Caring for ageing teeth

Dr Ang Kok Yang,a special needs dentist at Tan Tock Seng Hospital, attending to a 70-year-old patient, Ms Liew.

Ms Seow is 80 but is still meticulous about the care of her teeth. At least, she would be, if her ability to clean her teeth had not been affected by her medical conditions.

She has had three strokes, each of which resulted in some sensory deficits. She is at risk of tooth decay and gum problems as she has poor sensation of food stuck in certain parts of her mouth. Her motor skills are also weaker.

"Sometimes, she misses certain spots as her fingers are stiff. The dentist will show us where the spots are using a mirror. He tries to get her to do it herself," said her relative, Mary (not her real name), who is her caregiver.

Fortunately, Ms Seow is fond of her dentist, Dr Tay Chong Meng, said Mary, and is happy to do what he tells her.

Specially trained dentists like Dr Tay, an assistant professor at National University of Singapore's dentistry faculty and associate consultant at the university dental cluster, National University Hospital (NUH), are best at handling patients suffering from physical and functional limitations due to geriatric conditions.

Geriatric and special needs dentistry is a relatively new field that is expected to become more important here, given the rapidly ageing population.

Singapore welcomed its first geriatric and special needs dentists in 2012. That year, Dr Tay returned from his postgraduate training in Australia to work at NUH.

He is one of six recipients of postgraduate scholarships from the Ministry of Health (MOH) in geriatric and special needs dentistry, and the first of four who have returned from their training to work in Singapore. MOH began offering such scholarships in 2008.

All six will be with these four hospitals - NUH, Tan Tock Seng Hospital (TTSH), Khoo Teck Puat Hospital and Ng Teng Fong General Hospital, said an MOH spokesman.

By October, Dr Tan Mei Na, a prosthodontist undergoing advanced training in geriatric dentistry in the United States, will return to work at NUH, said Dr Tay.

The National Dental Centre of Singapore (NDCS), which now has two visiting geriatric and special needs dentists, plans to send two to three dentists overseas for such training, said Dr See Toh Yoong Liang, deputy head of its Geriatric Special Care Dentistry Clinic.

NDCS started this clinic last September, but has yet to launch it officially.

Currently, the Dental Specialists Accreditation Board is looking into whether geriatric and special needs dentistry should be a recognised speciality.

"Complex dental problems in our geriatric patients are mainly managed by prosthodontists (who help restore or replace missing teeth), while many adult special needs patients are cared for by paediatric dentists and some general dentists," said an MOH spokesman.

Dr See Toh said NDCS has seen more elderly patients over the past few years, including those with Parkinson's or Alzheimer's disease, or who have age-related mobility issues.

Patients with Parkinson's disease or dementia may have food remnants left in the mouth for longer periods due to reduced effective movement of their cheeks or tongues, said Dr Ang Kok Yang, a special needs dentist at TTSH.

This puts them at risk of tooth decay. The resulting loss of teeth may limit the variety of food that they consume and their speech.

Geriatric and special needs dentists have "an arsenal of tools and tricks to make dentistry easier for these patients", said Dr See Toh.

Take, for instance, patients with Parkinson's, which can cause trembling in the hands, arms, legs and face, stiffness and slow movement.

They are taught to use adaptive aids with enlarged toothbrushes, which allow them to continue caring for themselves.

In treating patients with Alzheimer's disease, the progressive nature of the condition must be taken into consideration.

While planning their dentures, the dentist considers the spacing so that more teeth can be added to the denture if more of the patient's teeth are extracted, said Dr Tay. The patient can then continue using the same denture, with some new features added.

More dentists will be exposed to this field as the six scholarship recipients will provide regular training and upgrading courses for general dentists and oral health therapists, said the MOH spokesman.

Dentist to Ah Kongs and Ah Mas

If you hear a dental patient screaming as if he were watching a gruesome horror movie, he could just be seeing Dr Ang Kok Yang for a routine dental check.

Dr Ang has also had his fingers bitten by patients with behavioural issues that can be caused by medical conditions, such as dementia, autism and stroke.

Yet, he is undeterred. Dr Ang, a dental registrar at Tan Tock Seng Hospital, completed three years of postgraduate training in special needs dentistry last January. That makes him the only special needs dentist working in the hospital.

He joins a small, but growing, pool of such dentists in Singapore. It is a speciality that deals with the oral health of people who have intellectual disability, or medical, physical or psychiatric issues. Around half of Dr Ang's patients are above 75 years old and they usually have medical conditions, such as dementia and Parkinson's disease.

Photo: Tan Tock Seng Hospital

"I enjoy treating the Ah Kongs (grandfathers) and Ah Mas (grandmothers). Just yesterday, I had an elderly patient who kept pinching my hand to get me to stop checking her teeth," Dr Ang said matter-of-factly.

"Now, I understand them better and why they do that. They see this person in a gown, with goggles on and the lights are on, and they think that you're going to hurt them."

Dr Ang had treated elderly and special needs patients before his training. Now he is trained to plan a patient's long-term dental care. "We try to optimise their oral condition before their health conditions deteriorate," he said.

"We also try to educate the family on what they can do to help their oral hygiene as the condition progresses."

He spends at least 45 minutes to an hour for the more complex cases that he sees now, compared with half an hour for a general patient he saw previously.

"It involves looking at the medical records, talking to the family and the patient," he said. "I also look at the speech therapy reports and their diet. Many don't realise that a lot of oral problems are dependent on their diet."

If his elderly patients are taking milk supplements, he would advise them to rinse their mouth as it is usually sweet, he said.

"A lot of them are on medications, which mostly lead to dry mouth, and that puts them at a higher risk of tooth decay."

He may also refer his patients to other specialists, like a psychologist, if he sees the need, he said.

Retiree Alice Liew, 70, who has lupus, a chronic autoimmune disease, and poor eyesight, first saw Dr Ang eight years ago.

"Before his further training, he would just look at my teeth and treat the problem itself," she said.

Now, he has a better understanding of her conditions and the related side effects from the medications, she said.

"He advised me to get my teeth extracted before I start the medications for osteoporosis, as the medications will affect the healing of my wounds."

Her teeth need to be extracted due to poor gum health that is partly caused by her lupus flares and partly by medications.

Toothy myths debunked

Some older adults have misconceptions about oral health. Dr Ansgar Cheng, a prosthodontist at Specialist Dental Group, debunks some common myths.

I will lose my teeth as I age.

Fact: Poor oral health can lead to the loss of teeth. However, research has shown that the loss of teeth is avoidable. It is also not unrealistic to expect to have good teeth for life if you take good care of them. The easy way to give your teeth the attention they deserve is to make it a habit to brush them twice a day, for two minutes each time.

I am already so old. It's okay if I forget to maintain oral hygiene.

Fact: Having older teeth does not mean they need less maintenance. In fact, more tender loving care should be given to older teeth. As you age, your teeth go through more wear and tear, making them more vulnerable to getting chipped or broken. Also, seniors become more prone to tooth decay because many medications (including those for high blood pressure, high cholesterol and asthma) can cause dry mouth. The lack of saliva impairs your ability to fight the harmful bacteria that cause tooth decay.

Dental work is expensive. I see the dentist only when I cannot bear the pain anymore.

Fact: The procedures get expensive because many people see the dentist only when they are in pain and the problem has become serious. Unpleasant dental issues are mostly avoidable if they are treated early.

This article was first published on March 1, 2016.
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