This Paper is about geriatric dentological Care in Restorative and Endodontics. Advances in medicine have extended the life span of our older population, it is very important for us to the evoke words of President John F. Kennedy, “it is not enough for a great nation to have added new years to life. Our objective must add new life to those years.” Seniors can expect to live longer today than ever before.
The problem of oral diseases tends to increase with age. With the evolution and developments in science and understanding of geriatric dentistry, early prevention and treatment will reduce oral disease and aid in the management of systemic diseases. With increase in number of such patients in dentistry has resulted in the preferred use of alternatives like endodontics than extractions to improve the longevity of the natural dentition
INDEX
CONTENTS
1 Introduction
2 Aging of Dental society
3 Classification
4 Biologic considerations in geriatric patients
a) Local
- Age changes-dental tissues
b) Systemic
- Physiological age changes
- Medical history- chronic diseases
- Dental Treatment considerations
- Possible drug interactions
5 Treatment Aspects for geriatric patients
a) Examination and Diagnosis
- Chief Complaint
- Medical history
- Dental history
- Diagnostic procedure
- Radiographic findings
b) Clinical decision making – Treatment planning
- Prognosis
- Consent form
c) Treating Xerostomia
d) Restoring Carious lesions
- Root caries
e) Aesthetic aspects
- Bleaching
- Veneering
f) Endodontic management of the geriatric patients
- Isolation
- Access opening
- Obturation
g) Considerations in Surgical therapy
h) Success and Failures in geriatric endodontics
6 Prevention
7 Conclusion
8 Bibliography
INTRODUCTION
‘ Its paradoxical, that the idea of living a long life appeals to everyone, but the idea of getting old doesn’t appeal to anyone’ - Andy Rooney
Geriatrics is the branch of medicine that concentrates on health promotion, prevention and treatment of disease and disability in later life. The term itself can be distinguished from gerontology, which is the study of the aging process itself.1
The term comes from the Greek geron meaning ‘old man’ and iatros meaning ‘healer’ and was proposed in 1909 by Dr Ignatz Leo Nascher.1
Good oral health is gradually recognized today as an integral part of the total healthcare picture that helps ensure well-being. Poor oral health is reflected as risk factor for poor overall health.
Advances in medicine have extended the life span of our older population, it is very important for us to the evoke words of President John F. Kennedy, “it is not enough for a great nation to have added new years to life. Our objective must add new life to those years.” Seniors can expect to live longer today than ever before.
The problem of oral diseases tends to increase with age. With the evolution and developments in science and understanding of geriatric dentistry, early prevention and treatment will reduce oral disease and aid in the management of systemic diseases. With increase in number of such patients in dentistry has resulted in the preferred use of alternatives like endodontics than extractions to improve the longevity of the natural dentition.1,2
Defining old age
There is no one accepted definition or threshold for old age, and yet there are a multitude of terms describing this life stage and progressions within it. Terms such as old, elderly, and senior, are often used to refer social constructs of chronologic age that mark changes in an individual’s participation within their sociocultural context or physical or functional capabilities. Other terms such as successful aging, frail elderly, and oldest old refer to loosely defined phases of the older age life stage with unique considerations.3
Chronological age refers to age as measured by calendar time since birth, while functional age or physiological age is based on performance capacities.
Gerontologists have divided the study of the older population into several categories based on chronological age:
- New-old (55-64 years)
- Young-old (65-74 years)
- Middle-old (75-84 years)
- Old-old (85-plus years)
The functional ability should be the standard that differentiates an individual’s capability to maintain activity.4
The dental needs of the elderly are also growing and changing. The management of old patients requires not only a consideration of the medical and dental aspects of aging, but also many other factors such as sensory function, socialization, and independent living. Many problems may interfere with providing older patients with dental care, including heightened dental complexity and limited finances. These difficulties can be overcome in the dental profession by education, clinical programs, research agendas, and legislative advocacy.
Diagnosis and treatment planning for the elderly patient in addition to the obvious dental issues must include considerations of the biological, psychological, social and economic status of the elderly patients.5
AGING OF DENTAL SOCIETY
Although the biology of aging is immutable, the threshold at which we decide an individual has reached old age varies substantially across countries and cultures. In most developed countries, 60 to 65 years, the age of retirement or pension benefits, has become synonymous with the onset of old age or senior status. In developing countries, the transition to older age may be the attainment of social roles assigned to older individuals or the loss of roles because of loss of physical of functional limitations. The United Nations agreed that the threshold for older age is 60 years; however, variation in disease, socioeconomic conditions, and access to basic needs may substantially influence the equivalency of age groups across various populations.3
The geriatric population is the most rapidly growing segment of the general population, a fact that will have dramatic implications for systemic and oral health in the future. The elderly population is expected to reach 20% by the year 2030 from just 5% in 1950. On the basis of mortality, the average median age of death is 80 years and 15% of population survives to age 100 years7.
Demographic changes associated with increase life expectancy will present new challenges and responsibilities for oral health provides. The most common causes of chronic illness and diseases are of the heart, cancer, cerebrovascular and pulmonary diseases. The most common chronic diseases in elderly people are arthritis, hypertension, heart disease, diabetes mellitus etc. All of these acute and chronic conditions have potential oral sequelae, in the old medically compromised patients. Additionally, the treatment of these diseases with medications, chemotherapy and radiotherapy has implications for the maintenance of oral health. Chronic impairments like hearing, visual, orthopedic, speech disorders are also common.
Not just that, oral cavity can give us lot of sign of systemic conditions which otherwise aren’t detected or surfaced yet.
The new elderly are healthier, better educated, have greater economic security, have greater expectations, are concerned about the quality of life and esthetics, they can be expected to retain more of their natural dentition, which can result in a wide range of oral problems demanding clinician’s attention. In addition, as medical care protracts life, practitioners must deal with increasing oral sequelae of systemic disease and pharmacotherapy.
India is in a state of demographic transition. The life expectancy at birth has increased; it was 62 years in 2004.3,6 At present the geriatric population (people >60 years of age) of India is 7.7% of the total population, i.e. 77 million. The UN Population Division estimates that by 2050 the geriatric population will double in Africa and triple in Asia. It has been estimated that one-sixth of the total world population of the elderly now lives in the developing countries of Southeast Asia6.
A few unique facts regarding the elderly population in India include the following6:
- The rate of growth of the elderly population is faster than that of the general population.
- There is a larger percentage of women among the elderly (52% of the >60 years and >55% of the >80 years age groups).
- Eighty per cent of the elderly population resides in bucolic areas.
- Nine per cent of the elderly live alone or with persons other than their immediate family members.
- Nearly 75% of the elderly are economically reliant on, with little difference between the urban and rural elderly.
- Three-fourths of the dependent elderly population is braced by their own family members.
- Thirty per cent of the elderly are below the poverty line. Only 53.5% of the urban elderly and 37% of the rural elderly possess some kind of financial assets.
Only 28% of the elderly population is literate (low compared with the national average).6
Age, ability to cooperate with dental treatment, and type of residence are important considerations in identifying preventive and treatment strategies. Future dental facilities for older patients (including root canal procedures) are expected to be of two general types:
1. Services for relatively healthy older adults who are functionally independent
2. Services for older patients with complex conditions and problems who are functionally dependent.
The second group will require care from clinicians who have advanced training in geriatric dentistry. This age group is being targeted in dental education programs and advanced training through improved curriculums, research, and publications on aging. The National Institute on Aging has stated that all dental professionals should receive education in the treatment of older adults as part of their basic professional education.7
CLASSIFICATION
A. Gerontologists divide the geriatric population into three age groups8
- Young old (65-74 years)
- Old (75-84 years)
- Old-old (85 years and above)
B. Depending on the degree of disability, the aged have also been classified into four categories as (according to D.C.N.A.)8
- Well elderly (One or two minor chronic medical conditions; independent
- Frail elderly (Simultaneous minor and major chronic, debilitating medical conditions, with drugs; self- sufficient living with support, a minority institutionalized)
- Functionally dependent elderly (same as category Ⅱ, but patient is incapacitated to the extend that independence is not possible; homebound or institutionalized)
- Severely disabled, medically compromised elderly (Health status depreciated to the extent of requiring steady maintenance; sanatorium or skilled nursing facility).
C. Classification by Sheldon Winkler 8
- Hard Elderly: Excellent physical and psychological condition
- Senile Elderly (Senile Aged Syndrome): Disabled physically and emotionally and may be described as handicapped, chronically ill, disabled and truly aged.
BIOLOGIC CONSIDERATIONS IN GERIATRIC PATIENTS
LOCAL CONSIDERSATION
AGE CHANGES-DENTAL TISSUES
1. Bone
Increasing age is associated with progressive reduction in bone mass resulting in osteoporosis. Age related osteoporosis is common in edentulous patients, and play a role in atrophy of alveolar and possibly basal bone, although no clear relationship has been established. Atrophy of alveolar bone is related mainly to tooth loss (Figure 1). Its extent of resorption increases with age resulting, in the absence of dentition, in loss of facial height with upwards and forwards positioning of the mandible. Loss of alveolar bone is more extensive and occurs more rapidly in the mandible than in the maxilla.
Levels of the cyclo-oxygenase 2 (COX 2) enzyme, which plays an essential role in bone repair, decline dramatically with ageing. This may explain the delayed bone healing that occurs in older patients. Cons endo related, surgery and even implant, hemisection etc Research is now being conducted to stimulate activity of the COX 2 enzyme and subsequent bone healing.8
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Figure 1. Extent of alveolar bone height following loss of lower teeth.9
2. Temporomandibular Joint (TMJ)
TMJ is difficult to distinguish changes due to ageing and from those related to osteoarthrosis. Excluding those changes due to osteoarthrosis, the main age changes are related to remodeling of the articular surfaces and disc in response to functional changes following tooth loss. Remodeling may result in disc displacement, particularly anterior displacement. The retrodiscal tissues may show adaptive changes associated with reduced cellularity and vascularity, and increased density of collagen, and may eventually function as an articular disc. However, in some cases the displacement may lead to perforation of the disc, particularly of its posterior attachment, resulting in progressive joint damage.9
3. Changes in Salivary Glands and Salivary Secretion
The reduced function of salivary gland is commonly associated with aging. The implications of disordered salivary gland maintenance of oral health. The presence of saliva protects the oral cavity the upper airway and digestive tract and facilitates numerous sensorimotor phenomena. The absence of saliva thus has many deleterious consequences to the host.
With advancing age, the salivary glands are known to undergo quantitative and qualitative histologic change. There is an atrophy of acinar tissue, a proliferation of ductal elements and some degenerative changes in the major salivary glands. These alterations tend to occur linearly with increasing age. Minor salivary glands also undergo similar degenerative changes with advancing age. Thus, there is a normal, uniform decrease in the acinar content of salivary gland tissue accompanying the aging process.
