were on polypharmacy. However, there was no difference between PFR and PRD patients regarding the number of medication groups and the number of medicaments. The dental treatment of elderly patients requires beside expertise in gerostomatology profound knowledge of pharmacotherapy in old age.

Introduction

Advances in medical care for the population are reflected in demographic change, which is characterized by increased life expectancy. It can be assumed that the percentage of seniors in our society will continue to increase. All of these developments have enhanced the importance of the medical discipline of geriatrics which is concerned with the special physical, mental, and functional aspects of the care of acute and chronic illnesses in senior patients.[1,2] In this context, the care of multimorbid patients who require dental and prosthetic treatment must also be taken into account.[3,4]

This can be particularly challenging, as the higher life expectancy will also lead to a long period of edentulousness, which increases the atrophy of the alveolar bone and makes adaptation to removable dentures more difficult.[5] The goal of gerostomatology is therefore to provide senior patients with the best possible dental care. This includes the fact that a large majority of these patients is administered several medications on a daily basis, whereby by definition, taking more than five medications is considered polypharmacotherapy.[6]

The aim of this study was to determine the number of medications taken daily by elderly patients undergoing prosthetic treatment and to identify the possible relationships between medication and the type of prosthesis used. We formulate the hypothesis that patients with removable dentures (PRD) have a higher polypharmacy rate than patients with fixed dentures (PFR). In addition, recommendations are made for daily practice in geriatric dentistry that address the topic of polypharmacy.

Methods

Study design and ethics

Between November 2019 and November 2021, 103 patients aged 70 years and more were included in the prospective and observational study at the Department of Prosthetic Dentistry at Saarland University. The study was submitted to and approved by the Ethics Committee of the University Hospital, Homburg, Saarland. (Ethics Committee No. 156/19). Age, gender, and the type of prosthesis worn were recorded during the dental examination. Daily medication was gathered using a questionnaire and adjusted with the GP’s medication plan.

The medication was scheduled into six main groups according to the anatomical-therapeutic-chemical (ATC) classification system of the World Health Organization (WHO):[7] Anticoagulants/platelet inhibitors, bisphosphonates/monoclonal antibodies, cytostatics/angiogenesis inhibitors, anti-diabetics, psychotropic/neurological drugs, and other medications. In addition, a patient-related medication analysis was performed on the number and type of medication taken.

Statistical analysis

Statistical analyses were performed using the SPSS Version 29.0.2.2 and DATAtab (2025) (DATAtab: Online statistics calculator. DATAtab e.U. Graz, Austria. URL https://datatab.de). Gender and type of prosthesis were used as group variables. Binary categorical variables were compared using Pearson’s chi-square test, or Fisher’s exact test if expected counts were <5. Continuous variables were assessed for normality with the Shapiro–Wilk test. Since data were non-normally distributed, comparisons between the two groups were performed using the Mann–Whitney U test. Continuous variables are reported as mean and standard deviation, categorical variables as counts and percentages. Spearman correlation analysis was used to determine the potential relationship between the number of medicaments and age. P <0.05 indicated statistical significance.

Results

Of the 103 study participants, 59 (57.3%) were female and 44 (42.7%) were male. The average age was 80.7 years (men 80.7 years, women 80.7 years; P = 0.979). There was no significant difference between men and women regarding the number of medication groups (men 2.0, women 1.9; P = 0.067). Twenty-six patients (25.2%) were fitted with fixed prosthetic restorations (PFR) and 77 patients (74.8%) with removable dentures (PRD). Table 1 shows the clinical characteristics of the study participants and the main results.

Table 1.

Clinical characteristics of the study participants and main findings

	Patient group		P
	PFR (n=26)	PRD (n=77)
Gender, n (%)
Women	16 (62)	43 (56)	0.612*
Men	10 (38)	34 (44)
Age, mean (SD), years	80.5 (6.1)	80.7 (5.8)	0.667**
Number of medication groups (SD)	1.6 (0.9)	2 (1)	0.053**
Number of medications (SD)	4.8 (2.8)	6 (4.3)	0.318**
Polypharmacy, n (%)	16 (62)	47 (61)	0.964*
Anticoagulants and platelet inhibitors, n (%)	8 (31)	38 (49)	0.099*
Biphosphonate, antibodies, n (%)	2 (8)	0	0.062***
Cytostatics, angiogenesis inhibitors, n (%)	2 (8)	0	0.062***
Antidiabetics, n (%)	1 (4)	19 (25)	0.021***
Psychotropic/neurological medications, n (%)	3 (12)	19 (25)	0.158*
Other medications, n (%)	24 (92)	72 (94)	0.834*

