The need for geriatric dental education in India: the geriatric health challenges of the millennium

Abstract

The rapid growth in the elderly population in a developing country such as India poses social and financial challenges by causing a shift towards non-communicable diseases and increases in chronic diseases. The economic impact of the burden of chronic diseases such as cardiovascular disease, hypertension, diabeties and cancer are high. The link between oral health and general health are particularly pronounced in older populations and impairs their quality of life. This paper reveals that in order to address the increasing health challenges and demands of a growing geriatric population, undergraduates and graduate students in dental schools should be given comprehensive or holistic health assessment training. Cost-effective modern educational strategies and educational tools such as problem-based learning will help to overcome the dearth of trained faculty in geriatric dentistry. Multidisciplinary health-care approaches and extended health-care team work are of vital importance to older patients who could benefit physically and psychologically from more efficient dental treatment. With often more than one chronic disease affecting individuals and use of polypharmacy, there is a need to increase overall knowledge of geriatric pharmacy and geriatric medicine. Measures to help older people remain healthy and active are a necessity in developing countries such as India for effective social and economic development.

INTRODUCTION

An ageing population is one of the most important aspects of the 21st century world-wide and will be one of the major challenges for the next millennium. An ageing population indicates a decline in the proportion of children and young people and an increase in the proportion of people aged 60 years and above¹. (According to the United Nations standards, age 60 years or above is used to describe ‘Older’ people.)

Demographic revolution

World-wide, the proportion of people aged 60 years and over is growing faster than any other age group. Decreased fertility rate and increasing longevity will account for ‘greying’ of the world’s population².

India is now home to 17% of the world’s people, with 77 million people above the age of 60 years in 2001, compared with China’s 127 million. The proportion of the elderly to the total population of India rose from 7.5% in 2001 to 8.2% in 2011. About 78% of the Indian elderly population lives in rural areas. In the age group of 70 years and above who had been married, 80% were widows and 27% were widowers3., 4..

Social and financial changes

In addition to the demographic changes, the elderly in India face several social and financial challenges. Changes in cultural values and beliefs, weaker family and social welfare systems, including lack of financial security, are some of the challenges. Dependency on young people and the decline of traditional extended family systems owing to rural to urban migration, and the increasing cost of health care, have become great challenges for public health.

With people living longer, isolation and social insecurity is felt by older persons because of the generation gap and change in life styles. Increased lifespan also results in more chronic functional disabilities, creating a need for assistance to manage the basic activities of daily living. The traditional system of ‘the lady’ of the house looking after the older family members at home is declining. Elderly women suffer more than their male counterparts because often they have no income of their own and are dependent on their spouses for all their basic needs. By giving less priority to their own health problems, elderly women try not to be a burden or cause any inconvenience to other family members. When a widow does not have the financial freedom to make health-care choices, it becomes the sole discretion of her children to decide about her health needs.

Shift in disease pattern and economic impact

With advancements in medical technology the human lifespan continues to increase, with the result that more people need health care in the later years of life. The global disease profile is shifting from infectious diseases to non-communicable and chronic diseases3., 1.. As individuals age, non-communicable diseases (NCD) become the leading causes of morbidity, disability and mortality, and are costly to treat⁴. Chronic diseases such as heart disease, cancer, stroke and diabetes are responsible for 60% of all annual deaths worldwide. Heart disease and stroke account for nearly six million people being hospitalised each year and cause disability for almost 10 million Americans aged 65 years and older. The costs of treatment approaches $329 billion each year when lost productivity from disability is taken into account⁵. In 2004, 4.8 million (59.4%) of the estimated 8.1 million deaths in India resulted from NCDs. Among the NCDs, oral diseases account for 0.5% of India’s burden of disease and the estimated disability adjusted life for years (DALYs) lost during 1998 as a result of oral diseases is 1,247,000 years⁶. In India the out-of-pocket health expenses incurred by households as a result of non-communicable disease increased from 31.6% in 1996 to 47.3% in 2004. The economic consequences of the growing burden of non-communicable diseases will likely result in enormous human and social costs.

Policy makers and public health systems may need to respond to this increase in burden of disease with revolutionary policy making and appropriate planning. This paper reveals the need to change and augment the geriatric curriculum to improve the knowledge, skills and attitudes of future oral health-care professionals.

