Transcript geriatric dentistry - public health dentistry

GERIATRIC DENTISTRY
Submitted by: jumana jabeen.
Guided by:
Dr.Mehmood muthedath.
Dr.Aseela ahamed
 INTRODUCTION
 DEFINITION
 SIZE OF THE PROBLEM
 CATEGORIES OF GERIATRIC PATIENT
 LEVEL OF DEPENDENCE
 CHANGES IN THE GERIATRIC PATIENT
 INTRA ORAL CHANGES
 COMMON MEDICAL PROBLEMS
 COMMON DENTAL PROBLEMS
 GERIATRICS IN PROSTHODONTICS
 GERIATRIC IN ENDODONTICS
 GERIATRICS IN PERIODONTICS
 GERIATRIC ANASTHESIA
 TREATMENT PLANNING
 IMPORTANT DUTIES IN THE TREATMENT OF ELDERLY
PATIENTS
 EXTENDED CARE FACILITIES
 MOBILE DENTAL CLINIC
 FINANCING 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.
 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.
IGNATZ.L.NASCHER
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.
GERODONTOLOGY
Defined as the multidisciplinary
study of the process of aging in
the oro-facial area and its
relation to the surroundings
Why it is imp?....



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.
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 changes
Pathological changes
Psychological changes
Local factors
 Loss of elasticity of skin
 Wrinkled, dry thin skin
 Diminution of the senses
 Loss of hair
 Thin, abraded oral mucosa
 Dry mouth
 Neuromial changes
 Loss of appetite
 Malnutrition
 Loss of taste sensation……
Acute inflammatory infections are less
common
Hypertensive vascular disease
Heart disease
Diabetes mellitus
Arteriosclerosis
Neoplasm
Cerebral hemorrhage
Disease of bone & joints
Nephritis……
Mental changes –
Impaired memory, rigidity of outlook & dislike
of changes….
Emotional disordersResults 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 lips
 Enlargement 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 .
Causecandidiasis,
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.
GINGIVA
 Most 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
 Edentulousness
 Dental caries (root caries)
 Periodontal diseases
 Severe attrition ,abrasion ,erosion …
 Oral mucosal lesions- premalignant lesions.
 Xerostomia
 Altered sensory function(taste sensation)
 Ulcerative lesions
 Oral 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 & glassy
Pulp 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: can injure the
major and minor salivary glands
which may lead to atrophy of the
secretary components and results in
varying degrees of temporary or
permanent xerostomia.

Toxic substances in
chemotherapeutic agents.
 Diabetes mellitus: Patients with poor
glycemic control, are more likely to complain
of xerostomia and may have decreased
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
2.
3.
4.
5.
Dry, burning mouth and throat.
Dry, cracking lips, especially in the
corners. The cracks may be tender and
bleed.
Problems with denture wearing.
Difficulty with speech due to soreness.
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 long
Let ice melt in the mouth
Restrict caffeine intake
Avoid mouth rinses containing alcohol
Coat lips with lubricant.
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.
Commercial oral moisturizing gels (OTC) includes:
Oral Balance.
XERO-Lube
Salivart
Moi-Stir Orex
Optimoist
 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 illfitting 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 cessation
Nutritional counselling
Anti microbial therapy- metronidazole /clindamycin
Regular 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
Home for aged women
Old age home in Hyderabad
 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.RAHN
2.Community dental health-ANTHONY.W.JONG
3.JONG’S community dental health-GEORGE.M.GLUCK
4.Essentials of preventive dentistry-SOBEN PETER
5.PARK’S textbook of preventive and social medicine
6.Moderate sedation / analgesia-MICHEAL KOST
7.Clinical practice of dental hygienist-ESTHER.M.WILKINS
8.Pathways of the pulp-STEPHEN COHEN
9.Textbook of preventive medicine-B.K.MAHAJAN
10.Medical problems in dentistry-CRISPIAN SCULLY
11.Textbook of community dentistry-SATEESH CHANDRA