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Senior Citizen(Geriatric)Dentistry
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Introduction
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Geriatric dentistry or gerodontics is the delivery of dental care to older adults
involving the diagnosis, prevention, and treatment of problems associated with normal
aging and age-related diseases as part of an interdisciplinary team with other health
care professionals.
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One of the most significant aspects of treating senior citizens is getting an accurate
list of all the medications they are taking, both prescription and over the counter
medications and being aware of any potential adverse interactions with the medications
that the dentist may need to place the patient on. As the number of medications
a patient is taking increases the chance of an adverse interaction increases geometrically.
This leads to a significant concern to all treating physicians not just dentists.
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Today the average senior citizen takes 5 prescription medications and two over the
counter medications on a daily basis, and it is not unusual for a senior citizen
to be taking 10 or more prescription medications and 5 or more over the counter
medications. It is quite obvious that medically managing a senior citizen is extremely
complex requiring extensive pharmaceutical knowledge.
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Another aspect of geriatric dentistry is accounting for the physical changes that
occur as we age. One of the most significant changes that we go through as we age
is that our lean muscle mass is replaced by adipose tissue (fat). This means someone
who is the same weight at 65 to 80 years old as they were when they were 30 years
old has more of their mass as fat and less of their mass as lean muscle when they
65 years old and older then when they were 30 years old. This has profound implications
on the way medications act, their potency, their half-life (the time they remain
in the body), their complications and their interactions with one another. These
changes affect what medications are appropriate to prescribe and often alter the
dosage from the recommended levels.
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Loss of dexterity especially in the hands due to age related maladies can cause
many patients difficulty with their daily oral hygiene. This can make it difficult
to grasp a toothbrush and nearly impossible to set and manipulate dental floss with
their fingers. Some solutions would be to recommend large handled toothbrushes that
are easier to grasp and the use of pre-strung dental floss in a Y-shaped holder.
Failing eyesight can also hinder proper hygiene. Patients can’t clean what they
can’t see. Fortunately corrective eyeglasses, vision enhancement surgeries and cataract
surgery all help improve patients’ vision.
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Physical accessibility to a health care provider and their facility can often effect
whether senior citizens receive health care. Limited personal mobility, difficulty
walking, difficulty climbing stairs and difficulty attaining transportation to and
from a health care facility can all limit and actually preclude senior citizens
from receiving the health care they need. Handicap parking, handicap accessible
facilities and handicap and senior public transportation can all help alleviate
these obstacles to heath care for the physically limited and handicapped patient.
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As with all health care a proper comprehensive health history, through examination,
through diagnostic tests and developing a rapport with each individual patient lead
to the best possible and most appropriate oral health treatment. Having a team oriented
approach in which the patient’s other health care providers are consulted with,
help develop and are aware of the proposed dental treatment plan will also help
to improve the patient’s oral care treatment. This multifaceted team type of approach
to health care becomes even more important for geriatric patients and medically
compromised patients than for healthy younger adults.
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Root Caries: An Epidemic of Age |
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Root caries is a lesion located on the root surface of a tooth, usually close to
or below the gingival margin. Root caries has become an important dental problem
because people are living longer and keeping their teeth longer. As patients grow
older, their gums recede and root surfaces are exposed, making them more susceptible
to root caries. Any caries-prone patient having gingival recession can develop root
caries. However, the elderly are usually more vulnerable to root caries because
of several medical conditions. Many older patients use medications that reduce saliva
flow and cause them to have a dry mouth. Root caries can be diagnosed by a dentist
during regular dental examination. X-rays are also helpful to diagnose root caries.Treatment
of root caries generally requires the placement of a restoration or crown. |
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Root caries is a common problem among the elderly. Root caries, by definition, occurs
on the root of the tooth..The term “primary” as it is used with root caries refers
to new dental caries occurring in the absence of a restoration. Secondary (recurrent)
root caries refers to caries occurring adjacent to an existing restoration.
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Root caries most often occurs supragingivally, at or close to (within 2 mm) the
cement enamel junction. This phenomenon is due to the location of the gingival margin
at the time conditions were favorable for caries to occur. The location of root
caries has been positively associated with age and gingival recession. Root caries
occurs in a location adjacent to the crest of the gingiva where dental plaque accumulates.
They occur predominantly on the proximal (mesial and distal) surfaces, followed
by the facial surface.
