The complexities involved with managing the

care of an elderly patient

TERRY J. LINDQUIST and RONALD L.
ETTINGER
J Am Dent Assoc 2003;134;593-600

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 C L I N I C A L P R A C T I C E ABSTRACT
Background. Treatment planning for
and managing the care of elderly patients
can be complicated for a number ofAreasons.
D
A
J
To understand the patient’s needs, one
✷ ✷
must understand the environment in which 

N
CON
the patient functions.

IO
CASE REPORT Case Description. The authors present

T
T

A
N

I
C
a case that illustrates some of
A theI Nsocial,
U

The complexities
U
G ED
R
economic, financial and transportation
1
TICLE
issues that are involved in treating elderly
involved with patients, as well as how the dynamics of the
interpersonal relationships influence the

managing the care of final treatment.

Clinical Implications. A dental treat-
ment plan can be difficult to outline to a
an elderly patient patient because modifying factors may

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make care complex and difficult to manage.
This requires good communication among
TERRY J. LINDQUIST, D.D.S., M.S.; RONALD L. the dentist, patient and family.
ETTINGER, B.D.S., M.D.S., D.D.Sc.

lanning treatment for and managing an crown lengthening; or to be extracted,

P elderly patient’s oral health care can be com-

plicated. Factors that may influence decision
making include, but are not limited to, social,
economic, financial, family, medical and trans-
portation issues, as well as the patient’s physical limita-
tions.1,2 Three studies that analyzed data from subjects
followed for 10 or more years found that
A dental age cohort, dental status, education,
treatment plan income and perceived need were all sig-
can be difficult nificant factors in predicting dental care
utilization for community dwelling older
to explain to a
adults. 3-5 More patients with complex
patient because social and medical histories are seeking
there are many care than in the past because the elderly
factors that can population is increasing in number and
make the care more elderly people are keeping some of
6,7
complex and their teeth. This aging cohort wants
and appreciates dental care that focuses
the outcome
on appearance and ability to eat.8,9 In
difficult to addition, a significant number of these
predict. older adults have discretionary money
to pay for dental care.6,7
The sequencing of a dental treatment plan can be dif-
ficult to explain to a patient because there are many fac-
tors 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;
until you remove the abutment and re-
examine 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 con-
stantly about their oral conditions, and
that treatment needs may change as
treatment progresses. The problems
encountered may be esthetic or func-
tional 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

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Copyright ©2003 American Dental Association. All rights reserved.
C L I N I C A L P R A C T I C E

BOX 1 was technically idealized care. The

projected amount of stress involved
MODIFYING FACTORS TO BE EVALUATED with an idealized treatment plan
IN A RATIONAL TREATMENT PLAN.* may pose health risks in older medi-
cally compromised patients and may
A RATIONAL TREATMENT PLAN SHOULD INCLUDE EVALUATION OF limit the potential benefit of the
THE FOLLOWING FACTORS: treatment, thus making it inappro-
dthe patient’s desires and expectations; priate.4 Berkey and colleagues1 used
dthe type and severity of the patient’s dental needs; a case history to illustrate the modi-
dhow the patient’s dental problems affect his or her quality of life; fying factors that needed to be eval-
dthe patient’s ability to tolerate the stress of treatment (his or uated in a rational treatment plan
her mental and medical statuses, as well as mobility);
dthe patient’s ability to maintain oral health independently; (Box 1). A key issue in the delivery
dthe probability of positive treatment outcomes; of oral health services for elderly
dthe availability of reasonable and less-extensive treatment people is understanding what an
alternatives;
dthe patient’s financial status; acceptable oral status is for a par-
dthe dentist’s ability to deliver the care needed, including ticular person.13-16 If patients are
resources such as skills and available equipment;
physically disabled or cognitively

