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GERIATRIC DENTISTRY
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.
GERIATRIC PATIENT
Ageing is the accumulation of changes over time. Ageing in humans is a multidimensional process including physical and psychosocial changes. The elderly are at greater risk for developing oral disease since gains in longevity result in more medically compromising conditions or systemic disease with oral manifestations.
GERIATRIC PATIENT
Most oral changes experienced by the elderly are not the result of ageing process itself, but are the consequences of systemic diseases, pharmacotherapy, functional disabilities, and cognitive impairment. The management of the oral problems in elderly patients does not depend on the development of new technical skills, but rather on the knowledge of biological, psychological and social aspects of age-related changes and disease-related changes; and the role of an interdisciplinary team
PHYSIOLOGICAL CHANGES
Lips
It showed that the smile gets wider transversely & narrower vertically with ageing. An increase of the orbicularis oris muscle angle defining the vermilion border in the old lip was observed. The lip height decreases and intercommissural distance increases with ageing
Lips
Naso-labial groove deepens, which produce a sagging look to the middle third of the face. atrophy at subcutaneous end buccal pads of fat hollows the cheeks due to loss of fat support for the pre symphysial pad of fat disappears and upper lip drops over maxillary teeth
Oral Mucosa
Histologically, there is evidence of epithelial thinning, less-prominent rete pegs, decreased cellular proliferation, loss of submucosal elastin and fat, and increased fibrotic connective tissues with degenerative alteration in collagen.
Clinically, these structural changes may be accompanied by dry thin smooth mucosal surfaces, with loss of elasticity and stippling.
Oral Mucosa
Wound healing and regeneration of tissue may be delayed in elderly individuals, yet older age plays only a minor role in the response of oral mucosa to injury.
Dentition
Changes in the dentition due to aging can be attributed to normal physiologic processes and to pathologic changes in response Losses of tooth translucency and surface details (e.g. perikymata and imbrication lines) are common changes during aging. External tooth changes include discoloration (to a yellowish brown color) and loss of enamel due to attrition ,abrasion, and erosion to functional and environmental stresses. Severe enamel wear will ultimately expose underlying dentin, which produces sclerotic and secondary dentin in response to trauma, caries, and masticatory forces.
Over time, Dentin undergoes a reduction in thermal, osmotic, and electrical sensitivity and pain perception, and its susceptibility to caries decreases. The dental pulp becomes smaller because of secondary dentin and pulp stone formation, and sometimes root canals become totally sclerosed Age-related pulpal changes diminish tooth sensitivity and pain perception, reduce responsiveness to pulp testing, and usually
Periodontium
The clinical appearance of periodontal tissues in an elderly individual reflects age-related changes and an accumulation of previous disease experiences and trauma over time. With increased age, gingival recession and loss of periodontal attachment and alveolar bone are essentially universal
However, changes in the periodontium that are attribable solely to age are not sufficient to lead to tooth loss, especially in a healthy adult Age-related immunologic changes and histologic alterations in periodontal tissues could alter the host response to dental plaque microorganisms, affecting the patients ability to respond to periodontal treatment.
Salivary Glands
Significant changes in salivary flow are not observed in healthy elderly persons. Histologically, there are age-related alterations in the cellular makeup of salivary glands, with an increase in connective tissue and adipose deposition and a decrease in acinar cells. This loss of fluid-producing acinar cells increases the susceptibility of an older individual to salivary perturbations such as those caused by medications with anticholinergic side effects.
change in number of taste buds with age No difference in salt discrimination Acuity in identifying sweet taste diminishes Slight decrement in ability to taste bitter No loss of sour taste identification
Multiple taste buds that are located on the tongue, palate, and oropharynx, help produce a strong resistance to taste changes. Nevertheless, medications, chemo and radiotherapy, trauma, surgery, and neurologic events can cause temporary or permanent taste changes in an older adult. Therefore, age and oral and systemic disorders and their treatments can adversely affect smell and taste function, which could place an older adult at risk for developing nutritional deficits and could adversely affect his or her quality of life.
chewing effectiveness Loss of opposing dentition changes in muscle strength and flexibility
The change in tongue function is gender and age dependent and follows the same trends as change in hand function with ageing leading to decrease in strength in older individuals and females It showed that swallowing pressures decline with age leading older people to work harder to produce adequate swallowing pressure and increasing the risk of developing dysphagia
In addition, the velocity of tongue upward and downward movements were statistically decreased in the elderly revealing a different oral motor behavior in the elderly compared to young adults. Conversely, systemic and oral disorders have an adverse effect on swallowing, which could place an older person at risk of choking or aspiration
Oral-Facial Pain
The presence of oral-facial pain in an older adult should not be attributed solely to the aging process. However, oral, systemic, psychological, and behavioral problems are more likely to be major contributors to oral-facial pain. Epidemiologic surveys suggest that both acute pain and chronic oral-facial pain are significant problems among elderly people.
