Periodontal Treatment for Older Adults

Sue S. Spackman and Janet G. Bauer

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CHAPTER

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HAPTER OUTLINE
DENTAL AND MEDICAL ASSESSMENTS Review of Dental History Review of Medical History Review of Medication Use Extraoral and Intraoral Examinations Assessment of Risk Quality of Life PERIODONTAL DISEASES IN OLDER ADULTS Etiology Relationship to Systemic Disease PERIODONTAL TREATMENT PLANNING PREVENTION OF PERIODONTAL DISEASE AND MAINTENANCE OF PERIODONTAL HEALTH IN OLDER ADULTS Chemotherapeutic Agents Risk Reduction CONCLUSION

THE AGING PERIODONTIUM Intrinsic Changes Stochastic Changes Physiologic Changes Functional Changes Clinical Changes DEMOGRAPHICS Population Distribution Health Status Functional Status Nutritional Status Psychosocial Factors Dentate Status Periodontal Status Caries Status Dental Visits Xerostomia Candidiasis

lder adults are expected to compose a larger proportion of the population than in the past. Population growth among long-lived older adults contributes to this increase worldwide. For dentistry, this means that older adults are retaining more of their natural dentition. Currently, almost 70% of older adults in the United States have natural teeth.17 However, retention of teeth may result in more teeth at risk for periodontal disease, and thus the prevalence of periodontal disease may be associated with aging. This association was addressed by Beck11 at the 1996 World Workshop on Periodontics: “It may be that risk factors do change as people age or at least the relative importance of risk factors change.”

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This chapter focuses on the interrelationship between aging and oral health, with an emphasis on periodontal health.

THE AGING PERIODONTIUM
Normal aging of the periodontium is a result of cellular aging. In general, cellular aging is the basis for the intrinsic changes seen in oral tissues over time. The aging process does not affect every tissue in the same way. For example, muscle tissue and nerve tissue undergo minimal renewal, whereas epithelial tissue, which is one of the primary components of the periodontium, always renews itself. 675

Copyright © 2006 elsevier. Uncorrected page proofs shown.

a decrease in the number of collagen fibers leads to a reduction or loss in tissue elasticity. This maturing population of cells continually undergoes a process of differentiation or maturation.676 PART 7 s Treatment of Periodontal Disease Intrinsic Changes In epithelium. loss of elasticity and increased resistance of the tissue may lead to decreased permeability. All these changes produce a decline in the physiologic processes of tissue. Thus. so the effect is to slow down the regenerative processes. provides new cells. or epithelial cell. In the aging process. On the other hand. Attrition is a compensatory change that acts as a stabilizer between loss of bony support and excessive leveraging from occlusal forces imposed on the teeth. vascular peripheral resistance (decreased blood supply) may secondarily decrease cellular function. There is a reduction in healing capacity and rate. Clinical Changes Compensatory changes occur as a result of aging or disease. the decreased cellular component has a concomitant effect to decrease cellular reserves and protein synthesis. this differentiated cell. With a loss of regenerative power. Stochastic Changes Stochastic changes occurring within cells also affect tissue. there are fewer and fewer of these cells to renew the dead ones. By definition. for example. develops more rapidly and more severely. situated in the basal layer. All these types of changes are seen in the alveolar bone. cementum shows cemental thickness. This affects the oral epithelium in that the tissue becomes thin. For example. glycosylation and cross-linking produce morphologic and physiologic changes. In addition. These changes affect the tooth or periodontium that presents the clinical condition. with loss of “sluiceways. Uncorrected page proofs shown. although some are secondary to physiologic deterioration. Thus there is a constant source of renewal (Figure 45-1). ready to return to the mitotic cycle and again produce both types of cells. Somatic mutations lead to decreased protein synthesis and structurally altered proteins.. An increase is seen in the food table area. Physiologic Changes In the periodontal ligament. the cells of the oral epithelium and periodontal ligament have reduced mitotic activity. A larger subpopulation of these cells (amplifying cells) produces cells available for subsequent maturation. structures become less soluble and more thermally stable. and the accumulation of wastes in the cell. efficiency is reduced because of missing Figure 45-1 Cell renewal cycle in which the basal cell produces the epithelial cell and returns to the progenitor cell population. With aging. this is related to the approximal wear of the posterior teeth. Functional changes are associated with reduced efficiency of mastication. manifesting as an increase in the edge-to-edge contact of the anterior teeth. with a loss of elasticity and increased mineralization (fossilization). the basal cell remains as part of the progenitor population of cells. In contrast. can no longer divide. A decrease in vascularity results in decreased production of mucopolysaccharides. Functional Changes With aging. Although effectiveness of mastication may remain.e. Free radicals contribute to the accumulation of waste in the cell. the number of progenitor cells decreases. Typically. These changes also affect the immune system and affect healing in the periodontium. Hayflick.” and in mesial migration. a progenitor population of cells (stem cells). with reduced keratinization. Structures become stiffer. a decrease in vascularity also occurs. Copyright © 2006 elsevier. observed that fetal cells (i. fibroblasts) displayed a consistently greater growth potential (approximately 50 cumulative population doublings) than those derived from adult tissues (20-30 cumulative population doublings). decreased nutrient flow. cell renewal takes place at a slower rate and with fewer cells. when present. Gingival recession and reductions in bone height are common conditions. Individuals are highly susceptible to viral and fungal infections because of abnormalities in T-cell function. This effect is characteristic of the age-related changes and biologic changes that occur with aging. A small subpopulation of these cells produces basal cells and retains proliferative potential of the tissue. By the action of gerontogene(s) or replicative senescence (Hayflick’s limit and telomere shortening). an American microbiologist. Inflammation. Most changes are primarily a result of aging. As the progenitor cells wear out and die. a reduction in “overjet” of the teeth is seen. the alveolar bone shows a decrease in bone density and an increase in bone resorption. As a result. however. These cells of the basal layer are the least differentiated cells of the oral epithelium. and all cells experience a reduction in metabolic rate. .