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dother issues (for example, the patient’s life span, family influ-
ences and expectations, and bioethical issues).
1 12
* Modified from Berkey and colleagues and Ettinger.
number of natural teeth among all age cohorts
and often do not seek care unless they have a per-
ceived problem.11 Therefore, when older people
seek care, it is imperative to resolve their chief
complaints as quickly as possible when devel-
oping the treatment plan. This
treatment plan must take into
account the patients’ attitudes,
their genetic predispositions to oral
disease, their lifestyles, their imperative to resolve
socialization and the environments
their chief complaints
that influence their health beliefs
12
and behaviors. Berkey and col- as
leagues1 identified four domains of
dental need: function, symptoma-
tology, pathology and esthetics. The
modifying factors that challenge
dentists when prioritizing and modifying treat-
ment 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
Ettinger12,14 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
impaired, dentists need to under-
stand their wider needs such as how
they function in their environments
with their medical problems, phar-
macotherapy, 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.
When older people This subjective restorative treat-
seek care, it is ment plan often is based on the den-
tists’ personal clinical experiences
rather than on “evidence-based”
studies.8,16
quickly as possible Successful dental care depends
when developing on good communication between
the treatment plan. dentists and patients, their families
or significant others, as well as
other health care providers. To
understand patients’ needs, one must understand
the environments in which patients function;
sociodemographic information provides some
clues. There also is more variation among older
adults than younger adults because they have
had different life experiences, health experiences
and expectations, and, thus, different perceptions
of need.17
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.

594 JADA, Vol. 134, May 2003

Copyright ©2003 American Dental Association. All rights reserved.
 C L I N I C A L P R A C T I C E

In this article, we TABLE

describe the longitudinal
oral health care of an 85- THE PATIENT’S MEDICATIONS AND THEIR DENTAL
year-old patient from the IMPLICATIONS AT THE INITIAL APPOINTMENT.*
time we first saw her
HEALTH PROBLEM MEDICATION AND POTENTIAL DENTAL DENTAL CARE
until her death five years MECHANISM OF SIDE EFFECTS MANAGEMENT ISSUES
later. The focus is not so ACTION

much on what dental care Hypertension Vasotec (Merck, Loss of taste, oral Orthostatic
was given but instead on and Heart Failure Miami Lakes, ulceration, hypotension; a need for
Fla.) (enalapril xerostomia, stress reduction, short
the interaction between maleate) ACE lichenoid and appointments and
the dentist and the inhibitor angioedema limit vasoconstrictor
patient and how the Hypertension Aldactone Gingival bleeding, Confusion, muscle
treatment evolved. (Searle, Pea- xerostomia and weakness and need for
pack, N.J.) lichenoid stress reduction
(spironolactone)
CASE REPORT diuretic
An 85-year-old woman Atrial Flutter Lanoxin (Glaxo- Sensitive gag Orthostatic
sought care at The Uni- SmithKline, reflex hypotension,

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versity of Iowa College of
Dentistry in 1994
because her general
dental practitioner had Hypertension
died and she had become
* Modified from Gage and Pickett.
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 sig-
nificant because she had had a myocardial infarc-
tion 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 pre-
viously, 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 physi-
cian’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
Greenford, Eng- photophobia, limit
land) (digoxin) vasoconstrictor and
cardiac glycoside need for stress
reduction
Magnesium None None
18
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.
Oral examination. College faculty and stu-
dents in the oral pathology, radiology and
medicine department conducted intra- and
extraoral examinations that revealed no mucosal
lesions or other pathosis. The temporo-
mandibular joint was within normal limits and
had no history of problems. No nodes were found
on palpation of the patient’s face and neck. Her
oral cavity did not appear dry, and saliva could
be expressed from the major salivary glands. She
did not report having any loss of taste and did not
exhibit any exaggerated gag reflex.
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 stu-
dents 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

