Lecture 17 Dental Considerations for the Ageing Patient Student.pdf
Transcript
DENTISTRY 3116 DENTAL CONSIDERATIONS IN THE AGEING PATIENT DR. CURTIS GREGOIRE BSC, DDS, MD, MSC, FRCDC CANADIAN POPULATION 16% OVER THE AGE OF 65 YEARS SAME % AS POPULATION NEW BORN TO 15 YEARS AGE RELATED HEALTH CHANGES ALMOST EVERY ORGAN SYSTEM UNDERGOES PROGRESSIVE DECLINE RESULTING IN DECREASED...
DENTISTRY 3116 DENTAL CONSIDERATIONS IN THE AGEING PATIENT DR. CURTIS GREGOIRE BSC, DDS, MD, MSC, FRCDC CANADIAN POPULATION 16% OVER THE AGE OF 65 YEARS SAME % AS POPULATION NEW BORN TO 15 YEARS AGE RELATED HEALTH CHANGES ALMOST EVERY ORGAN SYSTEM UNDERGOES PROGRESSIVE DECLINE RESULTING IN DECREASED PHYSIOLOGIC RESERVE AND ABILITY TO COMPENSATE FOR STRESS. THE CHALLENGE WITH MEDICAL AND DENTAL TREATMENT IN THE AGEING PATIENT IS THE COEXISTENCE OF DISEASE RATHER THAN AGE ITSELF. SPECIFIC INDICATORS T HE FOLLOWING ARE INDICATORS OF INCREASED RISK OF MORBIDITY AND MORTALITY IN THE AGEING PATIENT: ASA CLASS III OR IV REQUIRES AN EMERGENCY PROCEDURE RENAL FAILURE COPD RECENT MI ALBUMIN < 3.5G/DL ANEMIA REQUIRES ASSISTANCE WITH DAILY ACTIVITIES CARDIOVASCULAR SYSTEM MOST COMMON CHF VERY CO-MORBID CONDITION IN THE ELDERLY. PROMINENT NOT A DISEASE PER SAY INCREASES RISK FOR STROKE, PRE-EXISTING CHF INCREASES 2-4X’S MI AND RENAL FAILURE RISK OF SVT, MI, HYPO/HYPERTENSION AND CARDIAC ARREST CVS – AGE RELATED CHANGES STIFFENING OF VESSEL WALLS CAUSING INCREASE HOW DOES THE PVR THIS MANIFEST CLINICALLY? AGED HEART IS LESS RESPONSIVE TO SYMPATHETIC STIMULATION AND, THEREFORE, RELIES ON INCREASED PRELOAD WITH ATRIAL ENLARGEMENT TO COMPENSATE FOR DIASTOLIC DYSFUNCTION. SO WHAT? MUST CVS IN AN DURING PROCEDURES. MAINTAIN THE BASELINE EKG’S MAY UNSTRESSED, NORMOTENSIVE, NSR STATE AS POSSIBLE BE HELPFUL TO HAVE AS A REFERENCE. SPECIFICALLY DOES THE PATIENT HAVE AN ARRHYTHMIA WHICH IS THE MOST COMMON? WHAT IS AN IMPORTANT CONSIDERATION WHEN TREATING A PATIENT WITH THIS CONDITION? CARDIOVASCULAR SYSTEM MYOCARDIAL ISCHEMIA OFTEN PRESENTS ATYPICALLY. DUE TO COMORBIDITIES AS DIABETES MELLITUS, NOCICEPTIVE CHANGES, DEPRESSION AND DEMENTIA. CARDIOVASCULAR SYSTEM HYPERTENSION ORTHOSTATIC HYPOTENSION SIGNS AND SYMPTOMS: DIZZINESS ALTERED HEARING NAUSEA HEADACHE BLURRED VISION PULMONARY SYSTEM AGE-RELATED CHANGES IN THE PULMONARY SYSTEM INCLUDE A LOSS OF ELASTIC RECOIL OF THE LUNG AND IMPAIRED CHEST WALL MOVEMENT CAUSED BY MUSCLE ATROPHY, JOINT STIFFENING, AND SKELETAL CHANGES. IMPAIRED ELASTICITY CAUSES AIR TRAPPING AND VENTILATION-PERFUSION MISMATCHING LEADING TO DECREASED OXYGEN TRANSFER. (V/Q) PULMONARY SYSTEM