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SHORT COMMUNICATION Table of Contents   
Year : 2008  |  Volume : 19  |  Issue : 2  |  Page : 175-177
Geriatric dentistry: Is rethinking still required to begin undergraduate education?


1 Department of Dentistry, Government Medical College and Hospital, Sector 32, Chandigarh, India
2 Department of Oral Health Sciences Center, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh, India

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Date of Submission05-Aug-2007
Date of Decision01-Oct-2007
Date of Acceptance22-Nov-2007
 

How to cite this article:
Talwar M, Chawla HS. Geriatric dentistry: Is rethinking still required to begin undergraduate education?. Indian J Dent Res 2008;19:175-7

How to cite this URL:
Talwar M, Chawla HS. Geriatric dentistry: Is rethinking still required to begin undergraduate education?. Indian J Dent Res [serial online] 2008 [cited 2014 Oct 2];19:175-7. Available from: http://www.ijdr.in/text.asp?2008/19/2/175/40479
The demographic shift in the Indian population has been caused in part by an increase in the life expectancy. Increased longevity has resulted in a gradual transition in the population, with a reduction in the percentage of the child population (0-14 years) and an increase in the percentage of the elderly (60+ years).

Geriatric dentistry is a science that is a multidisciplinary and multidimensional approach to the management of the oral health problems of the elderly.

The elderly population in India is predicted to increase to comprise 12.5% of the total population by 2026. At present, only a few 'geriatric medicine' OPD services exist and they lack the required infrastructure. No oral health care centers exist in India. Although there is an increasing demand for geriatric oral health care, as yet, no formal training on this subject has been introduced in the dental curriculum. It is essential that future dental professionals have a proper conception of the dimensions of the services to be provided to the elderly, along with the appropriate skills. This would only be feasible through an education programme in geriatric dentistry, which should be started without further delay.


   Introduction Top


The twentieth century witnessed remarkable changes with regard to human longevity worldwide, and the twenty-first century is set to carry forward the gains in longevity further, both in the developing and the developed world. In India, the average life expectancy at birth increased from 50.5 years for males and 49.0 years for females in 1970-1975 to 61.8 years for the males and 64.1 years for females in 1999-2001; it is expected to reach 69.8 years for males and 72.3 years for females by 2021-2025. [1],[2] This rise in life expectancy in India is attributed primarily to the substantial reduction in mortality at different stages of life, which has been brought about by improved health care facilities, sanitation, environmental and public health reforms coupled with better hygiene and living conditions. As a result of the increasing life expectancy, the proportion of the elderly in the total population is projected to be around 20% in India and 32% in the developed nations by 2050. [3]

Keeping this increased life expectancy in mind, the age of retirement in many sectors in India is increasing and in some it has even gone up to 70 years. In some states, the retirement age has not been raised but this is because of the concerns regarding the resultant job cuts for the younger generation. As per the Government of India's classification, the elderly are those who are 60 years of age and above; these citizens become eligible for varied concessions offered by the government and other agencies. In the developed world, the elderly are those above the age of 65 years.

The demographic shift in the Indian population has serious health implications. Increase in longevity means that the community will have to bear a greater burden of disease, with a gradual transition toward the diseases of the elderly and the disabilities associated with aging. Among the many diseases and disabilities that the elderly suffer from, diseases related to the oral cavity occupy an important place. The physiological decline that occurs with ageing affects manual dexterity and this, coupled with reduced muscular tone, hampers adequate clearing of food particles from the oral cavity; in addition, there is likely to be gingival recession and increase in interdental spaces, which predisposes to increase in plaque retentive sites, all of which make the maintenance of optimum oral health difficult. In addition to this, there are changes in the oral ecology due to compounding factors (such as deficiencies in knowledge, attitudes, practices, socioeconomic status, systemic health, etc.) that increase the pathogenic potential of the oral microflora and predispose the elderly to oral health problems. Substantial increase in the number of elderly in India, accompanied by rising prevalence of dental illness, indicate that in future dentists will be required to treat an ever-growing proportion of elderly patients in their practice and will have to make appropriate adjustments and advancement in their professional skills.


   Geriatric Dentistry and the Common Dental Problems of the Elderly Top


Geriatric dentistry is a science which deals with the diagnosis, management, and prevention of all types of oral diseases in the elderly population. It focuses on delivery of dental care to the older population and addresses age-related dental ailments.