S. or stroke. sinusitis. and oral cancer. an increase of 28 years from 1900. population is expected to increase by 42%. and social well-being of older adults. dependent. and hearing impairments increase in frequency with advancing age. The expected increase in the proportion of older adults Increase life expectancy has changed the way the public and health care policy makers and providers think about “aging.” This paradigm shift is based on study of what promotes health and longevity. Clinicians need to focus on the particular oral disease susceptibilities of older patients and emphasize preventive measures. Dr. with centenarians (age 100+) increasing by 956%.49 Differences in population growth between urban and rural older adults have special significance to oral health. population.51 Most older adults have at least one chronic condition. Currently among older adults. From 2001 to 2010. and these individuals are retaining more of their teeth. education. approximately 7 in 10 deaths are caused by heart disease. dry mouth. mental. http://www. who may refuse to wear prosthetic appliances.53 DEMOGRAPHICS Health Status Population Distribution In 2000. and many have several chronic conditions. life expectancy (at birth) was projected to be 77 years. Older patients do not have an increased susceptibility to periodontal disease and respond well to periodontal therapy. will be 3% larger in rural areas. adults 65 years of age and older were 12. 1998. those 85 and older are expected to increase by 316%.48. hearing impairment. In 2000. “What genetic. the number of older adults with acute and chronic diseases continues to increase. cancer.Periodontal Treatment for Older Adults s CHAPTER 45 677 teeth. In these older adults. glaucoma. the risk for adverse changes in oral health and self-care may be greater. Adults who reached the age of 65 in 1990 could expect to live an average of 17 additional years. loose teeth. Advances in medical and dental care account for the increasing number of patients over 65 years of age with more remaining teeth. This population has unique problems that necessitate alterations in their treatment plans. By the mid–twenty-first century. including implant surgery. these patients often have increased risk of root caries. hypertension.49 In the early 1900s. Average life expectancy was 75 years in 1990. aging is seen in terms of “successful aging” or “healthy aging.S. did geriatrics (medicine for older adults) become a discipline in health care. Copyright © 2006 elsevier. nutrition counseling. In 1994 the chronic conditions that occurred most often in older adults were arthritis. including the increased need for assisting oral hygiene with mechanical devices and antiseptic mouthwashes and applying fluorides when there is evidence of root caries. On the other hand. cancer may become the leader during the twenty-first century.35 Not until the later half of the twentieth century. The greatest growth will occur in those age 85 and older (29%) and those l00 and older (65%). the U. biomedical. Current research is now examining aging in terms of the physical. and compensatory home and professional care techniques may be required. A “geriatric patient” is an older adult who is frail. orthopedic impairment. or noncompliance of the patient.” Instead of controlling chronic disease and morbidity. During this same period. TABLE 45-1 Percentage of Chronic Conditions in Older Adults Conditions Percentage Arthritis Hypertension Heart disease Hearing impairments Cataracts Orthopedic impairments Sinusitis Diabetes 50 36 32 29 17 16 15 10 Data from Administration on Aging: A profile of older Americans. aging can significantly alter the host immune response and inflammatory reactions to bacterial plaque and in different ways than in younger populations.0% of the U. Thus. the population age 65 and older is expected to increase by 126%. this population will grow by 13%. or 35 million people. not just disease or morbidity. Because rural older adults use dental services less than their urban counterparts. and diabetes (Table 45-1). heart disease. behavioral. many of which can cause problems such as xerostomia and decreased saliva. regular dental care. . or both and who requires health and social SCIENCE TRANSFER In the United States and throughout the world. The MacArthur Studies of Successful Aging asked the fundamental question. Uncorrected page proofs shown.gov. cataracts.dhhs. They also use more medications. cataract. poorly fitting prostheses. Ignatz Leo was the first to recognize that older adults had health needs and concerns that set them apart from younger adults. Of this population.49 Visual impairments. and social factors are crucial to maintaining health and functional capacities in the later years?”31 Despite this paradigm shift. Almost half of people age 65 and older have arthritis.aoa.49 The increase in the aging population is the result of the dramatic increase in life expectancy during the past and present centuries.1 Although heart disease remains the leading cause of death among older adults. the number of older adults is increasing. however.

The index of activities of daily oral hygiene (ADOH) is one such dental assessment instrument that quantifies the functional ability of older adults. this has emphasized an interdisciplinary approach to diagnosis. Thus. dressing. Functional impairments have a significant impact on oral health and self-care. and Mini-Mental State Questionnaire.20 Specialists in geriatric dentistry are geriatric dentists. alternative strategies and assistive devices are recommended. The focus is to include oral health as part of medical nutrition therapy (MNT) in achieving the patient’s total health needs. psychologic. ethnicity. Each assesses risks to morbidity and mortality in maintaining a patient’s optimal health and functional independence. or geriatric dentistry. in performing oral self-care tasks. These include activities of daily living (ADLs). Majority of older adults Access and use dental services similar fall into this category. as well as being sensitive to an individual’s all-encompassing social functioning. Thus the treatment plan must reflect the professional knowledge to resolve physical and psychologic aspects of health status. dieticians have educational content in oral care. Tinetti Balance and Gait Evaluation. edentulism and denture wearing in older adults may be related to poor quality of life and risk Copyright © 2006 elsevier. Sensory impairments and arthritis make it more difficult for older adults to understand dental outcomes. communicate oral health care needs and concerns. Care for geriatric patients crosses many disciplines. and those at risk instrumental activities of daily living. Accommodating dentists in the interdisciplinary team is increasing. but only to make them aware of services that they may need if they experience functional deficits that impair their daily activities (Table 45-2). geriatricians. Frail Those who reside in the community and maintain some degree of independence with assistance from others. for being institutionalized. and social functioning. have additional training in health care for frail and functionally dependent older adults. Include those who are institutionalized or are a at highest risk for institutionalization. esthetics. Shared decision making and patient education are needed to improve access and realize successful outcomes. an interdisciplinary team is formed to care for and treat geriatric patients and may include the dentist. For example. strategies may be developed to rehabilitate and then remeasure for improvements in functional deficits. Including dentistry in the interdisciplinary effort has benefits for the patient. Similar geriatric health and functional instruments used in medicine assist geriatric dentists in assessing risks that compromise oral health. If improvements are not forthcoming. including their participation in primary care.5 A “last frontier” for the interdisciplinary team is the community. geriatric depression scale (GDS). to younger adults in the community. Dependent on another for most if not all the instrumental and basic activities of daily living. Specialists in geriatric medicine. . and social and economic conditions.37 Likewise. support services to attain an optimal level of physical. and transportation problems were the three limitations that most homebound elderly experienced.” or spend activities of daily living and are most of their time in their dependent on another for most homes. treatment. personal relationships. Functional testing or measuring instruments may become part of the dentist’s armamentarium to assess an older adult’s ability to perform oral care tasks in achieving and maintaining oral health. oral care has been incorporated into nursing educational programs and practice for the geriatrician nurse practitioner. Uncorrected page proofs shown. and perform effective oral self-care. This functioning may include aspects of race. culture. The main focus of geriatrics is frail and functionally dependent older adults. and prevention of dental and oral diseases. From these findings.22 Functional Status In dentistry.8 The index of ADOH provides the dentist or dental assistant with the means to determine the functional ability of an older adult to manipulate aids used in daily oral hygiene care.678 PART 7 s Treatment of Periodontal Disease TABLE 45-2 Functional Categories for Older Adults Category Description Issues Limitations Functionally Those who reside in the community independent and receive little or no assistance. When geriatric patients require multidisciplinary strategies to improve their conditions at the community level. Functionally independent older adults are included. Functionally dependent Those who cannot maintain any level of independence and are totally dependent on assistance. Problems have been encountered when coordination is needed for geriatric patients to access multiple providers across a range of health care settings. and some aspects of these are important to dentists in identifying risks and functional declines. In geriatric medicine. Include those who are Need assistance with some “homebound. In dentistry for geriatric patients. Bathing. specifically frail and functionally dependent older adults. for example. prevention of oral diseases and improvements in healthy lifestyles have contributed to older adults keeping and maintaining their dentition. efforts have been less than satisfactory. numerous assessment instruments have been developed to assist the geriatrician.

