GERODONTOLOGY
GERODONTOLOGY
GERODONTOLOGY
INTRODUCTION
Aging is a normal, genetically dictated physiological processs.It is a state
of interplay between the physiologically contractile and pathologically
destructive metabolic process. It is a process of morphological and
functional involution that affects most organs of the body. It leads to
gradual impairment in performance of various systems, hence of the
individual as a whole
The increase in life expectancy is the result of improved hygiene,
prevention and control of infections in childhood, development of new
drugs and better dietary habits.
One of the problems of aging is that some of bodily functions do not
maintain their efficiency. The cells, tissues, and organs do not age at the
same rate. To obtain successful results with complete dentures in the
postmaturation group of patients, the dentist must understand these bodily
changes. He must anticipate the time at which they will occur and
recognize the symptoms in the diagnostic phase of his procedures.
There is high degree of variability in the functioning of the aged. Aging
rates vary among populations and among individuals in the same
populations. The oral cavity, like the rest of the body, undergoes gradual
aging changes, although senescence does not follow the same pattern in
all people. It is almost impossible to find two geriatric patients who are
exactly alike in all aspects.
Because of high degree of variability among geriatric individuals, each
patient must be evaluated individually by knowing 1) why the changes
occur, 2)how the changes are related to the physiologic and psychologic
status of the patient,and 3)what influence the changes will have on the
prosthodontic procedures.
GERODONTOLOGY
Jamieson wrote that “fitting the personality of the aged patient is often
more difficult than fitting the denture to the mouth.” Success in geriatric
dentistry can be the result of building up the patient’s confidence in the
dentist, regardless of the quality of the final prosthesis. The important
factor is to persuade or condition the patient to accept the dentures, to
wear them, and to use them. The emotional and psychologic make up of
the patient must be kept in the mind during the entire procedure.
The patient must be educated to understand and accept the reduced
efficiency of the artificial dentition. The prosthodontist must realize that
treatment of the aging can be difficult. When the dentist does not have the
impatience, or knowledge to treat the geriatric patient, he should refer the
patient to a dentist who has these qualifications. The prosthetic dental
problems of the geriatric patient should not be arbitrarily placed in the
untreatable category.
Overall, the management of problems encountered in the aging
population can seem like a series of objectionable compromises, but
adaptation is the hallmark of successful aging, and coping with
difficulties is an acceptable part of everyday life. Life at any age does
have pleasant surprises and rewards.
GERODONTOLOGY
DEFENITIONS:
Geriatrics: o The branch of medicine or dentistry that treats the problems
peculiar to the ageing patient,including the clinical problems of
senescence and senilit .
Gerodontics:
o The treatment of dental problems of aging persons or problems
peculiar to advanced age.
Gerodontology:
o The study of the dentition and dental problems in an elderly
person. People who are above the age of 65 years are termed as
geriatric persons.
Aging:
o The aging process may be defined as the sum of all morphological,
functional alterations that occur in an organism, and lead to
functional impairment, which decreases the ability to survive
stress.
o Aging is manifested at all levels
o The changes seen are not dramatic, but with time leads to
exponentially increasing mortality rate at the population levels.
o The origin of this complex aging phenomenon is at the “biological
level”
GERODONTOLOGY
REVIEW OF LITERATURE:
Different theories of aging:
Researchers1 postulated the concept of error catastrophe as a cause of
cellular aging by self amplification of errors is based on the feedback of
infidelity of information transfer, including DNA replication. Since this is
one of the few theories of aging for which specific predictions are test
able, it has received much attention
Some researchers2 in history of gerodontology mentions that a large
number of theories exist which claim that a single organ or organ system
is responsible for aging of organisms. They include thyroid, hypophysis,
adrenals, gonads, blood vessels, diencephalon and reticuloendothelial
system.
Researchers3 claimed that a genuine physiological aging process must be
o Universal :detectable in all number of species,
o Intrinsic :proceeding independently of outside influences,
o Progressive :developing gradually and irreversibly, and
o Deleterious :harmful to the survival of the organism
Studies5 lead to the discovery of another possible mechanisms for active
genetic regulation of aging involves the loss of DNA sequences
“repeated in tadem”.The genes coding for the formation ribosomal RNA,
normally present in numerous copies, are depleted markedly in human
nerve cells and other postmitotic cells: by the age 100 years
approximately 70% of the gene are lost . Similar depletion of copies of
certain genes has been reported from invitro studies on late passage cells
GERODONTOLOGY
i.e. those which have gone through many population doublings; here
kinetochorial DNA , associated with cell division was affected.
