Treatment Planning for Seniors With Financial Limitations

America’s older adult population is growing at an unprecedented rate.¹ In 2011, the earliest members of the baby boomer generation — those born between 1946 and 1964 — turned 65 and became eligible for Medicare.¹ In 2056, it is projected that, for the first time in history, the number of individuals age 65 and older will be greater than those age 18 and younger.² As the population of older adults grows, so does the demand for oral health care services.³ Most older adults experience the same dental needs as the general population — for example, prevention, risk management and restorative care. But the ability of this population to receive professional dental care is often limited, particularly for older adults who are homebound, living in long-term care facilities, or medically compromised.⁴

The cost of care may also present challenges.⁵ Most older adults in the U.S. pay out of pocket for elective dental treatment.⁶ These costs greatly impact patients’ decisions on what types of care will be obtained.^7,8 The large number of treatment options can also be daunting for this population.² When considering esthetic treatment, older adults not only must decide which option offers the best esthetics, but also the greatest longevity, and how much they are able to afford.

To best help their patients, clinicians should use a personalized approach that considers risks and remaining teeth and bone when advising older individuals about treatment options.⁹ While longevity is dependent on the level of functional risk and varies considerably from patient to patient, clinicians can certainly help these patients navigate the many esthetic options available in contemporary restorative dentistry — along with the associated costs.

There is no dental treatment that is precluded by age alone. There are, however, many coexisting factors that may impact the course of dental treatment for older adults. Cost, patient desires and beliefs, dental and medical histories, invasiveness and longevity of treatment, and oral health status are considerations that may affect the type and extent of treatment. Dentists are often faced with a quandary in which their patient needs or desires a complex and esthetic restoration, but has limited financial resources to pay for it. Fortunately, there is a range of restorative options that may be able to fulfill a patient’s functional and esthetic requirements.

RESTORATIVE MATERIALS

Materials used in the repair of single teeth include amalgam, composite or glass ionomer (often simply called resin), cast metal, combinations of ceramic on metal, all-ceramic and acrylic (used in removable and some fixed prostheses). When used to replace missing teeth, materials can be attached to adjacent teeth (bridges), part of removable complete dentures or partial dentures, or supported by implants.

Table 1 illustrates the full range of restorative options, as well as the associated costs. Older adults with limited resources should also be advised that dental schools offer low-cost opportunities for care. The lower prices listed in the table are for care provided by dental students at the University of Michigan School of Dentistry in Ann Arbor, as of April 2014. The higher costs are for services provided in an established private dental practice in Ann Arbor.

Of course, prices vary considerably throughout the U.S. Additionally, new fabrication methods are always being developed, so costs typically decrease with time. But the range of costs for treatment shown in Table 1 provides a reference for individuals considering options among different procedures and providers. It can also be used to help older adults make educated decisions about the dental care they will receive.

MAKING DECISIONS

The following examples encompass typical patient scenarios that clinicians are likely to encounter. By working with patients and considering the constraints of their financial position, options can be selected within the relevant column in Table 1.

Case 1 is a 72-year-old man with a broken upper front tooth. The patient is mostly dentate, particularly in anterior segments. A clinical examination reveals that tooth #8 is fractured at an oblique angle and approximately two-thirds of the crown is missing. Testing reveals a vital tooth with no pulp exposure, and the tooth is asymptomatic (aside from transient mild dentin sensitivity in response to extreme temperatures). There is adequate interocclusal space and interdental space for a restoration, with enough bone, and ridge height and width. There are no other contraindications to dental care. The treatment options include:

1. Composite resin ($123 to $244)
2. All-ceramic or porcelain-veneered-to-metal crown ($492 to $975)

The full-coverage crown option has the best long-term prognosis and is better able to withstand the incising forces during function. If expense is a major confounder, however, the patient should be informed that a resin restoration would suffice for a shorter duration. This approach, however, will also require the patient to pay attention to the distribution of forces while incising hard foods, such as raw vegetables. Either option is an acceptable way to restore the lost tooth structure and esthetics. Discussing these risks and benefits with the patient will help him choose the option that best fits his desires and resources.

