Den norske tannlegeforenings Tidende
16.02.2017
Age and health are important factors in any treatment. The main purpose of the article has been to discuss the need for replacing missing teeth in the frail elderly. Neither reliable definitions of acceptable oral function nor the need for tooth replacement exist. Nevertheless, the dentist must relate to these concepts. «The Shortened Dental Arch Concept» shows that acceptable oral function in the elderly can still be obtained, even in severely reduced dentitions.
Informed consent is only fulfilled when the elderly person is fully informed of all acceptable treatments. Optimal treatment can be impeded by a reduced ability to endure long-lasting, multiple appointments, motor diseases or financial limitations.
Some simplified prosthetic treatments with reduced longevity can be justified; others are contraindicated because of tissue harm. Prosthodontics may also sometimes be justified for the elderly even if oral diseases are imperfectly controlled. Deciding whether to repair or renew prostheses is difficult, and must be assessed individually.
Small fixed dental prostheses (bridges) are easy to produce, usually provide better oral function, may not cost more than partial removable dental prostheses, are preferred by the elderly and should never be excluded as an option. The need for replacing missing teeth in the elderly will persist, but should only be implemented after careful individual evaluations.
Why is it difficult to decide if missing teeth should be replaced?
The main focus of this paper is to discuss the need for replacement of missing teeth in the elderly. The object of any dental treatment is to maintain or even improve oral function. When teeth are missing, prosthodontics restore oral functions such as masticating, speaking, appearance and oral comfort. What constitutes acceptable levels for these functions is rather poorly defined, and there are no well-founded criteria regarding the need to replace teeth. Also, oral function has lately been increasingly associated with oral health related quality of life (OHRQoL). The present task therefore poses a number of challenging questions. Some of these may seem simple and easily answered, but several uncertainties exist.
Because of the lack of a generally accepted definition among professionals as to what constitutes an oral handicap, the objective need for tooth replacement is unclear both on a population and individual level. For that reason, the subjective need may be over-or under-estimated, resulting in inadequate or inappropriate treatment solutions. Tradition, culture, mentors' opinions, education, legal aspects in claim investigations about what is «generally accepted treatment standards» etc. have influenced clinicians and care planners more than we care to admit.
What is the role and effect of public guidelines?
Traditional «thinking" about prosthodontics and decision making still pervades official guidelines and regulations. A standard requirement for prosthetic rehabilitation is to establish an adequate oral function including mastication, speech and aesthetics. The Norwegian Health Authority (1) has published some guidelines regarding the replacement of missing teeth in which it is stated: «individual evaluations must be made about acceptable masticatory function and what is necessary for the individual to be able to communicate and have social relationships without hindrances that relate to teeth. Furthermore, the term «aesthetic zone» relates to teeth that the individual patient (our highlighting) considers necessary to be able to have normal social interaction without problems relating to teeth».
A comparable Swedish text from a regional guideline about refundable treatments for those in need of what is termed necessary dental treatment states that «the assessment implies that conservative and prosthetic treatments significantly increase the patient´s ability to eat and speak and provide a substantially elevated quality of life and well-being (our highlighting)» (2). Even if the public frame regulations like the above are only general guidelines, they still significantly influence decisions in clinical dentistry and add stress to both dentist and patient, with very low reliability.
What do experts say?
A Norwegian professor in gerodontology states: «Given the same dental condition, different patients may receive anything from no to quite extensive treatment. In an ailing 80-year-old with a reduced dentition, temporary fillings, temporary rebasing or just oral care can be a good treatment» (3). A Swedish associate professor within the same field emphasizes in an interview that «When the public dental service treats elderly, many follow the same standards as for a «normal adult», but much can be different in the elderly». She also points out the unclear knowledge and diagnostics that exist about how many teeth that are needed for oral function and chewing (4).
How many teeth do the elderly need for a satisfactory oral function?
The introduction by Käyser (5) in the 1970-ies of «The Shortened Dental Arch Concept» (SDA), known by many clinicians as the premolar-occlusion, represented a paradigm shift in prosthodontics. It was emphasised that «treatment goals can be limited and still satisfy patients' demand by using a problem-solving approach». This was contrary to the traditional philosophy in which a theoretical complete ideal dentition was pursued. It took many years before SDA reached its present near universal acceptance. Despite this, the SDA concept is still not widely practised (6,7).
The SDA, considered to be relevant for patients aged 40 - 80, provides in general terms a suboptimal but acceptable functionality. Käyser also suggested the Extremely Shortened Dental Arch Concept (ESDA), for patients 70 - 100 years of age, which provides a minimal but still individually acceptable functional level. As a consequence of the SDA and ESDA treatment philosophies, it may currently be considered less professional to over-treat than under-treat when replacing missing teeth; especially in older patients who are often not cognisant of their real needs.
What is meant by «elderly» and what is our target group?
"Elderly» is an elusive concept. Most dentists would consider a healthy, fit and active person aged 80 or over as any other patient and provide the generally used treatment option for adults.