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It afflicts a large percentage of geriatric patients and is a very difficult problem
for dentists to manage. The etiology of root caries is multifactorial. The factors
implicated in the development of root lesions include dietary habits, microbial
plaque, and a decreased salivary flow. Root lesions are often very difficult to
restore due to their location, problems with moisture control, and proximity to
the pulp and are therefore prone to high recurrence rates. The treatment and management
considerations for root caries vary depending upon the extent and location of the
lesion, as well as the type of materials being used. Under normal circumstances,
this loss of calcium (demineralization) is compensated for by the uptake of calcium
(remineralization) from the tooth's microenvironment. This dynamic process of demineralization
and remineralization takes place more or less continually and equally in a favorable
oral environment. In an unfavorable environment, the remineralization rate does
not sufficiently neutralize the rate of demineralization, and caries occurs.
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Clinical Features |
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The clinical investigators who studied root caries provided clinical descriptions
of the signs and symptoms of root caries lesions. The most commonly used clinical
signs to describe root caries utilized visual (color, contour, surface cavitation)
, and tactile (surface texture) specifications. There are no reported clinical symptoms
of root caries although pain may be present in advanced lesions.
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There is a characteristic distribution for root caries lesions within the oral cavity. |
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Mandibular molars most effected followed by maxillary anterior teeth & maxillary
posteriors. Mandibular anteriors seem to be least susceptible. The buccal and interproximal
surfaces are more susceptible than the palatal or lingual aspect of affected teeth.
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Risk Factors |
Risk factors associated with the high prevalence of root caries among older adults
include:
- Decrease salivary flow or xerostomia,
- Exposure of root surfaces due to periodontal (gum) disease,
- Chronic medical conditions,
- Radiation treatment for head and neck cancer,
- Physical limitations,
- Diminished manual dexterity due to stroke, arthritis, or Parkinson's disease,
- Cognitive deficits due to mental illness, depression, Alzheimer's disease or dementia,
Sjögren's syndrome (an autoimmune disease),
- Diabetes,
- Poor oral hygiene,
- Multiple medication use,
- Changes in dietary habits.
- Previous root caries experience, either in the form of filled surfaces or decayed
untreated lesions is also a potent risk factor for the development of new lesions
- Serum albumin concentration :A. Yoshihara (2003)conducted a study to evaluate, by
serum albumin concentrations, the relationship between the general health condition
and root caries. The findings of the study indicated that a relationship between
root caries and serum albumin concentration in these elderly subjects is highly
possible.
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Radiographs |
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For the proximal surfaces, radiography produces good results, but the supporting
evidence is weak.
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Management of root caries |
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Prevention (primary and secondary)
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Identification of risk factors for root caries at the individual level. An accurate
diagnosis of root caries. Dietary, oral hygiene and correct brushing advice. Appropriate
fluoride regimens such as high fluoride (e.g., 5 000ppm) dentifrice, gel, varnish.
Prescribe, if appropriate chlorhexidine (as a mouthwash, spray, gel or varnish),
other similar Antiseptics, and/or remineralizing products with calcium phosphopeptide-amorphous
calcium Phosphate (CPP-ACP). Prescribe regimens to stimulate salivary flow, such
as chewing gum with or without the inclusion of active ingredients (e.g., chlorhexidine,
xylitol, CPP-ACP), sucking sugarless candies, sucking buffered citric/fruit acid
tablets, using systemic cholinergic medications (e.g., pilocarpine/ cimeviline,
with monitoring of adverse effects) Prescribing saliva substitutes, such as gels,
sprays and liquids, with placement around dentures as well as on teeth and oral
soft tissues. Review patients on a schedule appropriate to their level of risk.
