Treatment of Geriatric Patients

 You have to treat the cause of the problem rather than the problem itself (Problem oriented
treatment which is wrong); you have to identify problems to prevent further same problems and
you have to run your treatment in a very conservative way.
 Patient concern usually is relief of pain
 Pattern of treatment should be:
o Relieving of Pain
o Run a conservative treatment (minimal damage or prevent damage) so you need a more
sophisticated treatment oriented service (that you see an overview)
 Prevention is usually measured using Feasibility studies (‫(الجدوى االقتصادية‬
 Prevention usually oriented to the child population because it is more feasible as this prevention
will live longer, and is more cost effective (If you paid 100 dollars for 50 years prevention this
means that the prevention costed 2 Dollars per year while if it lasts for five years only; this
means it costed 20 dollars per year) that is why prevention is more oriented to child population.
 One of the challenges is that Elderly patients (especially Egyptians) can refuse the prevention ( ‫يال‬
‫ )حسن الختام‬plus that doctors think problem oriented just to relief pain and that’s it.
 Factors influencing Preventive dental care for elderly patients:
o Illness and health related factors
 General ill health
 Discomfort
 Mobility
 Functional limitations
o Socio-demographic factors
 Education
 Income
 Gender
 Age
 Culture
 Ethnicity
 Place of residence
o Service-related factors (What can you provide to the patient)
 Dentist behavior and attitude
 Cost insurance (can the patient afford the treatment and is it covered or not
 Satisfaction with service (Short dental visit with most efficient work)
 Transport
o Attitudinal or subjective factors
 Personal beliefs
 Perceived importance (Appreciation and importance of what you’re doing)
 Fear and anxiety
  Resistance to change
 Perceived financial strain (can he afford the treatment?)
 Satisfaction with dental visits (he has to feel that he is benefitting from you)
 Your dental clinic should be equipped to provide dental care for:
o Special needs patients (your clinic should have a lever for example)
o Mental Disability
o Medically complex cases
 Do these cases have the right to make their own decisions about the treatment plan and they
can sign the consent or they can’t do so? This is still debatable
 Gillion identifies the possible conflict between the principles of helping those in need for help
and recognizing their right to make their own decision

Patients who are clearly (they are in coma for example) incompetent to make decisions ought to
have that decision made for them.

 Method for preventing plaque-induced infections (which are Periodontitis and Dental caries) is
inhibiting plaque formation; however, it depends on the ability of the patient to accomplish
adequate oral hygiene.
 Why elderly are more prone to plaque formation?
o Existing restoration (Marginal deterioration, roughness of the surface, saucerization of
amalgam, etc. which will favor plaque retention)
o Missing teeth (Disuse sides, drifting and
malalignment favors plaque retention)
o Malpositioning of teeth
o Gingival Recession
o Removable prosthesis
o Inadequate oral hygiene
 Elderly have inadequate oral hygiene due to:
o Lack of digital dexterity
o Impaired vision
o Physical limitations associated with diseases
like Parkinsonian.
o Decreased motivation
  How to help elderly patients to perform oral hygiene?
o Increase the size of the brush using acrylic resin for better handling
o Electric brushes
o Tooth picks (which are bad for young patients as it can cause gingival recession however
for elderly patients they already have gingival recession so, it is useful for them)
o Oral irrigator (water pick) (water stream that washes plaque and dilutes acids)
 Some elderly patients are dependent they need someone to help them to brush their teeth but
those caregiver are rare and very costy so, the caregivers does not offer optimal oral care due
to:
o Time constraints (they are few and there are a lot of patients)
o Difficulty in brushing other individuals teeth
o Lack of cooperation (from both patients or care givers)
o Lack of perceived need (usually females they feel they do not need care)
 So, you need to simplify the means of oral care for these patients like:
o Xylitol Gums (which is a natural sugar that is NOT carcinogenic) chewed after meals as it:
 Reduce acidogenicity of plaque (because of chewing which will increase salivary
flow that act as a buffer)
 Stimulate salivary flow
 Cleans retentive areas from food remnants (like at the margins of restorations)
 Decrease plaque accumulation

NB: Xylitol Gums keeps the sucrose molecule from binding to the mutans so, prevent them from
fermenting sucrose.

 It is very important during management is to stress on:

 Early Detection (starts from knowing the risk factors using Cariogram for example)
 Prevention
 Treatment of dental problems
 Obtaining oral care also requires willingness and help from the care givers

Problems affecting elderly patients:

1. Dental Caries

The upper picture show recurrent caries

under a restoration

The lower picture shows healthy gingiva

but the teeth showing abfraction as
well as severe attrition and wear
leading to loss of anatomy.

NB: So, the number and type of

restorations and wear areas can give an
indication of patient’s previous caries
experirnce (DMFS and DMFD??) &
predicting the risk factor

 New carious lesions in Enamel are uncommon (What decreases by age is the pits and fissure
caries however root caries is 80-100% in elder patients) unless:
o Changes in Medical status (xerostomia)
o Adopts a Diet conductive to caries

 Proximal root caries are more common than buccal root caries due to gingival recession that
causes food impaction in the interdental areas.

