In the seven years since Singapore welcomed its first geriatric and special needs dentist, more has been done to cater to the oral care needs of the frail elderly, though there is a clear need for even more dentists with such training as the population ages.
Today, there are five dentists who are trained in geriatric and special needs dentistry, working at four public hospitals, said a Ministry of Health (MOH) spokesman.
They are at Khoo Teck Puat Hospital, National University Hospital (NUH), Ng Teng Fong General Hospital and Tan Tock Seng Hospital, he said.
The Geriatric Special Care Dentistry Clinic at the National Dental Centre Singapore (NDCS) in Outram also has one geriatric and special needs dentist, and is expecting two more to complete such training.
The NDCS clinic's head, Dr Yang Jingrong said the plan is to offer another two or three more of such positions from July next year.
The exact number of geriatric dentists here is not clear, but a handful have completed the three-year training in geriatric and special needs dentistry while several others have completed a shorter, one-year training, she said.
Already, patient visits at the clinic, which opened in 2016, had almost doubled to nearly 8,000 by last year and demand is projected to outstrip supply.
The second national facility to offer geriatric and special needs dental health services and facilities - the National University Centre for Oral Health, Singapore (NUCOHS) - opened in July this year.
NDCS and NUCOHS have wheelchair tilting facilities that enable patients to receive treatment in their wheelchairs.
More dentists will be completing their training in this area. Two are already enrolled in the inaugural intake of the Graduate Diploma in Geriatric Dentistry at the National University of Singapore's (NUS) Faculty of Dentistry.
This two-year part-time programme allows practising dentists to equip themselves with the skills to look after the oral health needs of frail and medically compromised elderly living in the community or nursing homes.
Launched in July, it made it possible for dentists to get geriatric dentistry training locally instead of having to go overseas.
This was announced by the NUS dentistry faculty late last month in conjunction with its 90th-anniversary celebrations.
The fact that geriatric and special needs dentistry is not considered a dental speciality in Singapore may deter some from getting this training, though the MOH spokesman said last week that the ministry "will be reviewing the need for the various dental specialties, including geriatric and special needs dentistry".
Professor Patrick Finbarr Allen, dean of the NUS Faculty of Dentistry, said Singapore's elderly population can benefit from dentists who have advanced training in this field as they will have a broad appreciation of issues related to ageing and their impact on oral healthcare.
"A greying population brings with it multiple chronic conditions and studies have long recognised the systemic link between poor oral health and other chronic health conditions such as diabetes," he said.
"The training will allow these dentists to deliver evidence-based oral care and reduce the incidence of oral disease, poor nutrition and compromised quality of life associated with dental disease in the elderly population."
While the elderly can benefit from dentists with such training, the general dental practitioners and dental specialists are equipped to manage the oral health of most elderly patients, said the MOH spokesman.
"In cases where the general dentists are not able to manage, due to severe physical and cognitive impairment or complex medical conditions, the general dentist can make a referral to the geriatric dentist," said Dr Yang.
"This will ensure timely and appropriate care for patients who require the services of a geriatric dentist."
A geriatric dentist usually handles elderly patients with certain physical and cognitive impairment.
Physical impairment such as stroke and loss of ambulation can result in poorer self-performed oral hygiene, which results in increased risk of tooth decay due to the plaque accumulation, said Dr Yang.
It can also result in bleeding gums, due to the plaque accumulation resulting in gum infection.
"In managing these dental conditions, the geriatric dentist will need to think of solutions to help the elderly patient manage his or her own brushing," she said.
"This can include modifying toothbrushes to improve the grip or using an electric toothbrush."
If the elderly patient is looked after by a caregiver or helper at home, the dentist will need to educate and emphasise the importance of good oral hygiene to the caregiver, as well as advise the caregiver on the proper technique and positioning when brushing for her loved one.
Geriatric dentists also understand the changes that accompany cognitive impairment. For instance, dementia patients generally do not remember and follow instructions as well as before and may take a longer time to understand certain words or sentences, said Dr Yang.
"Aside from the longer time required in communicating to these patients, it is often difficult to perform new procedures for them."
Being unfamiliar with the procedures and environment, they are likely to be less cooperative and more resistant towards treatment. This is why those who are newly diagnosed with cognitive impairment should visit the dentist for a check-up and get the recommended dental treatment done before the cognitive impairment worsens, said Dr Yang.
Dental diseases take time to develop and may be ignored. However, untreated dental disease can lead to pain and discomfort when eating, said Dr Yang.
"If it takes place over a long period of time, nutrition can be affected," she said. "Poor nutrition in the elderly can potentially lead to increased infections and poorer wound healing capacity. Untreated dental disease can occasionally lead to facial swellings."
Dr Tan Mei Na, an associate consultant at the NUCOHS, who is one of three dentists there who have received additional training in geriatric dental care, said geriatric dentistry is about treating the patient holistically.
"We try not to look only at their oral conditions, we will also look at their social issues, their ability to accept treatment, etc," she said. "If there are behavioural issues, the dentists will see them at a slower pace. Instead of cleaning the whole mouth, we may clean it segment by segment."
The care also evolves with the patient as in the case of Dr Tan's 70-year-old patient with Parkinson's disease.
"When he came to me four years ago, he had a lot of tooth decay, but he had seen a dentist a year before that and his teeth were fine," she said.
After some probing, Dr Tan learnt from the patient's wife that he had developed a sweet tooth because of the disease and was eating chocolates at night. "
He was also concerned about his looks as he had missing teeth... we made him dentures," she said. "Over time, his condition deteriorated. He has a feeding tube now, so we have to make sure his mouth is cleaned well as there is a risk of getting aspiration pneumonia."
Aspiration pneumonia is a type of lung infection that occurs when food and saliva or other liquids are inhaled instead of being swallowed.
An NUH study published last year had found that cleaning the tongue may reduce the risk of getting it.
Dr Tan, who is also an assistant professor in the Faculty of Dentistry, NUS, said her elderly patients are generally very sweet, although some may bite, literally.
"Some of them don't understand what's going on and that makes them very frustrated," she said. "By the time, they come to see us, their teeth are in pretty bad shape and we have to extract the tooth. It's about communicating to them that we 're here to help them."
Dr Tan added that helping them to keep their mouth healthy will make them more comfortable and improve their quality of life.