Postulated6 causes for the deterioration of such genetic functions during
aging include
o insufficient repair of spontaneously damaged DNA,
o mutations in somatic cells ,and
o self-amplifications of errors, “error catastrophe”
A researchers7 discovered that with aging there is a loss of neurons in
several key areas of the brain and dendritic regression. The latter is
claimed to lead to “ progressive destructions of the dendritic domain.”
Studies8 found that the metabolic rate is more complicated in
homoiotherms. A classic experiment showed that in rats food restriction
prolongs in life span. This observation does not necessarily imply a
retardation of the aging processes, but could be due to
o Delayed maturation,
o Slowed growth,
o Reduced body fat,
o Reduced metabolic rate,or
o Changed metabolic patterns.
GERODONTOLOGY
Physiological changes in aging:
Some authors8 discovered that to carry out it’s functions effectively, the
kidney requires a large blood flow. In young people at rest 20% of the
cardiac output flows through the kidneys. However , with increasing age
there is a progressive decline in renal blood flow with flow in 90 years
olds being about one half of that in 40 year olds.
A study9 declared that cerebral metabolism and the blood flow related to
it are accepted indices of neural activity. Although there has been
considerable debate on the effects of age on these indices, it seems likely
that neither changes significantly with age at least up to age 70. Cerebral
blood flow does appear to decrease during the eighth decade even in
people free of brain disease; evidence for a decrease in cerebral
metabolism in healthy people over 80 years of age is less clear.
The author10 summarized the prodigious research from his laboratory
depicting physiological changes with age. This research shows a decline
in function in a broad spectrum of physiological process. The extent of
change varies from process to process with the conduction velocity of the
nerve impulse slowing only slightly to and marked decline observed in
renal and respiratory functions.
Research11 found that residual volume, which is the volume in the lungs
after maximal expiratory effort, increases with age. This is probably due
to a decrease in strength of the expiratory muscles, an increase in the
outward recoil force of the chest wall and increased tendency of small
airways to collapse and trap air in the alveoli with increasing age.
GERODONTOLOGY
Studies12 found that with advancing age, alveolar ducts and respiratory
bronchioles enlarge at the expense of the surrounding alveoli. As a result
a larger fraction of lung volume is contained in the alveolar ducts and
smaller volume in the alveoli. Alveolar surface area also decreases with
age. There is a loss in elastin fibers from the walls of the alveoli.
Researchers13 discovered that there does seem to be a small decrease in
plasma thyroxine(T4) concentrations in humans with advanced age . The
plasma concentration of free T3 does not change with age and this also
appears to be true of free T4,although there is one report of a significant
fall in plasma –free T4 with age. The rate of removal of T4 from the
circulation decreses with advancing age in humans. The reason that this
does not cause the plasma T4 concentration to increase is that the rate of
thyroid hormone secretion by the thyroid decreases proportionately.
Researchers14 discovered that there is loss of neurons with advancing age
but the loss is far from the uniform. Several cranial nerve nuclei shows
no age related loss of neurons. Locus cerulus and substantia nigra
undergo marked neuron loss.
Researchers15 documented that recent serial computed tomography
examinations of Japanese subjects provide rather strong support for the
concept of a decrease in brain weight with age with particularly striking
changes occurring after age 60.
It was found16 that in humans, plasma cortisol concentrations and its
diurnal rhythm remain unchanged even at very advanced ages.
GERODONTOLOGY
Nevertheless , the rate of secretion of cortisol does decrease with age but
there is a proportional decrease in the metabolic rate of disposal of
cortisol nor is there any evidence that the ability to secrete ACTH and
thus cortisol in response to stress is diminished with advancing age.
There is a marked decrease with advancing age in the plasma
concentrations of adrenal androgens, i.e. of the sulphate conjugates of
dehydroepiandrosterone and of androsterone. Elderly subjects do have a
diminished adrenal medullary response to stresses such as insulin
hypoglycaemia and vasomotor conditioning. Also there is a change in the
response to epinephrine at least at some target sites. Cessation of
reproduction in women occurs at menopause and appears to relate to a
primary loss in ovarian function. Plasma concentrations of luteinizing
hormone and follicle stimulating harmone increase in men with age.