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Treatment |
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Remineralization: Depending on the depth and extension of the lesion, management
may include remineralization, There is no doubt that remineralization of a carious
root surface lesion is practicable. The remineralised surface is dark brown or black
with a leathery texture initially and eventually hardens to a give a polished highly
mineralized surface. Surface Recontouring: The earliest form of interception should
be removal of softened tissue, followed by the recontouring of the root structure
to give it a smooth and cleansable surface. Restoration of the Defect; Once the
carious lesion has been established ,The repair of the lesion in the form of a restoration
becomes mandatory. Caries removal using hand instruments, supplemented by chemo-mechanical
caries removal systems, may be appropriate for specific groups of patients. There
is some evidence that glass-ionomer cement (conventional or resin-modified) may
be the material of choice for the restoration of root caries lesions, especially
if sub-gingival. |
Several materials and procedures can be used to restore decayed roots. However,
the type of restoration will be determined based on several factors. These factors
include:
- The extent and severity of the decay
- The patient's age and socioeconomic status
- The patient's motivation to improve oral health
- The patient's esthetic concerns
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Materials Used In Restoring Severe Cavitations: |
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Glass Ionomer with Fluoride Release
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- Is the material of choice
- Does not cause pulpal irritation
- Contains 20% fluoride
- Is relatively easy to place and esthetically compatible
- Is anticariogenic, antibacterial, and adhesive to root structure
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Resin Composite |
- Is not used as much as glass ionomer with fluoride
- Is not recommended for patients with poor oral hygiene
- Is not as effective as glass ionomer in releasing the fluoride it contains
- Can be used in patients with good oral hygiene
- In order for a material to be considered adequate for use in restoring root surface
caries it should: provide a good seal between the restoration and tooth, be esthetically
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Dentures |
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Full dentures are used to restore a patient's arch or mouth, both upper and lower
arches, when no teeth remain. Dentures replace the missing teeth allowing the patient
to chew food, restore the esthetics, support all the facial soft tissues, including
the lips and cheeks, and reestablish the vertical dimension of your bite (the distance
between your chin and nose). Dentures also aid in speaking, swallowing and smiling.
But for all dentures do they are still the worst restoration dentistry has to offer
and are therefore the restoration of last resort.
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The shortcomings of dentures are many and varied. Dentures are removable and therefore
can be lost or broken when out of the mouth. Dentures have nothing to attach to
therefore they lie passively on the gums and subsequently have little to no retention.
This makes dentures a potential source of social embarrassment if they happen to
come out while eating, speaking or laughing in public. This is especially true of
lower dentures since the amount of gum tissue they cover is far less than the surface
area of gum tissue upper dentures cover. This additonal surface area is what allows
upper dentures to be slightly more stable and more retentive than lower dentures.
Denture adhesives can add some retention in the short run, but as we will see, over
time the fact that all the teeth are missing will cause even the best-made dentures
to become ill fitting and have very little retention.
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Even the best made dentures become ill fitting over time because in the absence
of any teeth the body continually resorbs the jawbone making it smaller, weaker
and more susceptible to fractures. Dentures made even just a few years ago were
made to fit a larger jaw that no longer exists, so the dentures can't possibly fit
as well today as they did when they were first made. To minimize these adverse effects
of bone resorption there are several treatments that can be employed. The first
is to try to save any existing teeth or root tips that can be used as anchors to
attach an over denture to. Having root canals done allow the remaining teeth or
root tips to be saved and used for the anchor part of attachments for an over denture.
This gives the denture something to attach to and consequently increases the denture's
retention ten fold or more depending on the number of teeth and the type of attachments
used. The presence of the teeth or root tips also helps to preserve the level of
jawbone, which also improves the fit of the denture while decreasing the possibility
of sustaining a jaw fracture.
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Implants
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Implants can be used as anchors for the dentures when there are no teeth or root
tips. Just as with natural teeth and root tips the implants have the multiple functions
of improving the retention and fit of the dentures while preserving the jaw bone
of the patient. There are three levels of dentures attached to implants with each
level the amount of retention, the number of implants needed, the type of attachments
used, the complexity of the treatment and its associated costs increase. |
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The most fundamental denture attached to implants utilizes both 2 to 4 implants
and the patients gum tissue to retain the denture. These restorations are called
implant and tissue retained over dentures and usually employ attachments that are
magnets or ball and sockets. The second level denture is totally implant retained
and utilizes the patient gum tissue only for support. These are called implant retained
tissue supported over dentures and usually employ 4 implants and an anterior fixed
bar that is connected to the implants and which the over denture clasps onto. The
third and best level of over dentures is completely implant retained and implanted
supported thereby eliminating any need to use the patient's gum tissue for either
support or retention. These over dentures typically employ 6 to 8 implants that
are connected by a fixed bar that is nearly the entire length of the denture and
to which the denture attaches to. These fixed bars can be either a round bar or
for the best of the best a milled bar or spark erosion bar. These last two dentures
give the greatest retention, stability and bone preservation. |
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Geriatric Dental Education |
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Special knowledge, attitudes, technical skills required to care for older adults.