The real risk is attributed to unbalanced diets.Periodontal Treatment for Older Adults s CHAPTER 45 679 for undiagnosed oral disease. Rehabilitation with complete dentures may restore only 25% of normal chewing effectiveness. and the effects of depression or dementia. which may contribute to impaired chewing ability or loss of appetite. In addition. This is also associated with altered sensations of hunger. diseases and the medications used in their treatment.59 In managing periodontal disease. such as residential. In addition. living on a fixed income. Older adults do not compensate well. This may result in part from their poorer health status. the geriatric dentistry community has advocated the use of dental geriatricians to train general dentists in the care of geriatric dental patients. Thus. The cumulative effect of these changes may account for taste loss in the older adult. and diabetes.54 Nutritional Status Whereas “diet” refers to the consumption of types and varieties of food resources. The most common ageassociated chronic diseases are hypertension. Uncorrected page proofs shown. Kayak and Brudvik29 see this type of training essential to “successful aging” and periodontal health care in both dental practice and nontraditional settings. In response. the dental geriatrician is challenged with integrating primary care. and maintain tissue of living organisms. among older adults in the United States. is a common cause of fluid and electrolyte disturbance. Age changes in physiologic functioning. such as changes in central nervous system (CNS) receptors that detect changes in the level of sodium in blood. For example. inability to feed oneself. Economic and social factors have also been linked with significant changes in eating patterns. Secondary aging changes are a result of acute and chronic disease and medication use. a slower metabolic rate accompanied with decreased levels of physical activity explains why older adults have reduced food intake. In other words. In general. such as decreasing the variety in the diet. medical and dental geriatricians must incorporate knowledge of comorbidities to identify risks that manifest as reciprocation of disease and poor quality of life. or characteristic bland diets may result from lowered sensory-specific satiety. For example. salt and water imbalances) are associated with age- related changes in regulatory systems. dental services are a discretionary choice and not part of their primary care options. An older adult’s dietary patterns may be associated with numerous factors. With aging. or death of a spouse. Currently. such as loss of appetite. Dehydration. there is an increased risk of nutritional deficiencies among older adults. Age-associated decreases in saliva production and swallowing problems may also make eating difficult. On average. restore. impaired chewing can cause changes in food selection. increases the risk of nutrition-related illnesses. the real risk is not malnutrition. poor oral health. thirst. All these factors may affect the type and quality of food consumed. For many older adults. They may also indicate other medical comorbidities. Thus. hospital. 42% of older adults have no natural teeth. Minerals are important to the absorption and utilization of vitamins. foreign substances. in part because of primary aging. Both are important to antibody formation and the immune system in combating infection. Although geriatric medicine training programs have grown remarkably over the past three decades. More than half of people age 65 to 80 have a major olfactory impairment. uncompensated by increased thirst. oral health. and hospital practice settings. Anorexia. nutrition is the process by which food is used to provide energy and sustain. loneliness. Deconditioning is an almost complete disturbance of physical functioning. have been associated with poor-quality diets in older adults.13 Psychosocial Factors Dental diseases have their greatest effect on behaviors and mental and social well-being. food recognition diminishes with age. and satiety or fullness. and patient and caregiver education in nontraditional settings. hyperlipidemia. Electrolytic imbalances (e. this growth is still not producing the number of geriatricians needed to care for the growing older adult population. institutional. the training of dental geriatricians is much less. These aging-related disease states and social factors may result in inadequate consumption of nutrient-dense foods or inadequate intake of some vitamins and minerals. or take in more food.. including the aging process. dental diseases impact psychologic and social functioning and thus are almost always preventable by behavioral and social means. Poor nutrition and low body weight may often precede and predispose older adults to secondary age changes. when bodily changes alter their energy levels.54. perhaps because of conflicting economic priorities between medical and dental needs. These conditions may present when a frail older adult comes to the dental office seeking care and are seen more often in homebound. However. hormonal. Compounding effects of secondary aging may include impaired mobility. including metabolic. All these factors may place the older adult at risk for serious problems. Comparatively. Thus. body weight and lean body mass decline with age. and nursing home residents. . and social and economic conditions. failing health. and neural changes. Reductions are seen in fluid intake. or low food intake. which can lead to illness and death.g. older adults use fewer dental services. Social factors include isolation. Beyond middle age. and the use of dentures. 60% have tooth decay and 90% have periodontal disease. the rate of malnutrition is low. dental geriatricians as faculty are needed to train practitioners. and toxins (Table 45-3). older adults have a lowered enjoyment of foods because of deficits in smell and possibly taste. Economic factors include a lower economic status resulting from retirement. atherosclerosis. all of which may affect the amount and types of foods consumed. which may contribute to nutritional problems. socialization at meals may increase the amount of food consumed by older adults. The variety of foods eaten is reduced. energy needs and intake in older adults decline with age. lack of Copyright © 2006 elsevier. with 75% of those age 80 and older affected. nutrient malabsorption can be caused by altered gastric acid secretion or by interaction with medications.40 Of those with teeth. In other words.

Borrell et al. dental insurance or coverage by government-sponsored health care programs. and behavioral problems may adversely affect oral health. gender. higher educational achievement with lower poverty levels is a predictor for an increase in demand for oral health care among older adults. Among dentate non-Hispanic blacks. (2) quality of life. Coenzymes in metabolic processes and panthothenic acid Folic acid and Involved in DNA/RNA synthesis vitamin B12 Zinc More than 100 enzymes associated with carbohydrate and energy metabolism Protein catabolism and synthesis Nucleic acid synthesis Involved in hemoglobin. Poverty is less prevalent today among older adults for all race. and Mexican Americans 50 years of age and older. non-Hispanic whites. and 13% possessed a bachelor’s degree. and (3) economic productivity. Reciprocally.680 PART 7 s Treatment of Periodontal Disease TABLE 45-3 Nutrient Effects on the Immune Response EFFECT OF INSUFFICIENT INTAKE OF NUTRIENT Nutrient Component in Biological Processes Increase Function Decrease Function Protein energy intake Energy metabolism Deoxyribonucleic acid and ribonucleic acid (DNA/RNA) synthesis Bacterial adhesion Vitamin A Cellular differentiation and proliferation Integrity of immune system Bacterial adhesion Vitamin E Antioxidant protecting lipid membranes from oxidation Antioxidant that reduces free radicals that cause DNA damage to immune cells — Vitamin C — Riboflavin. Older adults with positive attitudes toward oral health have predictably better dental behaviors that translate into higher utilization rates of dental services. oral disease may affect behaviors. even those in higher-income groups. By 2015.28 However.49. . 2003. myoglobin. differences in the prevalence of periodontal disease were seen in relation to race. Those with more education were three to four times more likely to have visited a dentist in the past year. and ethnic groups. older adults have the highest disposable income of all ages. Thus. vitamin B6. only 64% of noninstitutionalized older adults completed at least high school. Adverse oral health conditions affect three aspects of daily living: (1) systemic health.12 suggest that race and ethnicity are important factors in combating health disparities. Impediments to the utilization of dental services are associated with low income and an associated lack of a regular source of care.57 Thus.. with 20% obtaining a bachelor’s degree. indicating that an informed and knowledgeable public provides a culture of healthy behaviors that guide older adults toward the long-term preservation of teeth and function. In 1995. Uncorrected page proofs shown.50 In general. Positive attitudes are highly associated with educational level. and cytochrome systems — — — Salivary antimicrobial properties Immunoglobulin production Lysozymes Activation of lymphocytes Production of antibodies Immune cell differentiation Response to antigens Antibody production Immunoglobulin production Production of lymphocytes Antibody synthesis Response of lymphocytes Phagocytic function Phagocytic function of neutrophils and macrophages Antibody response Cytotoxic T-cell activity Antibody synthesis Cytotoxic T-cell activity Lymphocyte response Production of lymphocytes Cytotoxic T-cell activity Phagocytic function of neutrophils Antibody response Phagocytic function of macrophages B-cell and T-cell proliferation Lymphocyte proliferation Neutrophil cytotoxic activity Antibody response Iron — Data from Boyd LD. or simply their functional status or independence. Copyright © 2006 elsevier. Madden TE: Dent Clin North Am 47:337. blacks had higher levels of periodontal disease.10 The education level of older adults is increasing. it is estimated that 76% of older adults will have completed at least high school. Those with higher education tend to be better off financially than those with low education.

