GERIATRIC DENTISTRY

Submitted by: jumana jabeen.Guided by:Dr.Mehmood muthedath.Dr.Aseela ahamed

INTRODUCTIONDEFINITIONSIZE OF THE PROBLEMCATEGORIES OF GERIATRIC PATIENTLEVEL OF DEPENDENCECHANGES IN THE GERIATRIC PATIENTINTRA ORAL CHANGESCOMMON MEDICAL PROBLEMSCOMMON DENTAL PROBLEMS GERIATRICS IN PROSTHODONTICSGERIATRIC IN ENDODONTICS

GERIATRICS IN PERIODONTICSGERIATRIC ANASTHESIATREATMENT PLANNINGIMPORTANT DUTIES IN THE TREATMENT OF

ELDERLY PATIENTSEXTENDED CARE FACILITIESMOBILE DENTAL CLINICFINANCING GERIATRIC ORAL HEALTH

Geriatric dentistry is emerging as special branch of dentistry since 1970.

As per the Government of India’s classification , the elderly are those who are 60 years of age and above and in the developed world, the elderly are those who above the age of 65 years.

IGNATZ.L.NASCHER

The word “Geriatrics” was coined by Ignatz . L.Nascher in 1909, known as the Father of Geriatrics.

Marjory warren –Mother of Geriatrics.

She established a special Geriatric unit in England in 1935.

MARJORY WARREN

I. ETTINGER DEFINITION -

The provision of dental care for adult persons with one or more chronic , debilitating, physical or mental illness with associated medications and psycho social problems.

Branch of dentistry that deals with special knowledge ,attitudes & technical skills required in the provision of oral health care to older adults. The term older adults has no specific chronological boundary , rather it refers to adults who are affected by physical, social, psychological , physiological & biologic changes associated with ageing with / without concomitant disease.

GERODONTOLOGYDefined as the multidisciplinary study of the process of aging in the oro-facial area and its relation to the surroundings

More adults will be maintaining their teeth, but their teeth will be more at risk for caries and periodontal diseases. These adults will need more preventive, restorative, and periodontal services to maintain these teeth.

The challenge in maintaining these teeth in older adults is the effects of caries and periodontal diseases through their lifetime are cumulative. Dental treatment becomes more complex than dental care for younger adults.

This complexity comes from the many changes associated with aging. The elderly may also have multiple physical and psychological problems that affect their treatment and require the dentist to have good medical knowledge and management skills.

Why it is imp?....

1) WELL ELDERLY – Independent living – one/ two minor

chronic medical disease.

2) FRAIL ELDERLY – Independent living – coexistent minor & major chronic, debilitating medical disease, dependent on drugs & few are institutionalized.

LEVEL OF DEPENDENCE….Dependence is defined as the need for assistance in performing daily routines of the body like bathing,dressing, transferring from bed to chair…..

Physiological changesPathological changesPsychological changesLocal factors

Loss of elasticity of skinWrinkled, dry thin skinDiminution of the senses Loss of hairThin, abraded oral mucosaDry mouthNeuromial changesLoss of appetiteMalnutritionLoss of taste sensation……

Acute inflammatory infections are less common

Hypertensive vascular diseaseHeart diseaseDiabetes mellitusArteriosclerosisNeoplasmCerebral hemorrhageDisease of bone & jointsNephritis……

Mental changes – Impaired memory, rigidity of outlook & dislike

of changes….

Emotional disorders- Results from social mal adjustment. Failure

in adaptation can result in bitterness , inner withdrawal , depression , weariness of life & even suicide

low BMR results in Crinkly sparse coarse hair , slow speech & perception

Xerostomia results in dry mucosa& dry lipsEnlargement of finger joints is the visible

evidence of osteoarthritis.Poor oral hygiene, soft tissue lesions, heavy

smoking & acetone breath of diabetic results in Halitosis…

SOFT TISSUE CHANGES :

LIPS – dry , purse string opening results from dehydration & loss of elasticity with in the tissues.

ANGULAR CHELITIS:

• Not specifically an age related disease.

Appears as skin folds with fissuring at the angles of the mouth .

Cause- candidiasis, Vit B deficiency.

Atrophic changes- Thin & less vascular mucosa with loss of elasticity. clinically the smooth shiny appearance is related to thinning of epithelium.

Hyperkeratosis – white patchy areas may develop as a result of irritation from sharp edges of broken teeth, restorations / dentures & from the use of tobacco.

Capillary fragility –facial bruises & petechia of the mucosa are common.

Leukoplakia

Oral sub mucous fibrosis

Macroglossia : Because of loss of tone of muscles of the cheek /expansions in the oral cavity as a result of loss of teeth.

Sublingual varicosities :Deep red/ bluish nodular dilated vessels on the ventral surface is common with elders. It does not call for any treatment unless symptoms appear.

