Strive-the Student View
December, 2006 edition

Case Study: The Geriatric Patient

 
By Suzanne Hubbard

Case Study: The Geriatric Patient
In the aging adult, problems with oral health can be multi-faceted. Looking at every aspect of health in the geriatric patient leads to better oral health outcomes. The following case study documents the complexity of the aging adult and the treatment that leads to overall health.

Case Report

In November 2005, a 77-year-old Caucasian female presented at the Laramie County Community College Dental Hygiene Clinic in Cheyenne, Wyo. The patient's chief complaint was the need for an oral prophylaxis.

Medical History
The patient's vital signs were within normal limits. She has an irregular heartbeat and high cholesterol for which she is under the advisement of a physician. She premedicated for the heart condition, taking two 500 mg tablets of amoxicillin, before the patient appointment. She also took two 500 mg tablets after the completion of the patient prophylaxis. For the cholesterol, she takes Lipitor, 20 mg day. In addition, the patient takes 3 mg of Coumadin and 81 mg baby aspirin each day for her heart condition.

Dental History
The patient attends her three-month recall visits regularly. She reported sensitivity to hot and cold, but she is not sensitive to sweets, eating three to four candy bars each day. The patient's oral home care is excellent, as she brushes twice a day with a soft toothbrush, flosses twice a day, and uses a fluoride mouth rinse each evening.

Examination Findings
The patient began the appointment with a prerinse of 10 ml of 0.12% chlorhexidine gluconate to reduce the number of oral microorganisms. An extraoral and an intraoral examination were conducted and the patient presented within normal limits. The patient examinations included a periodontal assessment, dental occlusion and oral habits and an oral hygiene evaluation to determine the patient hygiene performance (PHP). The PHP is an oral debris assessment used to determine the amount of surface material on tooth structure. In this particular case, the use of disclosing agent was administered using a swish and expectorate method. With the PHP scoring, the tooth is divided up into five subdivisions, vertically (three divisions, mesial, middle and distal), each of which is scored with a numerical value of one. On this particular patient, teeth numbers 3, 8, 14, 19, 24, and 30 were observed. The patient was given a numerical value for each of the six teeth, and the total was divided by six to get an average of the scores.

The clinical tissue examination revealed generalized red color, slight edematous consistency, smooth texture with slightly rolled margins and bulbous papillae. Probing depths were generalized 3-4 mm, with localized bleeding on probing especially in the molar regions. Recession was generalized 2-3 mm, and localized 3-4 mm affecting the facial and lingual anterior teeth of the mandible. The patient presented with Class II mobility on the mandibular anterior teeth, as well as mucogingival involvement. The patient' presented with localized Class I furcations of the mandibular molars. The patient's American Academy of Periodontology (AAP) periodontal classification was Moderate Chronic Periodontitis (AAP III) due to recession and bone loss. Radiographic findings presented with both vertical and horizontal bone loss. Clinical examination revealed extracted teeth, #1, #15, #16, #17, #18, #30, and #31. Full gold crowns existed on #2, #3, #19 (endodontic treatment with silver pins), #20 and #32. Porcelain composite restoration existed on the buccal of #6. Bilateral bridges existed on #3, #4 (pontic, porcelain fused to metal), #5 (PFM), and #11, #12 (pontic, porcelain fused to metal), #13 (crown), and #14 (crown). Distal occlusal amalgams existed on #21, and #28 with bilateral buccal amalgams. #29 is a mesial occlusal amalgam. Stress fractures were noted on #8 and #9. Slight plaque and interproximal calculus were detected.

Dental Hygiene Diagnosis and Treatment Plan
Based on the patient's examination, and because she did not want to premedicate for a second appointment, it was determined that the patient's treatment needs could be met in one appointment. After completion of all assessments, the dental hygiene care plan was presented. It was determined that seven vertical bitewings would adequately assess bone loss; and that oral debridement of all four quadrants via hand scaling/instrumentation, selective polishing, and fluoride administered in gel trays would be treatment-planned. The patient consented to treatment and signed the care plan. The patient was given disclosing solution and her PHP revealed a plaque score of 1.1. Hand scaling was performed on the patient. The patient complained of sensitivity during hand scaling, so the treatment plan was modified. Duraflor (desensitizing therapy) was used to occlude dentinal tubules exposed from the patient's recession. The patient signed the care plan for this modification. Selective polishing performed according to the care plan. Neutral sodium fluoride (2%) was administered in a mouth tray. A re-evaluation appointment for purposes of home health care implementation and patient education reiteration was set up for four weeks later.

