Preventive Dentistry Geriatric Dentistry Prevention Measures of Elderly Population د.عذراء مصطفى Aging is a natural process. Old age should be regarded as a normal, inevitable biological phenomenon. As a result of the advances made in medicine and public health measures in the last half of the 20 th century, there is a substantial increase in the life span of man. Elders above 65 years (old age) have health problems as a result of aging process, which calls for special consideration. Geriatric Dentistry is a science which deals with the diagnosis, management and prevention of all types of oral diseases in the elderly population. Ageing influenced by genetics, life style and environmental over the course of life span. Some body systems are more affected by this process than others. Geriatric Dentistry During the latter half of the 20th century, the age composition of the population changed dramatically, with more people living to older ages and the older population getting older. This demographic change will have a major impact on the delivery of general and oral-health care, as well as on the providers of these services. The "elderly" segment of the population is diverse and has been subdivided into the following categories: People aged 65 to 74 years are the new or young elderly who tend to be relatively healthy and active. People aged 75 to 84 years are the old or mid-old, who vary from those being healthy and active to those managing an array of chronic diseases People 85 years and older are the oldest-old, who tend to be physically more frail. This last group is the fastest-growing segment of the older adult population. Causes of increase in life expectancy Advances in medical technology and environmental and public health measures.the increase in the population 75 and 85 years and older is of particular concern to health-care providers, since this age group tends to present with the highest frequency of physical and cognitive disorders. 1
Life expectancy is the average number of years a group of individuals born during the same time period or cohort is expected to live. Between 1900 and 1997, life expectancy at birth increased from 46.3 years to 73.6 years for males, and from 48.3 to 79.4 for females Life Span is generally defined as the maximal length of life potentially possible.the age beyond which no one can expect to live. Human beings have a life span of approximately 120 years. Health Status The study of aging includes not only diseases that cause morbidity and mortality but also the conditions that cause disability and decline in independent functioning. The three leading causes of death in the elderly are: diseases of the heart, malignant neoplasm (cancer) and cerebrovascular disease (stroke) The most common chronic conditions are arthritis, hearing impairment, hypertension and heart disease. The majority of health conditions and diseases are the result of the accumulation of ones' lifestyle, genetic factors and environmental conditions. Physiologic Changes Associated with Aging The determinants of aging are complex, and include environmental exposures, genetics, lifestyle, and physiologic and psychological factors. The major results of the aging process are: The loss of elders' ability to function to capacity includes a decline in respiratory function and the inability to accommodate to temperature changes. a) a reduced physiologic reserve of many body functions (i.e., heart, lungs, kidney) b) an impaired homeostasis mechanism by which bodily activities are kept adjusted (i.e., fluid balance, temperature control and blood pressure control) c) an impaired immunonologic system, as well as related increased incidence of neoplastic and age-related autoimmune conditions Systemic condition and Oral Health Cardiovascular system The cardiovascular system of older adults tends to be more likely to develop ischemia, arrthymias, and heart failure, especially when concurrent illness is present. 2
Hearing impairment is common over the age of 60. Presbycusis is the most common type of hearing loss in older adults and is caused by both pathology and, in some cases, auditory processing Presbycusis causes gradual, progressive bilateral hearing loss, predominantly in the higher frequencies, as well as decline in speech discrimination. Both atherosclerosis and cumulative noise exposure may contribute to presbycusis. Communication with an individual affected by presbycusis is enhanced by slow, distinct vocalization at a low pitch. Shouting can actually be painful to the patient and does not improve the ability to understand what is being said. The immune system becomes less competent with age. However, the degree of deficiency is not severe enough that opportunistic infections occur commonly in the elderly population. Osteoporosis a common problem in the elderly, is an age-related disorder characterized by a decrease in bone mass and by an increased susceptibility to fractures. Losses in bone mass with advancing age are multifactorial,including inactivity, estrogen deficiency, nutritional