The dental diseases that the elderly are particularly prone to are root caries, attrition, periodontal disease, missing teeth because of earlier neglect, edentulism, poor quality of alveolar ridges, ill-fitting dentures, mucosal lesions, oral ulceration, dry mouth (xerostomia), oral cancers, and rampant caries. Many of these are the sequelae of neglect in the early years of life, for example, consumption of a cariogenic diet, lack of awareness regarding preventive aspects, and habits like smoking and/or tobacco, pan, and betel nut chewing. All these problems may increase in magnitude because of the declining immunity in old age and because of coexisting medical problems. As a result of poor systemic health, the elderly patient often does not pay sufficient attention to oral health. In addition, medications like antihypertensives, antipsychotics, anxiolytics, etc., lead to xerostomia, and the absence of the protective influences of saliva in the oral cavity increases the predisposition to oral disease. Financial constraints and lack of family support or of transportation facilities affect access to dental services in later life. The untreated oral cavity has its deleterious effects on comfort, aesthetics, speech, mastication and, consequently, on quality of life in old age. [4]

The main problem that the dentist faces when treating the elderly patient is that the complexity of treatment gets compounded with ageing. The oral cavity is an important part of the body, with a crucial role in chewing, swallowing, speech, facial expressions, and in maintaining the nutritional status and systemic health, as well as self-esteem. [5] Factors like mental illness, dementia, psychosis, neurosis, depression, Parkinson's disease, arthritis, stroke, and muscular fatigue, all common in the elderly, affect locomotor skills and hence the ability to seek treatment. In addition to this, the dentist's behavior and attitude toward the patient and the time that the dentist allocates for elderly patient is crucial if successful treatment is to be provided. The fear and anxiety felt by an elderly patient needs to be handled with empathy. Such patients need more of the dentist's time but, often, cannot afford to pay large amounts; earning more money being an important objective, the busy dentist has little time to spare for the elderly patient, who is quickly disposed of in clinics.

Most dentists assume that they are equipped with all the knowledge and skills required to treat the dental problems of the elderly, but this is not always so. A parallel can be drawn with pediatric dentistry. At one time, the same thinking prevailed regarding pediatric dentistry but, today, it is a major clinical specialty in dentistry. Similar was the case for the specialty of pediatrics when it first started in our country; a few medical colleges even had to name the pediatric department as the 'well-baby clinic' to run it as a separate specialized branch, as the medical practitioners of the day considered themselves capable of dealing with the medical problems of the pediatric population without any formal training. At present, we have superspecialties within pediatrics itself, such as neonatology, pediatric neurology, and pediatric gastroenterology.

Another factor worth emphasizing is that not many people want to work in this field due to lack of knowledge regarding the psychological management of these patients; the exception being those who are naturally interested in the welfare of the elderly. Provision of oral health care requires an insight into and expertise of the many facets that have now evolved in the treatment of elderly dental patients. Training in 'geriatric dentistry' would enable provision of affordable, quality oral health care, with appropriate attention to the special needs of an ageing population. Coordination of services for the elderly through a multidisciplinary team, including colleagues from geriatric medicine, is important and would contribute to meeting the dental care workload efficiently.

In the West, geriatric dentistry is a subject that is spread across the dental undergraduate curriculum and pertains to every aspect of provision of oral health care to the elderly. It is a specialty that takes care of oral health needs of the young old (65-74 years); old old (75-84 years), and the oldest old (85+ years). Careful consideration of all coexisting medical problems before initiating treatment is a cardinal rule in geriatric care. [6],[7]


   Expected Dental Workload Top


In the billion plus population of India there are 76.6 million elderly people (above 60 years of age) and It is predicted that the elderly population in India will increase to make up 12.5% of the total population by 2026. [2] In India the life expectancy has crossed 61.8 years for males and 64.1 years for females, and in some of the states like Kerala, Himachal Pradesh, and Punjab it has already exceeded this. In contrast to the increasing elderly population, the child (0-14 years) population, which was around 35% of the total population in 2001, is expected to decline further due to the thrust on family planning and the continuation of fertility transition. The magnitude of the dental requirements for the elderly can be gauged from the fact that the ratio of the percentage of the elderly to that of the pediatric population is approximately 7:35, i.e., the pediatric population is five times the elderly population. There are a large number of pediatric centers and doctors to provide medical and oral health services to the child population. These patients are healthy and have their parents to look after them, whereas there are no oral health care centers catering to the special needs of the elderly. That the present-day dentists do not really comprehend the oral health needs of the elderly is evident from the fact that as yet there has been no assessment of the dental problems of the elderly except for one such study by Shah and Sundaram, which was conducted in south Delhi in 2004. [8] With the changing family structure and the decline in traditional family support systems, more and more elderly people are being left to fend for themselves. Besides the increase in the numbers of the elderly population, their life expectancy is also expected to increase. [1] In spite of these demographic pointers indicative of the future volume of geriatric oral health care needs, there is no specialist in this field and, as yet, no formal training on this subject has been introduced in the dental curriculum.