OXYGENATION IS FURTHER IMPAIRED BY THE CLOSURE OF AN INCREASING NUMBER OF SMALL AIRWAYS AND DECREASED SURFACE AREA FOR GAS EXCHANGE. VITAL CAPACITY DECREASES WITH AGE, REFLECTING AN INCREASE IN DEAD SPACE VENTILATION. THE FORCED EXPIRATORY VOLUME IN 1 SECOND (FEV1) ALSO PROGRESSIVELY DECLINES. PULMONARY SYSTEM CILIARY FUNCTION AND COUGH ARE ALSO REDUCED, DECREASING THE CLEARANCE OF SECRETIONS POSTOPERATIVELY AND LEADING TO AN INCREASED RISK FOR ASPIRATION AND PNEUMONIA. PERI-PROCEDURAL CONSIDERATIONS IDENTIFYING STATUS. HOW? PATIENTS WITH LIMITED PULMONARY RESERVE AND MAXIMIZING PERFORMANCE RENAL CHANGES PROGRESSIVE REDUCTION IN RENAL MASS AND CREATININE CLEARANCE. GLOMERULOSCLEROSIS RESULTS IN A DECLINE IN RENAL PLASMA FLOW GLOMERULAR FILTRATION RATE ADDITIONALLY, AGE-RELATED GFR TO DECLINE. WHAT CONCERNS (GFR). (RPF) AND DECLINE IN CARDIAC OUTPUT ALSO CAUSES THE SHOULD THIS RAISE? IN RPF AND THE PERI-PROCEDURAL CONSIDERATIONS SLOWED DRUG ELIMINATION (FOR SEVERAL REASONS NOT ONLY REDUCED KIDNEY FUNCTION) CAN LEAD TO PROLONGED SEDATIVE EFFECTS OF ANESTHETIC AND NARCOTIC MEDICATION. DRUG-INDUCED ACUTE RENAL DYSFUNCTION FOLLOWING ADMINISTRATION OF NONSTEROIDAL ANTI-INFLAMMATORY MEDICATIONS, DIURETICS, AND ANTIBIOTICS. MOST COMMON MEDICAL PROBLEMS IN ADULTS OLDER THAN 65 YEARS OF AGE MOST COMMON CAUSES OF DEATH IN ADULTS OLDER THAN 65 YEARS OF AGE ADDITIONAL CONSIDERATIONS AGE RELATED CHANGES IN THE ORAL CAVITY AGING AND ASSOCIATED HEALTH AND FUNCTION. AGE SYSTEMIC DISEASES AND THEIR TREATMENTS CAN INFLUENCE ORAL ALONE DOES NOT PLAY A MAJOR ROLE IN IMPAIRED ORAL HEALTH. OLDER PATIENTS ARE MORE SUSCEPTIBLE TO SYSTEMIC CONDITIONS THAT MAY PREDISPOSE THEM TO DISEASES OF THE CRANIOFACIAL COMPLEX, LEADING TO MALNUTRITION , ALTERED ABILITY TO COMMUNICATE, SUSCEPTIBILITY TO INFECTIOUS DISEASES, AND DIMINISHED QUALITY OF LIFE. AGE RELATED CHANGES IN THE ORAL CAVITY FIRSTLY, THE “NEW” COHORT OF AGING PATIENTS ARE MUCH MORE LIKELY TO BE DENTATE AS COMPARED TO BEFORE. TEETH MOST COMMON AGE RELATED CHANGE INVOLVING THE TEETH ARE: ATTRITION PULPAL RECESSION AND FIBROSIS TEETH INCREASED RISK OF DEVELOPING NEW AND RECURRENT CORONAL CARIES AND ROOT SURFACE CARIES. THIS IS DUE TO: GINGIVAL RECESSION SALIVARY GLAND DYSFUNCTION LESS EFFECTIVE ORAL HYGIENE DIMINISHED ORAL-MOTOR FUNCTION GREATER RETENTION OF THE DENTITION RESTORATIVE TREATMENT DOES NOT DIFFER SIGNIFICANTLY CONSIDER FLUORIDE RELEASING RESTORATIONS FOR ROOT CARIES IN XEROSTOMIC PATIENTS MORE AGGRESSIVE RECALL VISITS DAILY FLUORIDE USE PERIODONTAL TISSUES PERIODONTAL CHANGES ATTRIBUTABLE SOLELY TO ADVANCING AGE ARE NOT SUFFICIENT