The Ageing Population

Question 1

Gerontology:

Answer 1

the study of social, psychological and biological aspects of ageing

Question 2

Geriatrics:

Answer 2

the branch of medicine which studies diseases in the older adults

Question 3

Gerontologists use 3 sub-groups:

Answer 3

Young old (65-74yrs), Old (75-84 yrs), Oldest old (85+yrs)

Question 4

Gerodontology :

Answer 4

dentistry for >65 year old

Question 5

Oral health trends

Answer 5

Adults retaining natural teeth into old age with fewer becoming edentate

Proportion of edentulism is declining:
28% (1978) —> 6% (2009)2

Proportion with >21 teeth1:
74% (1978) —> 86% (2009)

It is estimated by 2028, only 8% of 65-74yrs in UK will be edentate

Question 6

Challenges in dentistry

Answer 6

• positive attitude towards maintains dentition
• negative attitude towards extraction
• negative attitude towards dentures

Increasingly, accessible sources of info - older patients are better informed - less willing to accept tx based around removal of teeth and complete replacement dentures.
*Those who loose natural teeth tend to do so later in life, when many find it harder to accept removable prosthesis over natural teeth, later stage.

Question 7

What is the biggest reason for decrease in sound untreated teeth

Answer 7

Age is the biggest reason for decrease in sound and untreated teeth

Question 8

What age group is more restorative dentistry seen in and what are the challenges relating to this?

Answer 8

Complex restorative dentistry is increasingly prevalent in >45yrs

More maintenance, as more enter the ‘restorative cycle’
Maintenance of fixed multi-unit bridges and implants pose a huge challenge for those no longer able to maintain oral hygiene
Delivery of clinical care can be more challenging due to medical and social issues

Question 9

Medical considerations

Answer 9

1. Can directly influence oral tissues and health
   For example: diabetes, radiotherapy, poly-pharmacy
2. Can indirectly influence oral health
   For example: CVD, CVA, COPD, Arthritis, neurological deficit
3. Can limit ability to access/cope with treatment
   For example: CVD, COPD, Arthritis, neurological deficit

Influence on treatment planning…

Question 10

Give examples of the medical considerations that can affect treatment planning

Answer 10

DM poorly controlled= oral candiosis, angualr cheilitus, DRS. Dry mouth. Perio. Dx. And healing. ME. Hypoglyceamia.
RT= mucositis, xerostomia, mronj.
CVD= Infective endocardiditis. Meds and bleeding risk. Link to perio vv. Meds- s/e inc lichenoid rxn, ulcers, ginival hyperplasia. ME postural hypotension, faiting, angina, MI.
CVA= Meds and bleeding. Commonest cause of adult disability. OHE ability. Communication difficulty- speech. Poor denture control. Mobility issues. Consent. ME act FAST.
COPD= access, LOT. RF for oral cancer.
Neurological deficit= dementia and Alzheimer’s Disease.

Question 11

Medical considerations - explanation of activity

Answer 11

Question 12

Challenges in treating older cohort

Answer 12

• older pt more likely to attend, this decreases above age 85yo.
• dental anxiety decreases with age but increase over 85yo.
• Mobility: wheelchair etc, arthiritis, stroke.
• Rely on public transport
• An elderly patient’s living arrangements can influence access to oro-dental care.
• Independence: totally independent; frail, but with some independence; or ‘functionally’ dependent
• Teeth are probably a low priority for somebody who has CVD + bunions + RA probs.

Question 13

Approach to managing older pt

Answer 13

• Thorough assessment vital
• Build rapport with pt
• Patient-centred targets
• Assess wider issues such as social and familial support, transportation needs, anxiety issues, consent and perceived need for treatment.
• Work with practices, health authorities and colleagues to orient services appropriately
• Care aimed at maintaining OHR and pt quality of life
• Minimally invasive dentistry

Question 14

Primary prevention strategy for older pt

Answer 14

Same as any pt cohort

However there are specific challenges we need to consider for this group of pt

Question 15

What is biotene

Answer 15

JP pronamel + duraphat

Biotene:
Marketed to tx. dry mouth- reduce caries risk and improve oral comfort.

Biotene: mouthwashes, gels and toothpastes previously contained bioactive enzymes to protect teeth and soft tissues.

Biotène used to relieve symptoms of dry mouth by providing moisturizing relief.
Biotène alone does not act via prevention of plaque build-up mechanism or antimicrobial chemotherapeutic mechanism.