All the above mentioned facts highlight the need for education in geriatric dentistry, which will enable dental professionals to understand, document, plan, and deliver need-based oral health care to our elderly population. The educational programme should (i) empower professionals with the knowledge and skills to provide oral health services with empathy, (ii) create awareness of the special needs of the elderly: for example, transportation to a dentist's office requires assessment of activity levels, continence, transfer time, communication, appointment timings, duration of appointment, and legal and ethical considerations.

Setting up of treatment centers with relevant infrastructure, which takes into consideration the requirements of the ambulatory and non-ambulatory elderly, will have a substantial impact on meeting the workload. For the ambulatory elderly, oral health care services need to be provided at the chairside in a hospital setting with suitable rails, ramps, lifts, wheel chairs, and a walker for transfer to a dental office, all of which needs evaluation prior to the appointment.

Non-ambulatory elderly require a different delivery system. Residents in old-age homes, housebound elderly, older persons in long-term-care geriatric wards, and those in special care units like institutes for the mentally challenged and in hospices need on-site dental services that can be provided with portable equipment.

Awareness and knowledge would facilitate the setting up of separate health care units for the elderly along with oral health care clinics and involvement of multidisciplinary teams, mobile oral health services, domiciliary services in the urban and rural areas, and provision of systematic oral health care.


   Recommendations Top


Keeping in view the transformation in the nation's demographic profile, which will have far-reaching consequences in this millennium on socioeconomic conditions and the health resources of India, it is the responsibility of the dental profession and the educationists' to ensure that India has an adequate number of dentists with the appropriate knowledge and skills to treat the elderly. The planning should include the development of geriatric dentistry as a separate subject; it should be introduced initially in undergraduate teaching without any delay and subsequently postgraduate facilities will have to be developed. Simultaneously, upgradation of the existing infrastructure is required for provision of oral health services in a hospital setting such as in the dental operatory and geriatric wards, efforts must be directed at the development of outreach services for domiciliary care with portable equipment.

Undergraduate teaching is essential to establish the pattern of thought and provide the academic and clinical training to enable students to provide oral health care to the elderly.


   Acknowledgments Top


The authors thank Mr. Aswini Kumar Nanda, Research Coordinator, Population Research Center, Center for Research in Rural and Industrial Development (CRRID), Chandigarh, for the information provided on the population and the changing demographic profile of India.

 
   References Top

1.Registrar General, India, Report and tables on Age, Series-I, India, C-14, C-14 SC and C14 ST, Vol. I. Census of India 2001: New Delhi; 2004.  Back to cited text no. 1    
2.Registrar General, India, Population Projections for India and States 2002-2006: Report of the Technical Group on Population Projection Constituted by the National Commission on Population: New Delhi; 2006.  Back to cited text no. 2    
3.Press Release No pop/18, dated 24/2/2005, United Nations: New York.  Back to cited text no. 3    
4.Matthiessen PC. Demography-impact of an expanding elderly population. In : Pedersen PH, Loe H, editors. Textbook of geriatric dentistry. 2 nd ed. Copenhagen: Munksgaard; 1996. p. 505-27.  Back to cited text no. 4    
5.Position Paper. Periodontal disease as a potential risk factor for systemic diseases. J Periodontol 1998;69:841-50.  Back to cited text no. 5    
6.Nitschke I, Muller F, IIgner A, Reiber T. Undergraduate teaching in gerodontology in Austria, Switzerland and Germany. Gerodontology 2004;21:123-9.  Back to cited text no. 6    
7.Kalk W, de Baat C, Meeuwissen JH. Is there a need for gerodontology? Int Dent J 1992;42:209-16.  Back to cited text no. 7  [PUBMED]  
8.Shah N, Sundaram KR. Impact of socio-demographic variables oral hygiene practices oral habits and diet on dental caries experience of Indian elderly: A community based study. Gerodontology 2004;21:43-50.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]

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Correspondence Address:
Manjit Talwar
Department of Dentistry, Government Medical College and Hospital, Sector 32, Chandigarh
India
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DOI: 10.4103/0970-9290.40479

PMID: 18445942

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