deficiencies and age-related changes. Recent studies indicate that changes in alveolar bone as a result of osteoporosis may contribute to the progression of periodontal disease Also, a significant decrease in bone mass of the mandible may lead to fragility and increased resorption, risk of fracture, and failure of osseointegration of implants. Prevention, rather than treatment, is the key to the management of osteoporosis. Exercise, vitamins, a balanced diet, dietary calcium, and estrogen play a role in the treatment and prevention of osteoporosis. Nutrition deficiencies are common in the elderly patient anorexia and micronutrient deficiencies are common. Anorexia is multifactorial, affected by changes in taste and smell, lifestyle, physiologic, and psychological changes. Multivitamin supplementation can often improve nutritional status and immune function in this population of older adults. It is the responsibility of the dental team to be aware and to address the commonly seen age-related changes of aging. Oral-Disease Patterns This decline in edentulism appears to be the result of water fluoridation, increased public awareness of preventive approaches, improved access to services, and a decrease in early tooth loss. Although the prevalence of edentulism increases in the 3
non-institutionalized older age groups (10% of 45 to 54 years, 28.4% of 65 to 74, and 52.5% of 85+ years), these rates have steadily decreased over time. This decline in tooth loss results in more natural teeth at risk for caries (coronal, recurrent, and root) and periodontal diseases. As long as teeth are present, individuals remain at risk of dental caries. Unfortunately, many older adults do not place a priority on oral health care, and view seeing a dentist only to relieve pain and discomfort. As a result of increased deposits of secondary dentin and a reduced sensory ability, many older adults tend to seek care only when their decay is in a late stage. Barriers to Oral Health for Older Adults The many factors that are known to influence older people s utilization of dental services directly or indirectly can be divided into four main categories. 1. Illness and health related factors Oral health status. Experiencing discomfort. General ill health. Mobility, functional limitation. 2. Socio-demographic factors Place of residence. Education. Income. Age. Sex. Culture. Ethnicity. 3. Service-related factors Accessibility. Dentist behavior. Dentist attitude. Price of service Satisfaction with service. Transport. 4. Attitudinal or subjective factors. Personal beliefs. Feeling no need, perceived need. Perceived importance. Fear and anxiety. Resistance to change. Perceived financial strain. 4
Satisfaction with dental visits. Changes of tooth Structure Age changes in teeth include physiological wear with superimposed changes in morphology associated with pathology, including attrition and changes in the structure and composition of the dental hard tissues. Bone As physical activity diminishes in the later years, so too does the demand for new bone formation. Resorption exceeds deposition, resulting in a net loss of bone. By the time old age is reached, atrophy has resulted from slow resorption with very little remodeling. Not only is there a generalized decline in bone volume, but the composition of bone gradually alters also, resulting in reduced resilience and increased brittleness and fragility. Alveolar bone is one of the first bones to be affected by loss of mass. The periosteal and periodontal surfaces of alveolar bone become less resistant to harmful local oral trauma, inflammation, or disease.this is a major factor contributing to periodontal disease, loss of teeth, and, in the edentulous patient, inability to obtain adequate support and stability for dentures. In both the maxilla and the mandible, the amount, extent, and uniformity of the bone loss differ with varying etiologies and health status. It is now recognized that alveolar bone or residual ridge resorption is confounded by such factors as age, sex, race, and health status of the patient when the teeth are extracted; the tooth extraction technique; the diet of the patient; the presence of local factors; and the frequency of denture use Periodontium Epidemiological studies show that the prevalence and severity of periodontal disease increases with age This is most likely the result of repeated episodes of active destruction occurring over time rather than an intrinsic change associated with the ageing process itself. Periodontal changes attributable solely to advancing age are not sufficient to account for tooth loss, especially in a healthy adult. Gingival recession has been considered as an age change, but it is now known to be part of the clinical spectrum of periodontitis in which plaque is the main aetiological agent. There is no evidence that the elderly are particularly susceptible to periodontal disease, although confounding variables such as systemic diseases, reduced manual dexterity, oral factors and medications have an adverse effect on periodontal health. Enamel: Enamel The enamel tends to become more brittle and susceptible to chipping, cracking and fracture. It also becomes less permeable with age, reflecting the ionic 5