However, it is difficult to make a general decision about age-related status of fluid output from salivary glands. It appears that decreased salivary flow does not uniformly accompany the aging in healthy persons. These functional observations contrast with morphologic changes seen in aging salivary glands. One explanation that has been hypothesized to account for this is that salivary glands possess a functional reserve capacity, aiding the glands to maintain a constant fluid output throughout the human adult life span.
Chief problems associated with are mouth dryness and dental caries have been endorsed to the reduced salivary flow.10,11
4. In Oral Mucous Membrane
The oral mucosa performs essential protective functions that soundly affect the general health and well-being of the host.
A decline in protective barrier function of the oral mucosa could expose the aging host to myriads of pathogens and chemicals that enter the oral cavity during daily activities.
Both histologic layers of the oral mucosa, the epithelium, and connective tissue, have important defensive functions. A stratified epithelium, containing closely apposed, attached cells, and constitutes a physical barrier that interferes with the entry of toxic substances and microorganism. Mucosal epithelial cells also synthesize several substances that are critical for maintenance of the mucosal surface, such as keratin and laminin.
Oral mucosal surfaces also possess a protective self-cleansing mechanism provided by the natural turnover of the epithelial cells.
Earlier studies report that the oral mucosa becomes gradually thin, smooth with age and that it attains satin like oedematous appearance with loss of elasticity and stippling. The tongue in particular is reported to show marked clinical changes and to become smoother with loss of filiform papillae. With age, there is a tendency for development of sublingual varices and an increasing susceptibility to various pathological conditions such as Candida infections and a decreased rate of wound healing.
An additional complication in assessing oral mucosal status in older persons is the use of prosthetic appliances, which have significant potential to alter mucosal integrity if not maintained properly.10
5. In Nerves and Musculature
Muscle function is dependent on the performance of the nervous system and both exhibit independent age-related changes. Nerve cell loss is universal in old age and is exhibited in the brain and spinal cord. There are also age-related changes in neurotransmitters, resulting in motor dysfunction. Peripheral nerve function declines with age as there is a reduction in conduction velocity, increased latencies in multi-synaptic pathways, decreased conduction at neuromuscular junctions and loss of receptors.12
Sustained muscle function is a major requirement for the maintenance of speech and mastication. In all patients with advancing age there is a reduction in total muscle mass which occurs through a reduction in the number of muscle fibres rather than a major reduction in muscle fibre size. Electrophysiological studies have also shown a loss of motor units with age, particularly in those over the age of 60 years, which reveals as a reduction in muscle strength and reduced masticatory forces. Age induces a increase of the chewing process associated with a reduction in muscle activity, suggesting that elderly patients adapt their chewing behaviour to changes in chewing activity.13
Evidence suggests that edentate patients exhibit an increased reduction in muscle mass and a reduction in maximal bite forces compared with dentate patients. However, many edentate individuals successfully rehabilitated using complete dentures regard their masticatory function as satisfactory.14
6. Sensory Changes
It is known that taste and smell sensitivities change throughout life and often decrease with ageing. These changes can make foods become tasteless thus resulting in a reduction in appetite. Such taste and smell dysfunctions may be due to a variability of contributing factors including oral diseases, systemic conditions and their associated treatments. Most studies suggest that the sense of smell is more impaired by ageing than the sense of taste. Olfactory cells which respond to smells are renewed much more slowly in elderly people. Olfactory acuity declines with age as the number of olfactory nuclei in the brain decline and the olfactory receptors in the roof of the nasal cavity regress. As a result, older people mostly have greater difficulty differentiating among food odours than younger people.9,15
A diminution of taste results from the degeneration of taste buds and a reduction in their total number as rejuvenation is much slower in elderly people. Elderly people have significant differences in their sensory perception and capacity to detect the pleasantness of foods compared with younger people. This can lead to older people adding ingredients such as sugars or salt to foodstuffs which can have adverse health effects. Whilst chemosensory deficits experienced by elderly patients generally cannot be reversed, interventions, including intensification of the taste and odour of foods, can compensate for age-related perceptual losses. Amplified essences increase the number of molecules that interact with receptors and compensate for sensory losses. Evidence shows that such amplification can improve food palatability and acceptance, increase salivary flow and immunity, and reduce oral complaints in both sick and healthy older patients.16
7. Teeth
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. (Figure 2) 9
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Figure 2. Tooth wear of lower incisors in an elderly patient (note the dentine deposition obliterating the pulp chamber) 9.
Enamel
As age, Enamel tends to become more brittle and susceptible to chipping, cracking and fracture. It also becomes less penetrable, reflecting the ionic exchange which occurs between enamel and the oral environment throughout life.9 These tissues turn into less hydrated and experiences superficial increases in fluoride content with age, especially with the uses of dentifrice and tap water. Thickness of the enamel does change overtime, especially on the facial, proximal contacts, and incisal and occlusal surfaces due to the many chewing cycles and cleaning with abrasive dentifrices.1 Darkening of the enamel and staining has also been described and may be due to absorption of organic material (Figure 3) 9.
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Figure 3. Staining of lower anterior teeth in an elderly patient9.
Dentino-Pulpal Complex
The two main age-related changes in dentine are due to 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 resulted from 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.
Physiological age changes are as a result of continued production of secondary dentine. This reduces the height of pulp horns, makes the pulp shrink out of the crown and anterior teeth, reduces the distance between chamber roof and floor in posterior teeth and causes the pulp to narrow concentrically in roots (Figure 4).9
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Figure 4. Pulp chambers of a 70-year-old patient showing a reduction in depth of the pulp chamber.9
The diminishing pulp space can be further complicated by the growth of irregular calcifications around degenerating blood vessels and nerve cells. These changes usually comprise spheroid ‘pulp stones’ in the coronal chamber and linear deposits in the canals.17 Radiographs may suggest that these changes completely obliterate the pulp space, but they are usually interspersed with soft tissue that provides space and nutrition for microbial infection, while facilitating the path for operative disruption and entry (Figure 5) 9.
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Figure 5. Pulp stones in maxillary molar teeth9.
Pulps undergo physiological and reactive changes as patients age. Changes are not, uniform and are not uniquely concentrated in the chronologically old. Pulp canals in the elderly are not necessarily narrow and difficult to manage, and reactive changes in the young and middle-aged can be equally challenging.
As the pulp ages, it becomes 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 apparently large pulp, results in compaction of pulp tissue to form a dense collagenous plug that is 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.18
Cementum
Cementum continues to be formed throughout life, especially in the apical half of the root, resulting in a gradual increase in root 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, (Figure 6) and in forensic dentistry in age estimation. Increased amounts of cementum along with secondary and reparative dentine lessen tooth sensitivity and lessen perception to painful stimuli.9
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Figure 6: Secondary cementum at the apex
8. Nutrition in Old Age and Its Implications for Oral Care
Adequate nutrition is a vital factor in promoting the health and wellbeing of the aged. Inadequate nutrition may contribute to an accelerated physical and mental degeneration. Poor oral health can be a demoralising factor to nutritional status and health. Disorders of the oral cavity have contributed to poor eating habits in the elderly. Loose painful teeth or ill-fitting dentures may result in a reduced desire or ability to eat. A compromised nutritional status, in turn can further undermine the integrity of the oral cavity are closely interrelated, diet and nutrition should be considered as an integral part of the oral health assessment and management of the elderly.10
Caloric requirements usually reduce in the elderly because of a decline in the basal metabolic rate, brought on by reduced lean muscle mass and lower exercise levels. Appetite and food intake may also decrease, leading to an insufficient caloric intake and frequently results in insufficient consumption of calcium, iron and zinc more frequently in females. Approximately 8000 kJ (1900 kcal) is the required calorie requirement in 80 years old. An active elderly subject requires a protein intake of 0.97 g/kg of body weight per day. However, patients suffering from tissues necrosis or inflammation shows an increase in protein turnover and requirements. Among the vitamins, most nutrients are recommended in the same amounts for elderly as for younger people. But, certain groups of elderly, such as those homebound, with no access to sunlight, may have insufficient vitamin D and develop osteomalacia. The other important nutrients required by the older individuals are ascorbic acid, iron, and potassium.19
Dental status is considered to be an important contributing factor to health and adequate nutrition in elderly. Missing dentition and ill-fitting dentures cause difficulty in chewing and discernment of taste of foods.
Although chewing efficiency and nutritional status improve when inadequate dentition or edentulousness is corrected with partial or complete dentures, with these replacements, mastication is less efficient than with intact natural dentition. Denture status may contribute to dietary changes to soft; easily masticate certain foods, which are often high in fermentable carbohydrates that may predispose to the development of root caries lesions.19
The dentists are hence in an ideal position to subsidise to the well-being of the elderly population. Dentists should be observant to nutritional risk factors in the elderly population by careful screening and intervening in the early stages of nutritional problems when such interventions can be most valuable and effective.10
SYSTEMIC CONSIDERSATION
1 PHYSIOLOGICAL AGE CHANGES
Aging of the individual is ascertained at all levels of the organizational hierarchy, from the macromolecular to that of the population. Though, none of the many changes occurring at the macromolecular level is dramatic by itself, but the cumulative effect, they cause with time, the exponentially increasing mortality rate seen at the population level. Although death is the inevitable end result of the aging processes, an important consequence for health care delivery is the increased incidence of impairment, disability and handicap in the aging population.20
Manifestations of Aging:
Individuals vary considerably in both the rate and magnitude of age-related changes in cells, tissues and organs. The time of onset of age dependent changes varies, as well as the patterns of change. Alterations in one system or structure do not always signal aging of the whole organism, but any deterioration in one organ system must influence changes in other organs.
Some functions show predictable decline with age such as vital capacity, cardiac output, renal plasma flow, glomerular filtration rate, swallowing, tongue function, taste acuity and reaction time to mention a few. The rate of yearly loss seems to occur at about 0.8% to 0.9% of the functional capacity present at 30 years of age. Other functions, such as pH and electrolyte content of blood and verbal intelligence show no age-associated changes.
The aging process may then be defined “as the sum of all morphologic and functional alterations that occur in an organism and lead to function impairment, which decreases the ability to survive stress.”
The basis of this biological process lies in the changes in various macromolecules that is DNA to membrane proteins, which primarily lead to alterations in cell function. Impaired cell functions then cause deterioration of interactions between cells, which in turn results in impairments of tissue or organ functions. The last and critical step in the propagation of age changes at the biological level is the impaired capability to maintain homeostasis, disturbance lead to the death of the individual, when they can no longer be rectified in time.20
Pathological Processes:
Superimposed on the basic biological changes that occur with age is an increasing vulnerability to disease. Describing where the normal aging process end and disease processes begin is difficult. Hence present medicine should be aimed at increasing human life expectancy.