EDUCATION ON GERIATRIC DENTISTRY

With the rise in the number of elderly and consequent increase in the burden of disease the need for trained professionals in geriatrics is essential. Geriatric medicine is in its infancy in India and is the least developed specialty in medical sciences. Geriatric dentistry is better developed in most of the developed countries. In 2010, India had 291 dental colleges representing the highest number of dental colleges in the world. Each year 23,590 graduates and 1,600 postgraduates are produced⁷. The undergraduate course is a Bachelor of Dental Surgery and is a 5-year programme, but there is no geriatric dentistry as a component in the undergraduate curriculum.

Barriers and scope for development of geriatric dentistry

Geriatric dentistry is a multidisciplinary specialty which requires that education and training need address the normal physiological and psychological changes with age and the impact of these changes on the delivery of dental services.

The need for geriatric dental education was noted in the late 1970s. Most dental schools in the USA identified primary barriers to expansion as finances, curriculum time and limited expertise within the faculty. Limited financial resources and lack of trained professionals are the main barriers to geriatric dentistry in developing countries, including India. With a low oral health budget the training of geriatric dentists needs a cost-effective and beneficial approach.

Universities could benefit from modern information and communication technologies to commence courses in geriatric dentistry. Video conferencing with developed nations, sharing in their expertise through exchange programmes and a problem-based learning (PBL) method would be effective at the undergraduate level⁸. The PBL method has been pioneered and extensively used at McMaster University, Canada, where students solve problems and reflect on their experiences. Problem-based learning improves analytical thinking skills and has a positive effect on Physician competency after graduation⁹.

Health-care institutions could be a potential resource for geriatric training. It has been found that dentists with hands-on education experience in dental schools become more confident when treating and providing care for the elderly patients¹⁰.The mushrooming of old-age homes in India and the rising number of neglected or abandoned elderly who are compelled to seek institutional care has become a great challenge for modern Indian society. In India, these institutions could also benefit if used as clinical centres for geriatric training as the magnitude of dental problems and treatment requirements are high among the institutionalised elderly¹¹. Outreach rotation postings could utilise community-based clinical experiences to increase exposure, sensitise the undergraduate students and make them competent to manage elderly patients. MacEntee et al. described the experience of dental students on dental geriatrics rotation posting as unique and important to their clinical maturation¹².

Dental schools in India could organise short- and long-term geriatric programmes and monitor the value of these programmes for their students and recent graduates. A dental geriatrics curriculum requires a solid foundation in humanities in health care as much as technical skills and clinical reasoning to overcome the challenges of managing chronic diseases¹³.

Geriatric practice management

Given the importance of dentistry in total patient care, skills in evaluating patients holistically are required for effective management of geriatric practice. Anecdotal evidence has long suggested that graduate medical students avoid geriatrics because they do not like treating the elderly and their problems. Oral health professionals who treat the elderly should listen attentively to their concerns and questions. Often, more time is needed to interview and evaluate elderly patients. Dentures, eyeglasses and hearing aids, if normally worn, should be used to aid better communication. The oral health professional should demonstrate effective communication skills in order to encourage the trust of patients and acceptance of treatment. With the coming tsunami of ageing patients and their health challenges associated with various chronic diseases, dentists need to ‘doctor it up’. Although many older patients appear to be in good health, a systematic medical history using a comprehensive geriatric assessment can assist the dentist to identify subclinical disease. The use of a written patient-completed medical history questionnaire is a moral and legal necessity in the health-care system.

Many common diseases and medical treatments involve the oral cavity and give rise to oral symptoms and some oral diseases compromise general health. If necessary, the patient may be referred to a family physician for further evaluation. Often, the elderly are reluctant to report symptoms as they fear hospitalisation or perceive them as being part of the normal aging process. Difficulty in recalling past illness and drug use are also common. In these cases, certain interview questions could help to elicit useful information; family members or caregivers could also be a useful source of information.

Gerodontic treatment planning is a challenge for the dentist as various health factors and complexities have to be addressed before treatment or intervention. Identifying medical emergencies and modifying the plan for appropriate treatment should be done using a multidisciplinary approach to determine who to treat and who to refer for a medical evaluation. Knowledge of geriatric health insurance policies and procedures should be integral to the practice of geriatric medicine.