JADA, Vol. 134, May 2003 595

Copyright ©2003 American Dental Association. All rights reserved.
C L I N I C A L P R A C T I C E
teeth nos. 18-22). There was a lost incisal restora-
tion 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 proce-
dures with no difficulties.
Periapical radiographs and a pantomograph
showed normal bony trabecular patterns, gener-
alized 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 cal-
cification in the walls of the vessels. Our consul-
tant 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 insuffi-
cient to be used to determine the exact location of
the masses. The radiologist noted several
infrahyoid radiopaque masses that were consis-
tent 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
596 JADA, Vol. 134, May 2003
Copyright ©2003 American Dental Association. All rights reserved.
and hypertension, we needed to limit the vasocon-
strictor to 0.036 milligrams of epinephrine or two
cartridges and aspirate before injection during the
patient’s dental appointments.19 It also was advis-
able to not schedule the patient for an appoint-
ment 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 ortho-
static 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
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patient’s blood pressure. We routinely ask during
every appointment: “Has your health changed
since the last appointment? Have your medica-
tions 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 tech-
nique. During prophylaxis appointments, oral
hygiene was constantly reviewed. Due to the pres-
ence 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
 C L I N I C A L P R A C T I C E

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.
1995. Over the next year, the patient returned
for intermittent treatment only for fractured or
lost restorations and a periodontal examination.
College faculty and students in the operative den-
tistry and periodontics departments took peri-
apical radiographs, and the patient had a prophy-
laxis of her remaining dentition. In May 1995, Figure 1. Initial pantomograph of patient, November 1994.
college faculty and students in the
periodontics department noted that BOX 2
one of her FPDs (teeth nos. 18-22)

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was loose and that there was exten-
sive caries around the abutment.
She was evaluated in several
departments before being referred
for treatment to the prosthodontics
department.
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 con-
ducted 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.
At the patient’s request, the
treatment plan was limited to the
restoration of the mandibular arch.
THE PATIENT’S INITIAL TREATMENT
PLAN.
EMERGENCY OR PALLIATIVE CARE
dSurgical extraction of tooth no. 6 (impacted)
dPreviDent 5000 (Colgate-Palmolive, New York City) prescribed
to control caries
DISEASE CONTROL
dScaling and root planing of all remaining teeth
dAmalgam restoration for tooth no. 14
dRemoval of fixed partial denture, or FPD, (teeth nos. 2-8 and
18-22) and evaluation of abutments as to their restorability
RECONSTRUCTION
dReplacement of FPD (teeth nos. 2-8 or 18-22) or
dRemovable partial dentures, maxillary and mandibular
dFull cast crown for tooth no. 31
MAINTENANCE AND MONITORING
dRecall initially every four months to evaluate oral hygiene and
new caries
DIAGNOSIS
dImpacted tooth, recurrent caries, gingivitis, partial edentulous
ness, open margins on several FPD retainers, overhanging
restorations and periapical pathosis

This was done partly for financial

reasons, as well as the fact that
nothing on the maxillary arch was bothering her
and she felt it needed no treatment. It was rea-
sonable to focus on the mandibular arch because
evaluation of the mounted study casts showed
that the occlusal plane was appropriate and did
not need correction. Before finalizing the treat-
ment plan, the prosthodontist explained to the
patient that the loose FPD needed to be removed
and the abutments needed to be evaluated. The
modified treatment plan for the mandibular arch
after removal of the FPD was as follows: tooth no.
22 extraction due to vertical root fracture; tooth
no. 18 ET, amalgam core and restoration with a
full cast crown; tooth no. 31 ET, restoration with
amalgam and preparation as an overdenture
abutment (not enough tooth structure remained
for a crown, and crown lengthening in that area
would have been difficult because of the anatomy
of the tooth and the bone); tooth no. 23 a light-
cured glass ionomer; restoration and replacement
of the missing teeth with a cast metal mandibular
removable partial denture, or RPD.