Taste sensations : Taste buds are not reduced in no .Taste may be reduced/ abnormal taste reactions may occur ,primarily in people with diseased conditions & also loss of papillae due to nutritional deficiencies may lead to alteration in the taste sensation.

Appearance:Numerous small

furrows and fissures on the dorsum of the tongue. May be attributed to trauma, vitamin deficiencies, salivary gland dysfunction.

Decreased salivary flow /dryness of mouth is frequently seen in older people with pathologic change ,drug induced changes/ radiation induced degeneration of salivary gland.

Absence of protective influence of saliva in the oral cavity increases the predisposition to oral disease

Progressive loss of alveolar ridge after the teeth are extracted

TEETH – 1. CHANGES IN ENAMEL : Color change - teeth becomes

yellow to yellowish grey &yellowing of root.

Increase transparency. Increased demineralization. Cracks appear. Attrition, abrasion, erosion… Lower solubility during

etching when compared to young teeth.

Decrease permeability. Root canals become narrow.Change of collagen fibers .Sclerotic dentin formation.

Alteration of the cell structure.Decreased no of collagen fibers.Pulp calcification.Decrease sensitivity.Shrinking of the pulp cavity.Obliteration of root canals.Narrowing of pulp chamber due to

deposition of secondary dentin.

CEMENTUM Increased thickness. average thickness of the

cementum at 20 yrs of age was 0.095mm where as cementum from 60 yr old persons measured 0.215mm.

GINGIVAMost changes can be due to

effects of infection, irritation / to anatomic factors.

eg - gingival recession is most common in older individuals.

1. Cardio vascular disease :

~ Cardiac failure. ~ hypertensive & ischemic

heart disease. ~ temporal arteritis. 2. Respiratory disease :

~ chronic bronchitis & emphysema.

~ pneumonia.

~ poor vision. ~ stroke. ~ Multi infarct

dementia. ~ Trigeminal

neuralgia. ~ Alzheimer's disease. ~ Parkinsonism

~ Osteoarthritis. ~ Osteoporosis. ~ Pagets disease. 5. Hematological disease : ~ Chronic leukemia. ~ pernicious anemia

~Urinary retention. ~Prostatic hypertrophy &cancer. ~Renal failure.

7.PSYCHOLOGICAL PROBLEMS ~Insomnia ~Acute confusional states. ~Atypical facial pain.

8.OTHERS~Nutritional deficiencies ~Accidents ~Cancer

EdentulousnessDental caries (root caries)Periodontal diseasesSevere attrition ,abrasion ,erosion …Oral mucosal lesions- premalignant lesions.XerostomiaAltered sensory function(taste sensation)Ulcerative lesionsOral cancer….

ATTRITION :

~ physiologic wearing away of teeth as a result of tooth to tooth contact as in mastication.

~ the teeth of elderly people shows signs of wear, which may be the long term effect of diet, occupational factors, bruxism….

ABRASION

~ Pathological wearing away of tooth substance through some abnormal mechanical problems.

~is a V- shaped / wedge shaped ditch on the cervical area.

~ causes: use of an abrasive dentifrice.

improper tooth brushing improper use of dental floss/

toothpick……

Irreversible loss of dental hard tissue by a chemical process the does not involve bacteria.

Causes : GERD ,vomiting, citrus products , carbonated beverages.

Teeth become smooth & glassyPulp exposure causes hot & cold

sensitivity.rinse with water after reflux / vomiting.

Is one of the ten leading cancers in the world.Is primarily habit related & secondarily an age related disease.Increased incidence in older age groups is due to the prolonged duration of exposure , cellular aging& decreased immunological surveillance.90-95% of all oral malignancies are squamous cell carcinoma.Common site: lateral border& under surface of the tongue , buccal mucosa & lips

Causes : Betel tobacco quid chewing , bidi smoking, smoking (reverse smoking, pipe smoking…),alcohol, poor nutritional status , radiation…..

Site of occurrence is related to the customs &social habits in the religion

defined as a subjective complaint of dry mouth

that may result from a decrease in the production of saliva.

It affects 17- 29 % of population.Can cause significant morbidity & a

reduction in patient perception of quality of life

Conditions…

Anxiety or Depression HIV Diabetes, Type 1 or 2 Primary Biliary Cirrhosis Bone Marrow Transplantation Vasculitis Chronic Active Hepatitis Renal Dialysis

Ionizing radiation:Ionizing radiation: can injure can injure the major and minor salivary the major and minor salivary glands which may lead to glands which may lead to atrophy of the secretary atrophy of the secretary components and results in components and results in varying degrees of temporary or varying degrees of temporary or permanent xerostomia.permanent xerostomia.

