Australian Dental Journal, June, 1982

Volume 27, No. 3

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Undergraduate teaching in geriatric dentistry*

8. T. Homan

Senior Lecturer, Division of Community Dentistry, University of Queensland

ABsTRAcT-It is predicted that more Australians will retain their natural dentitions into old age and their dental needs will have to be met with a wide range of dental services by dentists acting with understanding, kindness, and sympathy. The empathy to do so requires experience of appropriate delivery systems in the environment in which the elderly live. For them the ability to eat a balanced and varied diet and to manage personal oral hygiene is very important for their well being. Undergraduate education must be adapted to strengthen the social orientation demanded.

(Received for publication November, 1981 .)

Introduction Undergraduate dental education equips dentists to

provide general dental services for persons of all ages. As very few oral diseases are characteristic of the elderly,’ their dental health needs are overwhelmingly conse- quential on health care in earlier years. It is part of a continuum, just as are their social needs.

Important social functions depend on a healthy dentition in a healthy mouth. This applies as much in old age as it does at any other period of life. This is not to deny that elderly people have special dental needs or special problems which are the end result of “a lifetime of use and abuse with medical, psychological and socio-economic problems”.2 Very often they have to

* Modified version of a paper “Undergraduate Teaching: Dentistry” which was delivered at the 17th Annual Conference of the Australian Association of Gerontology, Brisbane, October 1981.

Shklar G. Oral pathology in the aging individual. In: Toga CJ, Nandy K, Chauncey HH, eds. Geriatric dentistry. Massa- chusetts: Lexington Books, 1979:127-46.

Fishman N. Overview of the practitioner-patient relationship in aged persons. Ibid.: 243-6.

battle disability as well as the ageing process. Nor does it deny that the elderly comprise an increasing proportion of our population and that they must be able to have access to an appropriate share of health services.

These factors should not promote the development of geriatric dentistry as a specialty, but rather should encourage the view that the elderly need “special care”- care which must be rendered with understanding, patience, and sympathy.

A geriatric norm Tissue and bone atrophy, diminished salivary flow,

a poor healing rate, decreased masticatory ability, reduced pain sensitivity, and reduced taste sensitivity are the norm for the elderly. Unfortunately, so is neglect of oral hygiene.

The Australian Bureau of Statistics (ABS)I in its 1979 Dental Health Survey found that, of the one and one-quarter million (1,278,900) Australians aged 65 years or more, 11 per cent have natural teeth only;

’ Australian Bureau of Statistics. Dental Health (persons aged 15 years or more) February-May 1979. Canberra: Australian Bureau of Statistics, 1979. (Catalogue No. 4339.0).

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23 per cent have a combination of natural and false teeth; 65 per cent have false teeth only, and 1 per cent have no teeth.

The distribution by sex (Table 1) reveals important sociological differences.

There are no data available on the prevalence of either impaired function, the quality of dentures, or both, worn by Australians. However in Denmark where, like Australia, 88 per cent of people in the 65-74 age group wear dentures, Christensen4 reported alarming statistics which are shown in Table 2. A comparable situation could be anticipated in this country.

This survey also noted a change over time in the percentage of persons with dentures. In thirty years, Danes aged 35-44 years with removable dentures have decreased from 57 per cent to 31 per cent of that sub- population-a large reduction of 26 per cent.

A similar trend has occurred in the United States where GiftS reported, in persons 60 years or older wearing at least one complete denture, a 22 per cent reduction over the fifteen years from 1960 to 1975.

There are two reasons for stressing these data: firstly, to point up the maintenance requirements for persons with dentures; and secondly, to predict a change towards more dentate persons in Australia as we approach year 2000. The consequence of the latter will be more need for the whole spectrum of dental services for our geriatric population.

Will there be a parallel demand for these services? Once again, the 1979 ABS Survey3 is helpful. Only 38 per cent of persons 65 years or older have visited a dentist within the last three years, and 52 per cent have not seen a dentist for at least five years (Table 3).

Australian Dental Journal, June, 1982

TABLE 1 Dental status and sex of persons aged 65 pears or more:

Dental education and geriatric care If this situation is to improve, who will provide the

dental services? Where will they be provided? What range and standard of service should be available?

These aspects of care delivery are beyond the scope of this paper but they must be kept in mind when considering undergraduate education in geriatric dentistry.

Education in the health area can never be an end in itself. It must be oriented towards effective action to improve and maintain health status-in a way which is meaningful, in this instance, to the geriatric person. Optimal use of preventive measures is essential.

4 Christensen J . Oral health status of 65 to 74 year old Danes: a preliminary report of the replication of WHO’S Inter- national Collaborative Study in Denmark. J Dent Res 1977;56:Special Issue C:149-53.

