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Geriatric Dentistry: Before You Call 911

Course Number: 586

Physical Assessment

Treating elderly and medically compromised patients in a dental care setting have their own challenges that can potentially test any clinician to their limits, the physical symptoms present in elderly patients may include but not be limited to disability with motor function, balance, and other behavioral issues. For example, the greatest incidence of stroke is considered to be among adults sixty years and older, which further adds complexities to even simple dental procedures. Encountering more compromised elderly patients on a daily basis is never considered easy; however, with additional training the dental staff can improve their patient handling techniques and thus provide treatment to the best of their capacity, knowledge and clinical judgment.

The American Society of Anesthesiologists (ASA) Physical Status classification system was initially created in 1941 by the American Society of Anesthetists and as revised in 1961 by adding the sixth category. The purpose of the grading system was simply to assess the degree of a patient’s “sickness” or “physical state” prior to providing any treatment (Table 1). Describing patients’ preoperative physical status is used for record keeping, for communicating between colleagues, and to create a uniform system for statistical analysis.27 Despite its widespread acceptance, significant misunderstandings and discrepancies have always occurred when calibration methods were tried with various medical practitioners. There has always been an intent to look and eventually propose an alternative classification system for medical risk assessment that is based on medical complexities, anticipated complications and more over dental modifications.53

Table 1. ASA Physical Status Classification System.27

ClassificationDescription
ASA 1Healthy patients
ASA 2Mild to moderate systemic disease caused by the surgical condition or by other pathological processes, and medically well controlled
ASA 3Severe disease process which limits activity but is not incapacitating
ASA 4Severe incapacitating disease process that is a constant threat to life
ASA 5Moribund patient not expected to survive 24 hours with or without an operation
ASA 6Declared brain-dead patient whose organs are being removed for donor purposes

Taking a detailed medical history before starting any dental treatment is not only paramount but is a required ‘standard of care.’ Measuring the patient’s vital signs, including blood pressure (B.P.), heart rate (H.R.), pulse, and respiratory rate (R.R.), should be a standard practice in all dental offices. The dental team should consider the physical characteristics of the patient before concentrating on their dental problems. A detailed medical history including medical diagnoses, an updated list of all medications along with past surgeries or hospitalizations give the clinician a fair chance to evaluate the given circumstances.17 This history may also identify the need for the administration of a prophylactic antibiotic due to patient’s orthopedic or cardiac status before proceeding intraorally.

The research suggests for efficient geriatric patient screening, diagnosis, and care against the COVID outbreak specific guidelines were set for managing the patients requiring dental treatment. Even before the patient comes, these stages are started via phone, text monitoring, or video calls. A decision-making algorithm for treatment of patients in dental clinics has been described in the flowchart below.

Flowchart based algorithm for treating patients during COVID-19 pandemic.80

Some common medical conditions that may potentially be identified include:

Alzheimer’s Disease : Alzheimer’s disease is the most common type of dementia. It is a progressive disease that in its advanced stages has the tendency to destroy memory and other important mental functions. It’s considered to be part of a group of brain disorders that result in the loss of intellectual and social skills. These variations can be severe enough to interfere with the patient’s day-to-day life. The dental team has to be considerate and understand the severity of the condition before providing any instructions or discharging the patient from the clinic.28 A higher incidence of COVID-19 infection in older dementia patients also carries a higher risk of COVID-19 infection-related mortality. Although accurate data of the mortality rates linked to Alzheimer's Disease are still lacking, patients with Alzheimer's Disease have a greater rate of hospitalization, access to emergency rooms, and mortality from COVID-19 infection than elderly individuals without Alzheimer's.75

Arthritis : Arthritis generally is defined as an inflammation of one or more of joints. The most common forms are osteoarthritis that impact cartilage and rheumatoid arthritis that is considered to be an auto-immune disorder. The chief symptoms are joint pain and stiffness, which typically worsen with age. The sitting posture in a dental chair can be painful for the patient and must be corrected accordingly. There are specific pillows available (Figure 1) to provide extra support for the patients and make them more comfortable during their dental appointments.29

Photo showing support pillows available for dental chairs

Figure 1.

