Geriatric Dentistry: Reviewing for the Present, Preparing for the

Future 0802 – 4 credits

By

Natalie Kaweckyj, CDA, RDARF, CDPMA, COA,

COMSA, MADAA, BA

Certified Dental Assistants of BC 504-602 West Hastings Street

Vancouver, BC V6B 1P2

Tel: 604.714.1766 TF: 1.800.579.4440 Fax: 604.714.1767

Email: info@cdabc.org Web: www.cdabc.org

©2008 American Dental Assistants Association

“DANB Approval” indicates that a continuing educationcourse appears to meet certain specifications as describedin the DANB Recertification Guidelines. DANB does not,however, endorse or recommend any particular continuingeducation course and is not responsible for the quality ofany course content.

The ADAA is designated as a nationally approved sponsorby the Academy of General Dentistry. The formal continu-ing education programs of this sponsor are accepted byAGD for Fellowship, Mastership and membership mainte-nance credit. Approval does not imply acceptance by astate or provincial board of dentistry. The current term ofapproval extends from 04/10/1992 to 05/31/2011.

This course has been produced in part by a grant from theAmerican Dental Assistants Association Foundation.

The ADAA has an obligation to disseminate knowledge inthe field of dentistry. Sponsorship of a continuing educationprogram by the ADAA does not necessarily imply endorse-ment of a particular philosophy, product or technique.

CDABC Continuing Education

The Certified Dental Assistants of BC is pleased to offer you the opportunity to access these continuing education materials. The library provides you access to materials

for both personal and professional development.

Continuing Education Credits: Upon successful completion of the test, continuing education credits will be issued to you. You may use these credits toward the provincial renewal of your certification. If you have previously taken continuing education credits on the topic covered by this course, you should verify whether you are eligible to take additional credits in this subject area. The College of Dental Surgeons of BC is the regulatory body responsible for approving CE applications and they can be reached at www.cdsbc.org. The number of credits issued varies depending on the material. This information is provided on the first page of material, as well as on the website where you downloaded the course. To receive these credits you must achieve a score of at least 80% on the test within four attempts. Partial credit will not be issued. The Format: The continuing education material has been developed to ensure a standardised delivery of material. The number of questions on the test is developed to adequately test the content of the material, and vary from test to test.

Terms and Conditions: Members, login at www.cdabc.org > Continuing Education > CE Terms and Conditions for the full terms and conditions.

1

COURSE OBJECTIVESUpon completion of this course, the dental pro-

fessional should be able to: • Recognize the impact the older population

will have on the dental field.• Explain the need to assess each patient as

an individual and not categorize him or herby age.

• Describe aging as a lifelong process andexplain the overall impact on integratedorgans and systems.

• Explain the importance of obtaining a med-ical history update.

• Describe potential drug interactions withdrugs used in the dental setting.

• Summarize the importance of proper atti-tudes and their effect on interactionsbetween the dental team and the patient.

• Explain the correlation of certain medica-tions and oral conditions.

• Identify treatment modification for variousmedical and physical conditions.

• Recite home care modification for variousmedical and physical conditions.

• List special considerations for the develop-ment of treatment plans for the olderpatient.

• Describe how to assist and manage a patientwho is affected by tremors.

• Explain the need for premedication beforetreatment.

• Identify steps that patients may take to helpwith xerostomia and oral cancer.

• Discuss approaches for managing thepatient with Parkinson’s disease.

• Describe and explain the importance ofgood verbal and listening skills, and of pro-viding written instructions for the patient toavoid errors of interpretation.

OUTLINEI. IntroductionII. Older adult population

A. Aging process and changes in the body

B. Categories of "old"III. Medical History

A. Importance of updatesB. Medications currently being usedC. Understanding potential drug interac-

tions D. Understanding the need for premed-

icationIV. Aging of the dental tissues

A. Internal tooth structureB. Radiographic appearance

V. Dental treatmentA. RestorativeB. CosmeticC. Understanding anxiety

VI. Patient positioning for comfort and effi-ciency

The United States’ population is "graying" at aconsiderable rate with more than 31 millionAmericans 65 years of age or older. California hasthe largest number of elderly in the United Statesand the Census Bureau projects that California’selderly population will increase by 52% between1990 and 2010. According to the AmericanAssociation of Retired Persons, it is estimated thatby the year 2020, people 60 years of age and olderwill represent nearly 25% of the population base.Currently, there are an estimated 25,000 persons inthe United States 100 years old or older, and by2080 the number is expected to increase to morethan one million. Advances in health care technolo-gy along with the baby boom of the 1940s and1950s has resulted in more individuals survivinginto the eighth and ninth decades of life andbeyond, resulting in a larger percentage of the pop-

