Cometh the heavy metal generation

IN JUNE of last year the Government published the Steele Review into NHS dental services in England, providing recommendations on improving oral health and increasing access to quality dental care for all patients.

One interesting set of statistics cited in the report had to do with changing population patterns among dental patients. It highlighted a “demographic bubble” of patients now between 30 and 65 who have retained much of their natural dentition but with high levels of dental disease treated by fillings and other restorations – a so-called “heavy metal generation”.

In December the issue was further highlighted in a BBC News item in which the British Dental Association scientific adviser Professor Damien Walmsley warned that NHS dentistry faces a major challenge coping with the consequences of this ageing population.

So is UK dentistry prepared for the challenge and what are the medico-legal implications?

2020 and beyond

Concerns over an ageing dental patient population are not new. In 2003 the BDA published a policy paper entitled Oral Healthcare for Older People: 2020 Vision, prompted by concern that the planning of future dental services did not take account of major changes in the UK population.

It pointed out the extent to which the population is ageing. Increased life expectancy coupled with a falling birth rate means that by 2020 the proportion of people in the UK aged 65 and above will rise from a figure of 15.7 per cent (2003) to 18.9 per cent. It predicted “increasing numbers of older patients who need, and would like to have, complex restorations to ensure that they retain many of their natural teeth”.

Concerns have also been informed by predictions based on data obtained from four Adult Dental Health Surveys that have been conducted every 10 years since 1968, with the last undertaken in 1998. The latest survey is underway with results due in the autumn but predictions from previous data are that in 15 years an expected 40 to 50 per cent of patients over 65 will be dentate with 21 or more natural teeth.

So why are more older people keeping their teeth now?

“Predominantly because dentists are not taking them out,” says Angus Walls, Professor of Restorative Dentistry at Newcastle University and an expert on oral and dental problems of older people.

“It sounds like a stupid thing to say, but it’s true. Back at the inception of the NHS in 1948 and 1949 there was a huge unmet need for managing uncontrolled dental disease and the simplest and most reliable method for doing that was to take the teeth out. So you have this huge bubble of people who have no natural teeth slowly working their way through the population. And we are now getting to a stage where that bubble is in its 60s to 90s and the wave behind have natural teeth.”

The experience of this edentulous generation, he adds, has not been lost on younger patients.

“Most people realise now that dentures are an appalling replacement for teeth in terms of function, aesthetics, comfort and quality of life. Keeping teeth is a vastly preferable option.”

Nothing lasts forever

An ageing heavy metal population keen to retain ‘natural’ dentition brings some special challenges. Dental fillings and crowns are not permanent, despite patient expectations, and need to be repaired or replaced as further affected by decay, restoration failure or loss due to the weakened state of the restored tooth. A restoration lasting 10–20 years would be considered a good outcome.

Says Professor Walls: “Dentists are going to have to think about and learn how to manage failing crown and bridge work, as it can be a technical and mechanical nightmare with very complex treatment management decisions.”

Other factors come into play in dealing with older teeth. Gingival recession can expose the dentine root of the tooth, which is mechanically softer and has a higher critical pH for dissolution than the enamel of the crown. This makes the exposed root much more susceptible to decay than the crown. Treating root caries is often difficult and can easily result in loss of the tooth.

Oral hygiene can also be a problem in old age, says Professor Walls.

“With gingival recession the exposed shape of the tooth changes, with larger interproximal gaps and more places for plaque to accumulate. Patients need different hygiene techniques to clean those shapes effectively. And one thing dentists aren’t very good at is re-educating patients.

“Allied to these difficulties is that as people grow older they become less physically able to do small dexterous tasks. They develop arthritis in their hands; they lose fine motor control and become fatigued when doing fine motor tasks. So the physical act of brushing and cleaning becomes more of a challenge.”

One telling statistic from the last dental survey was that 78 per cent of over-65s years had visible plaque on their teeth – higher than any other age group. But 93 per cent reported that they brushed their teeth at least once daily, which suggests a lack of technique rather than motivation.

Reduced salivary flow is another common risk factor among the elderly – often a side-effect from common medications or polypharmacy. Dry mouth increases susceptibility to acidmediated disease, both decay and tooth wear.

And for some elderly people it can simply be a question of health priorities.

“The frequency of dental attendance falls with increasing age,” says Professor Walls. “But this may not be just from lack of access. Teeth are probably a low priority for somebody who has cardiovascular disease along with problems with their bunions and rheumatoid arthritis.”

Preparing for the future

Prevention rather than more dental treatment is a common theme in most of the reports addressing the issue of ageing dentition. A major priority in carrying forward the recommendations of the Steele Review will be to encourage dentists to carry out more preventive work.

“All of these problems are largely preventable by getting back to the good old-fashioned basics of brushing the teeth twice a day and keeping sugary snacks to mealtimes,” says Professor Damien Walmsley.

Educating older patients in proper brushing technique, he adds, along with the increased use of fluoride-containing toothpastes and mouth rinses would make a vast difference in the oral health of elderly patients.

It is also a matter of educating dentists, says Professor Walls. “Not just young dentists in training but those age 35 or older for whom a lot of this information wasn’t available when they were undergraduates. It’s a continuing education problem as well as an undergraduate challenge.”

Medico-legal risks

What of the growing medico-legal risks in treating an ageing population?

“The elderly today don’t tend to be particularly litigious,” according to Claire Renton, a dento-legal adviser at MDDUS. “But as younger, more litigious generations grow older there’s every reason to assume that will change.”

The main risks lie in failing restorations and more difficult treatments such as root caries. To avoid problems, she encourages members to consider increased provision of preventative measures for elderly patients. “Rather than just dentists being more risk aware we should be informing patients of the changing pattern of decay in elderly teeth, and encourage them to come for regular checkups. Practices might want to introduce a preventative programme aimed specifically at the elderly.”

Consent is another area of potential risk when dealing with elderly patients. It is important to ensure accuracy of understanding in consent among the elderly. Even impaired hearing can make this problematic. And as always, good record keeping is essential. Take accurate notes of all treatment and advice provided to patients, says Mrs Renton. “That way, older patients will be protected from decay and dentists from allegations of failure to properly advise.”

Jim Killgore is editor of MDDUS Summons