and cancer. as is mild to moderate periodontitis. 2004. by about 70%. sleep disturbances.3. Uncorrected page proofs shown. gastritis. temporomandibular joint disorders. Conditions such as oral clefts. Older adults are at greatest risk. decreased appetite. periodontal disease. including oral discomfort. at some time in their life. along with alcohol-related health problems. Depression may also accompany a wide variety of physical illnesses. Unfortunately. weight loss. It is expected that over the next three decades the average number of retained teeth will increase from the current 20 to 25. severe periodontal disease Dentate Status In dentistry the level of illness is measured as “tooth mortality” or tooth loss. of human diseases.9 payment for treatments will be the responsibility of the geriatric patient. Oral and facial pain from dentures. xerostomia. including dental caries (particularly root caries). and therefore differentiation from dementia is important. . withdrawal.S. especially in women. the number of teeth retained by older adults is expected to double. alcohol consumption has increased. when alcohol consumption was much lower. Oral health changes in health and functional well-being (functional disabilities) potentiate risks to oral disease. and systemic disease with oral symptoms. The classic signs and symptoms for depression include sadness.9 teeth. Periodontal Status The classic periodontal disease model suggested that virtually all older adults would. become susceptible to severe periodontitis.S. race and Hispanic origin. and severe caries are associated with feelings of embarrassment. However. and anxiety. alcohol may react differently in older than younger adults. in those over 65 years of age. A peak onset for alcoholrelated problems is 65 to 74 years. particularly dentistry. A decrease in body water content may produce higher peak serum ethanol levels. dental disease places all segments of the population at risk. and polyneuropathy. Most adults show some loss of probing attachment while maintaining a functional dentition. Older adults today grew up during Prohibition or the Great Depression. affecting 15% of adults over age 65 in the United States. especially those over 85 years of age.17 The most current estimates of tooth loss and tooth retention in the U. population indicate that 75% of older adults age 65 to 69 and over half of adults age 75 and older are dentate (Table 45-4).42 However. however. Geriatric depression is treatable. severe malocclusion. Since then. This result was attributed to an insidious process in which gingivitis slowly progressed into periodontitis.30 Depression is a common public health problem among elderly persons. with probable bone and tooth loss. Recognizing the signs of depression can significantly reduce depression. http://www. Alcohol-related disorders include alcohol abuse and dependence and alcoholic liver disease.Periodontal Treatment for Older Adults s CHAPTER 45 681 Both systemic health and quality of life are compromised when edentulism. edentulism and partial tooth loss declined substantially. such as fatigue. or one drink per day. 1988 to 1991 Age Group All Older Adults Male Female 50-54 55-59 60-64 65-69 70-74 75+ 88 82 76 74 69 56 90 82 77 73 71 53 86 83 76 75 67 58 Data from US Census Bureau: U. soft tissue lesions. In particular. oral cancer. cardiomyopathy. It may be the primary cause of somatic complaints.27 Behavioral problems may worsen oral conditions. and oral infections affect social interaction and daily behaviors. sex. The patterns of drinking and alcohol-related problems may not differ between older and younger problem drinkers. Many older adults. difficulty in decision making.19 Thus the risk of periodontal disease and dental caries is expected to be a major problem of older adults. However. poor appetite. alcohol consumption is directly correlated with clinical attachment loss in periodontal disease.gov/ipc/www/ usinterimproj/. A general consensus states that light drinking. xerostomia (dry mouth). Over a 30-year period. The suicide rate for those over 85 is about two times the national rate. and poorly fitting dentures affect eating and food choices. confusion. Mild gingivitis is common. In addition. alcohol intake may make older adults vulnerable to changes in the capacity of the liver to metabolize drugs and to symptomatic behaviors such as confusion. present with a less dramatic level of actual sadness and frequently have apparent cognitive impairment. By the year 2030.47 Periodontal disease may also be exacerbated in those with depression. TABLE 45-4 Percentage of Dentate Older Adults: United States. Because few older adults are covered by dental insurance. resulting in tooth loss seen predominantly after age 35 years. The current periodontal disease model suggests that only a small proportion of adults have advanced periodontal destruction.census. depression. and dementia. depression is not easy to recognize. which is often considered discretionary. interim projections by age. Thus. disorders associated with denture wearers. psychoses. an estimated 800 million increase in tooth retention. especially memory deficits. Costs and the inability to afford care will always affect health care utilization. missing teeth. so recognition of this disorder is a vital step in the prevention of disability and mortality. is not harmful as long as the older adult is reasonably healthy and not taking medications that interact with alcohol. Still among the most ubiquitous Copyright © 2006 elsevier. dissatisfaction. and irritability. it was asserted that susceptibility to periodontitis increased with age. cardiovascular disease. numerous reports suggest that alcohol as the primary substance of abuse is higher in the older than in the younger adult.

(From Brown LJ. but when disease occurs.) Caries Status Root caries is a disease that has a particular predilection for older adults.7 Thus. high-risk population of older adults. smoking. prevention programs. with one third (35%) of persons age 55 to 84 and less than half (46%) of persons age 85 and older having 3 mm or more of gingival recession (Figure 45-3). This natural occurrence in older adults is caused by dentinal sclerosis. it is usually in those age 85 and older.” or collar of caries extending circumferentially along the cementoenamel junction. • The progress of periodontal disease is episodic and infrequent. The bacterial flora associated with gingivitis and periodontitis shows similarities but does not reciprocate causally.to 65-year-old age group. although less than half of persons age 65 and older had loss of attachment measuring 5 mm or greater (Figure 45-5). Exposed root surfaces in combination with compromised health status and use of multiple medications make older adults at high risk for root caries. Once a lesion is present. Decayed or filled root surfaces were detected in 47% of persons age 65 to 74 and in 55. In older adults the active four-surface lesion produces a characteristic “apple coring. . diabetes mellitus. and 7% of persons age 65 and older (Figure 45-4).15 Advanced periodontal disease among older adults is not as common as once thought. not susceptibility. The prevalence of periodontal disease is therefore expected to increase with age11 as a result of a cumulative disease progression over time. • Most of the reported cases of periodontal disease occur in a small. and personal oral hygiene.33 In a 30-year preventive home care study. • There is a continued effort to identify risk factors for periodontal disease.14 Gingival recession increased with advancing age.9% of those 75 and older. Figure 45-3 Percentage of older persons with gingival recession. Figure 45-2 Severe periodontal disease with potential danger of tooth aspiration. one-surface and multiple-surface lesions progress aggressively to infect other adjoining tooth surfaces rather than cavitating the infected surface. but severe loss is detected in only a small proportion of older adults (Figure 45-2). it is likely that a sound root surface will remain caries free. Loss of the root Copyright © 2006 elsevier. the current model of periodontal disease indicates that the following: • The prevalence of periodontal disease is low and possibly decreasing.15 Moderate levels of attachment loss are seen in a high proportion of older adults. caries progression spreads without cavitation. recent data suggest that older adults who maintain optimum oral self-care are less susceptible to periodontitis. but relatively few sites with gingivitis develop periodontitis.7. including immune system dysfunction and ineffective oral self-care. Uncorrected page proofs shown. There may be exceptions to this. and it is unclear whether the higher prevalence of periodontal disease is a function of age or time. Kingman A: J Dent Res 75:672.63 The majority of older adults are at low risk for developing root caries. • Active and inactive disease sites coexist. 1988 to 1991. The amount of periodontal disease associated with age does not appear to be clinically significant. Caries examinations from phase I of NHANES III indicate that root caries prevalence increases greatly with age. The current risk factors suggested for periodontal disease include age. Attachment loss increases with age. In all. Brunelle JA. The model asserts that gingivitis does precede periodontitis. but mediating factors increase this risk. however. 1996.33 Figures 45-3 to 45-5 illustrate periodontal disease data from phase I of the third National Health and Nutrition Examination Survey (NHANES III) conducted in the United States from 1988 to 1991. Pocket depth of 6 mm or greater was detected in 7% of persons 45 to 54 years of age. and the presence of subgingival Porphyromonas gingivalis and Tannerella forsythia. with morphologic loss dependent on the balance of forces during demineralization and remineralization. The four-surface lesion becomes chronic.682 PART 7 s Treatment of Periodontal Disease is not a part of normal aging and is not the major cause of tooth loss. With the prospect of older adults retaining more of their teeth through improved access. periodontal findings showed a 75% improvement in the number of healthy periodontal sites in the 51. 8% of persons age 55 to 64. below the clinical enamel crown of the tooth.