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Classified by age (65 years or older) or functional categories (well, frail, disabled,
functionally dependent, cognitively (impaired, medically complex) impact of social,
psychological, interpersonal factors , polypharmacy and associated conditions physical
disabilities and cognitive dysfunction impact on compliance with instructions and
care.
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Technical procedures require modification due to medical conditions and age related
changes .
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older adults are retaining their natural teeth transdisciplinary focus with emerging
linkages between oral health and systemic health. Most frequent cause of aspiration
pneumonia is dental plaque around diseased teeth and poorly maintained dentures.
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Risk Factors for Gum diseases---
- Inadequate plaque removal .
- Diabetes mellitus.
- Smoking
- Poor nutrition .
- Genetics
- Immune status .
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Preventing Gum Disease
- Effective daily brushing/flossing and antimicrobial mouth rinses .
- Smoking cessation.
- Nutritional counseling .
- Address systemic diseases/conditions .
- Regular dental visits.
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Root Caries Risk Factors.
- Gingival recession.
- Physical disabilities.
- Existing restorations or appliances.
- Decreased salivary flow
- Medications
- Cancer therapy.
- Low socioeconomic status .
- As gums recede, roots are more exposed and vulnerable to caries.
- Desensitizing toothpaste or fluoride gel can reduce future caries and sensitivity.
- Restoration or extraction is required .
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Factors Contributing to Root Surface Decay .
- Gum recession .
- Poor oral hygiene due to physical and/or cognitive limitations .
- Dry mouth (xerostomia.)
- Frequent snacks between meals and beverages high in sugars .
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Prevention of Tooth Decay. .
- Plaque control .
- brushing and flossing .
- mouth rinses . (chlorhexidine )
- Use of fluorides (rinses, gels, varnishes)
- Dietary education (avoid frequent snacks and beverages high in sugars.
- Consider salivary substitutes for dry mouth or if salivary flow is reduced . .
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Dental Erosions
- Gastric acid erodes dentin and enamel.
- Causes: GERD, bulimia., citrus products .
- Teeth become smooth and glassy
- Pulp exposure causes hot and cold sensitivity .
- Rinse with water after reflux or vomiting .
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Dry Mouth |
Functions of Saliva --
- Lubrication
- Buffering microbial acids
- Cleansing
- Antimicrobial
- Swallowing
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Causes of Dry Mouth
- Side-effect of medications
- Diseases and disorders (Sjögren's syndrome, diabetes mellitus, depression)
- Radiation therapy to the head and neck
- Menopause
- Local factors (infections of salivary glands, obstructions)
- Eating disorders and dehydration
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Dry Mouth: Signs and Symptoms
- Dryness of oral tissues .
- Difficulties with speaking, eating dry foods, and swallowing .
- Increased thirst .
- Difficulty in wearing removable dentures.
- Increase in fungal infections .
- Rapidly increased dental decay.
- Increased plaque accumulation
- increased periodontal disease
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How to Manage Dry Mouth.
- Change in medications or dosages
- Stimulation of salivary glands (sugar-free gums, lozenges)
- Salivary substitutes
- Meticulous oral hygiene
- Non-alcohol antimicrobial mouth rinses
- Fluoride therapy to prevent tooth decay
- Frequent dental examinations
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Fungal Infections (Candidiasis )
Common in immunocompromised or malnourished elderly .
Usually asymptomatic but may cause burning .
Angular chilitis at corners of mouth can be very painful .
Treatment is topical or systemic antifungal agents.
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Oral Ulcerations
- Aphthous
- Traumatic
- Viral
- Bacterial
- Drug reactions
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Denture Related Problems
- Loose Denture
- Denture Sores
- Denture Stomatitis
- Papillary Hyperplasia
- Epulis Fissuratum
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Denture Stomatitis Causes
- Fungal infection (C. albicansalbicans)
- Poor denture hygiene, denture fit, nutrition
- Immunosuppression .
- Wearing dentures continuously day and night
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Denture Stomatitis Treatment
- Daily denture cleaning
- Wear dentures only Wear dentures only during the day .
- Rinse mouth with Rinse Nystatin
- Soak dentures in Nystatin mixed with water .
- Address denture fit (reline) and systemic issues.
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