Factors Influencing aging:
Two alternative views on the nature of aging are prevalent.
- Firstly, it is the result of random damage.
- Secondly, it is the result of some programmed hence controlled, degeneration of the organism.
Aging, in essence reflects a complex interaction of hereditary and epigenetic factors with environmental factors20.
Biologic Theories of Aging:
Various molecular models have been proposed to explain the various mechanisms of aging. The abundance of theories indicates the multitude of interpretations possible from the data on aging.
Many theories of aging presume that a single mechanism is responsible for all the characteristic changes seen with aging, focusing only on the derangements that occur at some target molecule.20
A; Genetic theories:
- Error theories:
The error theories of aging propose that senescence is related to the progressive accumulation of metabolic errors in macromolecules.
The implications of this theory are particularly serious for cells that do not divide after they have differentiated, such as brain and muscle cells. If they function poorly, they die and are not replaced. The results are less serious for dividing cells, such as those of the liver or the lining of the gastrointestinal tract. But however, the current data now argues preponderantly against the error catastrophe theory.20
- Somatic mutations:
The basic assumption of somatic mutations hypothesis is that just as spontaneous mutations occur in the germ line cells, so also they may occur in the somatic cells20.
- Redundancies:
Medvedev suggested that aging is attributable to loss of unique, non repeated, genetic information from the genome. The repetitions of some genes, the bulk of which are repressed to reduce the rate of aging20.
- Genetically programmed senescence:
The theory of genetically programmed senescence is the most general and the most comprehensive of the genetic theories. It is a deterministic theory, unlike the others that rely on randomly determined events. The theory of programmed senescence likens the aging process to the processes involved in the development of the organism, and aging is considered an extension of the development20.
- Disposable soma theory:
This theory presents an attempt at an unifying theory for aging. It does not deal with mechanism directly. Rather, it is concerned with the ramifications of the evolutionary or adaptive influences on the organism as they become manifested in senescence.20
B; Nongenetic theories :
- Immunologic theories:
With aging, the immune system tends to be less able to distinguish normal molecules from abnormal one, and so abnormal cells may proliferate and autoimmune actions take place.20
- Free radical theory:
Free radicals are ubiquitous, short lived, highly reactive chemicals produced during normal metabolic reactions. This theory postulates that free radicals combine with essential molecules, causing damage to DNA or other cellular aging and age associated diseases.20
- Cross-linking theory:
Aging has been postulated to be caused by molecules becoming irreversibly immobilised as a result of strong cross-linking of substances having a profound effect on physiologic function. Eg; cross linking of collagen, which is 25% of the total body protein, could affect the flow of nutrients and waste products from cells. These in turn, are believed to produce changes that are, in effect aging.20
- Metabolic rate or wear and tear theory:
It has been proposed that an increased metabolic rate, which presumably would result in greater wear-tear on the organism, result in a shorter life span. Thus, Sacher has calculated that, those species that have lower metabolic rates, have longer life span.
Thus, old age is inevitable but need not be debilitating. Identifying and understanding the underlying cause or causes of senescence would be beneficial for intervening in and slowing the aging process, thus allowing for a longer period of well-being during a person’s life, with relatively quick denouncement.20
CONSIDERATION OF PSYCHOLOGICAL STATUS OF GERIATRIC PATIENT
Depression is, unfortunately, a common occurrence among older adults. The fact that their activities and social interactions are more limited, and their nearest and dearest are often living far away, makes the adjustment to old age tough. Thus, most elderly face problems with self-perception and self-concept.
The theory of self-perception suggests that individuals infer opinions, attitudes, and internal states mostly through observing the behavior and circumstances in which they occur. On the other hand, self-concept is defined as the way an individual thinks, evaluates and perceives his self.
These two concepts change as an individual age. It has been observed that healthy older adults have more positive self-perception and self-concept compared to those who are lonely and suffer from health issues. Consequently, healthcare providers, especially those who are the primary caregivers should encourage seniors to have a positive attitude towards aging. This can help them increase their desire to live and make them more resilient to disease and mental illness.21
The concept of Homeostenosis
As people age, their capacity to withstand insults and injury to the normal functioning of the body diminishes. This is due to diminished “physiologic reserves”. So, smaller insults often have longer effects in older people, challenging their ability to function, causing them to become seriously ill.
The aging process includes 3 types of physiological changes: changes in cellular homeostatic mechanisms, which may include regulation of body temperature, as well as blood and extracellular fluid volumes; those related to a decrease in organ mass; and those involving a decline in, and loss of, the functional reserves of the body's systems (Table 1)22.
Table 1: Normal physiological changes in elderly patients.22
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2 MEDICAL HISTORY- CHRONIC DISEASES & DENTAL TREATMENT CONSIDERATIONS
More than 50 % of patients over 60 years of age are medically compromised and are on medication. Most commonly seen medical conditions are diabetes, hypertension, cardiovascular diseases, arthritis and neuromuscular problems like Parkinson's disease and Alzheimer's. The above clinical conditions can even trigger emergency situations during dental treatment if proper considerations and precautions are not taken. Therefore, all health care providers should be familiar with the course and the complications associated with these disease conditions.23
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COMMON ORAL LESIONS IN ELDERL
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3 POSSIBLE DRUG INTERACTIONS
Guidelines to Prescribe Medications for Older Patients
“Start low, go slow”
- Check for adverse drug events
- Take proper drug h/o previous medications, surgeries, present medications, allergies etc
- Use fewer drugs
- Old drugs for old people – safe to use drugs that have been time tested
- Drug interactions including the over the counter drug preparations.
- Use less frequent dosing intervals
- Medications easy to administer
- Clean instructions about usage of drugs
- Treatment adequately, do not discontinue a drug without achieving adequate therapeutic concentration unless adverse effects interfere.
- Incessant evaluation and monitoring for each drug that the patient is taking.28
Oral manifestations in Hypertensive Patients Drug Considerations29
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Drugs Used the Management of Rheumatoid Arthritis and Systemic Lupus Erythematosus: Dental considerations
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Systemic Conditions in Elderly Patients: Oral Treatment Considerations
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DRUG INTERACTIONS WITH DENTAL DRUGS33
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TREATMENT ASPECTS FOR GERIATRIC PATIENTS
A. EXAMINATION AND DIAGNOSIS
Chief Complaint
Most patients who are experiencing pain have a pulpal or periapical problem that requires root canal treatment or extraction. Dental needs are often manifested initially in the form of a complaint which usually contains the information necessary to make a diagnosis.7
Allow the patient to express the problem in his / her own words. Not only will this divulge symptoms but it also provides an opportunity to delineate the patient’s dental knowledge and ability to communicate and a rapport is set. This ability may be impaired because of problems with sight, hearing and mental status. Consultation with family, friends or physician is then done.8
Most geriatric patients do not complain about signs and symptoms of Pulpal and periapical diseases and may consider them minor when compared to their other health problems.
Pain associated with vital pulps (i.e. referred pain, pain caused by heat, cold or sweets) seem to reduce with age and severity diminishes over time. Heat sensitivity that occur as the only symptom suggests a reduced pulp volume such as that occurring in older pulps.
Pulp healing capacity is also reduced and necrosis may occur quickly after microbial invasion, again with reduced symptoms. The best patients are those who have had a successful root canal treatment.7,8
Medical History
It is important to focus on those factors that will truly indicate the risks undertaken in treating the older patient. Clinicians must recognize that the biologic or functional age of an individual is far more important than chronologic age.2 A medical history should be taken before the patient is brought into the treatment room, and a standardized form should be used to identify any disease or therapy that would alter treatment or its outcome. In general, aging causes dramatic changes to the cardiovascular, respiratory, and central nervous system (CNS) that results in most drug therapy needs.7 However, the decline in renal and liver function in older patients should also be considered when foreseeing behavior and interaction of drugs (e.g. anesthetics, analgesics, antibiotics) that may be used in dental treatment.8,5
The review of the patients’ medical history is the first opportunity for the dentist to talk with the patient. The time and consideration taken at the beginning will set the tone for the entire treatment process. This first impression should reflect a warm, caring practitioner, who is highly trained and able to help patients with complex treatments. Some older patients may need assistance in filling out the forms and may not be fully aware of their conditions or history. Some patients may withhold their date of birth to conceal their age for reasons of futility or even fear of ageism34. Vision deficits caused by outdated glassed or cataracts can adversely affect a patient’s ability to read the small print on many history forms. Consultation with the patient’s family, guardian, or physician may be necessary to complete the history; however, the dentist is ultimately responsible for the treatment.5
An updated history, including information on compliance with any prescribed treatment and sensitivity to medications, must be obtained at each visit and reviewed. In general, older adults use more drugs than younger patients, and most of these medications are potentially important to the dentist. The physicians’ Desk Reference should be consulted and any precaution or side effect of medication noted.22
Although geriatric patients are usually knowledgeable about their medical history, some may not understand the implications of their medical conditions in relation to dentistry or may be reluctant to let the clinician into their confidence. Their perceptions of their illnesses may not be accurate, so any clue to a patient’s conditions should be investigated.