noninstitutionalized population age 18 years and older. When challenged with medications Copyright © 2006 elsevier. Brunelle JA. and 75% of those with natural teeth reported a dental visit in the past year. The tooth may then be lost because of clinical outcomes that disallow its rehabilitation. older adults will account for a greater proportion of dental practice income and visits. their careseeking behaviors translate into use. continuous use. They have difficulty incorporating their perceived need into care-seeking behaviors. 1988 to 1991. Figure 45-4 Percentage of older persons with pocket depths by age. random-digit-dialed telephone survey of the U. Recent studies report dramatic increases in dentate older adults accessing dental care. leaving a pathway for infection. Dental Visits Fundamentally.62 Data from the 1995 Behavioral Risk Factor Surveillance System (BRFSS). . (From Brown LJ.S.16 As the trend for tooth retention in older adults continues.30.60 Dental expenditure data indicate that older adults have a higher cost per visit than younger persons and are willing to make a significant investment in dental care. the belief among dentate and edentulous older adults that their dental problems are a result of aging prevails. Despite clinically evident disease or problems. In addition. older adults make fewer dental visits: 21% to 53% of dentate adults visited the dentist in the last 12 months. (From Brown LJ. Among adults age 65 and older. not age. Xerostomia Saliva plays an essential role in maintaining oral health. and oral or tooth function is impaired (Figure 45-6). beliefs and values of older adults regarding the usefulness of dental care to resolve oral problems are limited. When dentate and edentulous adults express positive attitudes regarding the efficacy of dental care. Approximately 40% of these older adults utilize these visits for episodic care. Besides a loss of acinar cells occurring with aging. indicate that older adults are frequent users of dental services.Periodontal Treatment for Older Adults s CHAPTER 45 683 Figure 45-6 Root tips remain after coronal portion of the tooth is lost as a result of root caries. even when cost is not a barrier. and recent use of dental services. 1996. Those least likely to visit a dentist were older adults who were either homebound or institutionalized. dental visits by older adults are correlated with having teeth.) Figure 45-5 Percentage of older persons with loss of attachment by age. older adults in nursing homes seldom access dental services. and believe prevention or treatment would not be efficacious in solving their oral problems. Even the oldest persons in the elderly population have reversed earlier. Kingman A: J Dent Res 75:672. Uncorrected page proofs shown. with older adults now using dental services to the same extent as dentate adults between ages 35 and 44.57 Despite these trends.) structure may be so significant that it undermines the support of the clinical crown.16 Although their total consumption of dental services approximates that of younger adults. the tooth is at a high risk for fracture. 1988 to 1991. which is a continuous state-based. 62% of all respondents reported having a dental visit during the previous year. nursing home residents often refuse dental care. Kingman A: J Dent Res 75:672. negative attitudes and demonstrated increased awareness and concern for oral health.32. many older adults take medications for chronic medical conditions and disorders. However. indicating a lack of sustained and consistent care. Brunelle JA. When tooth structure is compromised. 1996.

and depression (Figure 45-7). heart valve problems. Caregiver status indicates be both local and systemic. A pathogenic infection occurs when C. Uncorrected page proofs shown. and values for dental treatment. and (3) salivary transplantation.26 Chronic atrophic candidiasis presents most often as an erythematous area under a maxillary denture and is associated with poor oral hygiene. The review should focus on a careful evaluation of systemic diseases and disorders. or functionally dependent. that cause dry mouth. older adults are more adversely affected than younger adults. and candidiasis. In patients without a prosthesis. artificial joints. and type of toothpaste used (fluoride vs. .25 More than 500 prescription and over-the-counter medications are associated with decreased saliva.684 PART 7 s Treatment of Periodontal Disease Figure 45-7 Severe xerostomia after radiation therapy when the parotid glands were not spared. Also included is a review of past restorations. Candidiasis is caused by an overproliferation of Candida The social history is reviewed to determine the patient’s albicans. extractions. desires. communication.32 Medications that induce xerostomia may also be associated with compromised chewing. The medical history review should also include medications taken regularly and allergies Candidiasis to medications. thyroid disorders. metals. Future research directions include (1) gene therapy approaches to direct salivary growth and differentiation or modify remaining tissues to promote secretion. radiographs taken. Medication use is frequently associated with dry mouth. alcohol infiltrates into the oral mucosal layers. and thyroid cancers. in severely compromised older adults. such as parotid-sparing radiation therapy. system can be considered a risk factor for candidiasis. and human immunodeficiency virus (HIV) are risk factors for acute pseudomembranous candidal infection.26 Chronic atrophic candidiasis. neck. or swallowing and increased risk for caries. stroke. including emergency and hospital visits and any serious illnesses (Box 45-1). Diabetes mellitus. albicans age. and diuretics. The effect of this treatment has been shown to reduce xerostomia in each of four domains of quality of life: eating. With improved secretagogues. Oral Obtaining a complete medical history may take longer candidiasis can occur with long-term use of antibiotics.26 the functional level of the patient as functionally Any condition compromising a patient’s immune independent. Symptomatic and corrective therapies have been suggested. The medications most often associated with xerostomia and decreased saliva are the tricyclic antidepressants. and use of corticosteroids. and caregiver status. certain cardiovascular conditions. the patient interview assists the patient in disclosing needs.36 DENTAL AND MEDICAL ASSESSMENTS Review of Dental History Initially. diabetes. head. particularly those that influence dental treatment. poorly controlled diabetes. certain medical diseases. Review of Medical History The medical history of the older adult should be detailed and should include a careful review of past and current medical and mental conditions. Sjögren’s syndrome. These results suggest that the efforts to reduce xerostomia using parotidsparing radiation therapy may improve broad aspects of quality of life. endodontic therapies. or chemotherapy. tobacco use (type and pack-years estimate). frail. especially for older adults with medical problems. removable and fixed units). and the frequency of tooth prophylaxis. Other useful information may include daily oral self-care regimens. and environmental allergens. Both xerostomia and quality-of-life scores improved significantly over time during the first year after therapy. well. or angular cheilitis. periodontal therapies. oral surgeries. or conditions are also associated with dry mouth. prosthetic appliances (including single and multiple. antihistamines. However. dry mouth. speaking. disorders. the time Copyright © 2006 elsevier. can also manifest itself in the creases or commissures of the lips. and emotion. The dental history includes dates of the last dental examination and visit. periodontal disease. A consultation with the patient’s physician is advisable. pain. tasting.26 A new treatment for candidiasis is being investigated using bioadhesive nanoparticles as modulators of adherence to buccal epithelial cells. the effects of conditions that result in reduced salivary function and increased caries will be ameliorated. such as radiation treatment for oral. however. Pseudomembranous candidiasis presents as white lesions that can be wiped away with gauze. bone marrow transplantation. and gnathologic treatments. (2) creation of a biocompatible artificial salivary gland. head and neck radiation therapy. fluoride status of the drinking water (bottled. antihypertensives. such as bleeding disorders and use of anticoagulants. and xerostomia. chronic atrophic candidiasis may present as a generalized redness or even generalized burning of the mouth. nonfluoride). Candidiasis can use. This occurs when a patient has a tendency to pool saliva around the corners of the mouth or constantly lick the lips in some cases. or if complicated or invasive procedures are planned. which supports the secretory reserve hypothesis of salivary function.23 steroid therapies. and community sources). preferences. leaving an erythematous area.