*Chi-Square test; **Mann–Whitney U-test; ***Fisher’s exact test. SD: Standard deviation; PFR: Patients with fixed restorations, PRD: Patients with removable dentures

Signs of polypharmacy

Of the 103 study participants, 63 took five or more medications daily. This corresponds to a patient proportion of 61% to whom the term polypharmacy applies. When examining the two sexes separately, polypharmacy was observed in 56% of women and 68% of men (P = 0.207). On average, each study participant took 5.7 different medicaments per day (men 5.9, women 5.5; P = 0.649). There was no significant correlation between the number of medications and age in years (P = 0. 222). Study participants with removable dentures (PRD) took 6 medications per day (standard deviation [SD] 4.3), study participants with fixed restorations (PFR) took an average of 4.8 (SD 2.8) medications per day (P = 0.318). Regarding the number of medication groups (1.6 ± 0.9 in PFR and 2 ± 1 in PRD) there was no significant difference. However considering the six medication groups according to the classification system of the WHO, the PRD-group took antidiabetic drugs significantly more frequent (4% in PFR and 25% in PRD; P = 0.021). The main results are shown in Figure 1.

Figure 1.

(a) Shows the correlation between age and number of medicationsin the studied cohort. There is no statistically significant correlation (P = 0.222). (b) Shows the number of medication groups stratified according to fixed (PFR) or removable dentures (PRD). There is no statistically significant difference (P = 0.053). (c) Shows the number of medications stratified according to fixed (PFR) and removable dentures (PRD). There is no statistically significant difference (P = 0.318). (d) Shows that patients with removable dentures (PRD) were more frequently on antidiabetics than patients with fixed dentures (PFR) (P = 0.021)

Patient-related analysis

The patient-related analysis showed that 47% of the study participants took anticoagulants/platelet inhibitors daily, 25% psychotropic/neurological drugs, 19% antidiabetics, 3% cytostatics/angiogenesis inhibitors, and 2% bisphosphonates/monoclonal antibodies. In addition, 93% of the patients took other medications, while only 6% of the study participants did not receive any medication therapy.

From the other medications category, 41% of patients were taking statins (cholesterol-lowering drugs), 32% were taking thyroid medications, 32% were taking proton-pump inhibitors (gastric acid secretion inhibitors), 29% were taking nutritional supplements, and 25% were taking analgesics. Pulmonary drugs were taken by 16%, uricostatics by 9%, antiprostatic hyperplasia drugs by 8%, anti-inflammatory drugs by 7%, incontinence drugs by 5%, muscle relaxants by 4%, digestive drugs by 4%, hypnotics by 4%, and antivertiginosa by 3% of patients. All others including immunosuppressants, tranquilizers, ophthalmological drugs, antivirals, antiemetics, antiparasitics, phosphodiesterase- inhibitors (PDE-5) inhibitors, anti-allergics, and androgen substitution preparations accounted for 1%.

Medication-related analysis

Of the medications taken, 24% belonged to the group of anticoagulants/platelet inhibitors, 12% to the group of psychotropic/neurological drugs, 11% to antidiabetics, 1% to bisphosphonates/monoclonal antibodies, 1% to cytostatics, and 51% other medications.

The analysis of the category of other medications revealed that 18% of these drugs were statins, which are used to lower cholesterol or blood lipid levels. Thyroid medications and proton pump inhibitors, which inhibit gastric acid secretion, each accounted for 14%. Food supplements amounted to 13%, analgesics to 11%, while medications for treating lung diseases had a share of 7%. Uricostatics, which are used to treat gout, accounted for 4%. Anti-inflammatory drugs and medications for prostate hyperplasia each had 3%. Muscle relaxants, medications for incontinence, agents for regulating digestion and hypnotics each accounted for 2%, antivertigo drugs for 1%. Drug groups with a share of <1% included immunosuppressants, tranquilizers, ophthalmological drugs, antivirals, antiemetics, antiparasitics, PDE-5 inhibitors, antiallergics, and androgen substitution preparations.

