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1

Definition
Gerontology:
Geriatrics:
Gerontologists 3 sub groups:

Gerodontology in dentistry:

what is more important than numerical age

Gerontology: the study of social, psychological and biological aspects of  ageing
• Geriatrics: the branch of medicine which studies diseases in the older  adults
• Gerontologists use 3 sub‐groups: Young old (65‐74yrs), Old (75‐84 yrs),  Oldest old (85+yrs)
• Gerodontology : dentistry for >65 year old
*Clinically, biological age is more appropriate than numerical

2

Demogrpahics

UK’s population is ageing – Lifestyle and healthcare  improvements – Decrease in fertility • Proportion of >65yrs: – 15% (1985) – 18% (2016) – 26% (2041) • The fastest increase in the 85+ years  age group

3

Oral Health trends

Adults retaining natural teeth into old  age with fewer becoming edentate • Proportion of edentulism is declining: – 28% (1978)   6% (2009)2 • Proportion with >21 teeth1: – 74% (1978)   86% (2009) – It is estimated by 2028, only 8%  of  65‐74yrs in UK will be edentate

• Changing attitudes towards oral health. – Positive attitude towards  maintaining dentition – Negative attitude towards  extractions – Negative attitude towards dentures

4

Oral health challeneges

– Age is the biggest reason for decrease in sound and  untreated teeth
– The average over 75yo have 13‐15 teeth, 50%  crowns restored and 20% exposed roots restored or  decayed

Complex restorative dentistry is  increasingly prevalent in >45yrs4 • More maintenance, as more enter the ‘restorative cycle’.  • Maintenance of fixed multi‐unit  bridges and implants pose a huge  challenge for those no longer  able to maintain oral hygiene
• Increasing prevalence of chronic  illness with age5 – 57% 65‐74yrs – 67% >75yrs • Can limit activity5 – 31% 65‐74yrs – 48% >75yrs

5

Grade Explanation of activity

0 Fully active, able to carry on  all pre‐disease performance  without restriction

1Restricted in physically  strenuous activity but  ambulatory and able to carry  out work of a light or  sedentary nature, e.g., light  house work, office work

2Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about  more than 50% of waking  hours
3 Capable of only limited  self-care, confined to bed or  chair more than 50% of  waking hours
4 Completely disabled. Cannot carry on any self-care. Totally  confined to bed or chair
5 Dead

6

Define Dementia:

A progressive, neurodegenerative disease that  effects the ability to perform daily living activities • Composed of a variety syndromes • There are over 100 different specific conditions  which can cause a person to have a dementia. • The commonest form of dementia is Alzheimer’s  Disease (AD), 60% of all dementia diagnoses. • Can be reversible and irreversible • Commonly attributed to “age” – 1 in 1000 <65yrs – 5‐10 in 100 >65yrs

.

7

Oral health dementia

If undiagnosed then liasewith GP, highlighting concerns and request a review. • Management will vary with progression of dementia • Gaining patient compliance • Consent • Medication for the management of dementia can have wide ranging side effects • Oral health and general health closely correlate with the terminal stages of neurogenic disease • No evidence that poor oral hygiene linked to dementia

8

Dementia Management

Close communication with patient and carers/family
Frequent support and health promotion
Monitoring progression of neurogenic disease
Short, simple and holistic treatment
Plan for the future

9

Safe guarding - Who is a Vulnerable Adult?

• 18+ • Who is or may be in need of community care  services • Due to: ‐Mental or other disability ‐Unable to take care of themselves  ‐Unable to protect themselves against harm or  exploitation
Factors contributing to vulnerability
• Older person who is particularly frail  • Individual with a mental disorder, including dementia or a  personality disorder  • Significant and impairing physical or sensory disability  • Learning disability  • Severe physical illness  • Unpaid carer who may be overburdened, under severe stress  or isolated 

10

Safe guarding- Key questions

Does the adult have care and support needs?
Is the person experiencing, or at risk of, abuse and neglect?
What is the nature and seriousness of the risks?
What does the adult at risk want to happen now?
If you remain unsure whether to raise a safeguarding concern, seek advice:

11

Safe guarding- Prevention

Assessing Individuals’ needs
Responding to harm/abuse
Responding to harm/abuse ‐Identifying relevant services
Responding to harm/abuse ‐taking a consensual
approach
Safeguarding

12

Medical considerations

1. Can directly influence oral tissues and  health – For example: diabetes, radiotherapy,  polypharmacy
2. Can indirectly influence oral health – For example: CVD, CVA, COPD, Arthritis,  neurological deficit 
3. Can limit ability to access/cope with  treatment – For example: CVD, COPD, Arthritis,  neurological deficit
• Influence on treatment planning

13

Impact on the patient and management

• Access
• Communication problems:  Impairments in hearing, vision
• Inability to consent
• Tolerance 
• Adaptation: to prosthesis, oral care  regimes
• Difficulty eating, speaking, swallowing
• Dry mouth
• Mucosal issues: atrophic mucosa and  decreased ability to repair.
• Candidosis
• Oral ulceration
• Taste disturbance
• Gingival overgrowth
• Lichenoid reaction
• Increased risk of disease
• Increased risk of poor/failure of healing

