MANAGEMENT OF GERIATRIC PATIENTS

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.

Exposed dentin and sclerosed pulpal chambers due dental attrition.

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.

Taste and Smell

No

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.

Mastication & Swallowing

Reduced

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).

COMMON ORAL DISEASES AND CONDITIONS IN ELDERLY

Two major dental problems in elderly patients:

Caries Periodontal

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.

Summary of Oral Disorders in Elderly Persons

Oral Tissue or Function
Oral mucosa

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

Oral and pharyngeal mucosa; dentition

Dentition

Periodontium

Salivary glands

Summary of Oral Disorders in Elderly Persons

Oral Tissue or Function
Chemosensory function Swallowing Edentulousness

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

and pain control

Congestive
stabile

heart failure

cardiopulmonary status and weight

Hypertension
Vital

signs check at each visit Check on adherence to dosage schedule

Valvular

damage, Heart murmur

prophylaxis

Antibiotic

Stroke
Short

AM Appointments Determine bleeding time (Coumadin) Minimum Vasoconstrictor

Arthritis
long

appointments may be uncomfortable aspirin usage prosthetic joint considerations

Steroid therapy
Appropriate

antimicrobial medications Steroid supplementation for dental procedures

Pulmonary Disease - COPD

Semi-upright

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

prevalence of oral health problems, especially among uncontrolled diabetics

candidiasis

unexplained

dry mouth multiple caries periodontal disease delayed wound healing impaired ability to resist infections

Cancer and cancer therapy

Oral

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

Risk of Adverse or Suboptimal Dental Outcomes Due to Noncompliance

Medications Oral

Health Instructions Follow-up Appointments

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

to accommodate patient limitations

Prosthodontic Considerations

Time and physical constraints of patients Functional status of patient

oral

hygiene ability to remove appliances medications

Quality of life issues

social

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

Status Dependent NOT Age Dependent

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

PREVENTIVE AND MAINTENANCE CONSIDERATIONS

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.