caries. Coordinating and managing oral health care in this manner may increase the success of dental outcomes. tongue. red or white patches. and varicosities (ventral side). Immune System Assess for pronounced inflammatory responses of the gingiva to infection. For this reason. palate. amount of subcutaneous fat. nodes. The periOther signs of oral cancer may be swollen lymph nodes odontal examination includes gingival bleeding points and difficulty swallowing and speaking. but also provides additional information. Also included are assessments of the skin. a product called OralCDx has been and dysfunction. Table 45-5 lists the top 20 drugs prescribed in the United States in 2003. waxy appearance of the tissue. Assess for systemic disease.21 Particularly and pocket depths. and painful tongue (may indicate vitamin B12 deficiency) • Geographic tongue (erythema migrans) • Oral infections (e. Assess for alteration in taste. BOX 45-2 Dental Examination: Assessments for Older Adult Patients Oral Epithelium Assess a decrease in intracellular water content. gingiva. Assessments Oral cancer may appear as an ulceration. a swelling. with oral cancer has not improved. ask patients to bring each medication bottle or package to the dental office. and cranial nerves involved in oral function.18.g. A major focus of these examinations is Xerostomia screening may be done by sialometry or the assessment for oral and pharyngeal cancer..41 and hard tissue of the oral cavity (Box 45-2). or a red or white sore that does not heal in 1 to 2 weeks. such as medication dose and number of physicians prescribing medications. the 5-year survival of patients for tissue abnormalities. Assess clinical complaints of the following: • Smooth. Findings include changes from normal. this computer-assisted brush biopsy test can The intraoral examination provides assessment of soft aid in screening for cancer. To obtain a complete list of prescription and OTC medications. ulcerations. Tongue Assess for defoliation of papillae. . fissures (dorsum side). depending on the Copyright © 2006 elsevier. and missing teeth. apparent lesions. and oropharyngeal area be painful. retromolar region. or expressing urgency in his or her demands? Assess pseudocooperativeness: Is the patient noncompliant in maintaining daily self-care? Assess perfectionism: Is the patient unrealistic in his or her expectations yet noncompliant in maintaining oral self-care regimens? Social History Assess the presence or lack of a support system for the frail and dependent older adult.4 and swellings. Many medications used by older adults can have a negative impact on oral health. occlusal dysfunction. With sialometry. Assess for a thin. and vertical dimension. candidiasis) Saliva Assess for xerostomia (altered salivary flow) that produces a decrease in the following: • • • • • Antibacterial activity Buffering capacity Transport of taste sensors Lubrication of the oral cavity Digestive function spent to disclose conditions will determine if the use of the interdisciplinary team is indicated.Periodontal Treatment for Older Adults s CHAPTER 45 685 BOX 45-1 Dental Patient Interview: Older Adult Medical (Physical) History Assess for endocrine and nutritional disorders. by oral examination. elasticity and vascularity of tissue. help to determine the state of the teeth: past restorations. cheeks. This not only helps to obtain a complete medication list. including the following: • • • • • • • • Intraoral dryness Burning sensations Altered tongue surface Dysphagia Cheilosis Alterations in taste Difficulty with speech Root caries Extraoral and Intraoral Examinations The extraoral examination provides assessments of the head and neck. Unfortunately. muscle tone. glossy. lesion and either a precancerous or early cancerous lesion. Note any signs of xerostomia. developed. Assess for a hyperkeratosis of keratin areas. repetitious. oral and pharyngeal cancer lesions may not mouth. Uncorrected page proofs shown. The head and neck examination determines if the skull is normal in shape with no traumatic injuries. The It can be difficult to differentiate between a benign temporomandibular joint is also assessed at this time.44 Review of Medication Use Older adults are high users of prescription and over-thecounter (OTC) medications. The remaining intraoral examination assesses the lips. floor of the alarming. Behavior History Assess overdependence: Is the patient demanding.

Copyright © 2006 elsevier. β1-selective (cardioselective) adrenoreceptor blocking agent Lipid-lowering agent used for treating cholesterolemia Estrogen used for treating menopause: hormone replacement therapy (HRT) Inhibits gastric acid secretion Selective H1-receptor antagonist used for treating allergies Nonsteroidal antiinflammatory agent Analgesic Both contained in Motrin Synthetic human thyroid used for treating hypothyroidism Various. Feb. A and B). antitussive. Monarch Pharmaceuticals Alprazolam Zoloft Albuterol Aerosol Toprol-XL Zocor Premarin Prevacid Zyrtec Ibuprofen Levoxyl Data from RxList: Top 200 prescriptions for 2003 by number of U. Pfizer US Pharmaceuticals Various. antipyretic Lipid-lowering agent used for treating cholesterolemia Synthetic human thyroid used for treating hypothyroidism Synthetic. data for two or more generic manufacturers have been combined. data for two or more generic manufacturers have been combined. Various. AstraZeneca MSD Wyeth Pharmaceuticals Tap Pharmaceuticals Pfizer US Pharmaceuticals Various. Uncorrected page proofs shown. the precise collection of saliva may require 5 to 15 minutes (Table 45-6).com/top200. 21. Pfizer US Pharmaceuticals Various. If only the tip of the tongue blade demonstrates wetness rather than a greater portion of the end of the blade. data for two or more generic manufacturers have been combined.htm. Various. data for two or more generic manufacturers have been combined. For example. Pfizer US Pharmaceuticals Various. prescriptions dispensed. The saliva collected from either the floor of the mouth or the buccal vestibules is absorbed onto the tongue blade (see Figure 45-8. data for two or more generic manufacturers have been combined. modified Carlson-Crittenden collectors are used to suction saliva from the parotid gland through Stensen’s duct. then an abnormal finding is noted (see Figure 45-8. type of gland. 2003 Brand Name Drug Action Manufacturer Hydrocodone w/APAP Lipitor Synthroid Atenolol Zithromax Amoxicillin Furosemide Hydrochlorothiazide Norvasc Lisinopril Opioid analgesic. Various. data for two or more generic manufacturers have been combined. data for two or more generic manufacturers have been combined. http://www. . data for two or more generic manufacturers have been combined. data for two or more generic manufacturers have been combined. Specific screening tools may be required for different gland types.S. A less quantitative measure of saliva for xerostomia is by oral examination using a tongue blade (Figure 45-8).686 PART 7 s Treatment of Periodontal Disease TABLE 45-5 Top 20 Drugs Prescribed in the United States. C). Pfizer US Pharmaceuticals Abbott Various. 2005. β1-selective (cardioselective) adrenoreceptor blocking agent Antibiotic similar to erythromycin Antibiotic-antibacterial drug Potent diuretic contained in Lasix Diuretic Antihypertensive Long-acting calcium channel blocker Synthetic peptide derivative used as an oral long-acting angiotensin-converting enzyme (ACE) inhibitor One of the benzodiazepine class of central nervous system–active compounds used for treating anxiety and contained in Xanax Selective serotonin reuptake inhibitor (SSRI) used for treating depression Inhalation aerosol used for treating asthma and contained in Proventil Synthetic.rxlist. and specialized equipment is used for the submandibular gland (through Wharton’s ducts) and the minor salivary glands.

43 B C Quality of Life The conditions predisposing the older patient to disease or changes in oral health status may result from physical or psychologic problems.61 Assessment tests use genetic markers to demonstrate susceptibility to periodontal disease. tobacco use. and death. . Copyright © 2006 elsevier. the risk factors that influence periodontal therapy are smoking.9. frequent use of alcohol. compliance. an indication of xerostomia. and End Results (SEER) data indicated that more than 50% of tongue and floor of mouth cancers had metastasized to a distant site at the time of diagnosis. indicating severe periodontitis in nonsmoking adults. At this stage. it was correlated with an odds ratio of 18. Specific genetic markers associated with increased levels of interleukin-1 (IL-1) production indicate a strong susceptibility to severe periodontitis in older adults. older adults who are experiencing the loss of teeth and the adjustment to removable appliances Figure 45-8 Tongue blade screen for saliva testing. This may require the dentist first to address the patient’s fears and expectations about treatment outcomes. Oral and pharyngeal cancer detected at later stages can cause disfigurement.0-0. stimulated 1. decreased quality of life. genetic susceptibility. Uncorrected page proofs shown. loss of function. Tongue blade screen showing minimal wetness.01-0.5-1.2 ml/min 0. Epidemiology. Oral cancer is treatable if discovered and treated early. wet the tongue blade for about 5 seconds. however. both in quality and quantity of foods. Whatever the cause. When the genotype for polymorphic IL-1 gene cluster was identified.0 ml/min 0. maintenance protocols. pain.0-2. the lesion may have already spread to the lymph nodes. or both. For example. and patient compliance. Oral and medical problems may influence the risk for disease.Periodontal Treatment for Older Adults s CHAPTER 45 687 TABLE 45-6 Sialometry for Xerostomia Screening: Salivary Flow Rates Category Normal Abnormal Whole saliva 0.39 Risk assessments may also serve as predictors for successful treatment outcomes.2 ml/min Whole saliva. A. These problems may be the result of the older person’s social conditions. Screening begins by placing the tongue blade in the sublingual area at the mandibular anterior quadrant. Most dentists can easily identify an early carcinoma in situ (Figure 45-9). oral dysfunction. these underlying problems must be addressed so that dental outcomes will be positive. and exposure to sunlight (lip). Surveillance. and nutritional disorders.4 ml/min Figure 45-9 Early carcinoma in situ. Risk factors for oral and pharyngeal cancer are age. For the saliva screen. B. Assessment of Risk A Assessment of risk is determined after completion of the patient interview and the extraoral and intraoral examinations. C. For example. and diabetes.

