giriatric lecture - operative

7/30/2019 Giriatric lecture - Operative

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Gerodontology:

Gerodontology Defined as the dentistry for the elderly. For those

who have not reached pensionable age, the elderly is any one over 65.

Others suggest that over 75 years of age. Rather than arbitrary cut-offs,

biological age should be considered. This new specialty, how ever is still in

its infancy.

Epidemiology:

Two factors are mainly responsible for the increasing relevance of

dentistry for the elderly, an increase in the population and the improvements

in dental health which have resulted in more people keeping their natural

teeth for longer. By 2001 the proportion aged > 75 years have increased by

22% and, 10% of adults were edentulous, compared with 25% in 1993.

General Health Problems:

The major overall problems are:

Age changes both physiologically and pathologically. Disease and drug therapy.

Delivery of care.

Normal physiological changes:-

Normal physiological changes may occur in older patients and should

not be mistaken for pathological conditions, For e.g. the skin and blood

vessels loss their elasticity due to degeneration of the elastic connective

tissue and delayed healing following surgical procedures may result in bones

become more brittle and easily broken with advancing age. Sensory


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impairment may lead to hearing loss, visual changes, alteration in taste and

smell.

Dental and mucosal changes may also be associated with the aging

process. A tooth can change shape due to many years of attrition, abrasion,

and wear of proximal surface. variation in pulp anatomy, physiology and

color changes due to extrinsic staining can occur with age and may lead to

increased brittleness of the teeth. A continuous thickening of the cementum

is frequently noted and is most pronounced in the apical regions. The

gingivae can become edematous, friable with a loss of stippling and recede.

The diminished salivary flow results in loss of elasticity of the oral mucosa

as well as increased caries rate. An understanding that these physiological or

metabolically change are not pathological is essential for proper operative

treatment planning for the geriatric patient.

Of primary importance in planning dental therapy is the biological or

physiological age of the older patients, not the chronological age. Factors

such as genetic disposition, physical or mental capabilities and the presence

of chronic disease may make an individual biological age older or younger

than his or her chronological age.

Consideration of these factors in the treatment plan is crucial for the

long-term success of many dental treatment of the older patient.

Disease and drug therapy:

Physiological changes associated with aging:- with the lengthening

life span and increase retention of teeth by older patients, dentist are treating

more geriatric patients. it is important to thoroughly understand the medical

and dental background of older adult patients.


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The geriatric populations can experience significant changes in

behavior and diet, as well as in oral and systemic health. Certain medications

and illnesses may alter oral physiology, oral hygiene and dental health.

Necessitating changes in treatment for example xerostomia or reduced

salivary flow may be side effect of anti-cholinergic and anti-hypertensive

medications and may result in increased caries incidence, mucosal

alterations and plaque retention.

The use of salivary stimulants such as sugar free candy drops,

artificial saliva or pilocarpine in more serious cases along with lowering

drug dosage, may lessen or relieve this symptom.

Additional considerations include the limited use of vasoconstrictors

in patients with advanced cardiovascular disease, reduced dosages of

diazepam to prevent over sedation due to poor renal- hepatic clearance with

aging, and interaction between drugs prescribed for dental purposes and the

patients other medications.

Restorative problems include:

The major overall problems are:

Root caries which can occur following exposure of root surface by

gingival recession, in association with changes in diet, decrease self-

cure, and decrease in salivary flow.

Tooth wear is especially prevalent when partial tooth loss has

occurred.

Pulpal changes including sclerosis and decrease repair capacity.

Root Surface Caries:-


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With gingival recession root dentine is exposed to carious attack the

treatment requires first, control of the etiological factors and for most

patients this involves dietary advice and oral hygiene. Topical fluoride may

aid remineralisation and prevent new lesions developing. However, active

lesions will require restoration with glass ionomer cement.

Prevention of root caries in susceptible patients is possible using

either a topical fluoride mouth rinse or fluoride containing artificial saliva.

e.g. Luborant or Orthana.

Tooth Substance loss (Tooth wear):-It is non- carious lesions that result in loss of tooth substance it include:

Attrition

Erosion

Abrasion

Some tooth wear during life is inevitable where it has classically tooth

brushes are blamed for the characteristic cervical notches, but it is nowthough that other factors may also be operating.

Attrition:

Is the mechanical wear of one tooth against another as a result of

functional or parafunctional movements of the mandible. It affects the

contacting incisal edges and occlusal surfaces of opposing teeth. Attrition

also affects interproximal surfaces. Increase in more abrasive diets and in

bruxism. It is often assumed that attrition is greater in patients with reduced

posterior support, but no evidence exists to support this. The bruxism may

decrease with increase of age.


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Causes:

1. Habits like tooth grinding or bruxism (usually due to stress).

2. Presence of erosion, some tooth wear is a combination of erosion and

attrition, enamel soften by acids may be worn away by mastication.

Clinical features:

The incisal or occlusal surfaces are worn result in decrease the

occlusogingival length of the tooth.

Length of the tooth becomes out of proportion to width.

in some cases the enamel of the cusp tips( or incisal edges is

worn off resulting in cupped-out areas because the exposed,softer dentin wears faster than the surrounding enamel.

Exposure of dentin on incisal &occlusal surface and some times

reaching the pulp.

Sensitivity to temperature and /or sweat.

Management and treatment:

Occlusal adjustment to remove interferences which trigger the

grinding.

Construction of acrylic bite plane for treatment of bruxism.