Congestive Heart Failure (CHF): CHF, also known as “heart failure,” occurs when heart muscles do not pump blood properly. Certain medical conditions, such as coronary artery disease and hypertension, gradually impact the heart’s functionality to fill and pump efficiently. Every patient with a history of CHF should be made to relax during the whole appointment. Any change in posture or any procedure should be explained in advance so as to reduce moments of stress or even momentary panic.30

There are substantial links between COVID-19 and Heart failure that go beyond pathophysiology. First and foremost, the COVID-19 pandemic affected hospitalization for heart failure (HF): a decline in HF hospital admission has been well documented, and this may have an effect on HF mortality. Second, people hospitalized for COVID-19 frequently have a history of heart failure (HF). Third, we've demonstrated the significant incidence of heart damage after COVID-19, which is frequently only detected through biomarker analysis. The prognosis can be drastically affected by HF, which may be a short- or long-term effect of COVID-19 inflammatory cardiomyopathy.78

Diabetes Mellitus (DM II): Type 2 diabetes is a chronic condition in which the way the body metabolizes blood glucose, is impaired. This is fairly important to both the dentist and dental hygienist as patients with uncontrolled DM-2 generally suffer with acute oral infections, periodontal disease and delayed wound healing. It has been shown in the literature that dental teams have a fairly high likelihood of detecting Type 2 DM in undiagnosed cases during initial dental screening.31,32

  1. Glycosylated Hemoglobin (Hb1Ac) is suggested to be less than 7%

  2. Normal Blood Glucose level is considered to be 5-7 mmol/L

  • Hypoglycemia (Blood Glucose level < 3mmol/L):

  • Signs/Symptoms: Cold, Clammy skin

  • Management:

    • Oral carbohydrate or 50% dextrose (if pt. is conscious)

    • Call 911 (if pt. is unconscious)

  • Hypoglycemia (Blood Glucose level > 15mmol/L) :

  • Signs/Symptoms: Warm, Dry skin

  • Management:

    • Hospitalize (if pt. is conscious)

    • ABCs, Oxygen or Call 911 (if pt. is unconscious)

Whether people with diabetes are more prone to contract COVID-19 than the general population cannot be determined from the available data. Instead of having a higher probability of contracting the virus, the issue that diabetics confront is that they are more likely to have worse complications if they do. Additionally, the likelihood that someone will have such catastrophic COVID-19 consequences increases the more health disorders they have (for instance, diabetes and heart disease). Additionally, older individuals are more likely to experience problems from the virus.79

Hypertension: High blood pressure or Hypertension (HTN) is a common condition in which the force of the blood against arterial walls is high enough that it may eventually cause health problems. A large number of older adults suffer from some form of HTN taking into consideration that narrowing of the arterial walls may be part of the normal aging process.33 The dental team’s role in screening undiagnosed and undertreated hypertension is very important since this may lead to improved monitoring and treatment.34 Measuring blood pressure should become part of routine practice in all dental offices, as this may also impact the total amount of epinephrine that can administrated to the individual. 58 Risks among elderly patients as reported by the American Academy of Cardiology suggest “in patients over the age of 60, isolated systolic hypertension is more common, and SBP is a better predictor of cardiovascular risk when compared to diastolic blood pressure (DBP)”.62 Morbidity and mortality from hypertension is expected to increase due to rapid growth of the geriatric population and the high prevalence of hypertension among this group.62 Blood pressure guidelines in adults is based on average blood pressure taken in a healthcare setting and is categorized into 4 levels: normal, elevated, hypertension stage 1 and hypertension stage 2 (Table 2).54

Table 2. Categories of BP in Adults*54


BP CategorySBPDBP
Normal<120 mm Hgand<80 mm Hg
Elevated120-129 mm Hgand<80 mm Hg
Hypertension
Stage 1130-139 mm Hgor80-89 mm Hg
Stage 2≥140 mm Hgor≥90 mm Hg

*Individuals with SBP and DBP in 2 categories should be designated to the higher BP category. BP indicates blood pressure (based on an average of ≥2 occasions, as detailed in DBP, diastolic blood pressure; and SBP systolic blood pressure.