Toxic substances in Toxic substances in chemotherapeutic agentschemotherapeutic agents.. Diabetes mellitus:Diabetes mellitus: Patients with Patients with

poor glycemic poor glycemic control, are more likely to complain of control, are more likely to complain of xerostomia and may have decreased xerostomia and may have decreased salivary flow.salivary flow.

Clinical Appearance

• Oral mucosa appears dry, pale, or atrophic.

• Tongue may be devoid of papillae with fissured and inflamed appearance.

• New and recurrent dental caries.• Difficulty with chewing,

swallowing, and tasting may occur.

• Fungal infections are common.

Strawberry tongue

Dry mouth will also see more candidiasis,characterised by the appearance of soft , elevated plaque most frequently occurring on the buccal mucosa &tongue &it resembling milk curds.Treatment : Nystatin mouth rinse.

Warning Signs in Xerostomia

Dry, burning mouth and throat.2. Dry, cracking lips, especially in

the corners. The cracks may be tender and bleed.

3. Problems with denture wearing.4. Difficulty with speech due to

soreness.5. Increased caries & periodontal

disease.

MANAGEMENT

The general approach to treating patients with hypo salivation and xerostomia is directed at palliative treatment for the relief of symptoms and prevention of oral complications. Consult with physician to decrease drug

dose, alter drug dosages, or substitute one xerostomia medication for a similar-acting drug with fewer salivary side effects.

Symptomatic Treatments: Sip water frequently all day longLet ice melt in the mouthRestrict caffeine intakeAvoid mouth rinses containing alcoholCoat lips with lubricant.

Commercial oral moisturizing gels (OTC) includes:Oral Balance.XERO-LubeSalivartMoi-Stir OrexOptimoist

Saliva Stimulants:

The use of sugar free gum, lemon drops or mints are conservative methods to temporarily stimulate salivary flow in patients with medication xerostomia or with salivary gland dysfunction.

Most common immunologic disorder associated with salivary gland disease.

Characterized by a lymphocyte-mediated destruction of the exocrine glands leading to xerostomia &keratoconjunctivitis sicca.

Average age of onset is 50 yrs.90% cases occurs in women

Edentulousness increase with age, at 85+ slightly more than 50% are edentulous.

More prevalent in persons with low income & little/ no education.

Most common problem seen in elderly people.

Common cause for tooth loss are caries & periodontal disease.

Denture placement is the treatment & now a days it is most acceptable.

Place a low priority on dental care. More irritable and demanding than

younger patients. Exaggerate troubles and complaints. Denture tolerance is reduced markedly. Ability to adjust to new dentures is

diminished. Adjustment period is slow. Low tolerance to new dentures.

Removable dentures are more acceptable than fixed dentures. Because of low cost, acceptability, adaptability……..

Select the material that is compatible to patient for gagging & dry mouth.

Prolonged denture wear (30+years) worn into class 2 ridge relation.

DENTURE SORE MOUTH –

Also called as chronic atrophic candidiasis is thought to be the most common symptoms of oral candidiasis. Most commonly seen in maxillary arch.

Treatment : Remove the denture from the mouth for an extended period of time.

Caused by wearing ill-fitting dentures for years and lining them with adhesives. This causes localized areas of inflammation and resorption of the remaining alveolar bone. resulting in a knife –edge ridge, impossible to wear denture without pain.

Therapy- “permanent” soft liner / mandibular implants.

Yearly recall for complete denture patients would provide needed interventions on a timely basis so that major problems may be avoided.

Changing dentures extensively will cause problems in any person-not just the elderly.

A more preventative approach to the lifetime service needs of complete denture patients helps reduce the negative stereotype associated with the geriatric denture patient.

Endodontics has been successfully performed on patients ranging from the age of 2-90 years .

Endodontics is far less traumatic than extraction in older patients.

If more teeth are being retained at older age, more of secondary/recurrent caries & root caries is evidenced in geriatric patients.

Etiology- gram positive bacteria- exacerbated by poor oral hygiene, salivary gland dysfunction, gingival recession(root caries)

Appearance: discolored(dark yellow to black) hard to soft lesions on coronal or root surfaces.

Increase in caries prevalence in elderly patients is mostly attributed to several risk factors such as long term hospitalization, high intake of refined CHO, lack availability of dental care & preventive services in addition to, local factors such as poor oral hygiene ,periodontal disease, gingival recession, xerostomia…..

Root surface caries increase with advancing age.

ROOT SURFACE CARIES –- Occurrence with root exposed by

periodontal infections. - Risk factors: gingival recession- decreased salivary flow- medications- cancer therapy- low socio economic

status.- existing

restorations/appliance

Pulpal calcification may interfere with location of remaining Pulpal space.

Heavily restored tooth may interfere with endodontic diagnosis & treatment.

