Elderly patients Flashcards
What challenges are there when managing older patients?
- Difficult to know who needs treatment as they often won’t seek treatment unless absolutely necessary
- medical issues might take priority so dental issues ignored
- Can they get to the surgery?
- Do we visit them at home?
- Do we provide an ambulance/taxi to bring to surgery for treatment
- issues affecting treatment of complete dentures - consequences of age and tooth loss
- lack of compliance
What are some common dental pathologies that the elderly face?
Denture stomatitis oral cancer denture granuloma lichen planus oral infections
What problems can the surgery cause for the elderly patient?
- access issues
- toilet
- lighting
- busy environment
- time
- noisy
- postural problems so chair is issue
- intolerant of long procedures
How can we make the dental experience easier for the elderly patient?
Seating – keep upright, or slowly alter position
Noise – low tones, reduce noise and speed
Confusion – reduce speed, less instruction-
- check medical history (GP or family)
Timing of appointment – medication, capability,convenience
How can we adapt the dentures without making massive changes that would be difficult for them to get used to?
Make small changes to existing dentures
-reline
=adapt existing denture
Copy existing dentures, having made alterations
Make new dentures that are similar to some aspects of previous dentures
How can age affect the treatment process?
Assessment and examination
-Rapport with patient
-Getting a clear medical history
-Understanding the patient’s problems
-Deciding on appropriate treatment
-Deciding on where best to treat the patient
AND
Ability to adapt to denture wearing
How can consequences of tooth loss affect the treatment process?
Affects
- impression taking,
- jaw registration,
- retention and stability of the denture
- and ability to wear the denture
What is the alveolar ridge?
After loss of the teeth the remaining alveolar bone forms the alveolar ridge
gives support to a denture
part of the denture-bearing area.
How much more resorption is there of the mandible compared to the maxilla?
4 times
Where is the resorption greater around an individual tooth?
Around an individual tooth, resorption is greater where the cortical plate is thinner
What does loss of teeth in the maxilla lead to?
loss of the teeth leads to:
greater loss of the thinner buccal cortical plate with gradual reduction in the width and length of the residual ridge
What does loss of teeth in the mandible lead to?
- Anteriorly - the buccal plate is slightly thinner so the residual ridge apparently moves slightly lingually
- In the premolar region - the buccal and lingual plates are of equal thickness and the residual ridge maintains its position
- In the molar region - the buccal plate is reinforced by the external oblique ridge, resorption of the thinner lingual plate occurs and there is apparent movement of the residual ridge buccally.
What happens if there is too little resorption?
- bulky alveolar ridges with little space to place dentures
- frequent denture fracture OR excessive face height (as increasing size of denture gives adequate strength)
What happens if there is irregular resorption?
- sharp bone
- tissues traumatised under dentures leading to ulcers/discomfort
- surgical reduction of ridge may be needed
What happens if there is excessive resorption?
- normal relationship of posterior teeth may be changed
- increase in width of mandible posteriorly - posterior crossbite
- anteriorly, buccal resorption of maxilla predominates with edge to edge incisor relationship or prominent mandible may occur
- in the mandible - mental foramen may become superficial
- mylohyoid ridge on lingual aspect of mandible becomes sharp and prominent
- both = pain during denture wear
What are the useful clinical techniques to help prosthetic treatment?
Check record
Windowed trays on a primary impression (window filled with fluid impression material to accommodate the flabby ridge) - anterior flabby ridge
Neutral Zone Impression Technique - anterior section of registration rims replaced by impression material
Retained roots - preserve alveolar bone
Polycarbonate - reduced likelihood of midline fracture
Soft Liners - more comfortable base over irregular ridges, processed onto denture in labs
oral surgery - implants, sulcus deepening, ridge augmentation
What is healthy life expectancy?
Summary measure of population health, estimates
based on question ‘How is your health in general?’ (Very
good, good, fair, bad, very bad)
What is disability-free life expectancy?