 Root caries Prevalence: a research was made on periodontally affected patients with gingival
recession during ONE year period; these patients developed about 160 new root caries lesion in
31 patients; this means that each patient developed around 5 new caries lesions in one year. 80
of them were recurrent caries (at the margins of the restorations)

NB: Closed Lesion: usually occurs in the enamel where the occlusal
surface appears intact while the lesion is undermining the occlusal
surface so, if you opened a small spot or a fissure of caries on the
occlusal surface you will find that the lesion is spreading
underneath the enamel undermining the cusps. (More aggressive and pulpally
directed)
Open Lesion: spread laterally (goes axially towards the line angles causing
decapitation of the whole crown and exposed to the oral cavity so, it is chronic
(usually occurs in root caries)
 Location & Appearance of root caries:
o Below the CEJ (because the cementum is usually removed as it is acid labile and cannot
withstand to be exposed in the oral environment so it become washed away ,and also
usually removed during root planning and curettage by periodontists
o Opened lesion: which means it is exposed to the oral cavity (chronic) however, although
it is less virulent than closed lesions and Actinomycins are less virulent than S.mutans
,but it should be treated as if it is aggressive due its high proximity to the pulp due to its
location and anatomy of the root where the dentin bridge decreases as you go apically
on the root; in addition, the it spreads directly through dentin which is porous unlike
closed lesions. (Premolar for example has dumbbell shaped root)
 Color: yellow or light brown and softwith no sharp demarcation
 Superficial spreading to the facial and proximal line angles (lateral spreading to the line angles)
 Pulp is very near
 Lesion develop rapidly because
o These areas have no enamel protection
o dentin less mineralized (porous)
o Amount of dentin bridge is very thin
 Maturation may occur as the lesion is exposed to the oral cavity appears brownish (arrested
caries)
  Microbiology of root caries:

Actinomycins Viscosis not S. Mutans because S. Mutans is a facultative but mainly anaerobe so, it
prefers anaerobic conditions (closed lesion) while in this case it is an open lesion.

 Diagnosis: (Mainly the same as any other carious lesion)

o Inspection
o Tactile sensation (probing)
o Radiographic examination
o Proximally by transilumination
o By discoloration

NB: sometimes it can occur below the gums proximally so, the patient suffers from severe pain and you
cannot see it.

It appears in vertical bitewings x-ray however it can be misinterpreted with a radiographical artifact
called cervical burnout

X-rays are not conclusive so, never depend on x-ray solely in your diagnosis ( it is a 2D picture of a 3D
object)

Professional
Prophylaxis: Scaling,
curettage and
polishing.
 Validity of preventive care was checked by Nyvad and others they discovered it decreased the
instance of root caries by 54% in one year

Remineralization and prevention methods:

 Fluoride Appliation: BUT, Do not use acidulated fluoride

 Synthetic Hydroxyapatite

 Casein phosphopeptide (mayyet el zabady)

 Bioactive glass

 NovaMin: which is very important as it is the only method that does not need Saliva so, it is mainly
used with patients suffering from xerostomia (which is common in elderly patients so, it is very
helpful for them)
 Ozone: it is not a treatment; it is a disinfectant when you apply it using its cap on the tooth it
oxidizes the bacterial cell membrane killing it (99.9% disinfection, but once you remove the cap the
tooth become infected again) so, you have to use Ozone then demineralize the tooth structure and
put the restoration to seal and protect the sterile field.

Factors Promoting Caries in elderly patients:

 RestorationsMarginsDiscrepancyRetentive features Recurrent caries (due to lack of seal)
 Anatomy of the teeth and restorations change forming retentive areas
 The restoration or the lesion itself can be inaccessible and cannot be cleaned

 Materials to be used:

o Amalgam: it CAN be used for root caries but it has the following disadvantages:
 It needs mechanical undercut which is very hard to be done on the root.
 It needs adequate condensation against the walls (should be confined, however root
caries extends proximally so, there is no axial wall (Not confined). This can be
overcame using a circumferential matrix and a window is opened through the
matrix adjacent to your cavity so, the amalgam will become confined during
condensation)
o Composite: it has the following disadvantages:
 Root caries is very close to the gums so; it should be very well polished to prevent
gingival irritation.
 It requires perfect isolation which is difficult in this case.
 Weak bond with dentin that usually lead to microleakage
o Glass ionomer: It is considered the material of choice because:
 True adhesion (Chelation bond with Calcium)
 Good marginal seal preventing microleakage
  Fluoride release
 Requires little or no preparation
 Biocompatible (minimal pulpal reaction)

However, Glass ionomer is very hard in its handling because:

 Requires a preshaped matrix (cervical foil and use it till intial setting of the GI)
 Avoid moisture contamination before, during or after application
 After removing the matrix you need to apply an isolating material like bonding agent or a
varnish.
 Needs conditioning of the cavity surface with polyacrylic acid
 Rubber dam can be used
 May or may not require a protective base

NB: Modified GI can be better

Syringe types also are preferred as they are: (Ketac or Fuji)
o Reduces voids
o Easier handling