Giriatric lecture - Operative
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Transcript of 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.