The Age of Dentistry
With 76 million baby boomers headed into their 60s, the need for geriatric care will only escalate.
In the late 1970s and early 1980s, professor Athena Papas went door-to-door in Tufts' neighboring communities, dragging mobile dental equipment up flights of stairs to provide oral health care to some of the city's neediest senior citizens. On one of her visits, Papas met a man who needed eight fillings across the front of his upper teeth. The decay had not only affected his appearance, but his demeanor. She suspects that was one reason his children had stopped visiting. "When your teeth aren't right, you don't smile as much, and others don't react as well to you," she says. "You can become this dour person without realizing it."
Poor oral health can indeed trigger a downward spiral in the elderly, who often become self-conscious about their speech or appearance and withdraw from social situations, including seeking out dental and medical care. With funding from the government and foundations, Papas, J67, established a geriatric outreach program to serve the homebound elderly, hoping to break that cycle and bring her patients out of their apartments.
Papas still remembers the broad smile the man flashed after she treated his extensive decay. "It motivated him to go out more." But when the government money dried up, so did many of the outreach programs. "It was very hard for me," she says.
Today, the situation is just as grave, if not more so. With 76 million baby boomers poised to enter their 60s, the need for geriatric dental care will only increase. Since 1990, the proportion of American citizens over age 65 has tripled. And unlike previous generations, nearly three-quarters of today's senior citizens retain many of their natural teeth.
But funding for care is just as scarce as it was 30 years ago. Just 15 percent of people ages 65 and older have dental insurance, with Medicare picking up none of the tab and Medicaid coverage varying widely from state to state. Moreover, misconceptions about aging and teeth persist, among the public as well as dentists. At Tufts University School of Dental Medicine, faculty who focus on geriatric dentistry are banking on a unique combination of education, research and outreach to prepare the next generation of dentists to handle the intricacies of caring for the elderly.
Notions about Aging
At Tufts, the third-year rotation in geriatric dentistry is as much about appreciating the complexities of aging as it is about teeth. Sometimes the dentistry is straightforward. When it isn't, Professor Hilde Tillman, D49, the course director, is happy to offer advice about treatment planning and management. Perhaps more important to Tillman is teaching students to challenge their assumptions about getting older.
She tells them about the geriatric clinic's oldest patient, who turned 102 during his treatment. "He came to us because he needed new dentures," Tillman says. "He was in custodial care because he had outlived most of his contemporaries, but he was completely independent. He was very well dressed. Whenever he came to the clinic, he had on a shirt and tie and hat." She does not hide her pride.
Mary Qian, D'10, with her patient.
Tillman developed Tufts' geriatric dentistry program nearly three decades ago, building on Papas' education and outreach efforts with the help of a $1 million grant from the National Institutes of Health. The course includes lectures on nutrition, exercise, cognitive disorders, stroke, cancer, periodontal disease, endodontics and rehabilitation—all as they relate to aging and dentistry. The course is a prelude to a rotation in the geriatric clinic and an opportunity to provide dental screenings for senior citizens in the community.
"Certainly the program has changed a lot from when we first started it," says Tillman. "We know now that with good care and prevention, teeth can be maintained throughout life."
Each week, Tillman and her students go over the cases they have seen in the clinic, discussing radiographs, medical histories and possible drug interactions. They also talk about the patient's broader life: Does he work? Does he use a cane or a wheelchair? How is his diet? Does he eat alone? The answers can make or break a treatment plan. The students learn about adaptive devices that can help patients with arthritis or stroke-related paralysis hold a toothbrush or use dental floss. Tillman stresses the team approach, with frequent consultations with physicians, psychiatrists, physiotherapists and occupational and speech therapists.
Tillman asks the students if they think their patient's physiological age matches his chronological age. The students are hesitant at first—this wasn't covered in a textbook—but soon realize she is asking them to question what they think they know about how a 60-, 70- or 80-year-old looks and acts.
Tillman tells the students not to be intimidated by the long lists of conditions their patients have been treated for, such as high blood pressure, high cholesterol, diabetes or even cancer. "Older people are survivors," she says. "They have survived many things, medical issues, dental issues."
Professor Hilde Tillman, below right, who developed Tufts' geriatric dentistry program nearly 30 years ago, says the profession needs more dentists to focus on treating the elderly. With her is Pablo Gonzalez, D'10, and his patient.
Students are well prepared for the medical challenges of the aging patient. Professor Kanchan Ganda, who came to Tufts Dental School in 1980 and became the first full-time physician faculty member in 1991, estimates that as many as eight or nine out of every 10 patients at the Tufts clinic are medically compromised. The clinic cares for many patients with hypertension, diabetes, heart disease, HIV or cancer "because we're recognized as a hub of optimal care for medically compromised patients," says Ganda.
Since 1991, Tufts students have taken medical classes in all four years of dental school. The program, developed by Ganda, teaches students to recognize the symptoms of common diseases, which lab tests can be used to assess them, and the best anesthetics, analgesics and antibiotics to treat them. Specialists from Tufts Medical Center lecture on subjects as diverse as rheumatology, cardiology, liver disease, emergency medicine, immunology and even domestic violence. Third-year dental students have five weeks of rotation through 26 specialties at Tufts Medical Center and the Joslin Diabetes Center, where they shadow clinicians and learn firsthand about caring for the medically compromised patient.
Students learn how elderly patients with Alzheimer's or dementia may have to be managed differently. They learn to coordinate patient care. "All the disciplines have to come together," says Ganda. "We do not have tunnel vision as far as patient care is concerned." (continued)
Story by Julie Flaherty and Jacqueline Mitchell, senior health sciences writers in Tufts Office of Publications
Photos by Laura Barisonzi
This story ran online on Mar. 23, 2009. It originally appeared in the Winter 2009 issue of Tufts Dental Medicine.