Studies17 found that the mean maximum heart rate during exercise also
decreases considerably with age. The cardiac output in the reclining
position decreases with age but in the sitting position at rest there is no
significant effect of age on cardiac output. Cardiac output increases
during exercise with work load in the young and the old. An increase in
resistance to blood flow occurs in many organs with increasing age
i.e.there is an increase in peripheral resistance with age.
Some studies18 found that although it is generally believed that central
nervous system functions decline markedly with age, this impression is
based more on observing the performance of individuals with disease
(e.g.senile dementia of the Alzheimer type) than on the careful
evaluation of individuals undergoing normal aging. Indeed , in the
absence of disease, most aged people remain altert with intact intellectual
GERODONTOLOGY
capabilities, sound judgement and creativity and with only a modest
decrease in mental agility.
Researchers19 discovered that the gastric glands decrease their secretion
with age and this includes volume and concentration of HCL, intrinsic
factor and pepsin. There may also be some reduction in the secretion of
pancreatic enzymes with age but more work is needed to be certain.
There is no evidence of a major change in biliary secretion with age.
A study20 claimed that a major consequence of the age related changes in
the cardiovascular systems is that the maximum cardiac output and
oxygen consumption during dynamic exercise decline with advancing
age in apparently normal people. They suggest that the two major
reasons, for this age related decline are the loss in responsiveness of the
heart to catecholamine and the increased vascular input impedance.
Some studies21 found that changes in sleep commonly occur with aging.
These changes involve a shortening of total sleep time at night,increasing
multiple brief awakenings and a shift to an earlier time of going to sleep
and awakening each day.
Cellular changes in aging:
A study22 mentioned that the first hint that mormal T cell functions might
decline with age came from the findings of morphologists who showed
that the thymic lymphatic mass decreased with age primarily as a result of
atrophy of the cortex
GERODONTOLOGY
.
As author23 mentioned that the human fibroblast model used to study
cellular aging has permitted the systematic study of events caused by
serial cell divisions. The first event observed was a decline in the
maximal density at confluence when growth stops. This permitted the
constructions of a survival curve for human fibroblasts, which was later
widely used to express their life span and as a reference to correlate
functional changes with the number of generations completed.
Some studies24 extensively studied DNA repair capacity as a function of
aging. A considerable amount of experiments show that ultraviolet-
induced repair and DNA strand rejoining are performed with the same
efficiency in old as in young cells.
Researchers25 conducted experiments on effects of ionizing radiation on
aging with the goal of checking somatic mutation theory. This led to a
new hypothesis to explain the aging of dividing cells. According to
them ,DNA strand switching, chromatin exchanges, chromosome
rearrangements, etc will destroy the interactions between various
domains,leading to aging.
Age changes in oral mucosa and periodontium:
The author26 did extensive studies on human preiodontium and observed
that width of periodontal ligament space of non-functional teeth is
narrower than functional teeth. This ,in future years paved the path for
some researchers to claim that teeth in elderly people have decreased
width of periodontium since they are not functional.
GERODONTOLOGY
Researchers27 observed the clinical changes associated with the tongue in
elderly people. The tongue shows loss of filiform papillae and
disturbance of sensory elements resulting in deterioration of taste
sensation and also burning sensation occasionally.
Studies28 found that with age the oral mucosa has been reported to
become increasingly thin, smooth and dry, to have a satin like, edematous
appearance with loss of elasticity and stippling, and to be more
susceptible to injury.
Studies29 found that among reported structural changes in human oral
epithelia associated with age are a thinning of the epithelial cell layers,
diminished keratinisation ,and alterations in the morphology of the
epithelium connective tissue interface.
Some studies30 mentioned that a decrease in width of periodontal
ligament with advancing age could be due to continuous deposition of
cementum on the root surface.
Some researchers31 worked on the classification of periodontal disease.
Periodontal disease has been divided in to 4 stages namely, the initial
lesion, the early lesion, the established lesion, and the advanced lesion.
Each lesion has characteristics that suggest an immunological response.
Characteristics of periodontal lesions .