Gift HC. The seventh age of man: oral health and the elderly. J Am Coll Dent 1979;46:204-13.

Franks A. The concept of oral rehabilitation. J Oral Rehabil l976;3 : I -&

’ Giddon DB. The mouth and the quality of life. NY J Dent 1978 :48 :3-10.

Persons Men Women Dental status per cent per cent per cent

Natural teeth only . . I I 14.8 7.7 Natural and false teeth . . 23 25.5 20.8 False teeth only . . . . 65 57.8 70.9 No teeth . . . . . . I I .9 0.6

No. of persons . . , . 550,900 728,000

$ Australian Bureau of Statistics, 1979.’

TABLE 2 Condition of dentures worn hy Danish men and w’omen aged

65-74 year.&

Full Partial dentures dentures per cent per cent

Faculty occlusion . . . . 64 70 Poor retention . . . . . . 3 3 -

Bad aesthetics . . . . . . I I 8 Failing stability . . . . . . 45

$ Christensen, 1977.4

TABLE 3 Time since last dental visit for persons aged 65 o r more pears1 1

Time since last visit Persons Per cent

Within last 18 months , , . . 320,000 25.0 More than 18 months to 3 years 166,400 13.0 More than 3 years to 5 years . . I18,900 9 . 3 More than 5 years , , . . 659.600 51.6 Never visited . . , . . . 13.900 1 . 1

Total . . . . , . . _ 1.278.900 100.00

1 1 Australian Bureau of Statistics, 1979.3

To keep this goal firmly in sight, the oral problems and concerns of the elderly must be appreciated. Franks6 considers these to be:-

(a) the ability to eat a balanced and varied diet; (b) the ability to manage personal oral hygiene; (c) concern to eat in a socially acceptable way; (d) concern to be able to communicate clearly by

speech ; (e) concern to be comfortable in public appearance

and satisfied with one‘s personal image. Put another way, the mouth is significant at the levels

of survival, socialization, and self-fulfilment’ when the quality of life is being considered.

Oral health in the elderly is not only a matter of the quality of life. Oral problems can cause death. For

Australian Dental Journal, June, 1982

example, in Victoria, oral cancer accounts for two per cent of all deaths from cancer. It is most prevalent in the elderly, and has a five year survival around 20 per cent according to Fowler, Reade, and Radden.8 In Canada, mortality rates from inhalation and ingestion of food are 4.69 per 100,000 per year (for males) and 3.32 (for females) between 70 and 79 years. These rates double for persons over 80 years.9 In these examples, early intervention and the maintenance of a properly functioning dentition, respectively, are critical con- siderations.

At the outset, it was argued that “special dental care” was appropriate for the elderly. In this view, the provider would be a generalist in dental services acting in concert with the elderly individual, and with other health pro- fessionals and community health and welfare agencies or institutions, where applicable. Most importantly, services would be provided with understanding, patience, and sympathy.

The various disciplines within Dentistry have adequate curriculum content to produce the general dental practitioner-registrable on graduation as such. However, the empathic care so necessary with the elderly requires a different type of experience which can only be obtained in a community setting.

It is recognized that one cannot “put an old head on young shoulders”. The age differential between the

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young dental graduates and their elderly patients may be fifty years-years of experience which, for the latter, have forged attitudes, habits, and a definitive outlook on their prospective life.

Ideally, the dental professional who should interact with the elderly is an experienced person whose pro- fessional skills are blended with a true appreciation of the elderly viewpoint.

Pragmatically, younger dentists will be called upon to treat elderly persons. So some initial experience must be provided in the undergraduate curriculum to pro- mote the understanding, patience and sympathy re- quired. It can only be a “trigger” experience-to be reinforced after graduation.

At the present time, this is provided at the University of Queensland through an elective subject in the Com- munity Dentistry strain which is available to final year dental students. It is concerned with the delivery of dental services in various community settings. It also brings students face to face with geriatric and handi- capped persons and with the dentists who provide services in the various dental care delivery systems.?

t A description of the course is available from the author on request

Fowler GG, Reade PC, Radden BG. Intraoral cancer in

“ Anderson DL. Death from improper mastication. Int Dent J Victoria. Med J Aust 1980;2:20-2.

1917;27 39-54,

Conclusion Dentistry has biological, technical, and social

orientations. The third of these has been the last to be recognized in dental curricula around the world. It is particularly important for undergraduate geriatric dentistry which requires extramural experience of appropriate dental care delivered in the community settings in which the elderly live. Subjects providing this type of experience will become a compulsory part of the undergraduate education of future dentists.

Dental School, University of Queensland,

Turbot Street, Brisbane, Qld., 4000.