Symptoms of undiagnosed illnesses may present the dentist with a screening opportunity that can disclose a condition that might otherwise go untreated or lead to an emergency. Management of medical emergencies in the dental office is best directed toward prevention rather than treatment.7,34
Few families are there with at least one member whose life has been extended as a result of medical progress. A great number have had diseases or disabilities controlled with therapies that may alter the clinician’s case selection. Root canal treatment is certainly far less traumatic in the extremes of age or health than is extraction.35
Dental History
The clinician should search patients’ records and explore their memories to determine the history of involved teeth or surrounding areas. The history may be as obvious as a recent pulp exposure and restoration, or it may be as subtle as a routine crown preparation 15 or 20 years ago.32 Any history of pain before or after treatments may establish the beginning of a degenerative process. Subclinical injuries caused by repeated episodes of decay and its treatment may accumulate and approach a clinically significant threshold that can be later exceeded after additional routine procedures. Multiple restorations on the same tooth are common.7,8
Recording information at the time of treatment may seem to be unnecessary “busy work,” but it could prove to be helpful in identifying the source of a complaint or disease many years later. A patient’s recall of dental treatments is usually limited to a few years, but the presence of certain materials or appliances, such as silver points, can sometimes date a procedure. Aging patients’ dental histories are rarely complete and may indicate treatment by several dentists at different locations. They likely have stood at least one dentist and been forced to establish a relationship with a new, younger dentist. This new dentist may find dental needs that require an updated treatment plan.36
Subjective symptoms:
The examiner can pursue responses to questions about the patient’s compliant, the stimulus or irritant that causes pain, the nature of the pain, and its relationship to the stimulus or irritant. This information is most useful in determining whether the source is pulpal disease, whether inflammation or infection has extended to the apical tissues, and whether these problems are reversible. Accordingly, the dentist can determine what types of tests are necessary to confirm findings or uncertainties.23,37
Diagnostic procedures:
It is important to remember that pulpal symptoms are usually chronic in older patients, and other sources of orofacial pain should be ruled out when pain is not soon localized. Much of the information to be attained from the complaint, history, and description of subjective symptoms can be gathered in a screening interview by the clinician’s assistant or over the phone by the receptionist. The need for treatment can be established and can provide a focus for the examination.36
Objective signs:
The intraoral and extraoral clinical examination provides valuable first-hand information about disease and previous treatment.7 The overall oral condition should not be overlooked while centering on the patient’s complaint, and all abnormal conditions should be recorded and investigated. Exposure to factors that contribute to oral cancers accumulate with age, and many systemic diseases may initially manifest prodromal oral signs or symptoms.34
Missing teeth contribute to reduced functional ability. The resultant loss of chewing efficiency leads to a higher carbohydrate diet of softer, more cariogenic foods. Increased sugar intake to recompense for loss of taste and xerostomia (often induced by medication) are also factors in the renewed susceptibility to caries.31
Gingival recession, which creates sensitivity and is hard to control, exposes cementum and dentin that are less resistant to decay (Figure 7). A clinical study of 600 patients older than age 60 showed that 70% had root caries and 100% had some degree of gingival recession.7
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Figure 7: gingival recession and exposed roots
The removal of root caries is irritating to the pulp and often results in pulp exposures or reparative dentin formation that affect the negotiation of the canal, should root canal treatment later be needed. Asymptomatic pulp exposures on one root surface of a multirooted tooth can result in the uncommon clinical situation of the presence of both vital and nonvital pulp tissue in the same tooth.7,24
Interproximal root caries is difficult to restore, and restoration failure as a result of continued decay is common. Although the microbiology of diseases is not substantially different in different age groups, the altered host response during aging may modify the progression of these diseases.32
Attrition. Abrasion, and erosion also expose dentin through a slower process that allows the pulp to respond with dentinal sclerosis and reparative dentin (Figure 8). Secondary dentin formation occurs throughout life and may eventually result in almost complete pulp obliteration.
Due to constant physiological changes, increased stress and bruxism. Attrition has become more common in old aged ,therefore night guard is recommended as precautionary measure. (Figure 9)
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Figure 8: Exposed Dentin due to Attrition and Erosion
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Figure 9 : Night guard as precautionary measure
In maxillary anterior teeth, the secondary dentin is formed on the lingual wall of the pulp chamber; in molar teeth the greatest deposition occurs on the floor of the chamber. Although this pulp may appear to recede, small pulpal remnants can remain or leave a less calcific tract that may lead to a pulp exposure.1
In general, canal and chamber volume are inversely proportional to age: as age increases, canal size decreases. Reparative dentin resulting from restorative procedures, trauma, attrition, and recurrent caries also contributes to diminution of canal and chamber size. In addition, the cemento-dentinal junction (CDJ) moves farther from the radiographic apex with continued cementum deposition. The thickness of young apical cementum is 100 to 200 µm and increases with age to two or three times that thickness.7
The calcification process associated with aging appears clinically to be of a more linear type than that which occurs in a younger tooth in response to caries, pulpotomy, or trauma.35
Dentinal tubules become more occluded with advancing age, decreasing tubular permeability. Lateral and accessory canals can calcify, thus decreasing their clinical significance.21
The compensating bite produced by missing and tilted teeth (or attrition) can cause temporomandibular joint (TMJ) dysfunction (less common in older adults) or loss of vertical dimension. The authors have observed diminished eruptive forces with age, reducing the amount of mesial drift and supra eruption. Any limitation on opening reduces available working time and the space needed for instrumentation.1,7
The presence of multiple restorations indicates a history of frequent insults and an accretion of irritants. Marginal leakage and microbial contamination of cavity walls is a major cause of pulpal injury. Violating principles of cavity, a reduced organic component to the dentin to increase susceptibility to cracks and cuspal fractures. In any further restorative procedures on such teeth, the clinician should consider the effect on the pulp and the effect on accessing and negotiating canals through such restorations if root canal therapy is indicated later.18
Many cracks or craze lines may be evident as a result of staining, but they do not indicate dentin penetration or pulp exposure. Pulp exposures caused by cracks are less likely to present acute problems in older patients and often penetrate the sulcus to create a periodontal defect, as well as a periapical one. If incomplete cracks are not detected early, the prognosis for cracked teeth in older patients is questionable.20
Periodontal disease may be the primary problem for dentate seniors. The relationship between pulpal and periodontal disease can be expected to be more significant with age. Retention of teeth alone demonstrates some resistance to periodontal disease. The increase in disease prevalence is largely attributable to an increase in the proportional size of the population who have retained their teeth. The periodontal tissues must be considered a pathway for sinus tracts. Narrow, bony-walled pockets associated with nonvital pulps are usually sinus tracts, but they can be resistant to root canal therapy alone when, with time, they become chronic periodontal pockets.1,20
Periodontal treatment can produce root sensitivity, disease, and pulp death. In developing a successful treatment plan it is significant to determine the effects of periodontal disease and its treatment on the pulp. The mere increase in incidence and severity of periodontal disease with age increases the need for combined therapy.11 The chronic nature of pulp disease demonstrated with sinus tracts can often be manifested in a periodontal pocket. Root canal treatment is commonly indicated before root amputations are performed. With age, the size and number of apical and accessory foramen are actually reduced as pathways of communication, as is the permeability of dentinal tubules.11,20
Examination of sinus tracts should include tracing with gutta – percha cones to establish the tracts’ origin. Sinus tracts may have long clinical histories and usually indicate the presence of chronic periapical inflammation (Figure 10).
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Figure 10: Examination of sinus tract using gutta percha
Their disappearance after treatment is an excellent indicator of healing. The presence of a sinus tract reduces the risk of interappointment or postoperative pain, although drainage may follow canal debridement or filling.17
Pulp testing:
Information collected from the patient’s complaint, history, and examination may be adequate to establish pulp vitality and to direct the clinician toward the techniques that are most useful in determining which tooth or teeth are the object of the complaint. Slow and gentle testing should be done to determine pulp and periapical status and whether palliative or definitive therapy is indicated.7 Vitality responses must correlate with clinical and radiographic findings and be interpreted as a supplement in developing clinical judgment.
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Figure 11: vitality testing of pulp
Transillumination and staining have been advocated as means to detect cracks, (Figure 12) but the presence of cracks is of little significance in the absence of complaints because most older teeth, especially molars, demonstrate some cracks.
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Figure 12: Transillumination of incisor to detect cracks
Vertically cracked teeth should always be considered when pulpal or periapical disease is observed and little or no cause for pulpal irritation can be observed clinically or radiographically.17 The high magnification available with microscopes during access opening and canal exploration permits visualization of the extent of cracks in determining prognosis. Cracks that are detected while the pulp is still vital can offer a reasonable prognosis if immediately restored with full cuspal coverage. The chronic nature of any periapical pathologic condition caused by vertically cracked teeth indicates that it is long-standing, and the prognosis is questionable (even when pocket depths appear normal). Periodontal pockets associated with cracks indicate a hopeless prognosis.
The reduced neural and vascular components of aged pulps, the overall reduced pulp volume, and the change in character of the ground substance create an environment that responds differently to both stimuli and irritants than that of younger pulps.7,17
There are fewer nerve branches in older pulps. This may be due to deteriorating changes resulting from mineralization of the nerve and nerve sheath. Consequently, the response to stimuli may be weaker than in the more highly innervated younger pulp.11
No correlation exists between the degree of response to electric pulp testing and the degree of inflammation. The presence or absence of response is of limited value and must be correlated with other tests, examination findings, and radiographs. Extensive restorations, pulp recession, and excessive calcifications are limitations in both performing and interpreting results of electric and thermal pulp testing. Attachments that reduce the amount of surface contact necessary to conduct the electric stimulus are available (Analytic Technology, Orange County, Calif.) and bridging the tip to a small area of tooth structure with an explorer has been suggested. Use of even this small electric stimulus in patients with pacemakers is not recommended; any such risk would outweigh the benefit. The same caution holds true for electrosurgical units.1,11
A test cavity is generally less useful and used as the test of last resort because of reduced dentin innervation. Vital pulps can produce pain; then the root canal treatment becomes part of the diagnostic procedure. Test cavities should be used only when other findings are suggestive but not conclusive.7,17
Diffuse pain of indistinct origin is also uncommon in older pulps and limits the need for selective anesthesia. Pulpal disease is progressive and produces signs or symptoms in a relatively short time. Nonodontogenic sources should be considered when factors associated with pulpal disease are not readily identified or when acute pain does not localize within a short time.17
Discoloration of single teeth may indicate pulp death, but this is a less likely cause of discoloration with advanced age. Dentin thickness is greater and the tubules are less permeable to blood or breakdown products from the pulp. Dentin deposition produces a yellow, opaque color that would indicate progressive calcification in a younger pulp; however, this is common in older teeth.18 (Figure 13)
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Figure 13: Discoloration of single tooth
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Indications for and techniques of taking radiographs do not differ much among adult age groups. However, several physiologic, anatomic changes can significantly affect their interpretation. Film placement may be adversely affected by tori but can be assisted by the depth of the vestibule. Older patients may be less capable of assisting in film placement, and holders that secure the position should be considered. The presence of tori, exostoses, and denser bone may require increased exposure times for proper diagnostic contrast. The subjective nature of interpretation can be reduced with correct processing, proper illumination, and magnification.8
The periapical area must be included in the diagnostic radiograph, which should be studied from the crown toward the apex. Angled radiographs should be ordered only after the original diagnostic radiograph suggests that more information is needed for diagnosis or to determine the degree of difficulty of treatment. Radio Visiography (RVG) may be more useful than conventional radiography in detecting early bone changes.7,8 (Figure 14)
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Figure 14: SLOB rule to detect number of canals present
In older patients, pulp recession is accelerated by reparative dentin and complicated by pulp stones and dystrophic calcification. Deep proximal or root decay and restorations may cause calcification between the observable chamber and root canal.9
The depth of the chamber should be measured from the occlusal surface and its mesiodistal position noted. receding pulp horns that are apparent on a radiograph may remain microscopically much higher.1 Deep restorations or extensive occlusal crown reduction may produce pulp exposures that were not expected. The axial inclinations of crowns may not correlate with the clinical observation when fixed or removable appliances are present. Access to the root canals is the most limiting condition in root canal treatment of older patients.9 (Figure 15)
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Figure 15: Axial inclination of molar is different from clinical observation
Canals should be examined for their number, size, shape, and curvature. Comparisons to adjacent teeth should be made. Small canals are the rule in older patients. A midroot disappearance of a detectable canal may indicate bifurcation rather than calcification. Canals calcify evenly throughout their length unless an irritant (e.g., decay, restoration, cervical abrasion) has separated the chamber from the root canal. The lamina dura should be examined in its entirety and anatomic landmarks distinguished from periapical radiolucency’s and radiopacities. The incidence of some odontogenic and nonodontogenic cysts and tumors characteristically increases with age, and this should be considered when vitality tests do not correlate with radiographic findings. However, the incidence of osteosclerosis and condensing osteitis decreases with age.