exchange which occurs between enamel and the oral environment throughout life. Darkening of the enamel and staining has also been described and may be due to absorption of organic materials. Dentino-pulpal complex: The two main age-related changes in dentine are continued formation of secondary dentine, resulting in reduction in size and in some cases obliteration of the pulp chamber, and dentinal sclerosis associated with the continued production of peritubular dentine. Both of these processes are also associated with caries and tooth wear. Dentine sclerosis may affect the use of adhesive systems with dentine. Sclerosis of radicular dentine tends to make the roots brittle and they may fracture during extraction. It is also associated with increased translucency of the root. This starts at the apex in the peripheral dentine just beneath the cementum and extends inwards and coronally with increasing age.as the pulp ages, it becomes less vascular, less cellular and more fibrotic, resulting in a reduced response to injury and decreased healing potential. There is also a reduced nerve supply which, together with a greater thickness of dentine, makes vitality testing more difficult. The tissue is tougher and may not be penetrated as easily with files. The risk this presents is that entry, even to a seemingly large pulp, results in compaction of pulp tissue to form a dense collagenous plug that is as impregnable as any calcified deposit. There is special merit in the elderly of removing pulp tissue with barbed broaches and the routine use of lubricants to allow instruments to glide through tissue rather than compacting it. Cementum Cementum continues to be formed throughout life, especially in the apical half of the root, resulting in a gradual increase in thickness to compensate for interproximal and occlusal attrition and in response to trauma, caries and periodontal disease. The amount of secondary cementum at the apex of a tooth is a factor that can be taken into account in radiographic working length estimation in endodontics, and in forensic dentistry in age estimation. Increased amounts of cementum along with secondary and reparative dentine diminish tooth sensitivity and reduce perception to painful stimuli Salivary Glands In early reports, decreased salivary flow was generally considered to be concomitant with increased age. More recent evidence indicates that the diminished salivary flow often noted in studies of elderly subjects is caused by pathologic conditions or pharmacologic effects of medications, rather than aging. Because diminished salivary flow does not occur in healthy, nonmedicated individuals, these findings emphasize that the elderly person might be susceptible to situations and therapies that result in a reduction of saliva availability 6
Oral Soft tissues Mucus membrane generally atrophy with age,changes over time including mucosal trauma, mucosal diseases, and salivary gland hypofunction can alter the clinical appearance and character of the oral tissues in older patients.the stratified squamous epithelium becomes thinner, loses elasticity, and atrophies with age. Increase keratinization of cheek and lips, palate less keratinized. Thinner oral mucosa is more easily damages and penetrated by some substances in food, which may give rise to etching or burning. A declining immunological responsiveness further increases the susceptibility to infection and trauma. An increased incidence of oral and systemic disorders, along with increased use of medications, may lead to oral mucosal disorders in elderly persons. Elderly patients may develop vesiculobullous, desquamative, ulcerative, lichenoid and infectious lesions of the oral cavity Common Oral Diseases Affecting Elderly Root Caries The nature of the root caries appear to be more severe in males and most likely to affect the molar regions. Risk factors: gingival recession, physical disabilities, decreased salivary flow, low SES. Other risk factors influencing the higher incidence of root caries among the older patient include: abrasion at the cementoenamel junction, fixed bridgework, removable partial dentures, long-term institutionalization, soft diets consisting of refined sugars and sticky, fermentable carbohydrates. Root caries prevention and therapy include: application of topical fluoride, dietary counseling, plaque control prevention of gingival recession. Restorative dental treatment 1. Shallow root caries 2. Smoothing the compromised root surface, 3. Improving access to oral hygiene, 4. Applying a topical fluoride 7
