Friday, 27 July 2018

Gerodontology for General Dental Practitioners

This blog post is based on a talk by James Shaw, a Geriatrician who spoke at the East Midlands CDS BDA Study Day.



In Geriatrics there are 3 main complexities:
  1. Frailty - where multiple body systems lose their inbuilt senses. Can physical or cognitive. 
  2. Polypharmacy
  3. Multimorbidities 


5Ms of Geriatrics


According to the British Society of Geriatrics, there are 5Ms every health care professional who deals with geriatric patients needs to know:

Multi-complexity - multiple morbidity

Mobility - impaired gait and balance. Falls risk

Mind - dementia, delirium, depression

Medicine - polypharmacy, adverse medication effects

Matters Most - an individual's own meaningful health outcomes and care preferences


Top tips when Prescribing in Polypharmacy 


  • Obtain an accurate medical history
  • Use the BNF
  • Assume reduced renal function in the elderly 
  • Be aware of side-effects and interactions e.g. warfarin and miconazole 
  • If you are in doubt, call their GP or pharmacist 
  • Be aware of anticoagulants/antiplatelets
  • Avoid NSAIDs in over 80s as around 50% will get GI side-effects
  • Use the smallest dose co-codamol when prescribing 
  • Avoid dihydrocodeine and tramodol as high risk of constipation 
  • Antibiotics which start with C (clindamycin, clarithromycin, co-amoxiclav) have increased risk of developing C. Difficile when prescribed in the elderly


Dry Mouth


This can be as a result of the increased prescription of anti-muscarinics for over active bladders. These increase the risk of dry mouth. Of course there can also be other factors such as polypharmacy, side effects of many medications or immunosuppression. 

If the effect is profound following prescription of anti-muscarinics, it may be worth referring back to their GP as in fact only around 50% of cases these drugs are effective in managing over active bladders. 

Some clinical tips in managing these patients include:
  • Prevention of caries is essential in these patients. Regular recalls, hygiene visits, fluoride applications and prescription of high fluoride toothpaste are recommended
  • Biotene oral gel used appropriately can help alleviate dry and sore tissues
  • Saliva sprays, gels, pastilles are options to help with symptoms but many patients prefer to manage with frequent sips of water or use of sugar-free chewing gum 
  • Consider referrals to their GP or oral medicine to investigate where appropriate


Osteoporosis


Osteoporosis should cue warning flags for dentists... we all know about MRONJ and it's association with dentistry. 

Oral alendronic acid taken once weekly has a very low incidence of MRONJ <0.01%, whereas IV bisphosphonates such as as zolendronate have an increased risk. IV bisphosphonates are more clinically effective and in some cases patients prefer zolendronate as instead of a tablet taken once a week (which is often forgotten), is a annual infusion IV. 

To read more about MRONJ and guidelines in dentistry see my previous post here


Team photo with the delegates from the day

A huge thank you to James for his talk and Charlotte Waite for organising the day. Look out for future posts summarising other talks from the day...


Do you treat geriatric patients? What challenges do you come across? Let me know in the comments below. 


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