Visual observation and verbal communication with the patient can provide the dentist with important clues to a patient’s dental anxiety. The most appropriate time to schedule an appointment for the medically compromised and fearful patient is usually earlier in the day. To reduce stress, the waiting time in the dental office reception and the dental treatment should ideally be shorter.

Positioning aged people during dental care

Acquiring information on age-related degenerative changes, such as those affecting the spine and joints resulting from osteoarthritis and osteoporosis are important. Appropriate treatment decisions are needed to treat patients with cervical spondylosis. Innovative clinical techniques and rationales for positioning patients with head support could reduce neck-related problems.

Blood flow changes caused by arteriosclerosis involving the carotid artery and vertebral system could result in dizziness in the elderly.

Postural hypotension or orthostatic hypotension results in a fall in blood pressure of at least 20 mmHg systolic pressure or 10 mmHg diastolic pressure when standing; this is caused primarily by gravity-induced blood pooling in the lower extremities. Patients who have been in a supine or semi-supine position in the dental chair throughout dental appointments lasting as long as 2–3 hours could develop postural hypotension¹⁴. There is an increased incidence of orthostatic hypotension with advancement of age and among those at higher risk are individuals who are in multidrug therapy, such as combinations of antihypertensives, diuretics, antidepressants and alpha blockers. Postural hypotension also occurs in patients with varicose veins and other vascular disorders of the leg. Untreated diabetes, nervous system disorders, such as Parkinson’s disease, diabetic neuropathy and prolonged bed rest are other risk factors¹⁵. During dental treatment such patients should be cautioned against rising to the upright position too rapidly. After conclusion of the dental treatment it is important to train dental students to elevate the dental chair slowly to prevent injuries or falls.

Geriatric pharmacy

The use of drugs is essential for safe and proper management of patients. Hence, every dentist must familiarise themselves with the pharmacological properties of commonly used drugs in dentistry such as the analgesics, antibiotics and central nervous system (CNS) depressants. It should be noted that ageing alters pharmacodynamics and pharmacokinetics.

With the incidence of various chronic diseases increasing, many elderly people use multiple medications for long durations and prescribing for older adults has become increasingly complex as treatment regimens have intensified. The elderly are users of prescription and non-prescription drugs as well as traditional medication. Drugs wisely used can minimise hospital care and help them to live independently; however, misuse of medications in the elderly is also common. Underuse and overuse of drugs needs special attention.

With the rapid rate of introduction of newer drugs in recent years, knowledge in geriatric pharmacy is important for oral health professionals treating them. Information gained from medical history and a dialogue history can help in prevention of adverse drug reactions. The risk of adverse reactions and iatrogenic illness are greater in elderly patients who are under polypharmacy than in younger agegroups. There is a need to promote and develop education and training programmes for oral health practitioners to improve disease management, including understanding of appropriate medication, drug-induced problems and polypharmacy, especially among the geriatric population¹⁶.

Geriatric health concerns

In addition to oral health problems many older adults suffer from more than one chronic disease. Oral health professionals need to augment their knowledge in geriatric medicine and gerontology in order to assess their patients more comprehensively. Knowledge of the common medical challenges of the ageing patient, such as anxiety, hypertension, diabetes and arthritis, needs emphasis. Asthma and thyroid disorders in the ageing population need appropriate clinical practice guidelines for better treatment outcomes.

Anxiety and stress are common as age advances. Stress elevates the body’s adrenaline level leading to increased blood pressure and cardiac rate. Management of stress is accomplished with sedatives. The elderly are heavy users of sedatives. However, the risk of addiction owing to over-prescribing of sedatives could lead to serious health problems affecting mental health, memory loss and lead to abnormal behaviour¹⁷.

Hypertension is a chronic disease common in old age. The risk of developing cerebrovascular accident (stroke) among hypertensive patients increases two- to three-fold as they grow older. Cerebrovascular accident (CVA) is the leading cause of long-term disability. At the start of each dental appointment routine blood pressure screening of all prospective dental patients could significantly help to minimise the development of CVA and other acute high blood pressure sequelae. Patients with blood pressure of 200 mmHg systolic or 115 mmHg diastolic or above should not receive elective dental treatment¹⁷. Following a stroke episode elective dental treatment should be withheld within the first 6 months. Emergency care for pain or infection should be managed non-invasively with medication. The treating dentist must be aware of the potential side-effects associated with each drug and the possible interactions with commonly used dental drugs (e.g. propranolol and adrenaline). Postural hypotension is a common side-effect of many antihypertensive drugs (see above).