The main active ingredient in its toothpastes is sodium monofluorosulphate prior to theGSKacquisition, previously contained it a enzymes such as glucose oxidase, lactoferrin, lysozyme with antibacterial and healing properties.

relieve pain within the oral mucosa,
reduce swallowing effort
increasing the individual’s quality of life

The four products are categorized by their main function.
Mouth Spray and Oral balance Gel are products for an individual requiring immediate relief.
Mouth Spray- instant moisturizing by directly spraying it into the mouth onto the surface of the tongue. The spray contains a high concentration of moisturizers and lubricants that provide moisturization for up to 2hrs, and freshens the breath with its mild mint flavour. This product is to be used throughout the day as needed.
The Oral balance Gel provides soothing relief from dry mouth by placing 1-2 cm of gel directly on the tongue and spreading it inside the mouth. It provides a long-lasting 4hr relief from the feeling of dryness while sleeping, and lubricates the mouth to aid in swallowing food. The gel also has a pH similar to natural saliva.
For constant relief in their daily routine, the options are Toothpaste or Mouthwash. Toothpaste- provides extra protection, gentle and non-irritating, has pH similar to saliva and contains fluoride. This product is to be used with daily brushing, 2 to 4 times.
Mouthwash is alcohol-free and immediately refreshes and moistens the mouth, high concentration of moisturizers and lubricants. the mouthwash helps maintain a neutral pH.15mL Mouthwash for 30 seconds after toothbrushing. This can be done up to 5 times per day.

Xero also: Avoid caffeine, tobacco, alcohol. Reduce salt in food. Room humidifier. Practice breathing via nose. Change meds? OTC?

Tooth mousse:
Anticariogenic complexes of amorphous calcium phosphate stabilized by casein phosphopeptides: a review.
- Evidence to date has highlighted a several-fold increase in tooth remineralization through the additive effects of fluoride, calcium and phosphate.

RecaldentTM which is sold for professional use as Tooth Mousse (10% CPP–ACP) as MI Paste Plus (in combination with 900 ppm fluoride).
In night guard for sens teeth.

Question 16

What is the best way to clean a denture

Answer 16

• Aim: disturb the biofilm on the denture
• Cochrane Review: Interventions for cleaning dentures in adults
• Poor quality evidence
• Weak evidence to support enzyme cleaners/ effervescent tablets
• Brushing with pastes can remove plaque and kill microbes better than inactive treatments.

Conclusion:
- No firm evidence to support brushing v. soaking in denture cleaner
- Both methods better than soaking in water

Question 17

How should pt clean their denture

Answer 17

Aim to remove PBF
Gentle brushing with soap (liquid detergent dish washing liquid) and warm water
NEVER clean your dentures with boiling or very hot water. - warp and effect its fit.

After cleaning, always rinse
- Brush with small-headed toothbrush - all the awkward corners.
- Use a soft to medium texture brush to avoid damaging the denture.
- NEVER use abrasive agents, powders or normal toothpaste on dentures. scratched acrylic surface- difficult to clean / prone to plaque accumulation+ staining.
- Morning and night. At least once a day is essential.
- Rinse after meal
- When your dentures are out, lightly brush your gums, palate and tongue then rinse the mouth.
Store in cold water / dry

As an adjunct eg DRS, the denture can be soaked twice a week in 0.1% hypochlorite solution or chlorhexidine solution for 20minutes.
sodium hypochlorite (such as Milton or Dentural). A couple of teaspoons of Milton to a glass of water. NOT suitable for dentures with metal plates or parts.

Milton tabs cold sterilisation
Active Ingredient: Troclosene Sodium
How to Use:
1 Clean Wash in warm soapy water, then rinse in cold water. 2 Prepare solution Fill your unit with 5L water, add 1 Milton Tablet.
3 Add items Close the lid and in just 15 minutes everything is ready to use. No need to rinse. Items can stay in the solution until needed.
Solution 1.89£ 500ml Milton Complete Protection Sterilising Fluid. 5L of water, add 30 ml (one capful) of Milton Sterilising Fluid (dilution at 0.6% v/v).

Metal dentures: Should be soaked in chlorhexidine mouthwash

Specialist denture cleansers:- Lots: two main types, crèmes (applied directly to the denture) and tablets (dissolved in water to make a solution).

Question 18

How often should you wear a denture

Answer 18

Leave your denture out at night. This will give your mouth a rest from the pressures of the denture. Allow saliva to circulate more freely in your mouth. Help prevent gum irritation and infections. At the very least, try to leave your denture out for a few hours a day.

Question 19

Considerations for treatment

Answer 19

Appreciate the circumstances unique to every patient
Work with patients to achieve patient-centred targets
Work with practices, health authorities and colleagues to orient services appropriately

…Be aware of local health trends

Question 20

Consider challenges and aetiology for oral condition

Answer 20

You may have thought about things such as OHE, Fluoride, dietary advise.

Lets consider some challenges:
- Reduced mouth opening
- An inability to tolerate long appointments
- Reduced dexterity

For a final time: create a visit-by-visit plan for this patients diagnoses:
Stage III grade C periodontitis – unstable, associated with oral hygiene
The patient has reduced dexterity so what tools could you use in the management of this
The patient struggles with long appointments, so how can we help to overcome this barrier: different chair position or is it better to strategically book appointments. Is a certain time of day or day in the week that is better?
Multiple carious lesions: some teeth are unrestorable – this may to be reassessed by a dentist

There are a large number of carious lesions – what is the aetiology of these. Radiotherapy/dry mouth are associated with this type of lesion
How will you treat these: what materials would work best, what preventative tools will you use
Practically: if mouth opening is reduced, are you aware of materials that might work better, or tools that may help you to achieve a better long-term restoration?