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restorative dentistry for the older patient cohort
denture design and root caries - poor denture design can increase the prevelance of root caries projected median age 2035 - 42.2 years proprotion of people aged 65 and over by 2035 - 23% trend in overall proportion of edentelous adults - fallen from 28% in 1978 to 6% in 2009 trend of proportion of adults maintaining 21 or more natural teeth - improved from 74% in 1978 to 86% 2009 level of complexity of patients over 45 years - typically a lot more complex, marked difference according to adhs study challenges within manageing older patients - treatment planning, provision of restorative care and maintainance of complex dentitions prevelance of chronic illness with age - increases with age, 67% of those over 75 years, half of those over 65 polypharmacy -
simultaneous use of multiple medications, can be a complex issue for the older population due to non concordance with drug regimens and increased n of drug interactions helping with communication barriers with elderly patietns - large fonts on instruction leaflets, audio induction loop systems, lip reading by sitting directly in front of patient, removing face masks, full face visors, appropriate language typical oral risk factors in older patients - cariogenic diets, xerostomia, lack of manual dexterity, systemic disease xerostomia and age - increases with age, associated as side effect of hundreds of medications xerostomia and oral health - significant, increased risk of caries, perio disease, recurrent candidal infections, dysphagia, difficulty with removable prosthetics lifestye medications to help with xerostomia - regular sips of water, sugar free gum, saliva substitutes dementia prevelance over 65 years - 7% dementia prevelance over 80 years - 17% dementia - progressive condition which results in a decline in memory, reasoning, communication skills what age groups are coronal caries most common -
progress into extensive discolored soft areas encircling the entire root surface progressing toward pulp colour of lesion and activity of lesion - this is not a reliable indicator of lesion activity appropriate preventative care of root caries in elderly - dependent on patients risk, habits, topical flouride, daily mouth rinses calcium and phosphate containing pastes - good adjunct to flouride in remineralisation of early carious lesions surface modication as caries prevention - beneficial where lesions have plaque retentitive areas in order to produce a cleansible surface ozone use - effective in reversing early root caries arrested root caries lesions presentation - hard shiny brown black areas on the root surface challenges in restoration of root caries - moisture control, predictable bonding to dentine and access (if interproximal or furcation areas involved) how many conventional preparation of root caries be carried out - may be completed with rotary instruments or soft infected dentine by atraumatic hand restorative art -
atraumatic restorative technique atraumatic restorative technique in older patients - often accepted well, doesnt routinely req local anaesthetic, can be completed in domicilliary setting what materials are normally used to restore root caries - adhesive restorations, glass ionomer, resin modified glass ionomer cements glass ionomer and resin modified glass ionomer for root caries - desirable properties for restoration including flouride release, adhesion to dentine, low technique sensitivity, great for high risk patients composite resin restoration for root caries - well placed composite resin restoration will be more appropriate for low risk patient with good oral hygiene production of restoration of root caries - important to produce cleansable surface to prevent further plaque accumulation toothwear accumulation in older patients - toothwear accumulates, with increasingly retained teeth in later adulthood it is an increasing challenge proportion of dentate 75 to 84 year olds showing signs of toothwear - 95% severe wear in dentate 75 to 84 year olds - 44% moderate, 6% severe physiological toothwear -
planning management of more complex and increase in occlusal vertical dimension - carefully planned on study models mounted in centric relation, diagnostic wax ups. use of removable prosthesis, crown lengthening older patients and perio prevalence - increased prevelance of pocketing, loss of attachment, perio accumulates systemic perio risk factors - genetics, smoking, diabetes, osteoporosis, stress local perio risk factors - anatomical and iatrogenic factors, partial dentures, restoration overhangs age related changes role in perio disease - altered host response to plaque, impaired neutrophil function, qualitative changes in microbial composition addressing perio risk factors in elderly - manual dexterity (electric toothbrush), gp input systemic conditions, recontouring restorations, smoking cessation root canal or extraction older patients - careful consideration, individual patient factors, remaining dentition, anticipated age related endo challenges when may endo treatment be preferable to extraction in older patient - to avoid extraction in patients at risk of osteoradionecrosis, bisphosphonate associated osteoradionecrosis
patient ability to comply with endo tratment (elderly) - patients with arthritis may be unable to lie in chair prolonged, patient motivation to maintain tooth or subsequent treatment implications of removing tooth from arch in older patients - strategic preservation may benefit overall treatment outcome, eg last standing molar, important occlusal contact, root as overdenture abutment benefits of preserving last standing molar - to aid retention of a removable rpd benefits of preserving important occlusal contact - to maintain functional eg chewing, speaking benefits of preserving retained root - can be an overdenture abutment preservation of intact anterior segment - advantageous for aesthetics, avoiding need for prosthetic replacement extraction of tooth preferable - where teeth have poor prognosis, unrestorable, non functional, insufficient perio support age related changes and pulpal pathology - may impair diagnosis, imped access, shaping and disinfection of root canal system sensibility testing in older patients - more challenging, possibly inconclusive due to increased pulpal response time, production of false negatives
rct comparing restoration of shortened dental arches with resin retained bridges compared to rpds - significantly lower incidence of caries in those with resin retained bridges age related changes and anatomical factors - flat atrophic ridges poor support, high frenal attachments, short sulcus depths and xerostomia compromise retention early identification of risk factors and patient expectations complete dentures - flat atrophic ridges, xerostomia, short sulcus depths alternative approach to conventional dentures - copy or replica technique, able to reproduce acceptable features from previously successful prosthesis whilst allowing less favourable features to be modified, involves fewer stages, less clinical time preservation of tooth roots as overdenture abutments - useful option improving denture support, preservin alveolar bone, maintains proprioception, psychological benefits root abutments ideally - stable in terms of caries and perio, good endo prognosis, favourable positions in arch dental implants to replace missing teeth - predictable, substantial evidence showing greater satisfaction and quality of life improvement two implant supported mandibular overdenture - mcgill and york consensus suggest it should be considered first choice standard of care in rehab of edentelous patients
why are 2 implant supported mandibular overdentures not used as widely in edentelous patients - treatment cost and resources remain a barrier, may become more common in future as edentelous patients decline general risk factors for failure of dental implants - poor general health, smoking, implant site, quality of bone, chronological age how should dental implants be considered - patient by patient basis, risk factors, personal expectations, financial prospects vary widely atraumatic restorative technique in older patients -