Resorption associated with chronic apical periodontitis may significantly alter the shape of the apex and the anatomy of the foramen through inflammatory osteoclastic activity. The narrowest point in the canal may be difficult to determine; it is positioned farther from the radiographic apex because of continued cementum deposition.9.11
A continued normal rate of cementum formation may be demonstrated by a canal or foramen that appears to end or exit short of the radiographic apex, and hypercementosis may completely obscure the apical anatomy.
B. CLINICAL DECISION MAKING – TREATMENT PLANNING
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Figure 16: Conventional treatment-planning process.38
Treatment planning is the culmination of a comprehensive diagnostic process that usually precedes routine treatment.39 It should address the underlying disease process giving rise to signs and symptoms found on examination and elicited from patients. Treatment plans should also attend to patients’ chief complaints as quickly as possible, rely on individual needs, and prevent and manage tooth loss. Furthermore, treatment plans should communicate the role of caregivers in maintenance and care, account for realistic circumstances, be continuously informed, make dental appointments as comfortable as possible, and emphasize continued monitoring of oral health and a functional dentition.40 The most influential factors in comprehensive treatment planning are patients’ disease status, followed by patients’ requests, and lastly, patients’ ability to pay. The treatment planning process facilitates diagnosis of disease(s) and results in a plan that accounts for patients’ interests and expectations, treats diagnosed problems, and provides a stepwise strategy for maintaining oral health.
MODELS OF GERIATRIC DENTAL TREATMENT PLANNING
This section provides an overview of treatment-planning models that attempt to account for the myriad of considerations accompanying dental care for the elderly, and (Figure 17). below presents a diagram summarizing of the factors presented in these models.41
A straightforward yet comprehensive approach to treatment planning for older adults uses the familiar mnemonic SOAP
1.S=Subjective findings
2.O=Objective findings
3.A=Assessment
4.P=Plan
In geriatric patients, the subjective findings include additional information concerning functional status as described by the ability to carry out ADLs and instrumental activities of daily living.41
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Figure 17: Considerations in treatment planning grouped by proximity to oral health.41
Another approach to treatment planning for older adults uses the easy to remember mnemonic OSCAR, which stands for
1.O-Oral factors
2.S-Systemic factors
3.C-Capability
4.A-Autonomy,
5.R-Reality.
The assessment should follow the order of the mnemonic.
Oral factors take into consideration the current dentition and restorations, periodontium, oral hygiene and root caries, salivary secretions, tooth loss, mucosal tissues, removable prosthesis, and occlusion.
Systemic factors encompass normal changes related to aging and comorbidity, effect of medications, and communication between the dentist and physician(s) in managing the geriatric dental patient with a medically compromised health status.
Capability refers to attributes such as the ability to carry out ADLs, walk with or without assistance, and control incontinence.
Autonomy relates to the patient’s ability to independently make health care decisions within the context of cognitive impairment stemming from a history of stroke, dementia, depression, or other conditions.
Lastly , Reality refers to financial issues and life expectancy.38
The rational treatment model considers the influence of modifying factors on primary factors, which in turn alter the biofilm and, consequently, the development of oral diseases and conditions.38 Modifying factors such as lifestyle, socioeconomic status, medications, cognition, disability, and medical and dental history alter the balance of diet, saliva, and genetics, and affects chemotherapeutics and oral hygiene.
This model, adapted from a caries risk model, explains how etiologic factors affect the development of caries, periodontal disease, tooth loss, and mucosal lesions. Furthermore, risks and benefits of treatment also influence whether no treatment, emergency care, limited treatment, or comprehensive care is planned.42
Another model uses a clinical reasoning sequence in decision making and resolution of dental problems.
In the model, 3 action sequences are presented in resolving dental problems:
(1) determine the cause
(2) choose an action
(3) implement the plan.
To determine cause, the problem must be defined, other possible causes considered, and possible causes tested.
To help choose an action, goals in consultation with the patient must be established, alternatives examined, and adverse consequences considered.
Finally, implementation of the plan involves anticipating potential problems, taking preventive actions, and setting up contingency plans.
This systematic approach can be successful if the steps in the action sequences are effective.36
Berkey et al.43 proposed a similar but different conceptual model. They suggested that in clinical decision making for older adults, there were four domains of dental need that needed to be integrated and these were function, symptomatology, pathology and aesthetics
To achieve these goals, the authors suggested that a series of questions needed to be answered, which were43:
(1) The patient’s desires and expectations.
(2) The type and severity of dental need.
(3) The impact on quality of life.
(4) The probability of positive outcomes.
(5) Reasonable treatment alternatives.
(6) The ability to tolerate the stress of treatment.
(7) The capability to maintain oral health.
(8) Financial and other resources.
(9) The dentist’s capabilities.
(10) Other issues.
DECISION-MAKING CAPACITY, COMPETENCY, AND INFORMED CONSENT
Before any dental examination, the clinician must obtain a valid consent to treat or not treat. In general, informed consent requires a disclosure of the relevant risks of, benefits of, and alternatives to treatment that potentially affect the patient’s decision on the treatment. However, proper disclosure by the clinician alone is insufficient to obtaining a valid consent. The patient must also possess decision-making capacity as defined by ability to comprehend, appreciate, and reason the contingencies of treatment or no treatment.44 The ability to weigh the risks and benefits of treatment, no treatment, and alternatives; and the ability to communicate his or her choices.
In some instances, especially in the elderly, determination of capacity may be unclear and subject to bias.38 The elderly with dementia and/or psychiatric illness, nursing home residents, and hospitalized elderly all have increased risk for reduced consent capacity. In most cases when a patient is determined to lack capacity, the clinician assigns a health care proxy to consent for that patient. Dentists are legally bound by the same process and standards as physicians and other health care professionals in securing informed consent. Therefore, dentists should know and comply with the legal obligation regarding capacity and informed consent for the state in which they practice. The evaluation for capacity to consent for treatment should be a fluid process to be evaluated at each treatment decision. The patient should have self-determination of as much of their treatment as possible.44
Although decision-making capacity and competency are similar; they are not synonymous. The legal determination of patient competency describes the ability of the patient to make informed decisions. However, patient competency differs in scope, determination, and purpose. Lack of capacity does not preclude a patient from making any decisions. Each decision varies in risk, benefits, and complexities, and should be independently assessed. When appropriate, patients should be empowered to make their own decisions. However, competency, formally determined by a court of law, concerns the individual’s mental capacity to make autonomous decisions in general.
At the time a person is determined incompetent, a court appoints a guardian who acts as a surrogate decision maker. In addition to health care decisions, the guardian handles decisions regarding contracts, finances, and other personal affairs. In this case, obtaining consent is straightforward; the guardian provides informed consent. A case is now presented that emphasizes many of the factors highlighted in this discussion of treatment-planning considerations.38
C. TREATMENT OF XEROSTOMIA
Unstimulated and stimulated salivary flow rates have been reported to decrease with aging and these functional changes are consistent with morphologic findings. However, recent studies have also demonstrated that both stimulated and unstimulated submandibular and parotid salivary flow rates are not decreased in healthy elderly subjects. Also decrease salivary, pH values have been correlated with decrease salivary flow rate, and the prevalence of crown and root caries is high among subjects with decrease salivary flow or lowered salivary pH. Therefore, elderly subjects with decrease salivation may also have low salivary pH values and be more susceptible to caries than their unaffected counterparts .
Etiology of Xerostomia in Older People45
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Management of Xerostomia
The first strategy for managing xerostomia is
a. frequent dental evaluations, because of the prevalence of complications.
b. A low-sugar diet, daily topical fluoride use
c. antimicrobial mouth rinses help prevent caries in patients with reduced salivary flow.
d. Sugar-free chewing gum, candies, and mints can stimulate remaining salivary secretions; artificial saliva and lubricants and the nighttime use of bedside humidifiers may ameliorate some xerostomic symptoms.
e. Dysphagia is managed with oral moisturizers and lubricants, careful use of fluids during eating, and dietary modifications.46
f. Two secretagogues, pilocarpine and cevimeline, have been approved by the Food and Drug Administration and can increase secretions and diminish xerostomic complaints in patients with sufficient exocrine tissue.
g. Pilocarpine is a nonselective muscarinic agonist, whereas cevimeline reportedly has a higher affinity for M1 and M3 muscarinic receptor subtypes. Because M2 and M4 receptors are located on cardiac and lung tissues, cevimeline can enhance salivary secretions while minimizing adverse effects on pulmonary and cardiac function.
h. Oral candidiasis, as previously mentioned, is a frequent complication of dry mouth and is most commonly treated with topical antifungal agents.
i. Angular cheilitis should be treated with a combination of antifungal and anti-inflammatory agents.
j. Instead of prescribing xerostomia-associated drugs, substitution with similar types of medications with fewer xerostomic side effects is preferred.
k. Serotonin specific reuptake inhibitors have been reported to cause less dry mouth than tricyclic antidepressants.
l. There are other strategies for alternating pharmaceutical regimens to avoid xerostomia.
m. If anticholinergic medications can be taken during the daytime, nocturnal xerostomia can be diminished, because salivary output is lowest at night. Also, if drug dosages can be divided, unwanted side effects from a single large dose can be avoided. Scrutiny of drug side effects can assist in diminishing the xerostomic potential of many pharmaceuticals used by older people.
n. Pilocarpine can improve symptoms of xerostomia when given during and after the completion of radiotherapy, and cevimeline hydrochloride may be useful as a more specific muscarinic agonist.47
D. Restoring Carious lesions
Restorative considerations for coronal caries
The selection of restorative techniques in older adults is more or less similar to that in younger population. However, permissible direct plastic restorative materials are preferred in the former as these restorations can be readily and inexpensively repaired or replaced. Owing to the presence of several risk factors, caries activity is quite high and therefore requires frequent maintenance which might not be easily done in an indirect restoration.46 (Figure 18)
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Figure 18: restoration cervical abrasion
Open sandwich technique is recommended because of poor bonding capacity of composite on root surface.
