Ed i to r ia l

Medication and treatment – more questions than answers?

There was a time when certain treatment options

for the older adult were not even considered by the

majority of dentists let alone the patient. Changes

in the dentition and the progressive loss of teeth

were accepted as the norm with the eventual pro-

vision of complete dentures with all the inherent

problems of a reduced masticatory ability,

decreased food choice and potentially, a limitation

of social activities. However, with the overall

improvement in oral health, the retention of the

natural dentition later in life, the development of

new dental techniques and materials and, in many

cases, the financial resources and knowledge of

patients, age is now not a barrier to any treatment

option. In fact, many of the elderly demand the

reasons as to why certain forms of treatment may

not be available from us as well as from our medical

colleagues.

In this issue of the journal a range of subjects

are covered from both ends of the care spectrum.

The retention of large numbers of natural teeth,

whether they support crowns or extensive

bridgework present particular problems associated

with root surface caries. Research in this area has

shown that remineralization of primary lesions is

possible using particular treatment modalities

involving fluoride-containing toothpastes supple-

mented by additional rinsing with an amine

fluoride–potassium fluoride solution. However,

there are a proportion of the older population

who are hospitalized and there is a need for

greater attention to be spent in maintaining teeth

and dentures. It would appear that there is need

to provide daily help in oral hygiene procedures

but unfortunately this is likely to be much more

difficult to deliver than might be expected. Fur-

ther papers deal with the behaviour of bone to

pressure and around implants as well as mucosal

and osseous disorders in frail elderly. It is reported

that the best way to reduce bone loss is to avoid

total extraction, preserve teeth, provide overden-

tures or place implant-supported prostheses.

However, it is important to understand how

tissues respond to a mechanically active environ-

ment and therefore there is a need for an optimal

implant design. Frail elderly present particular

problems, with their increased vulnerability to

oral pathoses, but not simply because of old age

per se. Oral diseases accompanying fragility are

reported as being due to a complicated mixture of

bio-psychosocial changes that accompany old age.

On a global front, all countries are experiencing a

growth in the numbers of elderly people in the

population. By 2020, the world population of the

elderly is expected to have trebled with an esti-

mated 700 million people aged 65 years and over of

whom 70% will be in developing countries with

the most elderly increasing at the fastest rate. These

figures hide certain interesting features in that

although the percentage of older adults in the

world is 9.97%, in more developed countries

(MDC) this is 19.42% compared with least devel-

oped countries (LDC) where it is 7.65%. To put it

another way, the average annual growth rate from

1960 to 1980 in MDC was 0.94%, but in LDC this

was 2.93%. However, for 1980–2001, this had

changed to 0.48 and 2.25%, respectively. The

consequences of these changes have meant that the

populations of the LDC form 81% of the total world

population with all the potential adverse effects

that this is likely to have on oral health care.

Age Concern Scotland has recently pointed out

that those over 50 contribute very significantly to

the economy of a country with their unpaid vol-

unteer work and caring for others such as partners

and grandchildren. In the UK, it is estimated that

they contribute £201 billion in paid work and £24

billion in unpaid work. So the idea of spreading

numbers of pensioners clogging the streets with

their Zimmer frames is far from the truth; they in

fact can play a vital supportive role in societies

around the world.

It has also been reported that older people are

not the major burden to the National Health Ser-

vice in the UK that was previously believed.

Researchers analysed the medical needs of 250,000

patients of different ages in the 3 years leading up

to their death. The study showed that healthcare

needs increased closer to death regardless of age.

They also found that patients spent an average of

23 days in hospital in the 3 years before their death,

with the days spent in hospital rising until the age

of 45 after which the number remained fairly

constant. The average number of times of admis-

sion was 3.6 before death, declining to about two in

the over-85s. Many older people also want to be at

home during their last illness leading about half of

all deaths occurring at home. With the increasing

numbers of the very old staying in nursing homes

the need for hospital admission is reduced. How-

ever, it should realise that the cost of acute care

will be greater in the elderly simply because they

� 2004 The Gerodontology Association, Gerodontology 2004; 21: 63–64 63

make up a greater proportion of those who are

dying.

Part of this process is related to medication and

its use in older adults. It has been reported that in

Finland those aged 65 years and over receive an

average of 3.8 prescriptions and for those aged 85

years and over it is 6.8. In the USA the level is 4.5

prescriptions of which 17.5% are not suitable and

adverse drug reactions account for 15% of hospital

admissions. As one becomes older, certain age-

related changes present, amongst which are the

increase in fat and a decrease in muscle tissue. As

drugs are either water or fat-soluble, this can lead

to increased toxicity and increased half-life of drugs

with decreased clearance. Certain drugs may have a

half-life of 12–18 hours in a young adult, which

may increase to 96 hours in the older adult. There

is also an increased possibility of drug–drug inter-

actions, particular with drugs such as warfarin as

well as drug-food interactions. This latter group

may involve drugs such as phenytoin and warfarin

interacting with various vitamin supplements.

There is also the problem of polypharmacy and

hyposalivation and we have all seen the effects in

our older dentate patients! Last but not least is the

level of compliance which unfortunately is very

variable. It has been reported that compliance

levels can be as low as 12% for minor disorders and

only reaches 95% where the condition is life

threatening. Considerable efforts need to be taken

to promote adherence for enhanced health.

‘‘I don’t want two diseases – one nature made, one

doctor made’’ Napoleon, 1820

James P. Newton

Editor

� 2004 The Gerodontology Association, Gerodontology 2004; 21: 63–64

64 Editorial