TO ACCOUNT FOR TOOTH LOSS, ESPECIALLY IN A HEALTHY ADULT. MULTIPLE CONFOUNDING VARIABLES, SUCH AS MEDICAL DISEASES, ORAL FACTORS, AND MEDICATIONS, HAVE AN ADVERSE INFLUENCE ON PERIODONTAL HEALTH. IMMUNOLOGIC CHANGES AND HISTOLOGIC ALTERATIONS IN THE PERIODONTAL TISSUES COULD ALTER HOST RESPONSE TO THE ORAL BACTERIAL FLORA. PERIODONTAL TISSUES THERE “LINK” PERIODONTAL HEALTH TO VARIOUS SYSTEMIC DISEASES CARDIOVASCULAR, ENDOCRINE, PULMONARY , AND INFECTIVE DISEASES. THE IS A SUCH AS TREATMENT OF PERIODONTAL DISEASES IN OLDER PATIENTS IS SIMILAR TO THAT IN YOUNGER PATIENTS EXCEPT THAT WOUND HEALING MAY TAKE LONGER. PERIODONTAL TISSUES DISEASE RESOLUTION CAN BE OBTAINED BY APPROPRIATE INTERVENTIONAL THERAPY AND REGULAR ORAL HYGIENE. CERTAIN PATIENTS, BASED ON MEDICAL STABILITY, MAY BE POOR CANDIDATES FOR PERIODONTAL SURGERY, LEAVING LOCALIZED THERAPY AND SYSTEMIC ANTIBIOTICS AS FIRSTLINE TREATMENTS. ORAL MUCOSA CHANGES THE SIMILAR TO THOSE FOUND IN THE SKIN. TISSUE BECOMES LESS ELASTIC OWING TO THE INCREASE IN COLLAGEN CROSS-LINKAGES IN THE DERMIS AND A LOSS OF ELASTIN. A REDUCTION IN EFFECTIVE BLOOD FLOW TO THE ORAL TISSUES IS ALSO SEEN DUE TO THE STIFFENING OF THE COLLAGENOUS WALLS OF BLOOD VESSELS AND THE DECREASE IN THEIR DIAMETER AS LIPID IS DEPOSITED. ORAL MUCOSA STRATIFIED AGE. SQUAMOUS EPITHELIUM BECOMES THINNER, LOSES ELASTICITY, AND ATROPHIES WITH A DECLINING IMMUNOLOGIC INFECTION AND TRAUMA. RESPONSIVENESS FURTHER INCREASES THE SUSCEPTIBILITY TO AN INCREASED INCIDENCE OF ORAL AND SYSTEMIC DISORDERS ALONG WITH INCREASED USE OF MEDICATIONS MAY LEAD TO ORAL MUCOSAL DISORDERS IN ELDERLY PERSONS. ORAL MUCOSA AN INCREASED PREVALENCE OF ORAL MUCOSAL CONDITIONS HAS BEEN REPORTED IN THE ELDERLY. THESE CONDITIONS INCLUDE XEROSTOMIA, ORAL LICHEN PLANUS AND THE VESICULOBULLOUS CONDITIONS. SCCA IS ALSO MORE COMMON IN THE AGING PATIENT. XEROSTOMIA RECENT EVIDENCE SUGGESTS THAT SIGNIFICANT CHANGES IN SALIVARY FLOW OR CERTAIN SALIVARY CONSTITUENTS ARE NOT OBSERVED IN HEALTHY ELDERLY PATIENTS. YET MANY OLDER PERSONS COMPLAIN OF XEROSTOMIA AND DEMONSTRATE DIMINISHED SALIVARY OUTPUT. THIS IS MOST LIKELY DUE TO SYSTEMIC DISEASES AND MEDICATIONS. XEROSTOMIA age related changes compounded with polypharmacy means they’re severely xerostomic MORE THAN 500 DRUGS HAVE BEEN REPORTED TO DECREASE SALIVARY FLOW, MOST SIGNIFICANTLY THE TRICYCLIC ANTIDEPRESSANTS, SEDATIVES AND HYPNOTICS, ANTIHISTAMINES, ANTIHYPERTENSIVES, CYTOTOXIC AGENTS, AND ANTI-PARKINSONIAN DRUGS. COMPILATIONS RELATED TO XEROSTOMIA CERVICAL CARIES LOSS OF DENTURE RETENTION PAIN WITH DENTURE WEAR DIFFICULTY ORAL