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Figure 19: Open sandwich technique
Root caries
Carious lesions are termed either primary (new lesions on previously unrestored surfaces) or secondary (new caries around existing restorations). They occur on the crowns of teeth and exposed root surfaces. Periodontal disease (gum disease), results in loss of gingival (gum) attachment and exposure of the tooth’s root surface. The root comprises the biologic structures cementum and dentin. Root surface cementum and dentin are more susceptible to cavitation because they are less mineralized than enamel, the biologic material that comprises the crown of the tooth, and begin to demineralize at a higher salivary pH. Older adults are retaining an increasing number of natural teeth, and nearly half of all individuals aged over 75 have experienced root caries.
Root caries is a major cause of tooth loss in older adults, and tooth loss is the most significant negative impact on oral health-related quality of life for the elderly47.
The need for improved preventive efforts and treatment strategies for this population is acute. Better clinical surveillance by public health agencies will drive decisions about oral health policy and education.
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Figure 20: Prevalence and risk factors
Aging is often associated with changes in oral morphology, chronic systemic disease such as diabetes, and decreasing dexterity, making personal oral hygiene more difficult, particularly for the oldest and most frail individuals. The pain of arthritis and neuropathies make it difficult to grasp or manipulate a manual toothbrush. Patients with dementia experience a higher prevalence of caries than those without dementia, and the rates are related to dementia type and severity.
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Figure 21: circumferential band of caries around the roots of teeth due to dry mouth
Root caries has peculiar pattern which seen as circumferential band around the roots of teeth due to dry mouth and xerostomia. (Figure 21)
Caries risk assessment
Understanding factors and behaviours that directly or indirectly impact caries pathogenesis offers opportunities to reduce the caries burden of the aging population. Caries Management by Risk Assessment (CAMBRA) is a conservative and effective approach to prevention and treatment of the disease across the life course.48 Caries pathogenesis is recognized as a balance between protective factors (fluoride, calcium phosphate paste, sufficient saliva, and antibacterial agents) and pathologic factors (cariogenic bacteria, inadequate salivary function, poor oral hygiene, and dietary habits – especially frequent ingestion of fermentable carbohydrates). Correctly assessing caries risk can identify a therapeutic treatment regimen for effectively managing the disease by reducing pathologic factors and enhancing protective factors, resulting in fewer carious lesions.48
CRITERIA USED TO DESCRIBE ROOT CARIES49
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Active root caries
Incipient
1) Surface texture: soft, can be penetrated with a dental explorer
2) Cavitation: surface defect less than 0.50 mm in depth
3) Pigmentation: amber to brown
Gross lesion
1) Surface texture: soft, can be penetrated with a dental explorer
2) Cavitation: surface defect greater than 0.50 mm in depth
3) Pigmentation: amber to brown
Arrested root caries
1) Surface texture: hard, smooth, polished appearance, not easily penetrated with a dental explorer, no resistance to removal
2) Cavitation: surface defect present
3) Pigmentation: brown to black
Root surface caries severity index49
Grade I (incipient)
1) Surface texture: soft, can be penetrated with a dental explorer
2) No surface defect
3) Pigmentation: variable, light tan to brown
Grade II (Shallow)
1) Surface texture: soft, irregular, rough, can be penetrated with a dental explorer
2) Surface defect (less than 0.50 mm in depth)
3) Pigmentation: variable, tan to dark brown
Grade III (cavitation)
1) Surface texture: soft can be penetrated with a dental explorer
2) Penetrating lesion, cavitation present (greater than 0.50 mm in depth), no pulpal involvement
3) Pigmentation: variable, light brown to dark brown
Grade IV (pulpal)
1) Deeply penetrating lesion with pulpal or root canal involvement
2) Pigmentation: variable brown to dark drown
High risk
1) Baseline radiographs
2) Prophylaxis with application, of chlorhexidine for 1 min followed by rinsing
3) Apply sealant to pits and fissures
4) Fluoride varnish application
5) Brushing twice a day with fluoridated toothpaste
6) Rinsing daily for 1 min with fluoride mouthwash (0.05% NaF) at bedtime
7) Oral hygiene instructions and diet counseling
8) Constant monitoring
Moderate risk
1) Prophylaxis by fluoride varnish application
2) Brushing twice a day with fluoridated toothpaste
3) Rinsing daily for 1 min fluoride mouthwash (0.05% NaF) at bedtime
4) Monitoring
Low risk
- Brushing twice a day with fluoridated toothpaste
- Monitor every 12-18 month interval
Clinical diagnosis of root caries
Root caries usually starts at or first below the CEJ as small, round, shallow, pigmented defect spreading laterally coalescing with neighboring lesions or forming a gutter. It usually undermines the cervical enamel.
Risk of root caries is 0.1-0.4 surfaces/person/year.
Cavity design
1) Retentive
2) Non- retentive
3) Mesial slot
Restorative materials used are
Reinforced ZnO2 Eugenol cement
Amalgam
Composite resin
GIC cement
Prevention: - chemical agents for plaque topical fluoride regimes
Special conditions
To be used when diagnosing root caries
1) When the coronal and root surfaces are both affected by a single lesion, it will be necessary to determine whether the lesion originated on the root or crown. If more than half the lesion is below the CEJ, the site of origin is assumed to be on the root surface and vice versa. When lesion appears to affect the root and coronal surfaces equally, both surfaces should be scored as being carious
2) When there is a retained root, all and root surfaces, should be regarded as being carious
3) When root surfaces contain both carious lesion and separate restoration, both are scored as being present
4) When a filling or lesion on posterior tooth or a lesion on an anterior tooth extends beyond the line angle onto the adjacent surface, the adj, surface is also included. However, a proximal filling on an anterior tooth is not considered to involve the adjacent lingual or labial surface unless it extends atleast a 3rd of the distance to opposite proximal surface
5) A deficiency in root restoration should not be scored as carious in absence of definitive visual and tactile criteria for caries even though some restorative treatment may be indicated
6) When coronal restoration, extends onto root surface > 3 mm beyond CEJ, root surface is deemed to be filled.
7) Decay root surface associated with coronal filling is recorded as recurrent coronal decay
Treatment options :
Fluoride
The anti-caries effects of fluoride are primarily topical in adults. The topical effect is described as a constant supply of low levels of fluoride at the biofilm/saliva/dental interface being the most beneficial in preventing dental caries. Therapeutic levels of fluoride can be achieved from drinking fluoridated water and the use of fluoride products (toothpaste, rinse, gel, varnish). Fluoride can inhibit plaque bacterial growth, but more significantly, fluoride inhibits demineralization and enhances remineralization of the tooth surface.50
The most widely used forms of fluoride delivery have been the subject of several systematic reviews, providing strong evidence supporting the use of dentifrices, gels, varnishes, and mouth rinses for the control of caries progression. Dentifrices with fluoride concentrations 1000 ppm and above have been shown to be clinically effective in caries prevention when compared to a placebo treatment.
Chlorhexidine
The use of chlorhexidine for caries prevention has been a controversial topic among dental educators and clinicians. Chlorhexidine rinses, gels, and varnishes or combinations of these items with fluoride have variable effects in caries prevention, and the evidence is regarded as “suggestive but incomplete.” The most persistent reductions of mutans streptococci have been achieved, in order of more effective to less effective, by chlorhexidine varnish followed by gels and, lastly, mouth rinses. While chlorhexidine has been widely used in Europe before gaining US Food and Drug Administration (FDA) approval, the only chlorhexidine-containing products currently marketed in the USA are chlorhexidine mouth rinses.
The preferred dosage regimen for rinsing is once a day with 5 cc of a 0.12% chlorhexidine gluconate solution for 1 week every month for a year.50 Patients should be informed of the likelihood of dark staining of their teeth during chlorhexidine use, and that the staining is easily removed during a dental prophylaxis.
Silver diamine fluoride
Recent interest in the antimicrobial use of silver compounds suggest that silver nitrate (SN) and silver diamine fluoride (SDF) are more effective at arresting active carious lesions and preventing new caries than fluoride varnish, and may be a valuable caries preventive intervention. Possible mechanisms for SDF’s clinical success include its antimicrobial activity against a cariogenic biofilm of Streptococcus mutans or Actinomyces naeslundii formed on dentin surfaces and slowing down the demineralization of dentin.51
While SDF is available from international chemists online and has been shown to be as safe as fluoride varnish, effective for treating carious lesions, and is widely used in other countries, it does not currently have FDA approval.
Caries removal
Partial caries removal has been found to greatly reduce the risk of pulp exposure. For asymptomatic teeth, partial caries removal generally results in no detriment to the patient from increased pulpal symptoms, decay progression under restorations, or premature loss of restorations. When pulpal exposure is a concern in treating deep lesions, partial caries removal is the preferred approach.52
Atraumatic restorative treatment
Atraumatic restorative treatment (ART) is an essential caries management technique for improving access to oral care. ART uses a high-viscosity glass ionomer restoration to restore single-surface lesions in permanent posterior teeth, including root carious lesions. There appears to be no difference in the survival of single-surface high-viscosity glass-ionomer ART restorations and amalgam restorations in permanent posterior teeth including Class V root surface lesions.53
E. AESTHETIC ASPECTS
“Smile has no age bar”. Most of the elderly lead an independent social life and are therefore conscious about their appearance. The aesthetic treatment for elderly could range from simple recontouring procedures to bleaching, laminates and crowns. Any major aesthetic rehabilitation should be undertaken only after proper occlusal and aesthetic analysis to achieve predictable results.23
Formerly, the age of 60–65 would be regarded as approaching retirement age but, in many modern societies, this is regarded as ‘middle-aged’. They probably have selftime to think about themselves and consider concentrating on aesthetic appearance which gives them more confidence. In many developed countries, 70 years is frequently regarded as a minimum acceptable life span.
Dentists therefore have to plan for appearance maintenance and possible improvement for many more years. This is in addition to maintaining chewing function for the long term.
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Figure 22: Aesthetic treatment
BLEACHING
The use of a variety of bleaching techniques has attracted much interest from the profession, as they are noninvasive and relatively simple to carry out. Contemporary bleaching systems are based primarily on hydrogen peroxide or one of its precursors, notably carbamide peroxide, and these are often used in combination with an activating agent such as heat or light.