ulation being elderly. In addition to the medical advances that have

enabled people to live longer and healthier lives,dental advances have resulted in the preservation ofhealthy dentition in these later years.Edentulousness and dentures are no longer theinevitable consequences of aging. In 1958, 65% ofthe older adult patients were edentulous and worefull dentures; in 1985 the percentage dropped downto 48%; currently, only 20% of older adult patientsare fully edentulous and wearing full dentures. Withthe increases in retention of natural dentition, moreelderly persons are being seen in dental practicesmore regularly in their advanced years to maintaintheir oral health. The older adult patient frequentlypresents a variety of treatment dilemmas duringdental care, and certain factors should be consideredwhen rendering treatment.

INTRODUCTION

2

VII. Management for particular conditionsA. Alzheimer’s DiseaseB. ArthritisC. Cardiac conditions D. DiabetesE. Parkinson’s diseaseF. Sensory ImpairedG. StrokeH Xerostomia

VIII. Homebound DentistryA. Home care aids and suggestionsB. Fluoride treatments

IX. Conveying post-treatment instructionsA. Communication is more than talkingB. Arranging appointments

X. SummaryXI. BibliographyXII. AppendicesXIII. About the AuthorXIV. Post Test

GLOSSARYActinomyces – A gram positive bacterium that

causes various diseases in humans.Angina Pectoris – severe pain around the heart

caused by a relative deficiency of oxygen supply tothe heart muscle.

Anticholinergic – An agent that blocks parasym-pathetic nerve impulses.

Antihistamine – An agent that opposes the actionof histamine, which is released from injured cells.

Antihypertensive – An agent that controls highblood pressure.

Antimetabolites – A substance that opposes theaction of a metabolite and is structurally similar to it.

Antiparkinsonian – An agent used in the treat-ment of Parkinson’s Disease.

APF – Acidulated phosphoric fluoride, has a pHof 3.5 and contains hydrofluoric acid.

Arrythmia – Irregularity of the heartbeat.Arteritis – Inflammation of the arteries, as seen

in diabetic patients.Arthritis – Inflammation of a joint, usually

accompanied by pain, swelling, and frequently,changes in structure.

Ataxia – Defective muscular coordination, espe-cially when voluntary muscular movements areattempted.

Atherosclerosis – The most common form ofarteriosclerosis, marked by cholesterol-lipid-calci-um deposits in artery linings.

Autonomic Nervous System (ANS) – The invol-untary part of the nervous system which represents

the motor innervation of smooth muscle, cardiacmuscle, and gland cells, and consists of two anatom-ically and physiologically distinct components.

Bacteremia – A condition when bacteria is pre-sent in the blood.

Basal Ganglia – Masses of gray matter in thecerebral hemispheres responsible for initiating linksin complex motor circuits.

Calcification – The process in which organic tis-sue (enamel, nerve tissue) becomes hardened.

Carious lesion – An area on the root or tooth thatis soft and disintegrating.

Cementoenamel – The point where the cementumof the root surface and the enamel of the crown meet.

Cerebrovascular Accident (CVA) – Stroke; ageneral term applied to cerebrovascular conditionsthat accompany either ischemic or hemorrhagiclesions. These conditions are usually secondary toatherosclerotic disease, hypertension, or both.

Cervical caries – Caries involving the neck ofthe tooth, above or below the junction between theroot cementum and the enamel crown.

Cholinergic – An agent that produces an effectof acetylcholine.

CNS – Central nervous system, the brain andspinal cord.

Cognitive function – Awareness with perception,reasoning, intuition, judgement, and memory. A per-son with normally functioning processes will haveinsight into his or her illness.

Congenital heart disease – Heart disease presentat birth.