What happens in the future if conditions suddenly change, as is not unusual in this age group? Space does not allow a full discussion of all possible aspects of replacement of missing teeth and necessary maintenance in the heterogeneous «elderly» group.
Our main focus will therefore be on frail elderly who are usually treated by general practitioners, as opposed to i
Gå til medietInformed consent is only fulfilled when the elderly person is fully informed of all acceptable treatments. Optimal treatment can be impeded by a reduced ability to endure long-lasting, multiple appointments, motor diseases or financial limitations.
Some simplified prosthetic treatments with reduced longevity can be justified; others are contraindicated because of tissue harm. Prosthodontics may also sometimes be justified for the elderly even if oral diseases are imperfectly controlled. Deciding whether to repair or renew prostheses is difficult, and must be assessed individually.
Small fixed dental prostheses (bridges) are easy to produce, usually provide better oral function, may not cost more than partial removable dental prostheses, are preferred by the elderly and should never be excluded as an option. The need for replacing missing teeth in the elderly will persist, but should only be implemented after careful individual evaluations.
Why is it difficult to decide if missing teeth should be replaced?
The main focus of this paper is to discuss the need for replacement of missing teeth in the elderly. The object of any dental treatment is to maintain or even improve oral function. When teeth are missing, prosthodontics restore oral functions such as masticating, speaking, appearance and oral comfort. What constitutes acceptable levels for these functions is rather poorly defined, and there are no well-founded criteria regarding the need to replace teeth. Also, oral function has lately been increasingly associated with oral health related quality of life (OHRQoL). The present task therefore poses a number of challenging questions. Some of these may seem simple and easily answered, but several uncertainties exist.
Because of the lack of a generally accepted definition among professionals as to what constitutes an oral handicap, the objective need for tooth replacement is unclear both on a population and individual level. For that reason, the subjective need may be over-or under-estimated, resulting in inadequate or inappropriate treatment solutions. Tradition, culture, mentors' opinions, education, legal aspects in claim investigations about what is «generally accepted treatment standards» etc. have influenced clinicians and care planners more than we care to admit.
What is the role and effect of public guidelines?
Traditional «thinking" about prosthodontics and decision making still pervades official guidelines and regulations. A standard requirement for prosthetic rehabilitation is to establish an adequate oral function including mastication, speech and aesthetics. The Norwegian Health Authority (1) has published some guidelines regarding the replacement of missing teeth in which it is stated: «individual evaluations must be made about acceptable masticatory function and what is necessary for the individual to be able to communicate and have social relationships without hindrances that relate to teeth. Furthermore, the term «aesthetic zone» relates to teeth that the individual patient (our highlighting) considers necessary to be able to have normal social interaction without problems relating to teeth».
A comparable Swedish text from a regional guideline about refundable treatments for those in need of what is termed necessary dental treatment states that «the assessment implies that conservative and prosthetic treatments significantly increase the patient´s ability to eat and speak and provide a substantially elevated quality of life and well-being (our highlighting)» (2). Even if the public frame regulations like the above are only general guidelines, they still significantly influence decisions in clinical dentistry and add stress to both dentist and patient, with very low reliability.
What do experts say?
A Norwegian professor in gerodontology states: «Given the same dental condition, different patients may receive anything from no to quite extensive treatment. In an ailing 80-year-old with a reduced dentition, temporary fillings, temporary rebasing or just oral care can be a good treatment» (3). A Swedish associate professor within the same field emphasizes in an interview that «When the public dental service treats elderly, many follow the same standards as for a «normal adult», but much can be different in the elderly». She also points out the unclear knowledge and diagnostics that exist about how many teeth that are needed for oral function and chewing (4).
How many teeth do the elderly need for a satisfactory oral function?
The introduction by Käyser (5) in the 1970-ies of «The Shortened Dental Arch Concept» (SDA), known by many clinicians as the premolar-occlusion, represented a paradigm shift in prosthodontics. It was emphasised that «treatment goals can be limited and still satisfy patients' demand by using a problem-solving approach». This was contrary to the traditional philosophy in which a theoretical complete ideal dentition was pursued. It took many years before SDA reached its present near universal acceptance. Despite this, the SDA concept is still not widely practised (6,7).
The SDA, considered to be relevant for patients aged 40 - 80, provides in general terms a suboptimal but acceptable functionality. Käyser also suggested the Extremely Shortened Dental Arch Concept (ESDA), for patients 70 - 100 years of age, which provides a minimal but still individually acceptable functional level. As a consequence of the SDA and ESDA treatment philosophies, it may currently be considered less professional to over-treat than under-treat when replacing missing teeth; especially in older patients who are often not cognisant of their real needs.
What is meant by «elderly» and what is our target group?
"Elderly» is an elusive concept. Most dentists would consider a healthy, fit and active person aged 80 or over as any other patient and provide the generally used treatment option for adults.
What happens in the future if conditions suddenly change, as is not unusual in this age group? Space does not allow a full discussion of all possible aspects of replacement of missing teeth and necessary maintenance in the heterogeneous «elderly» group.
Our main focus will therefore be on frail elderly who are usually treated by general practitioners, as opposed to i