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C L I N I C A L P R A C T I C E
Figure 2. Anterior view of patient when she visited the
prosthodontic department for an initial examination and
treatment, May 1996.
Figure 3. Occlusal view of the mandibular arch after
treatment was completed, June 1997. The mandibular
removable partial denture is not shown.
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 abut-
ment on tooth no. 31 served as a vertical stop for
better stabilization of the RPD.
In October of 1997, the patient returned for a
recall examination and reported some discomfort
with teeth nos. 2 and 8. She also said she was not
ready to undergo any treatment at that time. Also
598 JADA, Vol. 134, May 2003
Copyright ©2003 American Dental Association. All rights reserved.
in October 1997, which was three years after the
initial appointment, the patient had a minor
ischemic cerebrovascular accident with no
physical or mental losses and was prescribed
Coumadin (Bristol-Myers Squibb, New York
City). It then was necessary for us to contact her
physician in writing and receive her current
International Normalized Ratio, or INR, before
doing any deep scaling or extractions. Two
studies22,23 have shown that if the INR is between
2.5 to 3.0 or is lower there is little risk involved in
carrying out the planned dental procedures.
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 discus-
sion about activating the postponed treatment
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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 appoint-
ment, when we contacted her physician to deter-
mine 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 mesial-
occlusodistal, 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 dis-
cussion. 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 irre-
versible 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 Jan-
uary 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 appoint-
ment. 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.
In August 1999, we were informed that the
patient had died as a result of complications from
aortic stenosis.
DISCUSSION
Clinical decision making in dentistry tends to be
based on qualitative, subjective estimates that
the benefits of a specific treatment modality out-
weigh the alternatives. In dentistry, the clinician
traditionally has collected useful pieces of evi-
dence and synthesized them into a sequenced
subjective treatment plan, which usually is based
on the clinical experience.24 These decisions usu-
ally are based on the patient’s age-associated psy-
chological, social, biological and pathological pro-
file. 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
Copyright ©2003 American Dental Association. All rights reserved.
C L I N I C A L P R A C T I C E
Downloaded from jada.ada.org on April 8, 2011
Figure 4. Anterior view of the patient after treatment
was completed on the maxillary and mandibular arches,
April 1999.
achievable goals for each appointment. Despite
our patient’s advanced age and her health prob-
lems, 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 car-
ried out. She always decided when she was ready
for treatment. She was informed about her prob-
lems 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 avail-
ability 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 pos-
itive 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 imme-
diately 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
JADA, Vol. 134, May 2003 599
C L I N I C A L P R A C T I C E

are discussed for medical and legal documenta- 5. Strayer MS,

Kuthy RA, Casiwell
tion, for informed consent and to be a reference RJ, Moeschberger
for the patient. Clinicians need to recognize that ML. Predictors of
dental use for low
patients will not always follow their advice and income, urban elderly
should not be offended. Some older patients will people upon removal
of financial barriers.
seek care only when they perceive there is a Gerontologist
problem, which they believe the health profes- Dr. Lindquist is an Dr. Ettinger is a pro- 1997;37:110-6.
associate professor, fessor, Department of 6. Ettinger RL.
sional can help them solve. Department of Prosthodontics, and Cohort differences
A general dental practitioner could have pro- Prosthodontics, S422, Dows Institute for among aging popula-
Dental Science Dental Research, Col- tions: a challenge for
vided much of our patient’s dental care. The Building, College of lege of Dentistry, The the dental profession.
treatment procedures were straightforward Dentistry, The Univer- University of Iowa, Iowa Spec Care Dent
sity of Iowa, Iowa City, City. 1993;13:19-26.
because no adjustment in the occlusal plane or Iowa 52242, e-mail 7. Isman R, Isman
vertical dimension of occlusion was needed. It is “terry-lindquist@ B. Oral health
uiowa.edu”. Address America: Access to oral health services in the
important for dentists to understand when to reprint requests to Dr. United States 1997 and beyond. Chicago: Oral
refer surgical or restorative cases based on dental Lindquist. Health America; 1997:22-7.
8. Niessen LC, Mash LK, Gibson G. Practice
condition complexity, medical complications or management consideration for an aging popu-
procedures beyond the expertise of that dentist. lation. JADA 1993;124:55-60.

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CONCLUSIONS
The case report we discuss highlights two impor-
tant 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. ■
The authors thank Dr. Axel Ruprecht for interpreting the
pantomograph.
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