The most prevalent pain in the oral-facial complex involves the teeth and periodontium. Intraoral pain disorders affect teeth (eg, caries, root sensitivity), periodontium (eg, periodontal abscess), oral mucosa (eg, neoplasia, mucosal infection), and bone (eg, trauma, infection) and can also be idiopathic (eg, burning mouth syndrome).
disease
Caries
As
gingival recession increases, resulting in dental root surface exposure to the oral environment, the prevalence of root surface caries increases in the dentate elderly population. In addition, older persons frequently suffer from recurrent or secondary coronal caries. due to defective restorations, fractured fillings, poor oral
Periodontal disease
Deep periodontal pocketing, irregular dental visits, smoking, psychosocial stress, and poor socioeconomic status all are predictors of periodontal attachment loss in older patients. Dental plaque, gingival bleeding, and calculus accumulations develop as a result of softer diets, reduced oral motor activity, and salivary gland hypofunction.
Disorders
Cancers Vesiculobullous diseases Ulcerative diseases Viral diseases Fungal diseases Bacterial diseases Root surface caries Coronal caries Attrition Gingivitis Periodontitis Abscesses Obstructions Bacterial infections Hypofunction Cancers
Dentition
Periodontium
Salivary glands
Disorders
Taste dysfunction Smell dysfunction Delayed swallowing Aspiration Osteoporosis Atrophic mandible Denture difficulties Pain over the mental foramen Atypical facial pain Burning mouth syndrome Postherpetic neuralgia Trigeminal neuralgia
Pain sensation
RISK MANAGEMENT
Cardiovascular disease
Angina
anxiety
Congestive
stabile
heart failure
Hypertension
Vital
Antibiotic
Stroke
Short
Arthritis
long
Steroid therapy
Appropriate
Position Narcotics > Pulmonary Depression Nitrous Oxide Contraindicated Avoid Bilateral Mandibular or Palatal Blocks Avoid Use of Rubber Dam in Severe Disease
Radiation sequelae
Regular fluoride use Salivary substitutes and stimulants Aggressive oral hygiene and recall Pain management
Renal Disease
Renal Insufficiency Is Asymptomatic Renal Impairment May Alter Drug Clearance Hemodialysis (> 4 hours post) and Renal Transplant Patient's Should Be Managed in Close Cooperation With Physician
Diabetes Mellitus
high
unexplained
dry mouth multiple caries periodontal disease delayed wound healing impaired ability to resist infections
Consequences of Radiation and Chemotherapy Weight Loss and Malnutrition Pain control
Coagulation disorders
Alter
anticoagulation therapy Limit dentoalveolar surgery Use topical anticoagulation methods Prescription
Dementia
Increased
Immunosuppression
Appropriate
antimicrobial medications
Increased prevalence of functional status impairments and chronic disease in geriatric populations mandates modification in History taking and attention to risk assessment to decrease the likelihood of adverse events from dental intervention
TREATMENT CONSIDERATIONS
Endodontic Considerations
Time and physical constraints of patients Longer/more appointments due to reasons identified
Adjust
Prosthodontic Considerations
interaction nutrition/mastication
Prosthodontic Considerations
Regular assessment of dentures, denturebearing ridges, and all mucosal surfaces is required to reduce the risk of developing denture stomatitis, traumatic ulcerations, angular cheilitis, hyperplastic or granulomatous issue reactions, and (ultimately) alveolar atrophy. Denture adjustments and/or relines are may be necessary at regular intervals for the lifetime of the patient.
Surgery Considerations
Well Planned & Managed Consult with physician Check for Drugs Interactions &Metabolism Multiple extractions should be performed over several visits Implants
Medical
Periodontal Considerations
Advanced age is not a contraindication for periodontal surgery although certain systemic conditions (eg, congestive heart disease, diabetes) and medications (eg, anticoagulants, corticosteroids) may complicate surgical For most elderly patients, a nonsurgical approach with scaling and root planing and meticulous daily oral hygiene is indicated.
Periodontal Considerations
Systemic antimicrobial therapy (eg, metronidazole, tetracycline, clindamycin)may be helpful, but the practitioner must ensure that these medications are not contraindicated (eg, by renal, liver, or gastrointestinal disorders). If the periodontal disease is believed to arise from the patients medical conditions and their treatment, then a systemic approach to oral health management is required.
Periodontal Considerations
Finally, periodontal therapy often requires concurrent dental treatment to eliminate comorbid factors (defective restorations, poorly fitting prostheses, caries) commonly found in older patients.
Restorative Considerations
Restorative dental procedures for the elderly patient should be conservative. The treatment of coronal and root surface dental caries has been facilitated by the development and perfection of numerous restorative materials. Enamel- and dentin-bonding techniques are helpful in restoring destroyed tooth morphology due to caries, abrasion, attrition, and erosion.
Glass Ionomer cements (G.I.) is the restorative material of choice for elderly patients suffering of hypo-salivation, however (GI) lacks color stability Cosmetic dentistry has also made considerable advances that have implications or older adults. Conservative and esthetic restorative procedures have the potential to reverse the signs of dental aging, thereby making patients appear
Prevention of oral disease is an ongoing process throughout life Electric or battery operated tooth brush facilitate oral hygiene practice by elderly with limited manual dexterity Care givers whether they are family members or nursing home staff must be motivated to appreciate the importance of oral care to Oral Health and systemic Health
Fluoride treatment, such as home use of 0.4% stannous fluoride applied in a custom tray is recommended for patients with high levels of caries activity Chlorhexidine (Peridex), tetracycline and metronidazole are effective antimicrobials in the elderly.