Individualized care needed for older patients with caries

Dr. Gretchen Gibson examines the ramifications of caries in geriatric patients. Photo: Robb Cohen Photography & Video.

Treatment of caries in geriatric patients can be a perplexing endeavor. Along with advanced age, other contributing factors — xerostomia, multiple medical conditions, medications, decreased home care ability and past restorative treatments — can lead to patient presentations that seem overwhelming for patients and dental teams.

Dr. Gretchen Gibson, Fayetteville, Arkansas, looked at the prevalence, diagnosis, risk assessment, care and prevention of root and recurrent caries during her presentation, “Evidence-Based Prevention for High-Risk Adults,” at Thursday morning’s “Mini-Residency: Geriatrics.”

She pointed to a 2005 study that found an individual annually will experience one carious tooth surface.

“It doesn’t sound like a whole lot, but if you think about that for patients who are 20 and up, that’s a lot of caries,” said Dr. Gibson, adding that another study found the caries rate (.87 coronal and .57 root surfaces) in older adults to be 1.44 per person per year.

She advised attendees to bring a new thought process to their diagnoses.

“We have to think a little differently,” Dr. Gibson said. “Is it active? Is it arrested? Does it look capitated? What does the rest of the mouth look like? Is the mouth full of caries lesions, or is this a lone lesion?”

For older patients, dentists should consider lesion location, condition of the tooth, severity and extent of the lesion, and the affected tissue.

“There are some patients in head and neck radiation where it moves a lot faster, but, for the most part, caries is a slow-moving disease,” Dr. Gibson said. “What is the patient’s goal? Is it just to chew because aesthetics are not a big deal to them? Know the goal of your overall treatment plan.”

She pointed to arrested lesions and scars as an example, noting that patients should know up front that lesions become darker when they remineralize.

With regard to conducting a caries risk assessment, she said the National Institutes of Health Consensus Statement notes “restorations repair the tooth structure, but do not stop caries and have a finite life span.”

Dr. Gibson reviewed two risk assessment tools, one from the American Dental Association and the the Caries Management by Risk Assessment, but added that a systematic review of risk factors revealed that dentists could not look to one risk factor as the culprit.

“Caries is so multifactorial, and it’s so individual,” Dr. Gibson said. “You need to think about what you can change? I can’t change the patient’s age. I could work with them on their smoking. I can’t change the number of teeth they have, but I can try and make it where they don’t have fewer. We can try to do something about buffering capacity. We can try to help them with their salivary flow. Start thinking about the modifiable things.”

However, she said, “Your antenna needs to go up, and all the guns need to come out” when a patient has three lesions in three years.

Dr. Gibson shared the results of a 2005 study that convincingly showed that dentists using general risk assessment guidelines can categorize patients into groups who will experience a low, moderate and high need for caries-related restorative care.

“A caries risk assessment can be used to estimate risk of future caries, and then use this knowledge to customize your treatment,” she said. “If you don’t use it in your decision-making process, there is no reason to perform an assessment. Current caries is the best predictor of future caries. Consider more than one cavity in a year to be something to start to worry about. Know the list of common risk factors and consider them when you are planning treatment and diagnosing. Your subjective assessment of your patient’s caries risk has validity.”