Progress notes

This issue includes the perspectives of Dr. Charles Wakefield, professor and director of the Advanced Education in General Dentistry residency program, and one of the presenters at the recent Linda C. Niessen Geriatric Dentistry Symposium.

Wakefield has seen the situation all too often: A patient has restorative work that holds up beautifully for years. Then that individual gets on in age, and by the time the patient reaches his or her mid-70s, something may dramatically shift. Saliva quality and quantity may decrease. Decay may begin to run rampant. Then there’s a high probability that the patient is on a fixed income and will have to pay for extensive dental treatment out of pocket.

It may appear like a losing battle at first, but as this retired colonel in the U.S. Army Dental Corps and examiner for both the American and Federal Services boards of general dentistry reassures us, things are not always what they seem.

Here, Wakefield expands upon some of the gems shared during the symposium, cues us in on how to tackle decay and reveals his go-to restorative materials for geriatric patients. We also find out whether this baby boomer is ready to — gulp — become a member of the “new elderly” patient population.

BDRO: During the symposium you covered the gamut regarding giving geriatric patients the smiles they have always wanted, and there was one point that you kept driving home: the responsibility of the patient to play a part in treatment by practicing good daily oral hygiene before restorative materials can be placed. With this in mind, what are some options you could recommend to patients whose oral health is negatively impacting their restorations?

Wakefield: If you’re dealing with someone who has had restorative work for years, and all of a sudden you’re seeing a lot of decay, you’ve got to figure that out. How did this situation occur? You have to start addressing the reasons and causes before you start repairing. Maybe it’s the medication he or she is taking that causes dry mouth. Next, you have to educate the patient on how to maintain hygiene and how to assure a proper diet is being followed. Then you have to eliminate the pathology through restoration of decay.

We will have them rinse regularly with chlorhexidine; that kills off all the germs. Then you need a source of calcium and phosphate to remineralize the tooth structure. And you need a source of fluoride. I’ll have them chew on some gum with Xylitol — a type of alcohol found in sugar free gum. That’s incredibly important stuff as well. There are all these little things you have to do.

I’ll tell people early in the treatment plan, “The hardest work here has to be done by you. You’re going to have to do this every day for the rest of your life.” It’s about helping the patients to own their problems.

BDRO: We know that patients may require specific restorative materials given their individual needs. In a broad sense, what are some of the materials we are seeing more of these days? What are the benefits of these materials? What are their inherent challenges?

Wakefield: If you want something that’s aesthetic, we have some really good porcelains that we use now. There’s a really beautiful porcelain we are using a lot on veneers and crowns. I lean toward Empress and eMax, which is very, very hard. We can put that porcelain on larger restorations in posterior teeth. It’s also good-looking enough that you can use it for the front.

Then there’s zirconia. It’s just under a diamond in hardness. The thing with zirconia is that it’s so hard that you have to go through many procedures to bond it to the tooth. I try to stay away from zirconia, but when I do use it, I just cement it on the tooth with a special protocol; I don’t bond it.
Another material is the glass ionomer, which is really good because it’s a powerhouse of fluoride. As long as you’re rinsing with fluoride, a GI has a sustained release of fluoride because of its ability to recharge. We also write patients prescriptions for fluoride rinses to recharge glass ionomers. That is really, really good for controlling the decay that we fill.

BDRO: So are you well prepared to become one of the “new elderly” (many, many years from now, of course)?

Wakefield: I’m a baby boomer myself, but I don’t know if I’m prepared or not. I always tell the residents, “If you live long enough, you’ll be a special needs patient yourself.”
About 10 years ago I was getting my regular physical, and the doctor said, “Something’s up.” I was diagnosed with multiple myeloma. All the chemo went on for a year. I flossed and I brushed every single day, and I still never saw a red blood cell in my mouth the whole time. So I know that even if your platelets get dangerously low, if your hygiene is really good, you can do it. I’ve always been a pretty big believer in hygiene, but I really am now.