Steroid-induced gingivitis has been associated with postmenopausal women receiving steroid therapy. much of the ravages of the disease detected in older adults results from an accumulation of the disease over time. With treatment. In addition. it is thought that the cough reflex can be improved by reducing the oropharyngeal microbial pathogens present. Because periodontal disease has periods of exacerbation and remission. the dentist often may not have the special skills. studies have been conducted on the prevention of ventilator-associated pneumonia. diabetes. immune status. In general. smoking. In particular. understanding and documenting periods of active disease versus quiescent periods are essential to the formulation of the treatment plan and prognosis.26. Providing oral therapy for intensive care patients to reduce bacterial colonization in the mouth and teeth can reduce mortality and morbidity by 42%. tional deficits.24 The presence and extent of periodontal disease may be related to increased risk of weight loss in older. func- PERIODONTAL TREATMENT PLANNING Generally. salivary flow. Iatrogenic problems arise from side effects of treatment or from treatment procedures and range from drug interactions to medical emergencies. In less serious situations. the most appropriate care is to do nothing. Improvements in oral care have greatly reduced the incidence of pneumonia in elderly nursing home patients. referred to as iatrogenic effects. This gingival overgrowth further decreases a person’s ability to maintain good oral hygiene. genetics. Pneumonia is a common cause of morbidity and mortality in the older adult. and stroke. medications. calcium channel blockers. Under certain conditions. Changes in nutrient intake may be related to periodontal disease and a higher systemic inflammatory burden.6 reported an association between periodontal disease and left ventricular mass in untreated patients with essential hypertension. In some severely compromised patients. some older adults with physically or psychologically based behavior problems may require premedication in order for the dentist to deliver treatment.688 PART 7 s Treatment of Periodontal Disease or dentures can experience tremendous difficulty in accepting a reduced level of oral functioning. periodontal disease can be associated with coronary heart disease and cerebrovascular accident (CVA. In addition. Angeli et al.46 Because periodontitis is a chronic disease. One major referral base would be a trained hospital dentist who is capable of managing and treating the patient impaired by dementia or some physical problem or disease. . the dentist may need to become familiar with the referral resources to contact clinicians who can treat such patients.g.46 Evidence is limited on whether the risk factors for periodontal disease differ with age. Their coping mechanism may also be stressed because of other socially important factors. a periodontal examination may assist cardiovascular risk assessment in hypertensive patients. wellfunctioning adults. and anticonvulsants (e. mental health status. periodontal disease in older adults is not a rapidly progressive disease but often presents as longstanding chronic disease. nutrition. treatment is only rendered if the potential for sepsis is suspected. Thus the patient’s presenting conditions may affect the rendering of the treatment plan. Research has shown that the advanced stages of periodontitis are less prevalent than the moderate stages in the older adult population. This may require the dentist to obtain the additional training and equipment to treat this population. The goal of periodontal treatment for both young and old patients is to preserve function and eliminate or prevent the progression of inflammatory disease. This association is independent of smoking and diabetes mellitus.61 Some frequently prescribed medications for older adults can alter the gingival tissues. For example. there is a concomitant risk for causing problems.11 General health status. an older patient may not tolerate a reclining chair position for restorative procedures because of a chronic heart ailment or arthritis. Gingival overgrowth can be induced by such medications as cyclosporines. Uncorrected page proofs shown. For example.. and finances may modify the relationship between periodontal disease and age. For example. phenytoin) in the presence of poor oral hygiene.55 Expanding on these findings.26 Relationship to Systemic Disease A review of the literature by Loesche and Lopatin34 indicates that poor oral health has been associated with medical conditions such as aspiration pneumonia and cardiovascular disease. Otherwise. cardiovascular disease. Many conditions limit an older person’s ability to withstand or cope with dental treatment. This maintains the bone in the area and allows for a prosthetic appliance to be placed. especially in a rural community where access to services is extremely limited. the Surgeon General’s Report on Oral Health emphasizes that animal and population-based studies demonstrate an association between periodontal disease and diabetes. stroke).58 Copyright © 2006 elsevier.11.52 Recent investigations confirm these associations.26. a dentist may decide not to treat a cracked tooth but to dome it and leave its root intact in tissue. nifedipine.14 One theory is that many sites of advanced periodontal disease have resulted in tooth loss earlier in life. suggesting that older age is not a risk factor for periodontal disease.46 Periodontal disease must be diagnosed regardless of age.60 PERIODONTAL DISEASES IN OLDER ADULTS Etiology Periodontal disease in older adults is usually referred to as chronic periodontitis. Other conditions may limit the dentist’s ability to render treatment. the dentist uses a determination of the risk/benefit of treatment for patient-related outcomes in deciding whether or not to provide treatment. or training to meet the needs of poorly functioning or nonfunctioning older adults. such as esthetics and social esteem. equipment. treatment is withheld. Although the mechanism is currently under investigation. Alternatively.

depending on the dose. individualized care. and other scientists are creating high-quality office-based methods to access evidence-based decision-making programs and accommodating websites to help with complicated oral health care issues. Although chlorhexidine has not been studied in older adults. Assessments of overall health. The newer.62 age alone is not a contraindication for implant placement. For certain patients.46. and arthritis. and lifestyle behaviors that influence periodontal treatment.57 This may be partly caused by impairment of fine motor skills secondary to disease or injury.2. Older adults. and caregivers need to be informed and trained by dentists in the appropriate devices. and ability to tolerate treatment should be evaluated during treatment planning. long-term use (>6 months) has not been extensively studied.58 A common goal for all older adults is to decrease bacteria through oral hygiene and mechanical debridement. For older adults.57 Chlorhexidine is either bacteriostatic or bactericidal. or progression of disease.56 care. In addition.58 Chlorhexidine is a cationic bisbiguanide that has been used as a broad-spectrum antiseptic in medicine since the 1950s. suggest that it is also effective in older adults. oral and periodontal health.58 Dental implants are a reliable replacement for missing teeth in older adults. dentists. these barriers inhibit their achieving and maintaining optimum oral and periodontal health. Chlorhexidine may be particularly useful for older adults who have difficulty with plaque removal and those who take phenytoin. and permanent staining of teeth. Adverse effects of chlorhexidine include an increase in calculus formation.57 The American Dental Association (ADA) Council on Dental Therapeutics4 has approved chlorhexidine to help prevent and reduce supragingival plaque and gingivitis.4 Chlorhexidine is a prescription rinse for shortterm use (<6 months). older adults may have difficulty performing adequate oral hygiene because of compromised health. functional status. self-esteem. For individuals who are unable to comply with treatment. Interproximal brushes. Uncorrected page proofs shown. esthetics. Age alone is not a contraindication to surgery. the most important factors determining a successful outcome of periodontal treatment are plaque control and frequency of professional Copyright © 2006 elsevier. and mechanical flossing devices often can be used in place of traditional flossing with satisfactory outcomes. Individuals responding best to surgical therapy are those who are able to maintain the surgical result. The PREVENTION OF PERIODONTAL DISEASE AND MAINTENANCE OF PERIODONTAL HEALTH IN OLDER ADULTS For both younger and older persons. who have poor oral hygiene.58 Older adults may change toothbrush habits because of disabilities such as hemiplegia secondary to CVA. or cyclosporines and who are at risk for gingival hyperplasia. Surgical technique should minimize the amount of additional root exposure. topical antibiotic therapy may complement repeated subgingival instrumentation during supportive care. number of occlusal contacts. The outcomes are instrumental in achieving overall health. outcomes in younger persons. For this reason. Clinical trials with older adults show that the development or progression of periodontal disease can be prevented or arrested by the control of plaque. and techniques to provide oral selfcare and maintain healthy lifestyles. . Advanced age does not decrease plaque control. and individual patient preferences are also important. For those older adults who are homebound or institutionalized.46.57 Subantimicrobial tetracycline (Periostat) is useful in treating moderate to severe chronic periodontitis. calcium channel blockers. their families. however. a 0.Periodontal Treatment for Older Adults s CHAPTER 45 689 The goal of clinically managing periodontal disease in older adults is based on specific. palliative supportive periodontal care instead of surgical periodontal treatment is often the optimal treatment approach. Several factors must be considered during treatment planning for older individuals. Chemotherapeutic Agents Antiplaque Agents Patients who are unable to remove plaque adequately secondary to disease or disability may benefit from antiplaque agents such as chlorhexidine. outcome. chemotherapeutic agents.45. The major consideration is improving or maintaining function. Barriers to achieving these benefits are access and costs. medications. altered mental status. multidisciplinary strategies are increasingly becoming part of periodontal health care promotion. other health care professionals.2% concentration of chlorhexidine has been used for years as a preventive and therapeutic agent. Depending on the nature and extent of periodontal disease. and patient education are fundamental to promoting and maintaining optimum periodontal health. Prevention.58 Decision making for frail and functionally dependent older adults may be challenging to the general dentist. a nonsurgical approach is often the first treatment choice. with an emphasis on quality-of-life issues. tooth type. nutrition.38. subantimicrobial tetracycline. ability to perform oral hygiene procedures.46 The amount of remaining periodontal support or past periodontal destruction. and ease of maintenance are the criteria for successful management of an older adult. functional status. lightweight. including those with disabilities. Oral hygiene maintenance should also focus on root surfaces susceptible to caries.58 Periodontal disease severity. dementia. and Listerine or its generic counterparts.46.46 It is important first to remember that periodontal healing and recurrence of disease are not influenced by age. comfort. Emphasizing care over cure is the cornerstone of any proposed treatment plan. particularly a frail or functionally dependent older patient. or altered mobility and dexterity. The proportion of people who floss their teeth decreases after age 40 years. dysgeusia (altered taste). electric-powered toothbrushes may be more beneficial than a manual toothbrush for older adults with physical and sensory limitations. function. In Europe. The risks and benefits of both surgical and nonsurgical therapy should be considered.11 Factors to consider in the older patient are medical and mental health status. shaped wooden toothpicks. medications. or who are medically or mentally compromised or functionally impaired. surgical therapy may be indicated. visual difficulties.46. and quality of life.

