The sequencing of a dental treatment plan can be difficult to explain to a patient because there are many factors that can make the care complex and the outcome difficult to predict. Therefore, a treatment plan often must be dynamic. For instance, if you need to remove a fixed partial denture, or FPD, you will not know how many abutments will need endodontic therapy, or ET; crown lengthening; or to be extracted, until you remove the abutment and reexamine it. As treatment proceeds, the patient’s health may change, resulting in new modifying factors that will require constant re-evaluation and added communication with the patient based on his or her needs. Such a dynamic treatment plan can be difficult to explain because the final treatment plan evolves over time. Many patients expect that once treatment has been planned, it is decided and that is the end of the discussion. They may not understand that multiple factors can complicate care and that people may respond differently to the same treatment.

We have found that patients and their families should be informed constantly about their oral conditions, and that treatment needs may change as treatment progresses. The problems encountered may be esthetic or functional issues, as well as unanticipated emergencies, such as the need for ET, a fractured tooth or a tooth that may not be saved cost effectively.¹⁰

U.S. national data show that people 85 years of age and older have the least number of natural teeth among all age cohorts and often do not seek care unless they have a perceived problem.¹¹ Therefore, when older people seek care, it is imperative to resolve their chief complaints as quickly as possible when developing the treatment plan. This treatment plan must take into account the patients’ attitudes, their genetic predispositions to oral disease, their lifestyles, their socialization and the environments that influence their health beliefs and behaviors.¹² Berkey and colleagues¹ identified four domains of dental need: function, symptomatology, pathology and esthetics. The modifying factors that challenge dentists when prioritizing and modifying treatment interventions for elderly people likely are to be the fundamental issues of illness and frailty. The challenge and the complexity of treatment planning for older adults may depend on how the dental professional recognizes, prioritizes and balances the influences of multiple age-associated dental issues and patients’ changing systemic health and psychosocial factors, with their restorative and oral rehabilitative needs.¹³

When older people seek care, it is imperative to resolve their chief complaints as quickly as possible when developing the treatment plan.

Ettinger^12,14 introduced the concept of rational care in 1984. He explained that individualized care should occur only after evaluating all of the modifying factors and that this approach was much more appropriate for older patients than was technically idealized care. The projected amount of stress involved with an idealized treatment plan may pose health risks in older medically compromised patients and may limit the potential benefit of the treatment, thus making it inappropriate.⁴ Berkey and colleagues¹ used a case history to illustrate the modifying factors that needed to be evaluated in a rational treatment plan (Box 1). A key issue in the delivery of oral health services for elderly people is understanding what an acceptable oral status is for a particular person.^13–16 If patients are physically disabled or cognitively impaired, dentists need to understand their wider needs such as how they function in their environments with their medical problems, pharmacotherapy, their social support systems and the diverse sociological variables, as well as how oral health care fits into their environments.⁴ Clinical decisions in dentistry tend to be based on qualitative, subjective estimates that patients have specific treatment needs that will result in a net benefit to them. This subjective restorative treatment plan often is based on the dentists’ personal clinical experiences rather than on "evidence-based" studies.^8,16

Good communication also must be established with patients’ primary medical care providers. As older patients age, they are at higher risk of having an acute episode of a chronic disease than they were when they were younger, resulting in hospitalization and changes in medication, which can directly influence oral health.

In this article, we describe the longitudinal oral health care of an 85-year-old patient from the time we first saw her until her death five years later. The focus is not so much on what dental care was given but instead on the interaction between the dentist and the patient and how the treatment evolved.

	CASE REPORT

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An 85-year-old woman sought care at The University of Iowa College of Dentistry in 1994 because her general dental practitioner had died and she had become aware of a roughness on the upper right side in her mouth. She had been married to her husband for more than 50 years, and they had two adult children who were married and living out of state. She had lived most of her life in a small town in rural Iowa. She and her husband had run a lunch counter in the town for more than 20 years. She was retired from the business, but her husband continued to work, hauling cattle. Her dental history included routine dental care and a lingual frenectomy.

Medical history. Her medical history was significant because she had had a myocardial infarction 20 years previously. Her gallbladder also had been removed, and during the operation she had required a blood transfusion. She had had blood clots in one leg and one lung about five years previously, which were treated with medication. One ovary had been surgically removed because of a cyst about 10 years previously, and her uterus and bladder had been "repositioned" two or three times in the last few years. We confirmed her medical problems in a telephone call to her physician’s office where we spoke to the physician’s nurse.

