elderly people need healthy

mouths
Older Teeth, Gums &
Other Oral Bits z To maintain quality of life
• eating
• talking
Gerodontics
• smiling
z for medical reasons
• prevent infections
• cope with medication side effects

misconceptions
z tooth loss is an inevitable part of the aging process
z most teeth were lost as people became ‘long in the tooth’
because of advancing gum disease
misconceptions
z all older adults get severe gum disease
z dental decay occurs mainly in children
and was not a problem for the older adult

teeth

hard bits z Complete loss of teeth (edentulism

decreasing in Australia
(edentulism)) is

Tooth loss in Australia

1979 67% of 65+ were edentulous
Teeth
1996 39% of 65+ were edentulous
Bone

z Projections indicate that by 2019 less

25% of 75+ age group will be edentulous
Age changes in the teeth form

z macroscopic changes z wear and attrition

• colour z reduction in enamel
• form • occlusal/incisal
z microscopic changes • interproximal
• the enamel
• dentine
• cementum
• pulp

colour - ‘yellowing’ of teeth

z altered surface structure

z changes in refractory quality of enamel
z changes in quality and quantity of dentine
z change in colour and translucency
z pigmentation of anatomical defects
z corrosion products
z inadequate oral hygiene
z recession exposure of dentine

Problems with hard bits - teeth attrition

z attrition z Loss of enamel and or dentine through

z abrasion occlusal friction
z caries • incisal/occlusal
• coronal • interproximal
• root z Beck and Hunt (1985) found that:
z fracture • 75 % of elderly had at least one tooth with all
incisal or occlusal enamel lost to attrition
• 4% had one tooth worn right down to gingiva
 abrasion

z non-occlusal frictional factors

z occurs at neck of tooth
z traumatic tooth brushing and/or gum
disease cause gum recession and
exposes ‘softer’ part of the tooth
z vigorous scrubbing technique combined
with abrasive paste wears abrades tooth

caries

z big problem for the elderly

z 50 - 70 % of dentate have caries
z types:
• coronal
• root

coronal caries root caries

z 60 - 70% of older adults

z mainly of ‘recurrent’ type experience root caries (Holm-
Pederson & Loe 1996)

z mainly molar and z Mandibular molar and

premolar most frequently
premolar teeth involved
z prediction of risk:
z difficult to recognise • coronal caries
•
unless large •
calculus
plaque
• xerostomia
fracture
z
restored teeth
stress fractured
z root remnants
z sharp edges can cause chronic irritation
of soft tissues
The oral mucosa
z barrier between the external and internal
environments
z three broad areas
• masticatory mucosa - gums and hard palate
• lining mucosa - floor of the mouth, cheeks,
soft palate & ventral surface of tongue
• specialised mucosa - dorsum of the tongue
and the lips
Age changes in oral mucous
membranes
z general health influences:
‘dietary deficiencies of iron and B vitamins
and reduced estrogen levels in women
lead to atrophic changes of the mucosa’
(Bottomly 1979, Belding & Tade 1978)
soft bits
oral mucosa
gums
tongue
salivary glands
Age changes in oral mucous
membranes
z progressive age related changes in skin - oral
mucosa ?
z reported changes:
• mucosa becomes thin, smooth and dry with age
(Bottomly 1979, Kidd & Daly 1982).
• satin like and oedematous appearance with a loss of
elasticity and stippling (Pickett et al 1972).
• Becomes more susceptible to minor injury (Miles 1972).
• With age increasing susceptibility to various pathological
conditions such as candidal infections and decreased
rates of wound healing (Holm-Pederson & Loe,
Southham 1974).
Age changes in the
periodontium (gums)
z mild to moderate periodontal disease is high in
the elderly but severe periodontal disease is no
greater than in middle aged
z some changes in collagen fibres of periodontal
ligament
z functional adaptation
z however breakdown of the periodontal
attachment is not the result of age related
changes in the periodontium
age changes in the tongue
z decrease in number and sensitivity of
papillae
z sublingual varicosities are common but
not problematic
z nutritional factors may cause atrophic
glossitis - burning sensation
identification of those at risk
z functionally dependant and frail under
long term care
z medicated and poly-medicated
z disease
Root Caries
z Dental caries involves the loss of mineral
ions from the surface apatite crystals
that form enamel, dentine and
cementum
z For root surfaces this process begins
with cementum and sometimes dentine
z Both loss of minerals and loss of protein
(proteolysis)
age changes in salivary glands
z non-medicated older adults do not have
decreased salivary flow rates or altered
salivary composition due to aging (Baum 1986)
z medications are the most common cause of
decreased salivary flow and xerostomia in
older adults
z diseases such as Sjogrens syndrome and
radiation therapy and chemotherapy do have
direct effects on the salivary glands (Shay & Ship
1995)
Coronal caries
z Mainly of ‘recurrent’ type
z Mainly molar and premolar teeth
z Difficult to recognise unless large
Root vs coronal caries
z Unlike enamel caries surface may
appear softened at early stage
z Bacterial penetration earlier
z As long as individual has normal salivary
flow root caries progresses slowly
Epidemiology of root caries The caries process
z Examination of ancient skulls shows that Plaque & fermentable
root caries was more prevalent than Sound tooth
carbohydrates Plaque removal
coronal caries tissue Saliva
z Dependent institutionalised people are at Fluoride
higher risk Modified diet
z No epidemiological evidence that root
caries is directly associated with diet/ z In institutionalised individuals all of the factors
above are adverse

Root caries - epidemiology Root caries - location

z Root caries occurs on z Root caries can be

located any where
the root of the teeth
on the root surface
z May spread to the z Disagreement with
coronal portion of the lesions in the CEJ
tooth area
z Advanced root caries • Root to crown or
may track towards pulp • Crown to root?
z Who cares?