Case 2 is an 80-year-old woman with an upper lateral incisor (#7) fracture at the gumline. The radiograph indicates the tooth is abscessed and has a very short root. As a result, the tooth is not restorable and needs to be extracted. Her treatment options include:

1. Extract the tooth ($73 to $150) and leave the space
2. Replace the tooth with a bonded fiber ribbon that includes an acrylic denture tooth ($238 to $350)
3. Replace the tooth with an acrylic partial denture ($212 to $350)
4. Replace the tooth with a bonded, fixed partial denture ($949 to $2800)
5. Replace the tooth with a fixed partial denture bridge ($1607 to $3000)
6. Replace the tooth with an implant-supported crown ($1563 to $3500)

If the patient truly wants to replace the lost tooth, then the question is, which option provides the best long-term prognosis? The implant-supported crown is the choice for maximal esthetics and best long-term prognosis. This choice also rules out a removable prosthesis or a fixed prosthesis requiring supplemental hygiene aids and techniques. It is, however, the most expensive option. If finances are a concern, the patient must decide which of the remaining options — typically options 2, 3 or 4 — will offer the best risk-to-benefit ratio for the money. This varies based on individual patient factors and requires a thorough discussion with the patient, reviewing risks and benefits for each option.

Case 3 involves a 67-year-old woman with a broken tooth on the upper left that is very sensitive. Her exam reveals that she has fractured the buccal cusp of #13. Radiographic evaluation, however, indicates no periapical pathology. She states that she has limited financial ability. Her treatment options are:

1. Extraction without replacement ($73 to $150)
2. Pin-retained or bonded composite resin ($168 to $274)
3. Core buildup ($123 to $244) with an all-ceramic or porcelain-veneered-to-metal crown ($492 to $975)

This case presents the most difficult situation. Clearly, the best option is to restore the tooth (Option 3) for function, longevity and esthetics. If this is too expensive, the remaining restorative choice (Option 2) is a compromise on longevity. Often, a patient will ask if there is a way to keep the tooth a little longer in order to put off the extraction until the procedure becomes more financially feasible. In this situation, a compromise should be provided. Realistically, the patient and clinician both know that the tooth will need to be extracted — probably sooner than later. Nonetheless, Option 2 will allow the patient to maintain the tooth for esthetics and function, even though the prognosis is fair, at best.

Case 4 is a 78-year-old man with a loose bridge who has not seen a dentist in several years. The exam reveals that he has a bridge from tooth #6 to #11, which is loose on #11. A radiograph reveals the tooth is abscessed, with decay extending below the bone. The diagnosis for #11 is that it is nonrestorable and the tooth must be extracted. The patient has a very limited income. The initial treatment recommendation would be to cut the bridge apart between #6 and #7 and extract #11. Final treatment options are:

1. Do not restore — leave the patient edentulous from #7 to #12
2. Restore with an all-acrylic partial denture ($212 to $350)
3. Replace the teeth with an acrylic or metal/acrylic removable partial denture ($752 to $1500)
4. Replace the teeth with three implants and restore with a bridge ($13,800)

Due to the patient’s limited finances, only options 1 and 2 are realistic to consider. While leaving the space edentulous is certainly the least expensive, this would severely compromise the patient’s esthetics and ability to incise. Yet, if the patient does not have the ability to finance any other treatment, does not value esthetics, and is able to accommodate the loss of function, then Option 1 may be the best choice. Oral health professionals must remember that restoring esthetics and function fall under corrective measures and, while valuable, do not supersede their obligation to control disease.

Older patients living on fixed incomes who finance most or all of their dental expenses out of pocket need to understand the potential options and cost for esthetic restorative care. As can be seen by these examples, many options are available that vary in their level of esthetics, function, longevity and cost. It is up to the patient and clinician to discuss the risks and benefits associated with each option to determine the best strategy for the patient.

• America’s growing ranks of older adults, many of whom still retain their natural dentition, indicate that dental professionals are likely to treat increasing numbers of these patients.
• Many older adults are living on fixed incomes, and most pay out of pocket for elective dental treatment.⁶
• When considering which restorative option offers the best esthetics, older adults must also take into account which treatment promises the greatest longevity — and how much they are able to afford.
• Dental providers should use a personalized approach that considers risks and remaining teeth and bone when advising older patients about treatment options.⁹
• Coexisting factors that may impact treatment include cost, patient desires and beliefs, dental and medical histories, invasiveness and longevity of treatment, and oral health status.

• By weighing all available options, clinicians and older adult patients can determine the most appropriate course of treatment for each individual.

References