Osteoporosis: Osteoporosis causes bones to become weak and brittle and with post-menopausal older women being at highest risk, osteoporosis-related fractures commonly occur in the hip, wrist or spine.36 Osteoporosis can lead to bone loss in the jaw and most commonly tooth loss. Delta Dental, in its 2008 report, stated the dentist may be the first health professional to suspect osteoporosis and to refer the patient to their primary physician for further investigation.37

Oral health professionals must also be careful not to place their patients at risk for Bisphosphonate-Related Osteonecrosis of the Jaw (BRONJ) as it potentially can occur following invasive surgeries such as tooth extractions and generalized periodontal surgery. The incidence of BRONJ or medication Related Osteoporosis of Jaw (MRONJ)is much higher in patients who are on or have received intravenous form of bisphosphonate as compared to oral forms for various bone-related conditions.55 Since bisphosphonates have a half-life ranging up to 10 years,38 even those no longer on this medication may still be at risk. A detailed medical history for any patient with a diagnosis of osteoporosis along with the dosage, duration and route of bisphosphonate intake should be discussed before proceeding with any surgical procedures.39

Infection and the COVID-19 death rate have a strong positive correlation with vitamin D deficiency. The majority of the world's countries employ glucocorticoid medication to treat COVID-19 patients. Glucocorticoids may hasten bone loss in elderly patients receiving COVID-19 clinical treatment, increasing their risk of developing osteoporosis. The relationships and interactions between COVID-19, glucocorticoids, and osteoporosis should therefore be brought to the attention of clinicians and researchers (especially in elderly patients).76

Parkinson’s Disease (PD): PD is a progressive neurodegenerative disorder caused by loss of dopaminergic and non-dopaminergic neurons in the brain affecting movement, muscle control, and balance as well as several other non- motor functions. The use of even the simplest oral hygiene aids such as toothbrushes, toothpaste, and floss can be challenging for these patients and need be examined in detail. The oral hygiene devices and techniques (Figure 2) may require possible modification by the dentist or hygienist in order to make them more easily usable by the patient.17,40

Photo showing modified oral hygiene devices for patient usability

Figure 2.

Stroke: A stroke is a kind of “brain attack” with the main reason being the death of brain cells due to shortage of blood and deprivation of essential oxygen. This directly impacts the parts of the body under the control of that area of brain that’s affected. As a result, speech, stability or other muscle coordination may be lost. Also, these patients may have higher potential for bleeding issues after surgeries depending upon if the patient is on any blood thinners.41,42

Previously, dental practitioners used to generally postpone dental treatment until 6-12 months after a stroke, based on the presumed risk of recurrent stroke. However, current literature suggests that stroke patients including patients with higher risks of bacteremia who undergo dental procedures within one month to six months after ischemic vascular event, were not at an increased risk of experiencing a second event.46

Signs/Symptoms:

  • Severe headache, mostly affects one side of body

  • Visions changes

  • Speech impairment

Management:

  • Hospitalize/call 911

Asthma: As per current studies, older patients who are diagnosed with mild asthma can demonstrate the same level of breathing difficulties as any younger patient with severe asthma. According to the American Academy of Allergy, Asthma and Immunology, the senior age group represents the fastest growing segment in North America with more than two million cases above age 65 and older suffer from Asthma in some capacity.59

Researchers have examined the connection between COVID-19 and asthma. The great majority of these investigations so far have not discovered an elevated risk of COVID-19 disease severity in asthmatics. Furthermore, there doesn't seem to be any evidence that asthma increases the likelihood of getting COVID-19 disease.77

Signs/Symptoms:

  • Shortness of breath

  • Chest tightness or pain

  • Trouble sleeping caused by shortness of breath, coughing or wheezing

Management:

  • Albuterol (Salbutamol) (2 puffs)

  • Epinephrine (0.3-0.5 mg IV)

  • Avoid ASA

  • Avoid NSAIDS in cases of persistent or active asthma

The key for those who have asthma during this epidemic is to continue doing what you have been doing so far, taking your controlled medication as prescribed and notifying your healthcare practitioner of any new symptoms you may experience.

Syncope: The correlation of older adults and syncope is poorly understood. However, transient loss of consciousness and related falls can be regularly witnessed and is most frequently seen in dental clinics. Approximately, 3% of all visits to the emergency departments are due to syncope and older adults are especially vulnerable to these syncope related falls. It is commonly suggested that mechanisms such as dehydration, dental procedures related fear or stress or patients on hypertensive medications such as diuretics are more susceptible to syncope.63

Signs/Symptoms:

  • Pupil dilation

  • Increased BP and pulse rate

  • Vertigo, weakness

Management:

  • Oxygen administration

  • Patient should be made to rest in Trendelenburg Position (Figure 3) to increase oxygen flow to the brain

Photo showing the Trendelenburg Position

Figure 3.