A features of initial lesion
o Classic vasculitis of vessels subjacent to the junctional epithelium
o Exudation of fluid from the gingival sulcus
GERODONTOLOGY
o Increased migration of leukocytes in to junctional epithelium and
gingival sulcus
o Presence of serum proteins,especially extravascularly
o Alterations of the most coronal portion of the junctional epithelium
o Loss of perivascular collagen
Features of early lesion
o Presence and accentuation of the features described for the initial
lesion
o Accumulation of lymphoid cells immediately-sugjacent to the
junctional epithelium at the site of acute inflammation
o Cytopathic alterations in resident fibroblasts,possibly associated with
interactions with lymphoid cells
o Further loss of the collagen fiber network supporting the marginal
gingival
o Beginning proliferation of the basal cells of the junctional epithelium
Features of established lesion:
o Persistence of the manifestations of acute inflammation
o Predominance of plasma cells but with appreciable bone loss
o Presence of immunoglobins extravascularly in the connective tissues
and in junctional epithelium
o Continuing loss of connective tissue substance noted in the elderly
lesion
o Proliferation , apical migration, and lateral extension of the junctional
epithelium. Early pocket formation may or may not be present
Features of advanced lesion:
o Persistence of features described for the established lesion
GERODONTOLOGY
o Extension of the lesion in to alveolar bone and periodontal ligament
with significant bone loss
o Continued loss of collagen subjacent to pocket epithelium with
fibrosis at more distant sites.
Researchers’31 discovered that with respect to organic constituents in
parotid secretions, little change in total protein release has been reported. In
particular, when the secretion of granules, the anionic proline rich-protiens,
was evaluated, stable release was seen across the life span among both men
and women. These proteins, besides being useful markers for parotid
exocytosis, have an important physiologic role;that of maintaining calcium
and phosphate solubility.
Studies32 have evaluated submandibular salivary out put from healthy young
and elderly individuals and found severe impairment of more than 70% in
both unstimulated and citrate stimulated salivary flow in elderly.
Age changes in teeth
Studies33 reported that most characteristic age change in cementum is the
gradual increase in thickness. Cementum deposition occurs throughout life.
The total width of the cementum almost triples between the age of ten and 75
years.
Some researchers34 conducted studies on the composition of surface and
subsurface enamel and have clearly demonstrated difference in chemistry
between the two,for example in fluoride content. The crystal in surface
enamel are much thicker than those in the bulk of enamel.
GERODONTOLOGY
Some studies35 reported no significant differences in the density of enamel as
a function of age. However the nitrogen content increased with age .
Nitrogen content showed a gradual increase between 30 years to 60 years
and then a drastic rise.
Researchers36 mentioned that 6-7% of normal pulps exhibit mineralization’s
of various types while about 75% of the pulps from teeth with pathological
lesions showed changes. A 1:10 ratio of pulpal mineralization in non carious
teeth has been reported in young and individuals.
According to author37 under normal physiological conditions, only half the
dentinal tubules become completely obturated. Obturated dentin should be
considered as age change because it is not present in primary structures.
GERODONTOLOGY
Discussion
GERODONTOLOGY
Factors influencing aging
Genetic factors:o Mutationso Species specific life spanso Hybrid vigor o Sex o Parental ageo Twin studieso Premature aging syndromeo Cells in culture
Environmental factorso Physical and chemical components- radiationo Biologic factor- nutrition o Tropical countrieso Socio – economic factorso Low income groupso Bad housing o Poor working conditiono Stresses of life
Biologic theories of aging:
Genetic theories Non genetic theoriesError theories Immunologic theories
Somatic mutations free – radical theory
Reduncies Cross linking theory
Genetically programmed senescence Metabolic rate or wear and tear theory
Disposable soma theory
GERODONTOLOGY
Physiology of aging :
Physiological deteroration – increases with age
o It reduces physiological capacity and the ability to meet challenge
o It is progressive
o Major contributing factor to death of extremely old