Bleaching agents can be applied externally to the teeth (vital bleaching), or internally within the pulp chamber (non-vital bleaching). Both techniques aim to bleach the chromogens within the dentine, thereby changing the body colour of the tooth.54
Although 10% carbamide peroxide is generally associated with tooth whitening, the material was originally used as an oral antiseptic for gingival healing. It was being applied in a tray for wound healing when the tooth whitening side effect was discovered.55
Carbamide peroxide 10 and 15% has been has been classified by the United States Food and Drug Association as category 1, which means there are sufficient data to demonstrate that these agents are safe and effective for use in the oral cavity as oral antiseptic agents. Persons now involved in tooth whitening research report a loss of plaque during that time such that their teeth feel ‘squeaky clean’ much like after a prophylaxsis.55
I. Current research on safety noted that the pH of the saliva and the material in the tray is elevated to about eight in less than five minutes after application, and remains that for the duration of the application.
II. This occurrence is related to the urea in the composition. The pH values are crucial to preventing the formation of tooth decay, since root caries can start when the pH of the mouth is between 6 and 6.8
III. A further study has indicated that 10% Carbamide peroxide kills one of the two bacteria causing tooth decay. Gingival indices in bleaching studies have indicated some improvement in gingival scores, although the patient population involved in bleaching often has a very clean mouth for the onset of treatment.
IV. Carbamide peroxide is preferred rather than hydrogen peroxide, since the urea and Carbopol in 10% Carbamide peroxide allows it to be active up to 10 hours in the mouth, while hydrogen peroxide is only active for 30-60 minutes.54,55
Since carbamide peroxide kills lactobacillus, and Chlorhexidine kills strep mutans, one option is to both clean the teeth and destroy the lactobacillus bacteria by wearing the non-scalloped, no-reservoir tray overnight with 10% carbamide peroxide. This can be supplemented by using Chlorhexidine rinse for 30 seconds prior to bedtime. In addition to caries control, the 10% Carbamide peroxide can control the staining from Chlorhexidine.
The only side effect of this treatment is that the teeth will become white. For most people, this may be a benefit. However, since restorations do not change colour, there can be a mismatch between existing restorations and bleached teeth. Some restorations may need to be replaced due to this colour mismatch.
Sensitivity is often associated with bleaching. However, in elderly patients, the pulps have receded such that sensitivity is seldom a problem. The use of potassium nitrate in the bleaching tray for 10-30 minutes has been shown to alleviate this in most patients. Additionally, many bleaching products now contain this ingredient, and sensitivity levels have been greatly reduced with the combination of potassium nitrate and a soft tray, as well as by pre-brushing and using a desensitizing toothpaste during treatment.55,56
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Figure 23. Discoloured teeth in a 70-year-old patient.56
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Figure 24. Customized bleaching trays in position with 10% carbamide peroxide56
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Figure 25. Teeth after bleaching with 10% carbamide peroxide.56
VEENERING
New procedures, materials, and dentistry techniques provide senior people with an improved quality of life and a greater self esteem due to a confident esthetic smile.
Ceramic is more prone to microfracture and has a lower elasticity coefficient than composite resin, it still provides the highest esthetic results.57
Indirect veneers allow a good color stability and a high resistance to saliva, yet they are still very costly and time-consuming as they require many preliminary steps (wax up, adaptations…). Direct veneers are cheaper and quicker to use from a practitioner point of view, and although they require a high level of skill, they still allow the obtaining of an interesting esthetic result.
The recommended preparation depth varies between 0.3 and 1.0 mm. The most important reasons for this preparation recommendation are to avoid overcontour, maintain an adequate material thickness for masking the discoloured hard tooth tissues, and benefit from the better bonding abilities of the restoration to prepared enamel rather than unprepared enamel.58 Also recommended to increase etching of enamel.
When compared to full buccal restoration, partial veneers allow the preservation of sound enamel for tissue economy, ensures periodontal health and provides high esthetical results. However, the limit of the restoration may be visible with an impact on the esthetic outcome.
Described clinical techniques for assessment of Occlusal vertical dimension (OVD) loss59
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STEPS FOR TOOTH PREPARATION FOR VEENERING
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Figure 26 A, Initial situation (canine-to-canine view with contraster). B, Dental tissues after preparation. C, Isolation of the teeth using a rubber dam. D, Application of the etching agent. E, Rinsing with water and then drying. F, Application of the bonding agent. G, Application of partial veneers to the preparations. H, Photopolymerization using a glycerin film. I, Elimination of excess and polishing57
The therapeutic decision is a key for the treatment of any case and it is motivated by many factors.
Tissue economy must always be considered in all therapeutic decision in every clinical case. Minimally invasive treatments, such as partial veneers, should therefore be considered first as they allow the preservation of the dental tissue while still providing highly satisfactory esthetic results. Furthermore, the possibility of maintaining maximal residual enamel after removing a mobile chip despite the cracked appearance is a reasonable choice because the dentin-enamel junction can prevent any crack propagation in the dentin tissue.58
F. ENDODONTIC MANAGEMENT OF THE GERIATRIC PATIENTS
Single tooth rubber dam isolation should be use whenever possible. Badly broken-down teeth may not provide an adequate purchase point for the rubber dam clamp, and alternate rubber dam isolation methods should be considered. Multiple-tooth isolation may be used if adjacent teeth can be clamped and saliva output is low or a well-placed saliva ejector can be tolerated. A petroleum-based lubricant for the lips and gingiva reduces chafing from saliva or perspiration beneath the rubber dam. Reduction in salivary flow and gag reflex reduces the need for a saliva ejector. Artificial saliva is available and should be used just before isolation because it is difficult to apply after the dam is in place.
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Figure 27: Rubber dam isolation
Canals should be identified and their access maintained if restorative procedures are indicated for isolation. The clinician should not attempt isolation and access in a tooth with questionable marginal integrity of its restorations. Fluid-tight isolation cannot be compromised when sodium hypo-chlorite is used as an irrigant. Difficult-to-isolate defects produced by root decay present a good indication, in initial preparation, for the use of sonic hand pieces that use flow-through water as an irrigant.
1. Extended clamp known as silker and Glickman clamp is used for severely broken tooth. (Figure 28)
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Figure 28: Silker and Glickman clamp
2. The many merits of single visit root canal procedures should again be considered when isolation is compromised. The few minor benefits of multiple visit treatment are further reduced if an interappointment seal is difficult to obtain.
3. Careful placement and removal of cotton rolls during isolation should be done to avoid bleeding of gingiva as it is fragile in nature in elderly patients.
4. Use of thin gingival retraction cords to record better finish lines in impression
Local Anesthesia:
1. While performing root canal therapy sometimes they have to be convinced to take local anesthesia as at times they can do without it.
2. Cutting of dentin does not perform same level of response in older patient because of less number of low threshold, high conduction velocity nerve endings and do not extend for into dentin. In some cases these nerve endings are even absent. A painful response in some cases may occur when there is actual pulpal exposure.
3. Anatomic landmarks for needle placement are more pronounced in older patients Local Anesthesia should be deposited very slowly.
4. Reduced width of periodontal ligament makes needle placement for intraligamentary injection is more difficult.
While given intraosseous injection one thing should be kept in mind that intraosseous anesthesia is not prolonged.
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Figure 29: Administration of Local anesthesia
Because of this reason pulp tissue should be removed within 20 minutes. In older individual intraosseous anesthesia with 2% Lidocaine with 100,000 epinephrine solution leads to increase heart rate, therefore in these cases 3% Mepivacaine can be administered.
Because of reduced volume of pulp chamber, intra pulpal anesthesia is difficult in single rooted teeth and almost impossible in multirooted teeth.
In such cases wedging the needle in the canal to produce pressure for anesthesia is last resort.
In geriatric patients every effort should be made to produce profound anesthesia.
Access cavity preparations:
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Figure 30: Access cavity preparation
1. Adequate access and identification of canal orifice is most difficult part of providing root canal treatment.
2. Although multiple restorations and physiological changes may reduce the volume of pulp but buccolingual and mesiodistal positions remains the same.
3. Coronal tooth structure and restorations may be sacrificed when they compromise access cavity preparation.
4. While using surgical microscopes, magnifications in the range of 2.5x to 4.5 x are most comfortable. And these microscopes offer clear magnification of up to 25x or greater.
5. Locating calcified canal is most difficult and time consuming. In such cases most important tool is DG16 explorer, champagne bubble test. Now once the orifice is located and stainless steel 21 mm No.8 or No.10 K-files are used.
6. Initially NiTi files are not recommended and are contraindicated as they lack strength in long axis.
7. In case of calcified canals ultrasonics can be used to negotiate the canals .
8. Canals negotiated with watch winding motion with slight apical pressure.
9. Chelating agents are also used for negotiating canals and lead to perforation. In such cases repair should be done immediately.
10. Pain, bleeding or unfamiliar feel can lead to perforation. In such cases repair should be done immediately.
11. Sometimes it will take long time for searching a canal which is irritating to both clinician and the patient in such cases we should always opt for second appointment.
Working Length :
i. After the canal patency, working length determination is done.
ii. Because of hypercementosis, working length of 1-2 mm short of radiographic apex is preferred.
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Figure 31: Working length determination
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Figure 32: Hypercementosis roots
Cleaning and shaping:
The calcified appearance of the canals resulting from the aging process presents a much different clinical situation than that of a younger pulp in which trauma, pulpotomy, decay, or restorative procedures have induced premature canal obliteration. Unless further complicated by reparative dentin formation, this calcification appears to be much more concentric and linear. This allows easier penetration of canals once they are found. An older tooth is more likely to have a history of earlier treatments, with a combination of calcifications present.
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Figure 33: Calcified canal with mesial root of 1st maxillary molar
1. The length of the canal from the actual anatomic foramen to the CDJ increases with the deposition of cementum throughout life. The advantage of this situation in the treatment of teeth with vital pulps is countered by the presence of necrotic, infected debris in this longer canal when periapical pathosis is already present.
2. The actual CDJ width or most apical extent of the dentin remains constant with age.
3. Flaring of the canal should be performed as early in the procedure as possible to provide for a reservoir of irrigation solution and to reduce the stress on metal instruments that occurs when they bind with the canal walls. Thorough and frequent irrigation should be performed to remove the debris that could block access.
4. Hybrid technique should be preferably used because the canals are narrow and thin.
5. Files with a triangular or square cross section may penetrate into the walls with greater force than the fracture resistance of small files (when used with a reaming action) and result in instrument fatigue and fracture. The benefits of instruments with no rake angle and a crown down technique should be considered.
6. Because this CDJ is the narrowest constriction of the canal, it is the ideal place to terminate the canal preparation. This point may vary from 0.5 to 2.5 mm from the radiographic apex and be difficult to determine clinically.
7. Calcified canals reduce the clinician’s tactile sense in identifying the constriction clinically, and reduced periapical sensitivity in older patients reduces the patient’s response that would indicate penetration of the foramen.