Estimates based on those who answer yes to both:
• Do you have any physical or mental health conditions or illnesses
lasting or expected to last 12 months or more?
• Does your condition or illness/do any of your conditions or
illnesses reduce your ability to carry out day-to-day activities?
What is the biggest reason for decline in sound and untreated teeth?
Age
What is ageing?
Ageing as the combination of biological,
psychological and social processes that affect
people as they grow older
– Physical changes to the body
– Shifts in mental processing capacity
– Changes in society and the social context in which
people are ageing
• Age and ageing are therefore multidimensional
and so the study of ageing involves different
constructs aimed at these dimensions
What is age strata?
people who share similar social rights
and duties by virtue of age
What is age cohort?
people born at a particular time who
have experiences in common
What is the disengagement theory?
Functionalist theory (focuses on how elements of society work together) • Growing old as ‘inevitable mutual withdrawal or disengagement, resulting in decreased interaction between an ageing person and others in the social system he belongs to’ (Cumming and Henry, 1961, p.227) • Irreversible process
- backed by the fact that older people choose to visit the dentist less frequently
but when interviewed people want to keep their teeth - not about withdrawal from society
What is the structured dependency theory?
Individuals are not free to act in any way they see
fit
• Structured dependency theory approach focuses
on ways in which social institutions shape
people’s lives (see Walker, 1980; Townsend, 1981)
• Dependency structured by retirement, poverty,
institutionalisation in residential and nursing
homes and the restriction of domestic and
community roles
- backed by access to oral care
What is cultural gerontology?
- focuses on role of culture
- multiple cultures of ageing with different representations of old age
- the third age (Life after responsibilities of paid employment
and child rearing) - the challenge of individualisation
- the fourth age - attributed to ageing bodies, appearance etc - starting at about 80/85, the last years of life (Life after responsibilities of paid employment
and child rearing)
What is critical gerontology?
critiquing and changing society
3 main areas - structural pressures and constraints, meaning, empowerment
- ageing as socially constructed
- Ageing negotiated by the individual, but
considering the role of economic and political
systems in shaping power arrangements and
inequalities
What demographic population changes are occurring?
- Increase in numbers of older people
- People are living longer
- Medical intervention & treatment
- Better social conditions
- Improvements in public health
- Women living longer than men
- Baby boomers of 1940’s & 1960’s
What are the influences on ageing?
- Genetic & environmental factors
- Life-style
- Effect of illness and disability
- Effects of medication
- Personality: Rigid/pessimistic or flexible/optimistic
- Psychiatric history
- Level of independence:
- Mobility
- Activities of daily living - washing, dressing, bathing, personal hygiene
What is the oral/dental status of older people?
- Increasing numbers are dentate
- More concerned with retaining teeth
- Dentate more likely to attend regularly
- Greater expectations from dental services
- Greater awareness of oral & dental health
- More frail/functionally dependant who are dentate
What did the national service framework for older people 2001 do?
- Set national standards of care across health and social services for all older people
- ‘Person-centred care’ area included the single assessment process (SAP) which had an oral assessment component
- Rooting out age discrimination
- Promoting older peoples’ health & independence
- Fitting services around peoples’ needs
What were the recommendations for meeting the challenges of oral health for older people: a strategic review?
- Extended consultation to plan long-term dental care needs
- Train more dentists in gerodontology
- Equip other health professionals with oral health-care skills
What does NICE Guidance 48 say?
This guideline covers oral health, including dental health and daily mouth care, for adults in care homes.
The aim is to maintain and improve their oral health and ensure timely access to dental treatment.
What are the barriers to dental care for older adults?
- Medical problems
- Drug interactions
- Ability to understand and tolerate treatment
- Financial
- Access
- Low expectations
- Acceptance of loss of function and pain
What are the benefits of oral health care for older adults?
- Improve eating
- Improve speech
- Improve facial appearance
- Decrease pain
-All help to reduce social isolation. - Poor masticatory function may mean a poor/
restricted diet.