Central nervous system:o Impairment of learning and memory after 70 years
o Slowing of central processing
o Decrease in the brain size and weight
o Deterioration of the motor systems
o Decrease function of the extrapyramidal system
Cerebellar function
Muscular strength
o Increase in the
Movement time
Reaction time
o Sensory systems loss of
Vibratory perceptions in lower extremities
Touch
Taste
Smell
Hearing
GERODONTOLOGY
Vision
o Sleep
Shortening of sleep time
Increased multiple brief awakening
o Neuro muscular system
o Loss of muscle mass
o Loss of muscle strength
o Loss of muscle performance
Cardio – vascular system :
o Decrease in
Intrinsic heart rate
Mean maximum HR during exercise
Cardiac out put
Oxygen consumption
o Increase in
Peripheral resistance
Muscle stiffness
Contraction period
Thickness of walls of aorta
Respiratory system :
o Increase in residual volume
o Decrease in expiratory reserve volume
o No change in total lung capacity
o Marked changes in air flow
GERODONTOLOGY
Kidney and body fluids:
o Loss of
Weight of kidney
Glomeruli
o Deterioration of function
Progressive declination in renal blood flow
GFR( glomerular filtration rate)
Gastrointestinal system:
o Disordered contractions
o Spontaneous gastro – oesophageal reflex
o Slow gastric emptying
o Loss of fat absorption
o Very slight impairment of protein digestion
o Reduction in calcium absorption
o Decreased secretion by gastric glands- less volume and concentration of
HCL
Intrinsic factor
Pepsin
Endocrines:
o Adenohypophysis – secretion of tyrotropin is blunted
o Neurohypophysis – greater release of antidiuretic hormone
GERODONTOLOGY
o Thyroid – slight decrease in T4 ( thyroxine )
cortisol secretion is decreased
aldosterone decreased
o Insulin –decreased sensitivity of the target tissues to the action
Glucose intolerance
Reproduction:
o Men
Decline in sexual interest. Drive and vigor
Increase in plasma concentration of LH( leutenizing hormone) and
FSH( follicle stimulating hormone )
o Women
Marked decline in estrogen concentration after menopause
Miscellaneous
o Loss of lean body mass
o Body fat increase with age
o Decrease in BMR
o Reduced ability to maintain body temperature
o Immune system
Oral changes in aging:
Oral mucosa : The clinical picture is one that of atrophy
o Thin smooth dry – satin like
o Loss of elasticity and stippling
o More susceptible to injury
o Decreased repair potential
Frequent application of soft liners
Skin changes:
GERODONTOLOGY
o Wrinkled dry-patchy pigmentation
o Loss of elasticity and fine pattern
o Diminished bulk of muscles ,fat and connective tissue- drooping of skin
o Into folds and creases
Gingiva:
o Loss of stippling
o Oedematous appearance
o Thin keratinized layer
o Tissue is easily injured
Lips :
o Angular cheilitis
- Vit B deficiency
- Dehydration
Teeth
o Enamel
Attrition
Erosion
abrasion
o Fluoride content increases
o Enamel crackes-increases
o Enamel lamellae- increases
o Cementum increases in thickenss
o Dentin – secondary dentin formation
Obturation of dentinal tubules
GERODONTOLOGY
o Pulp : fibre increased
Blood supply- reduces
Pulpstones- increases
Salivary changes :
Salivary flow reduces
o Medication- Depression
-Insomnia
o Salivary gland atrophy
Consequences :
o Diminished functions like mastication
o Digestive problems
o Poor retention of denture
o Susceptibility of mucosa to frictional irritation from the movement
o Interference with patients ability to wear dentures
Excessive saliva :
Transient –on insertion of denture. No reduction in salivary output from
the parotid gland where as that of submandibular gland is reduced.
Sub mandibular gland: 45% of total output
o Changes in composition:
Ptyalin – decreases
Mucin - increase
GERODONTOLOGY
o Physical changes:
o Viscous ropy
- Plaque formation and growth of cariogenic bacteria
Treatment of xerostomia:
o Increase intake of water
o Frequent mouth rinses
o Lubricating jelly
o Silicone fluid
o Semisolid denture adhesives- Decrease irritation of the tissues
Temporarily increases denture retention
o Use of silogogues-pylocarpine hydrochloride or nitrate. 5 mg before
meals
o Sucking on sour candy
o Nicotinamide 250 to 400 mg tid for 2 weeks
Bone tissue:
o Compact or cortical bone
o Spongy or trabecular or cancellous bone
Effects of aging :
o Thinning of cortical bone
o Increase in porosity
o Loss of trabecular
o Cellular atropy
o sclerosis
Maxilla- narrower
GERODONTOLOGY
Manbible- wider posteriorly
Tongue and taste :
Smooth ,glossy or red and inflamed in appearance
Distuebed sensation – taste
soreness burning (post menopausal women)
Varicose vein on the ventral surface