A general medical practitioner was treating the patient for hypertension and arthritis. She was allergic to Procardia (Pfizer, New York City) and Lasix (Aventis, Strasbourg, France). Her daily medications were Vasotec (Merck, Miami Lakes, Fla.), Aldactone (Searle, Peapack, N.J.), Lanoxin (GlaxoSmithKline, Greenford, England) and magnesium (their potential oral and dental side effects and potential management problems are shown in the table).¹⁸ She was 5 feet 1.5 inches tall, weighed 140 pounds and her blood pressure at the initial appointment was 160 over 88 milligrams of mercury.

Her oral hygiene was fair to poor. The existing dentition included teeth nos. 2 through 12, 14, 15, 18 through 25 and 31. College faculty and students conducted the dental examination with a mirror, probe and explorer. There was a loose retainer on tooth no. 2 (a seven-unit FPD from teeth nos. 2–8) and caries on the lingual aspect of teeth nos. 8 and 10. There also was a loose retainer on tooth no. 22 (a five-unit FPD from teeth nos. 18–22). There was a lost incisal restoration on tooth no. 24 and recurrent caries on tooth no. 31.

College faculty and students in the oral pathology, radiology and medicine department conducted an initial periodontal examination, and they identified general gingival inflammation and bleeding on probing on all teeth. They noted interproximal probing depths of 4 mm or less for all teeth with the exception of a localized probing depth of 7 mm on the mesio-facial aspect of tooth no. 22.

The prosthodontist (T.J.L.) conducted an assessment of the vertical dimension of occlusion using esthetics and speech that showed that pairs of teeth were in contact, providing stability and function. The occlusion was not overclosed by wear. On mounted diagnostic casts, the occlusal plane had an appropriate contour. The patient tolerated the examination and diagnostic procedures with no difficulties.

Periapical radiographs and a pantomograph showed normal bony trabecular patterns, generalized horizontal bone loss around the remaining teeth and a periapical radiolucency associated with tooth no. 18. Tooth no. 6 was impacted, and caries were evident on the exposed crown. The crowns on teeth nos. 2, 8, 18 and 31 had poor marginal adaptation. Caries was evident on teeth nos. 22 and 23. There were several suprahyoid radiopaque masses visible in the area of the carotid arteries, and they were aligned as a group in linear fashion, suggesting the possibility of calcification in the walls of the vessels. Our consultant radiologist suggested that these masses did not have a tubular appearance nor was there a linear orientation of the individual masses, which would suggest that they were in a blood vessel. Unfortunately, the pantomograph was insufficient to be used to determine the exact location of the masses. The radiologist noted several infrahyoid radiopaque masses that were consistent with laryngeal cartilage complex calcification and ossification. The patient was informed of these findings but chose not to follow through with the referral to a medical specialist.

The initial diagnosis for this patient included an impacted tooth, recurrent caries, gingivitis, partial edentulousness, open margins on several FPD retainers, overhanging restorations and periapical pathosis.

Patient care management issues. Because the patient had a history of myocardial infarction and hypertension, we needed to limit the vasoconstrictor to 0.036 milligrams of epinephrine or two cartridges and aspirate before injection during the patient’s dental appointments.¹⁹ It also was advisable to not schedule the patient for an appointment before 9:00 a.m., due to a diurnal variation in the stickiness of the platelets and the increased risk of experiencing another myocardial infarction or a stroke between 6 a.m. and 9 a.m.^20,21

Our protocol suggested that we would need to decrease the patient’s stress by having shorter dental appointments and a positive environment, as well as having her sit up slowly to avoid orthostatic hypotension at the end of the appointment. Our protocol for all medically compromised patients at every appointment is that the dental assistant seats the patient and then take the patient’s blood pressure. We routinely ask during every appointment: "Has your health changed since the last appointment? Have your medications changed?"

We advised the patient to use a soft toothbrush on a daily basis. We did not suggest she use floss or additional oral aids, as it became clear during our discussion with her that she would not comply with supplementary home care. The patient’s oral hygiene was poor due to poor technique. During prophylaxis appointments, oral hygiene was constantly reviewed. Due to the presence of recurrent caries, we recommended that the patient use PreviDent 5000 (Colgate-Palmolive, New York City) on a daily basis.