Discussion

The senior group examined comprised male and female patients who were on average 80 years old. Their daily intake of 5.7 individual medications indicated polypharmacy. Women were more frequently affected in our cohort, although this was not statistically significant. In another investigation polypharmacy is judged as a major problem especially for women over 80.[6] Stratified by dental treatment, there were no differences in terms of the number of medications, the number of medication groups, or the various medication groups, with the exception of antidiabetics. Patients with removable dentures (PRD) took antidiabetic drugs significantly more often. This could reflect the finding that patients with diabetes have a higher risk of tooth loss.[8]

The medication-related analysis revealed that a quarter of the medicaments administered was anticoagulants/platelet inhibitors, followed by psychotropic/neurological drugs and antidiabetics. Bisphosphonates/monoclonal antibodies and cytostatics made up a small percentage. A substantial proportion took other medications. The patient-related medication analysis rendered no significant difference between men and women, with about half of the study participants taking anticoagulants/platelet inhibitors daily, followed by a quarter taking psychotropic/neurological drugs, followed by antidiabetics, cytostatics/angiogenesis inhibitors, and bisphosphonates/monoclonal antibodies. Moreover, almost all patients took additional other medications as well. It should be emphasized here that the group of other medications included a wide variety of different medications, the management of which requires extensive pharmacological knowledge. Only a small minority did not take any medication that could interfere with dental treatment in any way and therefore carries no risk of negative pharmacological interaction.

The strength of our study lies, on the one hand, in the fact that data were collected prospectively and that the number of cases for the cohort from a single institution is relatively high. On the other hand, the data were not collected solely on the basis of a questionnaire, which is often filled out very incompletely, but through the targeted collection of medication plans, to which every patient in Germany is legally entitled. Where necessary, the data were supplemented by contacting the patient’s family doctor. Thus we can assume that the medication intake data are relatively reliable overall. Finally, in the field of prosthetic dentistry, there has been little research to date on the issue of polypharmacy, so new material is being presented here.[9,10]

However, certain limitations must be taken into account when interpreting our results. First, the participants in this study were not only people who were at least 70 years old at the time of the survey and had full capacity to consent, but also exclusively patients of the Department of Prosthetic Dentistry at Saarland University which may not rule out a certain selection bias. It can therefore be assumed that these patients came to a specialist clinic specifically to have their restorations checked or prostheses made because they already had certain previous illnesses and/or to minimize possible risks that could arise from treatment elsewhere. Second, it cannot be determined with certainty whether the study participants actually took the medications specified in the survey form and prescribed by their family doctor every day or not. In addtion, individual and isolated taken doses of self-administered medications and over the counter medications were not systematically recorded. Therefore, there may be a certain number of unreported cases with regard to these substances.

Third, the ATC-classification used to group medications is not perfect. In some cases, very different medications are grouped together, even though they differ significantly in their mechanism of action and spectrum of side effects. Nevertheless, it is necessary to summarize the large number of officially approved medications, and the ATC-classification represents a kind of compromise solution that is used internationally and recommended by the WHO.

When treating elderly patients, dentists are faced with very specific challenges. In addition to technical expertise, good knowledge of pharmacotherapy in high age is required.[3] If a patient takes at least five or more medications a day, this is referred to as polypharmacy. An increased level of undesirable side effects and drug interactions can be expected, with the risk increasing with the number of medications.[4,11] In a 2022 study, the interactions between commonly prescribed dental medications and general medications taken were analyzed and almost 10% of serious interactions were identified.[12] Particular attention should be paid to the interactions that can occur with local anesthesia.[13,14] In addition, interactions with analgesics play an important role.[15] Since a quarter of the study participants took anticoagulants/antiplatelet agents daily, referral to a specialist clinic should be considered for dental surgery.

In order to meet the challenges of future, it is essential to prepare the medical training of dentists and dental teams for the situation that patients with complex medical problems and polymedication routinely come to dental care.[16] It is crucial for the dentist to comprehend the effects of such medications on the planned dental treatment.[17] In particular, inappropriate polypharmacy should be omitted. The use of checklists (for example PRISCUS list), consultation with a pharmacologist, referral guidelines, and purposeful communication strategies with patients and general practitioners may contribute to improvement.[18,19] A common and internationally recognized taxonomy for describing and defining adherence to medications should be developed for this purpose.[20] The consultation of databases can be of supportive help indicating the risk of undesirable effects due to interactions. It can also be expected that by implementing further algorithms, artificial intelligence will reach a level that can provide valuable assistance to the clinician in avoiding adverse events when patients with polymedication present for dental treatment. However, long-term results (e.g., complications or treatment successes in connection with polypharmacy) are currently lacking and these aspects must be researched intensively in future.

Conclusion

Polypharmacy in senior patients is a condition that dentists should apprehend in the medical history to adapt their treatment accordingly. Given the increasing number of senior dental patients, polypharmacy should also be incorporated in medical training, and the associated factors should be intensively researched.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.