Root caries - location What causes gingival recession?

z Root caries most often

z Periodontal disease
occurs supragingivally z Periodontal
z Usually within 2mm of the treatment
CEJ
z Positively associated with z Ironically over
age and gingival zealous brushing
recession/exposed
cementum z In some cases
z Occurs predominately on chronic trauma
the proximal surfaces
followed by the
facial/buccal

Epidemiology of root caries
z Prevalence of root caries is low until
about 60 yrs but then increases
z In some developed countries as high as
70% (Fejerskov & Nyvad 1996)
z In developed countries high rates of
restoration and re-restoration (Fure & Zickert
1990)
z Underlying causes are not addressed
(Kidd et al 2000)
Periodontal disease and root
caries
z Seichter (1987) review of research suggests
that periodontal pathology changes the micro-
hardness of dentine
z Root surface response to periodontal
inflamation:
• Lysis of cementoblasts
• Changes in the pre-cementum-cementum interface
• Decrease in surface mineralisation
• Cemental resorption

Clinical signs Clinical signs

z Early root caries z Much literature describes difficulty in
appears to spread measuring/diagnosing root caries
out along and track
along the CEJ
z Advanced lesions z Variations in signs and symptoms and in
teed to track towards interpretation by clinicians
the pulp

Clinical signs Clinical signs

z Most commonly used clinical signs z Literature fails to correlate root colour
include: with caries activity although most agree
• Visual: it is strongly indicative
• Colour z Cavitation may be present in early
• Contour stages of lesion development
• Cavitation z Blunt probe may be used to determine
• Tactile relative softness of the lesion – be
careful!
Reliability of visual-tactile
diagnosis Why is reliability so difficult
z Root caries diagnosis studies show z Differences in colour interpretation
limited reliability z Disagreement over the tactile
z Good at diagnosing filled cavities but nt interpretations
decayed
z Intra-examiner reliability has been shown
to be better (but not much) than inter-
examiner reliability

radiography Diagnosis of lesion activity

z Can be used for z Kidd et al (2000) provides the following
interproximal lesions criteria:
• Active lesions
• Inactive lesions
• Leathery (intermediate) lesions

Active lesions Inactive lesions

z Close to the gingival margin z Smooth and shiny
z Plaque covered and soft when felt with a blunt z Hard
probe z Not covered with plaque
z May occur with or without cavitation
z Often some distance from the gingival
z Neighbouring lesions may coalesce and margin
eventually encircle tooth
z May or may not be cavitated
z Lesions do not appear to extend apically with
gum recession – rather new lesions develop z Consistency may be more reliable than
colour
Leathery intermediate lesions Managing root caries

z Removal of plaque necessary z Three possible approaches

z Dark leathery consistency
• Nothing
• Arrest
z Virtually without cavitation • Restore

arrest Is arrest possible?

z Fluoride application z De Paola randomised double-blind clinical trial (USA)
z 71 > 65 year olds
z Improved homecare z Root caries rated as:
• C1 – well defined softened area yellowish or light brown but
z Reduction/suppression of microflora without cavitation – could be penetrated by probe
z Changes in diet • C2 – softened area yellowish or light brown with surface
disruption (cavitation)
z Address dry diet • AC –arrested caries with dark colour with leathery
consistency with or without cavitation – little or no
penetration by probe
z Reduce sugary medications
z Anything beyond C2 was excluded

method results
z Both groups examined % of buccal C1s arrested at 4, 8 and 12 months
z Root caries was isolated and dried
Group 4 months 8 months 12 months
z Treatment group got 12,000ppm NaF gel
for two minutes, control received placebo
z Both groups received OHI and Control 18 28 40
instruction on applying brush on gel Treatment 39 95 91
z Both groups received Colgate toothpaste 4 months X2 4.67 p <0.05
and brushes and take-home instructions 8 months X2 22.61 p < 0.001
12 months X2 13.29 p <0.001
 results Good results but what are
% of buccal C2s arrested at 4, 8 and 12 months
the limitations of this
study?
Group 4 months 8 months 12 months

Control 0 5 8
Treatment 13 53 57

4 months X2 4.30 p <0.05

8 months X2 22.89 p < 0.001
12 months X2 29.32 p <0.001

Preliminary Caries Diagnosis and

Restore Management of Root Surfaces

z Dental restorations on rots should be

different from coronal
z Restoration surrounded by dentine not
enamel
z Little guidance in texts on restoring root
caries

http://crse-nt.dent.umich.edu/cariology/Chart6.htm