Implementation of Treatment
Treatment began as soon as the care plan had been signed confirming patient consent. Seven vertical bitewing radiographs were taken. Full-mouth debridement was performed via hand scaling. Selective polishing was performed. Duraflor was given for patient sensitivity. Neutral sodium fluoride was administered in gel trays, and the patient was scheduled for a re-evaluation appointment.

Patient Education/Oral Hygiene Instruction
Patient education was conducted at several times throughout the treatment plan. The patient's diet and age were ascertained, and the patient's answers to the following questions were recorded.

• Was the patient eating a balanced diet?
• Was the patient eating chocolate with a meal or eating the candy bars separately from a meal?
• Was the patient taking vitamin and/or mineral supplements for nutritional needs? Education was given about medications, xerostomia and oral health.
• Did the patient feel that her mouth was dry?
• Did the patient drink enough water throughout the day? Education about aging, gingival recession and sensitivity was relevant.
• Did the patient notice sensitivity in the areas of recession? Did the patient use toothpaste formulated for sensitive teeth?

The patient's responses were noted and it was deemed that the patient was not eating as well as she could be. The patient did not take a multi-vitamin, and noted that her mouth was consistently dry. The patient felt she drank enough water-six, six-ounce glasses each day. The patient noticed sensitivity upon brushing.

When the patient demonstrated brushing, she showed a scrub-brush method. Oral hygiene instruction included the modified Bass technique, used in conjunction with toothpaste for sensitive teeth. Patient education was provided about the relationship of dry tissues to medications. A lubricating mouthrinse with fluoride was suggested, and samples were sent home with the patient. When demonstrating flossing, the patient showed a perfect "C" shape technique. For edentulous areas, it was recommended that the patient use gauze strips. For the bilateral bridges, it was recommended that the patient use a floss threader and tufted floss or a thick yarn. The patient demonstrated each different technique and satisfactorily met the requirements in both patient compliance and understanding. The patient felt as though she were able to fit these recommendations into her daily regimen.

Treatment Outcome
The most involved oral manifestation included recession, mobility and mucogingival involvement, especially localized to the anterior teeth. Clinical findings were discussed with the patient and, based on those findings, the patient was given several options: 1) mandibular anterior implants, 2) surgical grafting (as long as the bone levels weren't compromised) or 3) leaving the teeth alone. The patient stated that, due to her age, she felt her teeth would outlast her body, and she chose to leave the teeth alone. The patient was thoroughly informed of her oral condition and options were presented to her.

Upon her re-evaluation appointment, the patient's probing depths and recession levels remained virtually the same. However, her gingival tissue presented healthier and the tissue color was a light pink. The patient noticed a difference in her tissues at her re-evaluation. The patient had implemented the oral hygiene instruction given and the assessment for her PHP. Her plaque score was lowered from a 1.1 to a 0.5.

Prognosis
The prognosis for this patient is fair. The patient has excellent oral hygiene home care. At this time, she is maintaining her oral health and has revised her eating habits, except the intake of chocolate. She agreed to brush after she eats a candy bar. She discussed the implementation of a multi-vitamin with calcium with her physician, and he advised her to do so. She will continue coming to the clinic for her regular three-month appointments.

Conclusion
The oral health of the aging adult is complex and many factors play into oral as well as overall health. Diet, multiple medications, xerostomia, supplements, risk factors such as local factors and systemic factors related to aging, recession, sensitivity, and manual dexterity are examples of what clinicians look for when viewing the oral care issues of the geriatric patient and satisfactorily meeting their treatment needs.

Suzanne Hubbard is currently a senior student at Laramie County Community College in Cheyenne, Wyoming. When not studying for exams or National Boards, she enjoys spending time with her family.