The patient did not know how to drive a car, so she relied on her husband to bring her to the dental school for treatment, and they had to accommodate his work schedule. She had a very active social life, which involved her church and social groups in her town. Each year she and her husband spent most of the winter in Texas. The cost of dental treatment was a significant concern for her.

Sequence of treatment. 1994. The patient’s treatment started at The University of Iowa’s College of Dentistry in November 1994. Her chief complaint was the roughness in her mouth that was identified in the oral pathology, radiology and medicine department as an impacted canine, which was starting to erupt; it had begun bothering her one month previously. (A panoramic radiograph taken at the time is shown in Figure 1.) The admissions clinic developed an initial treatment plan (Box 2). In December 1994, the impacted canine was removed in the clinic in the oral and maxilliofacial surgery department. This was the only treatment the patient wanted at that time because she felt that her dental treatment could be postponed until spring so it would not interfere with her winter in Texas. The surgeon did not prescribe antibiotics, and the only analgesic the patient used was acetaminophen.

View larger version (89K): [in this window] [in a new window]   Figure 1. Initial pantomograph of patient, November 1994.

1996. The patient did not visit the prosthodontics department until May 1996, as she felt no need until that time to pursue treatment (Figure 2). The prosthodontist conducted a careful oral examination and discussed a tentative outline of a treatment plan with the patient. At this same visit, the patient reported having discomfort with tooth no. 31, so the prosthodontist removed the crown, excavated the caries and placed a provisional restoration.

View larger version (88K): [in this window] [in a new window]   Figure 2. Anterior view of patient when she visited the prosthodontic department for an initial examination and treatment, May 1996.

1997. The treatment progressed uneventfully, and in June 1997 the cast metal mandibular RPD was delivered (Figure 3). We designed the crown on tooth no. 18 to serve as a distal abutment to improve the stabilization of the mandibular RPD. The patient commented that that side of the RPD "stayed in place better." The overdenture abutment on tooth no. 31 served as a vertical stop for better stabilization of the RPD.

View larger version (105K): [in this window] [in a new window]   Figure 3. Occlusal view of the mandibular arch after treatment was completed, June 1997. The mandibular removable partial denture is not shown.

1998. In March 1998, the patient came to a recall examination with a chief complaint of broken tooth no. 9, which was fractured at the gingival margin. This event resulted in a discussion about activating the postponed treatment plan for the maxillary arch. We removed an FPD before determining the final treatment plan.

In April 1998, we removed the maxillary FPD, deemed teeth nos. 2, 9 and 10 nonrestorable due to extensive caries, and referred the patient to an oral surgeon to have the three teeth extracted. We temporarily restored tooth no. 8 with a light-cured glass ionomer (Fuji II, GC America, Alsip, Ill.) and made an impression for the fabricating an interim RPD. Before the extraction appointment, when we contacted her physician to determine her INR, the physician had her stop taking Coumadin for two days before the visit and for one day after to decrease her INR from 3.5 to 1.8.

In May 1998, 14 days after the extractions were performed, we replaced the mesialocclusodistal, or MOD, amalgam restoration on tooth no. 12 and delivered an interim RPD. We finalized the treatment plan for the maxillary arch, and the patient agreed to it after some discussion. The treatment plan included tooth no. 8 porcelain-fused-to-metal surveyed crown; tooth no. 14 MOD amalgam; a maxillary cast metal RPD; and prophylaxis for the remaining teeth. We kept tooth no. 8 in the arch and gave it a crown to stabilize the RPD so there would be a tripod effect.

In July 1998, the patient came to the dental school with discomfort associated with tooth no. 14. We decided that ET was required, as the tooth did not respond to an electrical pulp test. The tooth’s response to palpation was negative, and it acted positively to percussion. We diagnosed irreversible pulpitis. After ET was completed, we placed an amalgam core as a foundation.

In October 1998, we prepared teeth nos. 14 and 8 for crowns and made the restorations in January 1999. We also made a final impression for the RPD. At this time, the crown on tooth no. 18 came off, and we noted that caries was present. We then removed it and placed an intermediate restorative material as a temporary restoration. After discussion with the patient, we decided that the tooth was to be kept as an overdenture abutment.