Deeper compromised surfaces need to be cleaned out and restored with a restorable dental material.there are many types of materials currently used to restore carious lesions on the root surfaces: amalgam; composite resins; auto-cured and dual-cured glass ionomer cements. Because both coronal and root caries are plaque-related diseases, measures that limit or inhibit plaque formation should be effective in prevention. Mechanical oral hygiene techniques and chemical antimicrobial agents such as chlorhexidine reduce bacterial flora and substrate. Even dietary modification decreases the amount of substrate, acid production, and decalcification of the teeth.individuals eliminate or reduce the intake of foods that are soft, sticky, retentive, or high in sugar and if they chew firm foods. Local Anesthesia Most restorative procedures can be done with no discomfort in the absence of local anesthetic or with minimal infiltration of anesthetic, Excluding the anesthetic is especially advantageous for patients with neurological diseases. Periodontal disease The rate of periodontal disease progression partly related to the mass and composition of the oral microbiota and the host's ability to respond to this microbial population, research has focused on new diagnostic and treatment modalities, such as DNA diagnostic probes, enzymatic assays and bacterial analyses, the use of lasers, new pharmaceutical preparations earlier identification of periodontal disease and risk factors are done which result in early treatment to help reduce disease progression and its subsequent loss of teeth. Tooth Loss and Edentulousness Tooth loss is an irreversible, cumulative process that is no longer considered a natural consequence of aging. Instead, it is known to be the ultimate sequelae of the two most common dental diseases, dental caries and periodontal disease. Nevertheless, tooth loss increases in frequency with age. By age 65 years, approximately 40% of Americans have lost all their teeth; another 20% have lost more than half their teeth. recent studies of tooth loss in adult populations indicate that caries is most often the cause for tooth extractions. Xerostomia 8
Various factors can play a role in the patient s perception of xerostomia, e.g. medications, surgical intervention, chemotherapy and radiotherapy treatment of cancer intensifies changes in salivary function. Other common factors including: aging, diabetes, mouth breathing, smoking, and Sjögren s syndrome aggravate the condition. Commonly administered medications associated with xerostomia include: anticholinergics, antihistamines, antihypertensives, antiparkinsonians, diuretics, narcotic analgesics,sedatives, and tranquilizers,saliva performs a variety of functions in maintaining dental health. They include: Antibacterial and microbial action. Assistance in swallowing. Buffering of acids produced by oral bacteria. Lubrication of tissues and aids in the breakdown of food. Remineralization of tooth surfaces. Treatment use of artificial saliva substitutes, and chewing gum,toothpaste formulated to treat xerostomia. In the more severe cases, such as patients receiving radiotherapy for cancer of the head and neck,or patients with Sjögren s syndrome, a systemic cholinergic stimulant may be administered if no contraindications exist. In all cases, good hydration is essential with water being the drink of choice. Caffeine should be avoided as it is dehydrating, as should sugared candies or cough drops, which aid in root caries. Fluoride treatments Mouth gel and rinses 0.02% sodium fluoride (fortnight) 0.4% stannous fluoride gel (daily) 0.05% sodium fluoride (daily) For patients with extensive dental work or for those with a higher decay rate, over the counter and prescription mouth rinses, gels, or toothpastes may be indicated fluoride in-office delivery systems considered safe and effective. Multiple surface root caries can be managed as an infection using a combination 9
of treatment. Teeth Wear An aging population with longer retention of teeth is at increased risk for both abrasion and erosion.the incidence of both of these conditions increases with age simply because any damage to the teeth is cumulative. In patients with xerostomia, the diminution in the mucin level of the oral cavity provides less lubrication and protection, posing an even greater risk for abrasion and erosion. A major etiologic factor of abrasion is overzealous and improper toothbrushing with a hard bristle brush or an abrasive dentifrice. Treatment : Occlusal splint, Psychotropic medication or muscle relaxant, Psychological counselling. Oral Cancer person 65yrs of age and older are 7 times more likely to be diagnosed with oral cancer than under 65yrs of age. Area to be concerned: Tongue, floor of mouth, lower lip. Compromise the most common locations for oral cancers. Visit the dentist every six months. At each visit: 1- receive a comprehensive intra and extra oral examination, 2- and a thorough questioning regarding changes in oral conditions and habits. 3- Radiography should be taken periodically. 4- When redness, irritation, bleeding, soreness, sensitivity to temperature changes and/or chewing is present to such a degree that it interferes with daily routine or persists for more than 2 weeks, the problem should be investigated by a dentist. With early diagnosis, the prognosis is much improved. 10