What are common oral health problems for older people?
Tooth loss and replacement
Tooth wear
Collapsing/failing/terminal dentition
Dry mouth due to medication
Compromised self-care due to disability
What is happening to the demographic of older people retaining teeth?
- Decreasing proportion of edentulous
- No previous denture wearing experience
- Doing so later in life
- Less able to learn skills
- High expectations
- Greater challenge to the profession
What can a dry mouth lead to?
- Difficulty in wearing dentures
- Root caries
- Difficulty with mastication
- Difficulty with speech
- Soreness & ulcers
- Lack of appetite
What is the shortened dental arch concept?
Kayser showed as long ago as 1981 that anterior teeth and premolars can, at least for several years, compensate for the function of molars
Recent follow-up studies by; Witter, Kayser et al have shown that SDA’s do provide occlusal stability & do not correlate with signs & symptoms of TMJ dysfunction. J Oral Rehab 1994;21 ;113-125 & J Oral Rehab 1994; 21 :353-366
So we can be quite justified in removing heavily broken down molars which have a poor life expectancy if we have 10 occluding pairs of teeth in th 40-80 age group or 8 pairs in the over 70’s.
What are the treatment challenges in the Community?
- Accessing those who currently not seen by a dentist
- Assessments and screening
- Treatment planning
- Patient management
- Treatment
What do the national care standards 2003 say about oral health service for older people?
No service user moves into a residential home without having a needs assessment, and this must include oral health
Care staff must maintain personal and oral hygiene of each service user
Service user must have access to dental services
How is assessment and screening of older people’s oral health carried out?
Assessments of referrals often done on domiciliary basis
Screening of medium/long stay units
Screening of homes - some carried out by the Salaried Service
12 GDPs in ROCS project covering 98% Care Homes in Sheffield
How is treatment planning for older people approached?
- Problem oriented approach to immediate treatment needs
- Multidisciplinary approach
- Maintenance of quality standards
- Repair not replace
Informed consent - Evaluation of provisional treatment plan
- Maintenance of oral hygiene
- Simple patient specific treatments
How are older patients managed?
- Well trained and capable support staff
- Contact with outside agencies eg carers/GP’s
- Organisation of transport
- Moving and handling
- Senior Colleagues
How to deal with prevention in older patients?
- Continuing Care and regular visits/recalls.
- Familiarity with the patient and carers.
- Communication
- Developing a working relationship with the carers.
- Involvement of the whole dental team
- Training Care Staff in Oral Health Promotion.
How may age of the patient affect the assessment, examination and post denture stages?
-Rapport with patient
-Getting a clear medical history
-Understanding the patient’s problems
-Deciding on appropriate treatment
-Deciding on where best to treat the patient
AND
Ability to adapt to denture wearing
What stages do consequences of tooth loss affect?
Impression taking
jaw registration
retention and stability of the denture
and ability to wear the denture
What happens in the maxilla after a loss of the teeth?
Leads to greater loss of the thinner buccal cortical plate with gradual reduction in the width and length of the residual ridge
What happens in the mandible after a loss of the teeth?
Anteriorly - the buccal plate is slightly thinner so the residual ridge apparently moves slightly lingually.
In the premolar region - the buccal and lingual plates are of equal thickness and the residual ridge maintains its position.
In the molar region - the buccal plate is reinforced by the external oblique ridge, resorption of the thinner lingual plate occurs and there is apparent movement of the residual ridge buccally.
What are the problems with increasing the size of the denture to give adequate strength in too little resorption?
Compromises appearance
encroaches FWS
compromises function - unable to speak, eat
What is a summary of the oral health survey by PHE? (for older people)
Older adults are less likely to rate their oral health as good, and appear to have poorer oral health related quality of life
Difficulty of access for older adults living in care homes
Limited knowledge about provision by ‘care in your home’ services
Focus on oral hygiene and denture cleaning, need for training on recognition of urgent problems
What are the dimensions of age?