Tongue size:
Does not vary with age but over development of intrinsic muscles hence
larger tongue ( loss of teeth mastication and to keep the loose denture)
Impact of environmental and social forces on gagging:
An older person’s life is basically roleless. Unstructuted by the society and
conspicuously lacking in norma.Rosow( 1974)
General medical aspects of aging:
Cardiopulmonary disorders:
o Valvular heart disease
o Cardiac arrhythmias
o Coronary artery disease/ischemic heart disease
o Hypertension
o Congestive heart failure
o Chronic bronchitis/emphysema
Nervous system disorders:
o CVA( cerebrovascular accidents) or strokes
o Parkinson’s disease
o Tardive dyskinesia
Rheumatologic disorders:
GERODONTOLOGY
o Temporal arthritis
o Osteoporosis
o Osteoarthritis
Miscellaneous disorders:
o Leukaemia
o Iron deficiency anaemia
o Diabetes mellitus
o Thyroid disorders
o Urinary incontinenc
Geropsychiatric disorders:
Situational disorders:
o Associated with emotional crisis or prolonged situational stress
o Improper oral hygiene
o Sustained muscular tension
Bruxism
Atypical facial form
o Burning mouth or tongue
o Such patients should be treated with compassion, respect and
willingness to comfort
Affective disorders:
o Depression :
Usually co-operative
Appear to forget clear instructions
Fatigue easily and require several short appointments
o Side effects of anti depressants
Burning mouth
GERODONTOLOGY
Postural dizziness
Excitemet
Tachycardia
Rapid speech
Confusion
o Anxiety disorders:
Apprehensiveness
Worry
Agitation
Tachycardia
Dizziness
Weakness
Visual ad gastro intestinal disturbance
Fatigue and headache
Insomnia
Sometimes depressive mood elements
o Treatment
Benzodiazepines
Tricyclic antidepressants
o Disorders of congestive function
Dementia , deliria and toxic confusional states
Premedications :
GERODONTOLOGY
o Aggressive , confused and frightened patients
o Haloperidol 1-2 mg
o Thiothixine 2-5 mg ,one hour before the treatment
o Thioridazine 25-50 mg the night before the procedure
Paranoid states:
Paranoid is a group of symptoms involving suspiciousness on others.
Chronic mental disorder persisting in to late life:
o Chronic schizophrenics who survive in to their 60 and 70 years
display no florid psychotic symptoms , showing only impoverishment
of social .intellectual and emotional life ,social and financial
dependency and occasional odd habits.They neglect even an extensive
oral disease
Aging And Nutrition
o The diagnosis of a nutritional deficiency- stomatitis must always be
consistent with a background of nutritional impairment and substantiated
by a conservative interpretation of the data derived from a careful and
complete diet survey, a probing medical history and physical
examination, and appropriate laboratory and roentogenographic
determination.
Etiology of dietary deficiency:
o Lack of proper food intake
GERODONTOLOGY
low income and lack of knowledge on how to spend the money
available for food to the best advantage.
Physical handicaps, lack of mobility which makes preparation of food
difficult
Poor facility
Poor dentitionor improper dentures
Depression boredom, anxiety and loneliness
o Disease which interfere with
Digestion
Absorption
Utilization of foods
Eg : oral cancers
Oral symptoms of nutritional deficiencies:
o The symptoms may antidate ,coincide with, or follow the appearance of
deficiency induced signs.
o They are represented by
Burning
Soreness
Tenderness
Dryness
Sialorrhea
Loss of diminution of taste ( ageusia or dysgausia)
o Soreness and burning of tongue:
Iron deficiency anemia
Vit B12 responsive pernicious anemia
o Stomatodynia :
Pellagra
Sprue
GERODONTOLOGY
Kwashiorkor
Scurvy
Nutritional microcytic anemia
o Xerostomia :
Vit A deficiency
Ariboflavinosis
Pellagra pernicious anemia
Iron deficiency anemia
Sprue
Dehydration
o Sialorrhea
Acute nutritional deficiency stomatitis
Acute pellagra
o Impairment of taste sense:
Pellagra
Pernicious anemia
Oral signs of nutritional deficiency:
o Cheilosis
o Gingivitis
o Glossitis
Lip lesions
o Deficiencies of riboflavin , niacin ,protein ,vitamin B12,folic acid, iron
pyridoxine, pantothenic acid and vitamin C.
Gingivitis
o Deficiencies of niacin, tryptophan, and vitamin C
Glossitis :
GERODONTOLOGY
o Niacin , folic acid ,vit B12, pyridoxine, protein, and iron deficiency
Treatment of nutritional deficiencies:
General principles:
o A well balanced high protein ( 120-150gm) diet should be administered
with adequate calories, vitamins, and minerals.
o Therapeutic amounts of specific nutrients should be added as a
supplements to the daily diet.
