The Ageing Dentition Flashcards
what is the life course of a dentition
primary dentition
secondary dentition
partially dentate
edentulous
what are the reasons that teeth can be missing
- congenitally missing
- trauma
- head and neck cancer
- periodontal disease
- dental caries
- endodontic infection
- NCTSL
- exfoliation
what are the risk factors for losing teeth / missing teeth
- socio-cultural
- environmental
- lifestyle
- medical status
- HPV
- alcohol
- smoking / tobacco use
- nutritional deficiency
- genetic
- socioeconomic status
- sugar
- oral hygiene
- access
- impairment / disability
- salivary flow
- health system
what are some of the challenges of the aging population
• Increased number of people with long term conditions
○ An estimated 4 million older people in the UK (36% of people aged 65-74 and 47% of those aged 75+) have a limiting longstanding illness.
• Increasing age with concurrent increase in co-morbidities (55-98%) ○ - Cardiovascular Diseases and Stroke ○ - Cancer ○ - Diabetes ○ - COPD
• Polypharmacy
○ Over 65s currently taking 10 medications or more = 16.4%
○ An older patient on multiple medications (many of which will have mouth dryness as a side effect) means the effect is compounded so dry mouth can be quite profound
§ A dry mouth can cause riot for your oral health and your quality of life in these situations
in regards to dental care, what impact does the aging population and systemic disease have
- A population at an increased risk of oral disease
- Polypharmacy
- Impaired ability to co-operate
• Access - moving and handling
○ Hoisting
○ Transfer to the dental chair
○ Mobility aids
- Medical conditions complicate the provision of dental treatment
- Medical conditions contraindicate the provision of dental treatment
what problems can the aging dentition experience
- poor oral hygiene
- caries
- periodontal disease
- oral mucosal diseases
- lichen planus
- head and neck cancer
why might an older person have poorer oral hygiene
- Perhaps the patient is relying on someone else to do their oral hygiene for them
○ Caring for Smiles is trying hard to address the training for someone caring for someone else’s oral hygiene - Perhaps the patient is caring for themselves but they have reduced co-ordination mobility, they don’t have strength in their arms to carry an electric toothbrush
○ Lots of barriers here
why can caries be a problem in the aging population?
what sort of caries causes the biggest problems
- Root caries is a real enemy in the older population
○ Root caries becomes circumferential which can then cause the crown to snap off
○ Especially if someone is wearing a partial denture the risk of root caries increases because there is extra plaque retention factors in the mouth where the gingival clasps are meeting
how does periodontal disease present problems in the aging population
- When patients have significant deep pockets it is a harbour for all the bacteria and periodontal pathogens
○ These pathogens have a potential link to both systemic and inflammatory disease
how can oral mucosal diseases impact elderly patients
- If the patients are not examined regularly then it is really easy to miss these fungal infections like denture induced stomatitis or ulcerative lichen planus
○ Things that can contribute to a poorer quality of life for the individual - You can also really commonly get traumatic ulcers
how can lichen planus cause problems to the elderly
- discomfort when eating
- Difficulty in performing oral hygiene
- Risk of malignant transformation
what can contraindicate certain therapies / treatments
• Systemic disease and polypharmacy may contraindicate certain therapies
○ Can be difficult to treat if they are already on multiple medications or have multiple other conditions which means they might not be able to tolerate our treatment for lichen planus (or other diseases)
○ Or that our treatment for this is actually contraindicated because of their other medical status as well
○ Can be complex
what is essential when treating a patient with head and neck cancer
Early Assessment, Diagnosis and Management are essential
but this doesnt happen often
why might patients not present with head and neck cancer until the disease is more advanced
○ Delay in diagnosis
○ Symptoms unable to be communicated
○ Lack of attention paid
○ Misdiagnosis
Or maybe they were treated inappropriately for their symptoms eg maybe they thought it was a fungal infection or something
what is the most common cause of death in patients with dysphagia associated with neurological impairment
aspiration pneumonia
in what patients does aspiration pneumonia usually occur
usually occur in older adults who are dependent
○ Often receiving their nutrition through a NG Tube or they might be peg fed so they are not necessarily eating orally
○ They are commonly mouth breathing
○ They can be dehydrated
○ Sometimes not receiving any regular oral hygiene
§ this is because some people believe if you are not eating then why would you need to clean the teeth
§ But can still get this build up of plaque and a kind of crusting is seen around the oral mucosa
is aspiration pneumonia preventable
This condition is entirely preventable
○ It is as simple as ensuring good oral hygiene measures on a regular basis
○ Unfair as an older person should expect to eb pain free and comfortable
○ A dirty mouth from a carer’s point of view can lead to a life threatening spread of infection and the patient’s quality of life being seriously compromised by this but it is so easy to fix
what does good oral hygiene mean for older people
- Having good social relationships
- Maintaining social activities and retaining a role in society
- Having a positive psychological outlook
- Having good health and mobility
- To enjoy life and to retain one’s independence and control over life
what are teeth important to older people
“Frail older people are positively influenced by natural teeth and this effect seems to increase with increasing frailty”
“Preservation of teeth contributes to a positive body image and self worth”
Important for nutrition as well
what is important in treatment planning for a patient in the early stages of dementia
- Should oral assessment be part of multi-disciplinary care of the person with dementia following diagnosis?
- Planning for the future as we consider the progressive nature of dementia
- Assessment
- Identify and attempt to retain “Key Teeth”
- Focus on high quality restorations
• Are complex restorative treatments able to be cared for in the long term?
○ Want to try and avoid complex treatment
○ You might not want to start crown and bridgework and implants ~ not saying don’t do it but do think about the future
○ Will this patient be able to care for this complex restorative work in the future, will the oral hygiene be there?
