Monday, 4 May 2015

Our Patients are Changing....

How many of your patients are the 'elderly'? The increasing life expectancy of our patients together with the improvement of oral care means that people are keeping their teeth for longer. 
Back in March I attended the Gerodontology conference in London - this blog post is based on this study day. 



I have previously touched on the implications of this shift in our patient demographic on periodontal health in a previous post (see here), but the increasing age of our patients has other implications in other areas of their mouths than just their gums. 

Failing restorations and Tooth Wear


Older patients present with a challenge to dentists - one of the main issues is their polypharmacy. Specifically, some medications can lead to a decrease in salivary flow (i.e. xerostomia) which can cause problems such as root caries, periodontal breakdown and tooth wear as a result of the prolonged retention of their teeth.

Therefore, the main risk factors for caries in older patients are:

  • Poor oral hygiene
  • Xerostomia
  • Diet
The elderly are more at risk from root caries due to their decreased salivary flow, dentures, lack of dexterity, a shift from complex to simple sugars and poor oral hygiene. 

Treatment options for root caries:
  1. Remineralise (fluoride, CPP-ACP)
  2. Recontour
  3. Restore intra-coronally 
  4. Restore extra-coronally
Should all missing teeth be restored? 
No - if the patient can function i.e. eat and speak effectively, you can accept spaces e.g. Shortened Dental Arch. You can then avoid problems that are introduced with removable prostheses e.g. caries, poor adaptation in older patients, candida etc. 


Treatment and classification of Tooth Wear (Tulloch and Watson)


Catagory 1 - appearance is satisfactory but treatment is required

Discuss the cause of the wear with the patient, prevention measures should be taken (diet, fluoride), place plastic restorations to restore function and prevent further wear, nocturnal appliances in bruxists should be supplied, full or partial coverage restorations if required and regular review. 

Catagory 2 - appearance is unsatisfactory, treatment is required and there is space for the placement of restorations

As above

Catagory 3 - appearance is unsatisfactory, treatment is required and there is no space for the placement of restorations

These cases may require referral to specialist or secondary care if you are not confidence in reorganising their occlusion or opening their OVD.

Thanks to Professor David Hussey for his talk.


Prosthetics

Is there still a need for removable prosthetics in the UK?
94% of UK adults are dentate, but in the over 75 group, 34% of them are edentulous and fixed prostheses are not always appropriate e.g. lack of tooth tissue, alveolus, resources. Therefore, despite the decreasing demand for prosthetics, it it still important to be able to provide these treatments in practice.

Anatomical considerations that can cause issues when making complete dentures:

  • Atrophic mandibular ridge
  • Flabby ridges
  • Big ridges
  • Frenal attachments
  • Tuberosity
  • Genial tubercle
  • Mylohyoid ridge
So how can we overcome these challenges, specifically atrophic ridges.... Overdentures 

If using teeth as overdenture abutments, there can be some challenges e.g. endodontic treatment, maintenance requirements, fracture of the acrylic, undercuts or intra-arch space. 
Implants can also be used as abutments, but there may be medical or patient barriers to implant placement e.g. osteoporosis, bisphosphonates, ability to withstand surgery.

As mentioned above, the decreased saliva flow in older medicated patients can cause a lot of problems when constructing dentures. Whilst we can try to artifically substitute saliva when it is deficient, a lot of patients will prefer just sipping water frequently. 


Thanks to Professor Janice Ellis for her talk - it was nice to see a familiar face!

Endodontics

There are a number of endodontic challenges in older patients:

  • Patient factors e.g. ability to recline, to tolerate lengthy procedure or rubber dam, access (mouth props may be useful)
  • Medical history
  • Finances/attitude of patient
  • Tooth factors e.g. strategic importance, periodontal status, restorability, endodontic considerations
Since post-operative pain following endodontics in necrotic teeth is around 80-90%, our usual advice of taking NSAIDs to manage this may not be appropriate in patients on certain medications or medical conditions.  

Examples of strategic teeth that you would be more inclined to try to save by treating endodontically include:
  • Distal abutment to free end saddle
  • Overdenture abutments
  • Bridge abutments
  • Alveolar ridge maintenance
  • Local parameters
  • OVD maintenance 
Together with the above issues, older patients will tend to have calcified canals and pulp chambers particularly if the tooth has been subject to trauma or repeated dental restorations.

Top Tips for Calcified Canals

  1. Plan well by studying your radiograph
  2. If you have any concerns regarding orientation, disassemble the tooth first
  3. Good lighting and magnification are essential
  4. Use a DG16 prove to check where you are
  5. Irrigation copiously with EDTA/NaOCl
  6. Use safe-ended burs to refine the pulp floor and gooseneck burs help
  7. C-pilot files can be used to help negotiate calcified canals 
Thanks to Bhavin Bhuva for his talk. 

Domiciliary Care


Older people are more likely to have a limiting life long illness, some serious enough for the patient to be confined to their home or even to their bed. These patients will still require dental care and therefore the expansion of domiciliary services has to meet this growing need.

There are some specific issues that come up when practising out in the community in this way:
  • Appropriate training for staff
  • Mental capacity and consent for patients
  • Appropriate treatment within the domiciliary setting
  • Environmental risk assessment
  • Infection control - zoning, use of disposables 
  • Equipment e.g. portable units, light sources, portable suction, oxygen
  • Safeguarding
Techniques such as the Atraumatic Restorative Technique (ART) and use of agents such as Carisolv can be really useful in a domiciliary setting. 

Thanks to Debbie Lewis for her talk


How do you feel about the changing demographics of our patient base as well as their changing expectations? What challenges have you faced treating these patients? Please leave your comments in the section below.

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