A significant percentage of dental patients show signs of increased cardiovascular activity as a result of fear. Anxiety leads to an increase in catecholamines such as adrenaline and noradrenaline in the circulating blood, which increase the heart rate and blood pressure. This fact is of particular importance to the dental profession in order to use the stress reduction protocol. Short, morning appointments, effective pain control measures and psycho-sedation during treatment could decrease stress.

The prevalence of diabetes mellitus increases in the older agegroups. High blood sugar or low blood sugar levels are acute complications of this disease, which require ongoing medical care. Dental treatment could pose a potential threat to diabetic patients. In order to prevent acute illness and reduce the risk of long-term complications the doctor needs to be aware of modifications needed in treatment management. For example, prolonged anaesthesia (use of long-acting anaesthetics) after treatment with extensive dental procedures could delay the patient’s next meal, leading to increased risk of hypoglycaemia. Before any dental appointment there is a need to advise the diabetic patient to take their usual insulin dose and eat a normal breakfast. Scheduling dental appointments earlier in the day, modifications in dental treatment, use of shorter-acting local anaesthetics could minimise post-treatment eating delays. Antibiotic coverage in the postsurgical period could be appropriate to control infection, pain or stress.

The chronic complications of diabetes mellitus can affect various parts of the body such as the vascular system, kidneys, nervous system, eyes, skin, mouth and lower extremities. Oral complications include xerostomia, infection, poor healing, caries, candidiasis, gingivitis, periodontal disease and burning mouth syndrome. Older adults with poorly controlled diabetes may have impaired salivary flow in comparison with subjects with better controlled sugar level¹⁸. Blood sugar levels should be considered before any oral surgical procedures.

Neurological problems

Diseases affecting the neuromuscular system are common with age increase. The signs and symptoms as well as the complications and implications of these disorders or their treatment can have significant impact on oral health and on disease management. Dental treatment in early stages of the disease is important in order to improve the quality of life.

Cerebrovascular disease refers to disorders that result in damage to the cerebral blood vessels leading to impaired circulation. Neurological events related to CVA cause long-term disability and stroke-related deaths. Following stroke, patients may experience several oral problems including masticatory and facial paralysis, lost touch sensation and dysphasia. The consequences of diminished motor function of masticatory and facial muscles could lead to impairment of food intake, poor nutrition and weight loss. Decreased food clearance from the mouth and reduced dexterity of the hands affects the maintenance of oral hygiene. Many CVA patients receive antihypertensive and antiplatelet drugs in their long-term management to reduce the morbidity and mortality associated with a stroke episode. Thus, management of patients taking antiplatelet and anticoagulant medications could be a concern that will require medical consultation before treatment. Use of non-steroidal anti-inflammatory drugs (NSAIDs) may increase risk of bleeding and long-term use may reduce the protective effect of aspirin. Adrenaline containing local anaesthetics should be used minimally and guidelines followed for patients with cardiovascular disease¹⁹.

Parkinson’s disease is a chronic progressive neurodegenerative disorder that affects the body’s nervous system. Resting tremor in arms, legs, jaw and face, postural instability and difficulty in walking are common. Patients are unable to brush their own teeth because of weakness of the muscle. Drugs taken by these patients can cause xerostomia.

Alzheimer disease is a progressive neurological disorder seen in the ageing population that manifests as memory loss, personality changes, cognitive dysfunction and functional impairment. Poor oral hygiene, difficulty in wearing dentures and inability to carry out oral hygiene procedures all affect oral health. Poor patient compliance, difficulty in gaining accurate information, under-reporting of symptoms and poor patient cooperation are some of the difficulties in treating such patients²⁰. In these cases caregivers can play a crucial role in maintaining the patient’s records.

Geriatric oral health problems

Oral diseases are the most common of the chronic diseases. Their prevalence, their impact on individuals and on society and the expense of their treatment are important public health concerns. Oral health assessment of the elderly should focus on areas such as root and coronal caries, periodontal disease, tooth wear, recurrent caries and oral cancer.

