Restorative Dental Surgery, the Elderly and Shared Decision Making

A wise professor of medicine always told me as a young physician, “Eighty-year olds are to be revered and not messed with.”   This is especially true for those 90 or older.  Here in South Florida there is always some senior citizen telling us today’s 80 is yesterday’s 60 and today’s 70 is yesterday’s 50.  It just isn’t so.  I see this erroneous belief of the elderly having the healing power of younger individuals   highlighted in the area of cosmetic and restorative surgery and dentistry in my affluent youth-seeking community.

We all want to look our best. In many cases this requires pulling teeth, placing implants and covering those implanted posts with crowns to produce that young smile and maintain a chewing surface. Most times it’s better to do less.

Pulling rotten teeth, obtaining dentures or using a bridge and practicing meticulous hygiene on the gums may be the better course.  Don’t tell this to 91 year old Hal who is mildly cognitively impaired, and his loving caring daughter who sent him for extensive dental surgery.   This gentleman had an artificial aortic valve placed by the less invasive TAVR method a few years back. He was required to take antibiotics before the procedure to prevent a heart valve infection as per the guidelines of the American Heart Association, American College of Infectious Disease and American Dental Society.

His former physician taught infectious diseases in a major academic center and felt he needed a longer course of antibiotics than the guidelines recommended.  Several weeks later he had intractable back pain and severe diarrhea. He was diagnosed with antibiotic related colitis and treated appropriately with oral vancomycin. The back pain was more problematic.  His daughter self-referred him to a physical therapist who could not find a way to obtain relief.

He came to me as a new patient with severe back pain and, after hospitalizing him for pain relief and with the assistance of an infectious disease expert, we were able to document an infection of the heart valve and an infection of the back disc space causing the excruciating pain. The infection originated with the disturbance of his gums and teeth during the dental work. He received 10 weeks of intravenous antibiotics and four months of physical therapy at a skilled nursing facility before he was able to return to his home with help.

At that point he and his family were advised to limit the dental work, follow antibiotic guidelines for the work being done and clear the work and antibiotic regimen with his internist and local infectious disease physician prior to undergoing non-life-threatening non-emergency procedures. It was no surprise however when I received a phone call from his aide saying he had diarrhea after a dental procedure and the daughter chose to use the prolonged antibiotic protocol that the former doctor had recommended years ago.  One of the aides had given the patient immodium several days prior to the call to me to slow down the diarrhea so now the body’s natural clearing response to a pathogen had been delayed by a medication choice.

He was examined and found to have a mildly tender abdomen. A digital rectal exam identified microscopic blood in his loose stools.   A stool evaluation identified clostridia difficile as the causative agent of his antibiotic related colitis. He is now back on medications for this entity and hopefully it will control the disease while we keep him hydrated and out of the hospital again.  More is not always better. The frail elderly need to be revered and not messed with. Palliative rather than aggressive therapy may be best in this patient population.

Mrs. Sommerville is another example. A beautiful mid-eighties woman, she looked years younger. She signed up for pulling all her teeth on her lower jaw and recreating her smile with implants. She was given an opioid medication for pain control. Post-surgery she ran a fever for several days.  After taking the opioid for pain relief she fell and hit her head. She was referred to a hospital ER where she was noted to have a subdural hematoma from the fall (blood on the brain) and positive blood cultures from the oral bacteria which seeded the bloodstream during her dental procedure.  I suggested transferring her to a facility that had the neurosurgical capabilities to treat the complications of a subdural hematoma. The patient did not want to be transferred and, in the era of shared decision making, the consulting neurologist was comfortable obtaining serial MRI scans to observe the brain bleed and follow its course.  The MRI’s didn’t get done on a timely fashion because the patient had just had hair extensions placed by her hair stylist and the metal clips were not permitted in the magnetic range of the MRI machine. The patient refused to allow anyone but her hair stylist to remove the extensions and his schedule didn’t permit his visit to the hospital for 48 hours.

Both situations exemplify the zest for life and vitality human beings exhibit. In both cases, less would have been preferential.

I suggest that as we get older before considering cosmetic procedures, we discuss it with our medical doctors and review the pros and cons and alternatives. I am not accusing the dentists of being too aggressive but maybe too accommodating with no real geriatric training to help them in their clinical decision making.