Desensitizing agents, varnish contains fluoride or fluoride mouth

wash.

Restorative treatment is indicated when:

1. Patient concern about aesthetic

2. Patient complains of sensitivity.

3. Change in vertical dimension and TMJ problems

4. Pulp exposure occurs.

Root canal therapy for pulpaly involved teeth.


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Veneers or crowns in severe cases (to correct aesthetic, functions and

restore correct vertical dimension).

Erosion:-

It is loss of tooth substance from non-bacterial origin and is usually

chemical attack. Chemical erosion is a chronic, localized loss of dental hard

tissue that is chemically etched away from the tooth structure by acid.

The incidence of erosion appears to be increase but this may be the

result of an increase of an increase awareness of the problem. As the

presence of acid results only in demineralization, for loss for tooth substanceto occur erosion must act in conjunction with attrition or abrasion or both.

Erosion will be enhanced if the buffering capacity of the saliva is decreased.

for e.g. in dehydration secondary to alcoholism. Classically, see smooth

plaque-free surface with proud restoration whether the acid is industrial,

dietary or gastrointestinal in origin such as gastric reflux.

Causes:

The causes of erosion are exogenous and endogenous chemicals

which come from three sources; diet, stomach and environment.

Dietary erosion: affects the labial surfaces of upper anterior teeth.

It is caused by an excess of food and drinks with a low pH like:

1. Citrus fruit and fruit juices (citric acid).

2. Pickles and other foods& drinks containing vinegar (acetic- acid).

3. Carbonated drinks (carbonic acid).

Endogenous reason of erosion:

Commonly affects the palatal surfaces of upper anterior teeth and the

occlusal and buccal surfaces of lower posterior teeth. Caused by the


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regurgitation of gastric acid (hydrochloric acid) from the stomach in patients

with:

1. Digestive disorder including hiatus hernia and chronic indigestion

2. Anorexia and bulimia nervosa.

3. Gastroesophageal reflux

4. Chronic alcoholism.

5. Voluntary regurgitation.

Industrial causes of erosion:

This type of erosion commonly affects the labial surfaces of the upper

and lower anterior teeth. Caused by industrial processes which produces

acids, fumes or droplets.

Idiopathic erosion

Flexure (elastic bending) of the tooth from occlusal trauma and heavy

force in eccentric occlusion causes stress concentration at the cervical

portion of the tooth, resulting in loosening and gradual loss of enamel rods

from tooth surface by micro fractures. This process is referred to as

abfraction

Clinical features:

Found in areas free from plaque but exposed to acids.

Appear as notched cervical lesions, crescent, dished or wedged shaped

Defects.

Has smooth glazed surface.

Exposure of dentin and sometimes reaching the pulp.

Sensitivity to temperature &/or sweats (when the lesion advanced)

Management and treatment:


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In early stages, the treatment should emphasis on prevention and

monitoring. The use of fluoride mouth rinses and topical application of

fluoride varnishes or neutral gels would slow down the progression of

erosion as well as reducing symptoms of sensitivity if present).

At later stages, Restorations become necessary especially when:

1. Patient concerns about appearance.

2. Tooth becomes sensitive.

3. Deep defect that compromise the structural integrity of the tooth.

4. The defect contributes to a periodontal problem.

5. The depth of the defect is judged to be close to the pulp.

Direct tooth coloured restorative materials

Restorative materials used may be, composite resin, combination of

GIC and composite resin (sandwich technique), resin modified glass

ionomer cement or compomers.

Minimal cavity preparation is required which include:

Bevelling of enamel margins.

Roughening of the internal sclerotic cavity wall to remove the highly

calcified outer layer and expose the dentinal collagen network to the

adhesive.

Retention groove is placed in non-enamel areas only (improve

retention).

Amalgam or direct gold

Amalgam or direct gold are also indicated to restore erosion areas in

posterior teeth. They are non adhesive materials therefore, cavity preparation

(Class V) is required to make the area retentive.


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Full crown or cast restoration

Full crown or cast restoration is the treatment of choice in cases where

erosion has caused the teeth to be significantly weakened or if the other

surfaces of the tooth are extensively involved by caries and / or restoration in

addition to the erosion area.

Abrasion:-

Abrasion is physical wear of tooth caused by an external agent.

Classically, toothbrushes are blamed for the characteristic cervical notches,

but it is now thought that other factors may also be operating.

Causes:

1. Forceful tooth brushing technique

2. Abrasive toothpaste and powders (smokers tooth powder).

3. Habits such as holding a pipe stem or pins by the teeth, (can cause

wear in the form of notches in the incisal edges).

Clinical features:

*Seen as a sharp v shaped notch or dish (saucer) shaped notch with rounded

margins located in the gingival third of the labial surface of the teeth.

Has smooth glazed surface.

Exposure of dentin and sometimes reaching the pulp.

Sensitivity to temp and / or sweetness.

Gingival recession.

Sometimes similar to erosion and it can be difficult to make a clear

distinction between them

Management and treatment


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Preventive treatment, changing the abrasive activity like method of

brushing or the tooth paste type.

Restorative treatment options are similar to that of erosion.

Root Caries

Early carious root lesions are soft/leathery lesions that cover small areas of

the root (less than 5 millimeter square in size) and are not cavitated as seen

below.

Advanced root lesions are soft/leathery with a large surface area or a cavity

(5 millimeter square or larger) shown below.


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Hard and discolored areas with no signs of cavitation should be classified as

questionable in the images below.

giriatric lecture - operative

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