Risk factors for oral diseases such as diet, hygiene, smoking, alcohol and stress are common to a number of chronic diseases. An emphasis on the common risk approach with adequate personal-, professional- and population-based preventive programmes could help maintain good oral health. Oral diseases are not only the consequence of ageing as systemic conditions and their treatment, they also have an impact on oral health. For example²¹ the use of antihypertensive medications can cause salivary dysfunction and gingival enlargement, chronic use of corticosteroids predisposes patients to oral fungal infection. The extended use of broad-spectrum antibiotics could increase the risk of developing oral fungal infection and antibiotic resistance. Constant use of medication and dryness of mouth are significantly correlated and may require salivary substitutes as saliva is the body’s first-line of defence against caries. Recent research has also linked chronic oral infections to diseases such as diabetes, heart and lung diseases and stroke.

The ability to enjoy food, proper chewing, digestion, speech and retention of removable prosthesis are affected when the flow of saliva decreases. With changes in consistency and decreased flow of the saliva, the elderly become more easily susceptible to oral diseases.

The prevalence of periodontal disease and the number of teeth to be extracted because of periodontal disease increases with age. Edentulous elderly Australians are reported to be less likely to use oral health services than dentate persons²². The same study showed that dentate persons used oral health services within the past 12 months and among them more than 80% preferred private dental facility²². This emphasises the need for private practitioners to be competent in the management of oral health problems of the elderly.

The consequences of periodontitis and tooth loss detract from quality of life not only in relation to oral health but also in relation to general health. Tooth pain, infection and missing teeth could all result in decreased social interactions, altered sleep and dietary habits and modify food intake of the elderly, which can lead to malnutrition and increased risk of various non-communicable diseases.

The elderly experience a wide spectrum of oral mucosal lesions. Oral lesions with and without symptoms are common, especially among those using a prosthesis. The progressive impact of smoking and drinking on the development of soft tissue lesions are more apparent in older adults. Cancer chemotherapy and radiation, and the use of drugs as well as tobacco can cause changes in the mucosae. Suspicious lesions need to be examined thoroughly so training in oral cancer screening to identify lesions at the initial stage would be cost effective.

Other age-related disabilities

The elderly are susceptible to alcohol-related diseases, including malnutrition, liver, gastric and pancreatic diseases. Older people also are at greater risk of alcohol-related falls and injuries, in addition to the potential hazards associated with mixing alcohol and medications. The presence of alcohol on the breath could prompt the doctor to evaluate the patient for dental fear and anxiety, however, drugs known to affect central nervous system should be used with caution. Treatment services related to alcohol problems should also be considered.

Arthritis is a common cause of disability and limits activity for the elderly. Rheumatoid arthritis is the most common form of arthritis, especially in women. It is characterised by persistent synovitis, systemic inflammation, joint pain and stiffness, which may be associated with long-term use of salicylates (aspirin) or NSAIDs, some of which may alter blood clotting¹⁴. Limited functional activity is seen in osteoporosis where the bones become fragile. Knowledge of various adaptive devices that help patients with arthritis or stroke-related paralysis to hold a tooth brush or use dental floss is necessary. Other common age-related disabilities are vision and hearing losses. Treating such patients needs time and with compassionate care.

The oral health needs and treatment for the mentally and physically disabled, whether ambulatory, chair bound, house-bound or institution-bound are a concern.

CONCLUSION

Increased longevity is one of humanity’s greatest achievements and many older persons continue to contribute to their families, communities and societies in many different ways. They often serve as caretakers for the children of working parents, orphans and other vulnerable people in their families and communities. Their wisdom and experience can be invaluable in many other areas as well. The elderly deserve to be treated with respect and kindness and if policies are put in place that support their wellbeing and contributions, older people can be a tremendous resource. Therefore the essential knowledge of tomorrow’s oral health professionals must include geriatric care utilising a multidisciplinary approach. This paper provides reasons for implementing a geriatrics curriculum at institutional level to ensure that our future oral health practitioners will have adequate knowledge and skills in addition to suitable attitudes and social responsibility in treating our elderly.

Acknowledgement

I acknowledge the efforts of Becky Fairley in editing this manuscript for grammatical errors.

Competing interests

Nothing to declare.