Daily therapeutic dose:
Folic acid 5 to 10 mg
Niacin amide 150 to 250 mg
Riboflavin 10- 15 mg
Ascorbic acid 150- 300 mg
Vit A 25000-50000 units
Vit D 3000- 5000 units
Medicinal iron 200-400 mg (1.2 gm of ferrous sulphate)
Vit B12 10- 15 µg
o Coexisting diseases which cause secondary nutritional deficiencies or
increase the nutritional requirements must be controlled or eliminated
whenever possible.
o Symptomatic and supportive treatment should be given to get rid of and
comfort the patient in the presence of pain ,infection, vomiting, diarrohea
and dehydration.
PHARMOCOLOGY AND AGING:
General consideration;
o In general ,elderly people use 30% of all prescribed medications (Nielsen
et al 1981). Thus it is important to know if drug dosage has to be changed
when older persons are considered
GERODONTOLOGY
o Significant changes in pharmacokinetics and pharmacodynamics do occur
with increasing age
Compliance:
o The number of different drugs prescribed and
o The number of doses given per day of each drug
o More than 3 different drugs and more than 2 doses for a day of each drug
decrease compliance significantly
o Elderly patients are not necessarily more prone to non compliance than
younger patients
Absorption :
o A series of physiologic functions in the gastrointestinal changes with age.
o There is decrease in
Gastric emptying rate
Secretion of hydrochloric acid
Gastrointestinal mobility
Intestinal blood flow
Efficiency of many active transport systems
o As a result, a higher plasma drug levels are found in elderly patient
Volume of distribution:
o The total body weight declines steadily after the age 50 years, because of
loss of intracellular water and of lean body mass. While adipose tissue
mass is increased.
Clinical significance:
o The volume distribution of lipid soluble drugs is higher, where as that of
water soluble drugs is decreased
GERODONTOLOGY
Protein binding:
o The concentration of serum albumin decreased with advancing age.
In aged 3.5 g/ dl
Young adults 4-4.5 g/dl
o This causes on increased unbound fraction of drugs and influence the
distributution of drugs
Metabolism:
o The hepatic blood flow decreases with age and rate of metabolism of high
clearance drugs such as propranolol and lidocain whose elimination are
highly flow dependent is reduced in the elderly.
o The elimination of low clearance drugs depends primarily on the activity
of the hepatic microsomal drug metabolizing enzymes. The enzymes
activity per unit liver also decreased with advancing age.
Renal excretion:
o Renal function evaluated on the basis of inulin clearance or by
endogenous creatinine decreases considerably with age.
Young -20 to 22 mg/kg/24 hr
Old – 10 mg/kg/24 hr
o Dosage modifications are necessary primarily to drugs for which the
renal excretion of the parent compound or the active metabolites is the
major mechanism of elimination
Pharmacodynamics :
GERODONTOLOGY
o Reduced hepatic synthesis of blood clotting factors with a resulting
greater sensitivity to the action of oral anticoagulants
o Diazepam and nitrazepam (10 mg) appear to result in greater depression
of the central nervous system.
Adverse reactions :
o Frequency of adverse drug reactions is greater in the elderly . However
older persons take more medications and this must be taken in to
consideration.
DRUGS IN DENTAL PRACTICE:
Antibiotics:
o Water soluble antibiotics like penicillins , cephalosporins,
aminoglycosides, tetracyclins will be affected by the age –dependent
decrease in renal function.
o In contrst lipid soluble antibiotics like erythromycin, chloramphenicol are
primarily metabolized in liver resulting in more hydrophilic metabolites
which are subsequently excreted by kidneys.
Penicillins:
o Excretion of these drugs is much reduced in the elderly compared to
younger subjects.
o Because of high therapeutic index the modification of dosage to
compensate for reduced renal clearance is not necessary.
o In general normal doses of all penicillins can be safely prescribed to all
elderly patients regardless of age.
Erythromycin:
GERODONTOLOGY
o High therapeutic index
o Therefore normal dosages should be prescribed to all patients irrespective
of age
Metronidagole and tinidazole:
o It is advisable to use lower dosages of metronidazole in this age group to
avoid accumulation of active water soluble metabolites when kidneys
function is reduced.
o The excretion of tinidazole is unchanged in renal failure.
Sulfamethizole:
The half-life of sulfamethizole is significantly prolonged in the elderly
(181±13 min)as compared to younger subjects (10
GERODONTOLOGY
Top Related