Chronological (length of life measured in years since birth)
Biological (physical ageing, based on changes in health, fitness, functioning and appearance)
Social (norms and expectations relating to age)
Personal (moment in the life course reached in relation to personal aims)
Subjective (how we feel ‘inside’)
What is the life course?
a sequence of socially defined events and roles that the individual enacts over time”. In particular, the approach focuses on the connection between individuals and the historical and socioeconomic context in which these individuals lived.
What are various mechanisms that affect experiences of dentistry and oral health?
Legal rule changes
Ongoing research
Social campaigning
Changes to beliefs > changes to social rules/norms
Shaped by social, cultural and material changes
What are the four ages of life?
First Age: an era for dependence, socialization, immaturity, and learning
Second Age: an era for independence, maturity, responsibility, and working
Third Age: an era for personal achievement and fulfillment after retirement, and
Fourth Age: an era for the final dependence, decrepitude, and death
What is the oral care as a life course project? (goals, values, practices, outcomes)
GOALS – developing a plan to keep one’s teeth into older age.
VALUES – seeing good teeth as important, age appropriate ideas
“THE GOOD DENTIST”,
PRACTICES – tooth brushing, dental attendance, having work done,
OUTCOMES – DMFT, OHRQoL
What are the characteristics of ageing?
Increased mortality
Increased susceptibility & vulnerability to disease
Changes in biochemical composition of tissues - Increased protein crosslinking, aberrant folding, lipofuscin accumulaton
Decrease in physiological capacity
Reduced ability to respond to environmental stimuli
What is Galen’s theory of ageing?
Changes in body humours beginning in early life
Slow increase in dryness & coldness of the body
What is Roger Bacon’s theory of ageing?
Wear & tear theory
Result of abuses & insults to the body
Good hygiene may slow process
What is Hutchinson-Gildford Progeria?
Rare genetic disorder
Mutation in LMNA encoding nuclear envelope protein: lamin A
Affects RNA transcription & chromatin organisation
Lack of DNA strand rejoining after irradiation
Accelerated ageing (atherosclerosis)
Usually die by 13
The altered protein makes the nuclear envelope unstable and progressively damages the nucleus, making cells more likely to die prematurely.
What is Werner syndrome?
Mutation in WRN, DNA helicase family
‘caretaker of the genome’: DNA repair and transcription
Baldness, hair and skin ageing, calicification of vessels, cancers, cataracts, arthritis, diabetes
Die by age 50
How many times do cells usually divide?
50 times
What are telomeres?
DNA sequences
Protect the ends of chromosomes
Progressive shortening with age
What does telomerase do?
Reverse transcriptase
Stabilizes telomere
length
As a cell begins to become cancerous, it divides more often, and its telomeres become very short. If its telomeres get too short, the cell may die. Often times, these cells escape death by making more telomerase enzyme, which prevents the telomeres from getting even shorter
How does molecular ageing occur?
Intrinsic thermodynamic instability of biomolecules
3D structure cannot be maintained
Conformational change, aggregation, precipitation, amyloid formation
Free radicals
Accumulation of oxidative damage in proteins & DNA
Damage to mitochondrial DNA:
e- leak from e- transport, form free radicals leading to more DNA damage
Why does calorific restriction reduce ageing? (3 reasons)
Reduced oxidant production by mitochondria- less ROS damage
Induction of SIRT1- key regulator of cell defence
Increased protein turnover- lack of accumulation of damaged protein
How did institutionalised elderly people compare to free living in the national diet and nutrition survey 1999?
Institutionalised has a lower mean number of teeth, higher decay, unsound teeth, more unsound teeth, more root caries and heavier plaque deposits
How many occluding pairs are needed for age 20-50, age 40-80 and age 70+?
20-50 - 12 pairs optimal
40-80 10 pairs suboptimal
70+ 8 pairs minimal