8. Increased incidence of hypercementosis, in which the constriction is even farther from the apex, makes penetration into the cemental canal almost impossible.
9. Achieving and maintaining apical patency is more difficult. Apical root resorption associated with periapical pathosis further changes the shape, size, and position of the constriction.
10. The use of electronic, apex finding devices is sometimes limited in heavily restored teeth when contact with metal can bleed off the cement.
11. The frequency and intensity of discomfort after instrumentation has not been shown to be related to the amount of preparation, the type of interappointment medication or temporary filling, the pulp or periapical status, the tooth number or age, or whether the root canal filling is completed at the same appointment.
12. The more constricted dentin and cementum junction (DCJ) permits a much smaller pulp wound and resists penetration, even with the initial small files. Patency is difficult to establish and maintain.
13. Dentin debris creates a matrix early in the preparations and further reduces the risk of over instrumentation or the forcing of debris into the periapical tissues, which could cause an acute apical periodontitis or abscess. Further access to periapical tissues through the canal is likewise limited.
Intracanal Medicaments :
i. calcium hydroxide, this is antimicrobial agent and inhibits growth between appointments and also may release periapical inflammation. It is indicated if pulp is necrotic and canal preparation is essentially complete.
ii. Phenols and aldehyde, chlorhexidine and corticosteroids are also used as intracanal medicaments, as these act as anti-inflammatory and antimicrobial agents.
Obturation :
1) For the elderly patient, the prudent clinician selects gutta-percha filling techniques that do not require unusually large midroot tapers or generate pressure in this area, which could result in root fracture.
2) Coronal seal plays an important role in maintaining the apically sealed environment and has significant impact on long term success. Even a root-filled tooth should not have its canals exposed to the oral environment.
3) Permanent restorative procedures should be scheduled as soon as possible and intermediate restorative materials selected and properly placed to maintain a seal.
4) Then Glass ionomer cements are of value for this purpose when mechanical retention is not ensured with the preparation.
5) Vertical compaction and thermafill technique should be used carefully or avoided as it may damage the thin periodontal ligament.
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Figure 34: Obturation of mandibular molar
G. CONSIDERATIONS IN SURGICAL THERAPY
1. Generally considerations and indications for endodontic surgery are not affected by age. The need for establishment of drainage and relief of pain are not common indications for surgery.
2. Anatomic complications of the root canal system, such as small or completely calcified canals, nonnegotiable root curvatures, extensive apical root resorption, or pulp stones, occur with greater frequency in older patients.
3. Perforation during access, losing length during instrumentation, ledging, and instrument separation are iatrogenic treatment complications associated with treatment of calcified canals.
4. Medical considerations may require consultation but do not contraindicate surgical treatment when extraction is the alternative.
5. In most instances surgical treatment may be performed less traumatically than an extraction, which may also result in the need for surgical access to complete root removal.
6. A thorough medical history and evaluation should reveal the need for any special considerations, such as prophylactic antibiotic premedication, sedation, hospitalization, or more detailed evaluation.
7. Local considerations in treatment of older patients include an increase in the incidence of fenestrated or dehisced roots and exostoses.
8. The thickness of overlying soft and bony tissue is usually reduced, and apically positioned muscle attachments extend the depth of the vestibule.
9. Smaller amounts of anesthetic and vasoconstrictor are needed for profound anesthesia. Tissue is less resilient, and resistance to reflection appears to be diminished.
10. The oral cavity is usually more accessible with the teeth closed together because the lips can more easily be stretched. The apex can actually be more surgically accessible in older patients. Agility to gain such access varies with skill of the surgeon; however, some areas are unreachable by even the most experienced clinicians.
11. The position of anatomic features, such as the sinus, floor of the nose, and neurovascular bundles, remains the same, but their relationship to surrounding structures may change when teeth have been lost.
12. The need may arise to combine endodontic and periodontic flap procedures, and every effort should be made to complete these procedures in one sitting.
13. To maintain periosteal vascularity the gingiva should be kept moist through out the surgical procedure.
14. Papillae preservation flap surgery should be performed in case of preexisting crowns to avoid gingiva recession post surgery so that crown margin remains unexposed.(Figure 31)
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Figure 35: papillae preservation flap surgery in preexisting crown
15. When apicoectomy is to be performed, the surgeon must consider whether the root that will be left is long enough and thick enough for the tooth to continue remain functional and stable. This factor is especially important when the tooth will be used as an abutment.
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Figure 36: Apicoectomy
16. Hemisection ,bicuspidization surgery will be contraindicated in conditions of severe bone resorption and gingival recession.
17. Ecchymosis is a more common postoperative finding in older patients and may appear to be extreme. The patient should be reassured that this condition is normal and that normal color may take as long as 2 weeks to return. The blue discoloration will change to brown and yellow before it disappears. Immediate application of an ice pack after surgery reduces bleeding and initiates coagulation to reduce the extent of ecchymosis. Later, application of heat helps to dissipate the discoloration.
18. Use of lasers during surgery gives bloodless field and reduces chair time.
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Figure 37: laser procedure
H. SUCCESS AND FAILURES OF GERIATRIC ENDODONTICS
1. Factors leading to failures increases with age as a result of this retreatment is more common in older individuals.
2. Rate of bone formation and normal resorption decreases with age and also ageing results in greater porosity.
3. Overlooked canals are a more common cause of failure in older patients, which explains the increased clinical indications for retrograde fillings when surgical treatment is attempted.
4. In geriatric patients 6 moths recall visit may not be adequate and it may take as long as 2 years to produce healing that would occur at 6 minutes in an adolescent.
5. Healing potential is overall reduced in geriatric patients
Preventive dentistry for the older adult61
Goal
1) Increase awareness of prevention of oral disease
2) Promote oral hygiene practices
3) Dental education and promotion of dental hygiene programs
Preventive dentistry components
1) Mechanical plaque removal
- Basic and essential oral home care procedure which prevents caries, periodontal disease and enhances overall sense of well being
- The preferred method of brushing for most elders is sulcular brushing with soft tooth brush (bass method)
- Persons having gingival recession should brush with extra soft toothbrush, use very light pressure or modify the brushing method (roll stroke method). Brushing should be effective and thorough, people with diminished manual dexterity may use automatized or adaptive toothbrush/electric toothbrush.
- Use of dentifrice is recommended as it helps to loosen plaque and remove plaque from tooth surface, inhibit calculus formation.
2) Interproximal plaque removal
Use of Dental floss/dental tape are difficult for the impaired manual legerdemain elderly person to hold or one with proper use is important or else causes gingiva tear or inflammation
Interproximal brush is easier to use
a) Gauze / pipe cleaner
b) Rubber tip
c) Balsa wood wedges
3) Rinses
Certain rinses may be beneficial to individual’s oral health whereas others may be adverse or may exacerbate existing pathological conditions. It is important for the dental professional to determine if any rinse used on an elderly person is enhancing oral health or having a questionable or deleterious effective cosmetic rinse used for mouth freshening effect.
1) Contains alcohol which is dehydrating and irritating effect
2) Mask underlying causes of oral diseases like halitosis causing delay in seeking dental treatment therapeutic rinses are more useful
- Chlorhexidine, sodium benzoate, sangunaria, etc.
Chlorhexidine in elderly
1) Predominantly effective in gingivitis
2) Effective against variety of plaque bacteria
3) Elderly who have undergone periodontal surgery
4) In F.P.D to maintain tissue integrity
5) Decrease oral mucositis and candidiasis in immune-suppressed patients who are undergoing bone marrow transplants and in oncology patients undergoing intensive chemotherapy.
Role of topical fluoride
Topical fluoride in the form of gels, varnishes, rinses or dentifrices play an important role in caries prone older patient, decrease risk of root caries.
Remineralising rinses
An elderly person who continually experience new coronal or root carious lesion as a consequence of severe xerostomia can be helped to maintain dentition by, use of remineralising solution that replaces calcium and phosphate loss from enamel or cementum during the caries process.
Plaque control for the elderly with physical limitations
1) Electric brushes à having enlarged handles for good grip
Limitations – Prosthetic heart valves pacemakers
2) Adoptive aids – in arthritis patients
Enlarge handle
1) Washcloth
2) Aluminum foil
3) Insert handle into sponge rubber ball, plastic bicycle handle grip, sponge hair roller, velcostrap to reduce shoulder pain
Care of Soft tissues
Dentures should be removed before recuperate for night
- Relief of compression of soft tissue and massage the tissues under denture
- Ask patients to check for any inflamed or irritated areas and see the dentist for the same
Denture care
Importance of cleaning dentures are
1) Stain, plaque, calculus formation is removed
2) Breeding ground for bacterial and fungal organisms
3) Esthetics
4) Offensive mouth odor
Immersion (soaking) cleansers like salt water, water, alkaline peroxide.
Dependent Patient
Elderly patients may be severely debilitated, physically handicapped, semiconscious or mentally incapable of carrying oral hygiene procedures, in such situation care take/caregiver should be instructed.
Preventive dentistry services for elderly in community
1) Educational presentation – Tell, show, do
2) Counseling
3) Screenings
Long term care institutions
1) In service training of staff, nurses, occupational therapists and dietary staff
2) Oral health assessment of patients to assist the staff dentist in determining priority of need for dental care among patients
3) Helping to determine which patients require total oral care by nursing staff and those who might be capable of being trained to perform total or limited oral self-care
4) Provide instructions to patients for self-care
5) Provide identification labels to all dentures
6) Perform prophylaxis and fluoride treatment
CONCLUSION
A large portion of our population consists of the old or the aged. Treatment of geriatric patients require special care as the treatment procedure is more multifaceted. It can be seen that geriatric restorative and endodontic care will gain a more significant role in complete dental care as our aging population recognizes that a complete dentition, and not complete dentures, is a part of their providence.
The needs, expectations, desires, and demands of older people may exceed those of any age group, and the gratitude shown by older adult patients is among the most satisfying of professional experiences. While it is surely wonderful that more geriatric patients are actively seeking dental treatment, it is also true that restorative and endodontic treatment for these patients is far more challenging and hence every specialty dentist will be primed to meet the challenge.
Old age is not a contraindication for restorative and endodontic treatment. Interest to redeem their natural dentition to outlast their lives has developed in all of us. For this goal we dentists should work towards the population of older people to have their full masticatory complements.
The impoverishment of hour is to keep this age group in mind while formulating dental education programs which can provide advanced training in geriatric dentistry and increase awareness through improved curriculum, research and publications on aging.
Respect the Old When You Are Young. Help the Weak When You Are Strong. Confess the Fault When You Are Wrong.
Because One Day in Life You Will Be Old, Weak And Wrong - Buddha
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