1999. In April 1999, a cast metal maxillary RPD was delivered (Figure 4). The patient told us she had been hospitalized for 12 days with an infection in her leg just before the dental appointment. Later that month, after placing an amalgam in the access canal of tooth no. 18 and preparing it as an overdenture abutment, we added an extension to the left side of the mandibular RPD to make a reline impression for an addition to the RPD. The addition and reline were completed, the denture was delivered and postoperative adjustments were made. Keeping tooth no. 18 helped the patient because it remained as a vertical stop, which stabilized the RPD even though it was now a distal extension partial denture.

View larger version (86K): [in this window] [in a new window]   Figure 4. Anterior view of the patient after treatment was completed on the maxillary and mandibular arches, April 1999.

	DISCUSSION

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Clinical decision making in dentistry tends to be based on qualitative, subjective estimates that the benefits of a specific treatment modality outweigh the alternatives. In dentistry, the clinician traditionally has collected useful pieces of evidence and synthesized them into a sequenced subjective treatment plan, which usually is based on the clinical experience.²⁴ These decisions usually are based on the patient’s age-associated psychological, social, biological and pathological profile. Grembowski and colleagues²⁵ have indicated that clinical decision making should be a social process that includes the dentist, patient and sometimes others. What was unique about the patient in our case report was her determination to be in control of the decision-making process, as well as the timing of her dental treatment.

As patients age, their physical and mental health may deteriorate and may require their dentists to alter their treatment plans. An elderly patient may not be able to coordinate or tolerate extensive restorative procedures, and often it may be necessary to shorten appointments and define achievable goals for each appointment. Despite our patient’s advanced age and her health problems, altering the treatment plan was not an issue with her.

Our patient needed to be in control of whatever treatment was planned and when it would be carried out. She always decided when she was ready for treatment. She was informed about her problems but was not interested in addressing them until she perceived a need. Treatment also was scheduled around transportation issues, which included her husband’s work schedule. The patient’s social schedule also influenced her availability for treatment. As a result of all of these complicated issues, the treatment was completed over a long time span. This did not seem to be a problem for the patient and did not appear to interfere with her quality of life. The patient and her husband had philosophical attitudes toward dentistry. The treatment plans were outlined before the start of any planned dental work, and the patient and her husband had remarkably positive attitudes toward the dental treatment and never complained. When the dynamics of the treatment plan changed because of unexpected problems, we explained the issues to the patient and her husband, addressed their concerns immediately and received permission to carry on with the next phase of the treatment.

During consultations and initial and recall examinations with patients and their families, it is important to document all of the questions that are discussed for medical and legal documentation, for informed consent and to be a reference for the patient. Clinicians need to recognize that patients will not always follow their advice and should not be offended. Some older patients will seek care only when they perceive there is a problem, which they believe the health professional can help them solve.

A general dental practitioner could have provided much of our patient’s dental care. The treatment procedures were straightforward because no adjustment in the occlusal plane or vertical dimension of occlusion was needed. It is important for dentists to understand when to refer surgical or restorative cases based on dental condition complexity, medical complications or procedures beyond the expertise of that dentist.

	CONCLUSIONS

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The case report we discuss highlights two important points about the dental treatment for this particular older adult patient. The first was to make an initial diagnosis based on a complete examination, including consultation with her physician followed by an evaluation, and then develop an initial treatment plan with alternative treatment options. The second important point was that the treatment plan needed to be dynamic because of the continuing influences of the modifying factors.

The dental treatment for this patient could be addressed as a single arch problem despite the complexity of the entire case, because the vertical dimension of occlusion and the occlusal plane were clinically acceptable.

View larger version (132K): [in this window] [in a new window]   Dr. Lindquist is an associate professor, Department of Prosthodontics, S422, Dental Science Building, College of Dentistry, The University of Iowa, Iowa City, Iowa 52242, e-mail "terry-lindquist{at}uiowa.edu". Address reprint requests to Dr. Lindquist.

View larger version (130K): [in this window] [in a new window]   Dr. Ettinger is a professor, Department of Prosthodontics, and Dows Institute for Dental Research, College of Dentistry, The University of Iowa, Iowa City.