For behavioral modification. Prescription 1. Both forms of nicotine replacement have been shown to increase cessation rates when used in combination with behavioral interventions. Saliva Substitute. The tests suggested to screen for alcohol abuse are the self-administered questionnaire. .600 ppm fluoride ion. Listerine may benefit patients who do not tolerate the taste or staining of chlorhexidine and who prefer OTC medicaments that are less expensive and easier to obtain. Nicotine replacement therapy should probably not be considered for the following persons: • Individuals who have not previously tried to quit. Listerine has been shown to be effective in reducing plaque and gingivitis compared with placebo rinses in young healthy adults. foam. Advise the patient to stop using tobacco. Promotes remineralization of early carious lesions. 2. with a sensitivity of about 50% and a specificity over 90%. annoyed. and the CAGE (from a series of four questions about drinking: cut down. result in much higher patient cessation rates than if only two or three are used. It is not recommended for use for more than 6 months. Salivart). The most common treatment for alcoholism is referral to a substance abuse facility. Listerine is generally contraindicated in patients under treatment for alcoholism who take Antabuse (disulfiram). The MAST with a cutoff score of 5 produces sensitivity ranging from 50% to 70% and a specificity above 90%. Clinical studies show that all four components. Fluoride’s effects are as follows46.1% neutral sodium fluoride gels are available with a fluoride concentration of 5000 ppm fluoride ion. and eye-opener) questionnaire.4 Saliva Substitutes Saliva substitutes. used routinely. Patients with dry mouth may also benefit by stimulating saliva flow with sugarless candies and sugarless gum.9%. 4. Xylitol chewing gum has been shown to have anticariogenic properties in children. revised (DSM-IIIR). • Individuals who have tried to quit and have not had significant physical symptoms of nicotine withdrawal. they usually contain salt ions. the Michigan Alcoholism Screening Test (MAST). 3. Topical fluorides are recommended for the prevention and treatment of dental caries.6% to 26. nicotine replacement therapy may help strongly addicted patients. 3. Medicated chewing gum with xylitol and chlorhexidine or xylitol alone has the added benefits of reducing oral plaque scores and gingivitis in elderly persons who live in residential facilities. Biotene products are marketed to relieve the symptoms of xerostomia. paraben (preservative). Under investigation is acupuncture-like Copyright © 2006 elsevier. Assist the patient in stopping by selecting a quitting date (usually within the next 4 weeks). a flavoring agent. Most smokers (90%) quit “cold turkey.” However. and fourth edition (DSM-IV). 2.690 PART 7 s Treatment of Periodontal Disease active ingredient in Periostat is doxycycline hyclate.4 Most saliva substitutes can be used as desired by patients and are dispensed in spray bottle. “nature’s cavity fighter.57 transcutaneous nerve stimulation (Codetron). Alcoholism and alcohol abuse are diagnosed using the Diagnostic and Statistical Manual of Mental Disorders. Is bactericidal to bacterial plaque. the most effective treatment is a program that emphasizes older adult–specific groups using nonconfrontational therapy and encouraging reminiscence as well as discussion of Fluoride Fluoride.. rinses. Unlike traditional acupuncture therapy. a four-item screening tool (Figure 45-10). cellulose derivative or animal mucins. • Individuals who use only small amounts of tobacco or who are occasional users. a method to treat radiation-induced xerostomia.g. Listerine may exacerbate xerostomia because of its high alcohol content. For the older adults.57 In addition. In concert with scaling and root planing. Listerine antiseptic and its generic counterparts are approved by the ADA Council on Dental Therapeutics4 to help prevent and reduce supragingival plaque and gingivitis. Acupuncture therapy has demonstrated improvements lasting up to 3 years. Their composition is varied. ranging from 21. A score of 2 in the elderly patient (an affirmative answer to two questions) provides clinical evidence or suspicion of alcohol abuse.46. • Individuals who do not receive behavioral support from clinic staff. or oral swab stick. Ask the patient about tobacco. and fluoride.64 Risk Reduction Cessation of tobacco use has been primarily an issue of patient compliance.” is the most effective caries-preventive agent currently available. or varnish products are between 9050 and 22. and menthol). which are intended to match the chemical and physical traits of saliva.38 have shown this treatment to be effective in institutionalized older adults. Uncorrected page proofs shown. The ADA’s seal of approval has been granted for some artificial saliva products (e. and gels that contain concentrations of 230 to 1500 parts per million (ppm) of fluoride ions. thymol. however. third edition. Arrange patient follow-up services. Periostat is contraindicated for those patients with an allergy to tetracycline.5 Salivary substitutes and stimulants are only effective in the short term.4. Nicotine replacement therapy is intended to be used for a few (6-12) weeks so that patients can learn psychologic and social coping skills without going through nicotine withdrawal at the same time. are available to relieve the symptoms of dry mouth. The transdermal nicotine patch or nicotine polacrilex (gum) can reduce the symptoms of nicotine withdrawal. the four steps to tobacco cessation are as follows: 1. guilty. Reduces enamel solubility. rinse/swish bottle. Professionally applied fluoride gel. Codetron does not use invasive needles to achieve stimulation. OTC fluorides include fluoride dentifrices. This method helps the patient to produce their own saliva and reduce symptoms of xerostomia for several months. products such as dry-mouth toothpastes and moisturizing gels are also available. The active ingredients in Listerine are methyl salicylate and three essential oils (eucalyptol. Mohammad et al.57: 1.

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