Long standing periodontal disease may affect Pulpal status.

Attrition, abrasion., gingival recession is more prevalent.

contd…….

Medical histories tend to be more complex.Keeping the older pts informed&

knowledgeable may take longer.Elderly pts may have postural problems as

well as stamina consideration.It may have complications of dry mouth.

In the older patients ,it may take longer time for peri apical lesions to heal than in a younger pts.

Treat the elderly pts with dignity & respect.Prevention of Tooth Decay ~ Plaque control : brushing and flossing mouth rinses (chlorhexidine) ~ Use of fluorides (rinses, gels, varnishes) ~ Dietary education (avoid frequent snacks & beverages high in sugars) ~ Consider salivary substitutes for dry mouth ~ More frequent dental examinations.

Periodontal tissues reflect the health & disease of the patient.

High prevalence of periodontitis are common in geriatric age group &it deteriorates with advancing age.

Exacerbated in the elderly by diminished motor dexterity(arthritis , stroke)&poor oral hygiene

Risk factors : Inadequate plaque removal Diabetes mellitus Smoking Poor nutrition Genetics Immune status

Effective daily brushing/flossing &anti microbial mouth rinses.

Smoking cessationNutritional counsellingAnti microbial therapy- metronidazole

/clindamycinRegular dental visits…..

Pre operative care for elderly pts differ from that of younger pts . it requires knowledge's about changes associated with aging, physiology& its relation to surgical anaesthesia.

Pre operative evaluation of pt is must because of age related diseases , decreased functional activity…..

Pharmacokinetics& pharmacodynamics of drugs is also different, more over, the elderly pts use multiple medications may alter the homeostatic mechanism

RECOMMENDATIONS – There must be special emphasis on history

taking including a review of the pt drug regimen& history of cardiovascular disease.

Pt must be questioned regarding episodes of syncope, especially on awakening/ sitting up.

Background noise should be minimised. Appointments should arranged to meet the

needs of the pt . Cardiac & nephrotic pts are better seen in morning . arthritic pts are better seen in after noon.

Patient education & motivation Oral examination Nutrition counselling Teaching of tooth brushing &flossing methods Teaching of maintianing natural teeth(if exist) Teaching of care for false teeth checking of artificial dentures for proper fitting Checking of follow up of the instructions...

In most of the countries there are -extended care facility homes -old age homes -senior citizen homes - ashrams• In India , senior citizens homes are

becoming popular. beside the govt agencies ,muncipalities, social service societies& trust running these homes.

Anand nagar mavthar-vridhashram

Old age home in Hyderabad

Home for aged women

It provide dental care to home bound & institutionalised pts at their door steps.

It consist of generally one/two dental surgeon & two dental auxiliaries.

A dental health program consist of emergency program , treatment program , preventive program &program co-ordination.

Financing of oral health services for the older population differs from financing in younger pts.

Dental care , unlike medical care , is heavily financed through the private sector.

Out of pocket payment remains the dominant method of paying for dental treatment.

In 1987,only 3% of dental expenditures were paid by Medicaid &Medicare(USA)

Medicare, title 18 of the security act, is a program intended to provide health

insurance for those age of 65 the programs pays for hospital & physician services

Medicaid , title 19 of the social security act enacted in 1965 , is a joint federal state program in which the states are allowed to determine eligibility requirements & coverage.

The only effective oral health care benefit plan for the older population is one that is part of comprehensive benefit package developed with the understanding that oral health is an integral part of general health…

The aging of population& the apparent decrease in the prevalence of dental caries in children have shifted attention to the oral health needs of older adults.

The challenge of dental profession will be to develop oral health promotion & disease prevention program & treatment &financing strategies that will meet the unique needs of individuals.

With the shift of population towards older leads to a need will arise for expanded courses in internal medicine ,pharmacology, gerodontology in the dental curriculum.

In addition, the complex nature of the aging process will demand on increase in the interdisciplinary communication among dental health & health personal to optimise treatment outcomes.

Thus , oral health care should be recognised as primary health care service that is essential for general health &well being of older adults..

1.Textbook of complete denture-ARTHUR.O.RAHN2.Community dental health-ANTHONY.W.JONG3.JONG’S community dental health-

GEORGE.M.GLUCK4.Essentials of preventive dentistry-SOBEN PETER5.PARK’S textbook of preventive and social

medicine6.Moderate sedation / analgesia-MICHEAL KOST7.Clinical practice of dental hygienist-

ESTHER.M.WILKINS8.Pathways of the pulp-STEPHEN COHEN9.Textbook of preventive medicine-B.K.MAHAJAN10.Medical problems in dentistry-CRISPIAN SCULLY11.Textbook of community dentistry-SATEESH

CHANDRA