saliva is important to retain the denture SPEAKING AND SWALLOWING AND OROPHARYNGEAL CANDIDIASIS LICHEN PLANUS A CHRONIC, SYSTEMIC, MUCOCUTANEOUS DISEASE. PREVALENCE FIGURES RANGE FROM WHEN 0.1% TO 4%. MANIFESTING IN THE ORAL CAVITY , THE BUCCAL MUCOSA, TONGUE AND GINGIVA ARE THE MOST COMMON SITES, WHEREAS THE PALATE IS LESS COMMONLY AFFECTED. OLP SIX TYPES: RETICULAR PAPULAR PLAQUE-LIKE EROSIVE ATROPHIC BULLOUS erosive is the most clinically relevant because its painful gregoire says for reticular there’s really no need to treat, just avoid spices and citrus to prevent pain TREATMENT TRIAMCINOLONE (KENALOG) IN ORABASE treat erosive with kenalog 1 MG/G T RIAMCINOLONE DISP: 30/60 SIG: APPLY GRAMS TO AFFECTED AREA AFTERWARDS. 2-3 TIMES PER DAY, DO NOT EAT OR DRINK FOR 30 MIN higher potency if kenalog hasn’t worked TREATMENT FLUOCINONIDE GEL 0.05% DISP: 30/60 GRAMS SIG: APPLY TO AFFECTED AREAS ON GAUZE PAD, HOLD IN PLACE FOR 2 MIN AND THEN REMOVE. REPEAT UP TO FOUR TIMES PER DAY AS NEEDED FOR UP TO TWO WEEKS. NO FOOD OR DRINK FOR 30MIN AFTER APPLICATION. TREATMENT this rinse is used for generalized E-LP DEXAMETHASONE ELIXIR 0.5MG/5ML DISP: 300ML SIG: SWISH WITH 5ML AND HOLD IN MOUTH REPEAT FOUR TIMES PER DAY FOR 2 WEEKS. FOR TWO MINUTES, THEN SPIT (OR SWALLOW). VESICULOBULLOUS LESIONS PEMPHIGUS VULGARIS IS A RARE BUT SEVERE AUTO-IMMUNE BLISTERING DISEASE OF THE SKIN AND MUCOUS MEMBRANES THAT IS TWICE AS COMMON IN FEMALES AS IN MALES. PV = chicken wire VESICULOBULLOUS LESIONS M UCOUS MEMBRANE PEMPHIGOID) PEMPHIGOID (CICITRICIAL PV and MMP treated with systemic steroids ORAL SQUAMOUS CELL CARCINOMA INCREASED RISK AS WE AGE. COMMON SITES/RISK FACTORS NOW CHANGING – OP SCCA (HPV) FISSURED TONGUE/ATROPHIC TONGUE bald tongue/atrophic tongue → loss of filiform pap. conditions: B12/folate and iron deficiency burning sensation due to subclinical candida DENTURE RELATED CONDITIONS ONE-THIRD TO ONE-HALF OF THE OLDER PEOPLE WEAR FULL DENTURES, WHILE AS MANY AS THREE-QUARTERS WEAR REMOVABLE FULL AND OR PARTIAL DENTURES. DENTURE USE RAISES THE PROBABILITY OF HAV ING ONE OR MORE ORAL MUCOSAL LESIONS IN THE ELDERLY. T HE WEARING OF DENTURES IS ASSOCIATED WITH PARTICULAR ORAL MUCOSAL LESIONS, THESE INCLUDE: DENTURE STOMATITIS DENTURE RELATED HYPERPLASIA ANGULAR CHELITIS TRAUMATIC ULCERS DENTURE STOMATITIS ANGULAR CHEILITIS loss of VDO excessive wetness causes overgrowth of bacteria ORAL MOTOR AND SENSORY FUNCTION ALTERATIONS AGING. THE IN MASTICATION, SWALLOWING, AND ORAL MUSCULAR POSTURE OCCUR WITH MOST COMMONLY REPORTED ORAL MOTOR DISTURBANCE IN OLDER PATIENTS IS ALTERED MASTICATION.