- Establish a preventative regime
- Good idea if the patient wears dentures is to consider taking replica impressions of these dentures because the chances are if this patient is going to go into a care home or hospital in the future they are very likely to get lost
why is it a good idea to take replica impressions of the denture
○ If a patient has dementia and loses their dentures then it can be tricky for them to get used to new dentures
○ Or can even be tricky for the dentist to construct the dentures
○ Good idea to have the replica dentures so you have them should these problems arise
○ There is an economic issue and a storage issue but with 3D scanning and imaging becoming more popular it might be possible to store on a computer
what are the key teeth to retain for quality of life
• Occluding pairs of teeth
○ Aid in mastication so this will improve nutrition
- Number of teeth
- Attempt to retain anterior teeth
why is keeping natural teeth through prevention better than complex treatments (ie the cure)
- Natural teeth have a significant impact on QoL
- Chewing and eating
- Nutrition
- Independence / pride and achievement
- Social aspects of life
what is important in treatment planning for a patient in the mid stages of dementia
- Maintenance and prevention are essential
- Ability to co-operate may deteriorate limiting the ability to provide care intervention
- Consideration must be given to medical status and its implications upon provision of care
- Access becomes increasingly more challenging
• Always go back to basics: teeth must be kept clean and healthy
○ Every day prevention
• Consider seeing the patient in a domiciliary setting such as going to their home or their care home
○ More settled and familiar environments
why can access be more challenging for these patients
○ Older people should have equal access to care as anyone else but this is not always the case
○ Legislations have improved access to premises, especially high street clinics
○ But patients who require ambulance transport can only be delivered to a hospital site so they cannot go to their general dentist on the high street in an ambulance
○ Now patients have to book their own ambulance transport whereas before it would have been done through the GP or through the dentist so this now means that this patient needs to have a good level of communication and understanding or that they have someone who is going to advocate for them and who is going to organise the transport and arrange a time and place etc
○ These patients mightn’t be allowed to bring family members or carers with them in ambulance transport (especially during COVID) and these patients might suffer from anxieties and phobias and they do need to be supported so sometimes it isn’t necessarily fear
○ As well as this, some older people are now eligible to pay for the dental treatment so this creates an added anxiety: can this patient actually afford to go to the dentist?
§ Just being in a care setting doesn’t always exempt them from paying
what is ART
atraumatic restorative technique
what are risk factors of restoration failure
○ Lower number of tooth brushings/day
○ Absence of prosthesis
○ Posterior location of the tooth
○ Higher baseline plaque index
how is ART carried out
○ Excavate your caries as far as possible without getting into the pulp
○ So you are wanting to remove the infected, soft, dentine but leave affected dentine as a layer on top of the pulp
○ Then you seal it in with glass ionomer
○ Similar to the Hall Technique where you cut off the food supply for the bacteria and the caries and this helps to stabilise things
○ Renders the tooth more cleansable and makes it easier for the older person or carer to clean
○ Doesn’t need loads of equipment so if you are treating on a domiciliary visit you can just do it with a spin excavator and some GI
Relatively quick
what is important in treatment planning for a patient in the late stages of dementia
- Focus on comfort
- Moist, clean and healthy mouth which is free of pain and infection
• Non-invasive
○ Don’t want to go in and do surgical on someone who is completely uncooperative and who doesn’t have capacity to consent and who doesn’t really understand what is going on
• Emergency management – limited options
○ Difficult ~ need to treat quickly but it is often very difficult to treat them
○ Options to be able to treat them are limited
are oral biofilm-based diseases controllable
yes
- We can control the reactants
○ We can control the environment and the oral hygiene and the sugar levels, give fluoride and operative intervention
○ We can balance this equilibrium and get good health - There are also other outlying factors which can influence things but we know that the biofilm based diseases can be controlled by local measures
- Very achievable but very dependent on the level and quality of care
what are the reactants in oral bio-film diseases
- oral hyigene (removal of biofilm)
- sugar
- level and quality of care
- teeth
- fluoride
- operative intervention where indicated
what are the products in oral bio-film diseases equilibirum
good / reasonable oral health if we get the balance right
if we get the balance right in the equilibirum of oral bio-film diseases for the elderly what are the outcomes
• Reasonable oral health, without pain or infection
○ Improve quality of life
- Oral comfort to allow for social interaction
- Limit operative dental care
- Avoid the challenges associated with sedation
- Avoid the significant morbidity and risks associated with General Anaesthesia
- Move away from pharmacological approaches to care to embrace philosophies centred around the individual
who is involved in the team approach to holistic care
- Carers
- Family and relatives
- Dentists and Dental Care Professionals
- Medical Professionals
- Public Health
what is the best way to communicate with a patient who has dementia
• Approach from the front
○ So they can see you coming
• Break it down tasks into steps – short words, simple sentences
○ Short and to the point so they know what is expected
• Non-verbal – smile, gentle touch
○ Build the rapport
• Get the environment right – quiet, avoid sensory overload
○ Privacy important
what communication techniques should be used for patients with dementia
- Rescuing
- Distraction
• Bridging
○ If they ask a question that the answer to it might upset them just give a brief answer and then move on
○ Pose a new question and try and kind of turn the conversation onto something else
• Hand- over- hand
○ Create contact
○ Means you can guide them and assist them when you are moving places
• Chaining
what act is there to protect vulnerable people
The Adults with Incapacity Act is there to protect vulnerable people
what is caring for smiles
- National programme to promote good oral health for residents in care homes
- Training carers
- Empowering carers and breaking down barriers
- Valuing dependent people and the people involved in their care