14

Our approach to providing care

• Patient‐centred targets
•Assess wider issues such as social and familial support, transportation needs,  anxiety issues, consent and perceived need for treatment.
• Work with practices, health authorities and colleagues to orient services  appropriately
• Care aimed at maintaining a functional dentition
• Minimally invasive dentistry
• Functionally‐orientated treatment planning

15

Best way to clean a denture

Aim: disturb the biofilm on the denture
Cochrane Review: Interventions for cleaning dentures in adults  ‐Poor quality evidence ‐Weak evidence to support enzyme cleaners/ effervescent tablets ‐Brushing with pastes can remove plaque and kill microbes better than  inactive treatments.  
Conclusion: ‐No firm evidence to support brushing v soaking  ‐Both methods better than soaking in water.

16

How should a denture be stored overnight?

• Dentures in water after cleaning to prevent warping. • NHS choices • British Oral Health Foundation
• Dry storage • British Society of Gerodontology
• Dry storage benefits? Manfrediet al 2013 –organisms in denture biofilm less likely  to survive in dry storage

17

Social consideration

• Cost 
• Attendance
• Anxiety
• Mobility
• Living arrangements and independence.
• Perceived importance/need to  maintain health
• Perceived need to self‐care (e.g.  maintain healthy diet)

18

Prevention strategy tailored to individual needs.

All measures are coordinated and supervised by the dental team and reinforced  with good patient motivation.  Home and surgery‐based.
Evidence‐based components: Plaque control and regular tooth‐brushing with fluoridated toothpaste Increase fluoride availability Denture hygiene advise  Diet advise Fissure sealants  Regular dental assessments with appropriate radiographs. 

19

NICE 2016 guidance for oral health for adults in care homes

 
Outlines responsibilities of:  Care home managers /Care home staff providing/daily care to residents o People who provide oral  health services to care homes  (CDS, GDPs, OHP teams)

• ‘Dentures should be considered an important reservoir of  organisms which could colonisethe pharynx, and the  importance of controlling denture plaque for the prevention of  aspiration pneumonia cannot be overemphasised.’
• ‘Where rigorous oral hygiene procedures have been instituted  a reduction in the rate of pneumonia and deaths has resulted.’

20

Treatment- informed consent

Informed Consent: Any advice given should also be provided  in written format that the patient can refer to at home or give  to a relative or carer to read.  • Use large font  • Need additional time or extra visits to tolerate treatment. 

21

Treatment- Caries

Coronal caries most common in 25‐34 yrsand 75-84yrs (ADHS 2009). Secondary caries has increasing prevalence with  age  • Root caries more common 20% 75‐80yrs with  root caries. 
Risk factors for caries increases with age Complexity of restorations increases with age Ability to undergo complex treatment reduces  with age

22

Treatment prevention

Prevention • Different approach to prevention – Increased use of mouthwash, varnish, gels – Promoting healthy diet – Involving carers/family • MID

23

Treatment Periodontal disease

Periodontal Disease
Issues • Chronic periodontitis often presents in the  more mature patients. 61% 75‐84yrs affected  by >4mm periodontal pockets.  BUT severe  periodontitis is not a natural consequence of  aging.  • Cumulative effect of disease • Physiological changes • Increasing risk factors
Management • Important to effectively assess  prognosis • Be aware of contraindications to  treatments • Work with family and carers • Utilise the most suitable oral hygiene  tools • Liaise with GP/medical colleagues  where appropriate

24

Treatment tooth wear

TW increases with age. 52% 16‐24yo  compared to 95% 75‐84yo with any wear.  • Toothwearprevalence: – 95% of dentate 75‐84yrs (ADHS 2009) – 44% moderate wear – 6% severe wear • Ability to undergo complex treatment reduces  with age
Management • Prevention remains important • Different approach to prevention – Increased use of mouthwash, varnish, gels – Promoting healthy diet – Involving carers/family • Protect tooth tissue • Adhesive dentistry • Be aware of physiologic and pathologic tooth  wear

25

Treatment Oral Cancer

Issues: • Most cases of mouth cancer occur in  older adults aged 50 to 74.  • Only one in eight (12.5%) cases affect  people younger than 50.
Management: • Oral cancer screening.  • Early detection and referral. • BDA  Oral cancer Toolkit: to help dental  health professionals identify and refer  possible cases of oral cancer. • Control risk factors

26

Shortened Dental Arch

• A concept suggesting that replacement of every tooth is not  necessary • A patient may be able to maintain a good QoLwith a “shortened  dental arch” if: – Function is maintained – Aesthetic requirements are satisfied • The remaining dentition must however satisfy these requirements • In some cases it might be useful to plan for replacement teeth if  the remaining teeth are of poor prognosis

27

Dentue care

Dentures must be kept clean to avoid infections
Gloves/soap+denture cream/ toothbrush of denture brush/ soaking solution such as sodium hypochlorite (milton) / named denture container
Brush denture to remove any food and bacteria
Try to rinse denture after every meal
Soak dentures daily in sodium hypochlorite 1%
Soak for 3 minutes- plastic denture
1 minute- dentures with mental parts