Congestive Heart Failure (CHF) – Inability ofthe heart to maintain circulation due to sodium andwater retention resulting in edema and congestion inthe lungs and/or peripheral circulatory system.

Contraindication – Any symptom or circum-stance indicating the inappropriateness of an other-wise advisable treatment or usage.

Degenerative – Deteriorating.Dementia – General designation for mental dete-

rioration.Demineralization – Loss of hardened structure

from the tooth surface.Dentifrice – Toothpaste.Diabetes mellitus – A chronic disorder of carbohy-

drate metabolism, marked by hyperglycemia andresulting from the inadequate production or use ofinsulin.

Disorientation – Loss of bearings, or state ofmental confusion as to time, place, or identity.

Diuretic – An agent that increases urine secre-tion.

3

Dopamine – A catecholamine neurotransmittersynthesized by the adrenal gland, implicated insome forms of psychosis and abnormal movementdisorders.

Dystonic – A state of abnormal tonicity in anytissues.

Emphysema – A chronic pulmonary disease.Endocarditis – Inflammation in the lining of the

heart that may involve the heart valves; resultingfrom an invasion of microorganisms or an abnormalimmunological reaction.

Epinephrine – A vasoconstrictor used in somelocal anesthetics to prolong the anesthetizing action.

Etiology – The cause of a disease.Gerentologist – An individual who studies all

aspects of aging, including physiological, patho-logical, psychological, economic, and sociologicalproblems.

Hemiplegia – Paralysis on one side of the body.Hemostasis – An arrest of bleeding.Hyperglycemic – Increased blood sugar as in

diabetes; increases susceptibility to infections.Hypertension – A condition in which the indi-

vidual has a higher than normal blood pressure.Hypertrophy – An increase in size. Hypotension – A condition in which the individ-

ual has a lower than normal blood pressure.Incontinence – The inability to retain urine or

feces because of loss of sphincter control or cerebralor spinal lesions.

Insulin dependent diabetes (IDDM) – Type Idiabetes in which the individual must administerinsulin shots to control insulin levels.

Intramuscularly – Administration within a muscle.Intravenously – Administration within a vein.Myocardial infarction – A condition in which

there is partial or complete occlusion of one or moreof the coronary arteries; a heart attack.

Myocardium – The middle layers of the walls ofthe heart, composed of cardiac muscle.

NaF – Sodium fluoride; used in the prevention ofdental caries.

Nephropathy – Disease of the kidneys.Neuropathy – A classical term for any disorder

affecting any segment of the nervous system. Neurotransmitter – Specialized chemicals pro-

duced by the nerve cells that assisting in transferringinformation from one neuron to the next.

Neuron – A nerve cell.Non-insulin dependent diabetes (NIDDM) –

Type II diabetes in which the individual is able tocontrol insulin levels through diet or oral medication.

Odontoblast – One of the cells forming the sur-

face layer of the dental papilla that is responsible forthe formation of the dentin of a tooth; after the toothis formed, the odontoblasts line the pulp cavity andcontinue to produce dentin.

Orthostatic – An effect caused by standing orsitting upright too quickly.

Overalimentation – The process of over-nour-ishing the body with food.

Parkinson’s Disease – A chronic nervous dis-ease characterized by a fine, slowly spreadingtremor, muscular weakness and rigidity, and a pecu-liar gait.

PPM – Parts per million; used in fluoride classi-fication.

Primary – Principal.Prophylactic – An agent or regimen that con-

tributes to the prevention of infection and disease.Prosthetic – Replaced body parts, as in joints.Prothrombin time – The time it takes for clot-

ting to occur after thromboplastin and calcium areadded to decalcified blood; used to evaluate theeffect of administration of anticoagulant drugs.

Psychomotor – Concerning physical activityassociated with mental processes.

Quinolone – Any of a general class of broadspectrum antibiotics that are readily absorbed fromthe gastrointestinal tract and have a low incidence ofadverse reactions.

Recurrent caries – Dental caries that develop atthe small imperfections between the tooth surfaceand a restoration, caused by plaque at the imper-fections.

Regimen – A system designed to improve ormaintain a certain condition under control.

Remineralization – Therapeutic replacement ofthe mineral content of the tooth after it has been dis-rupted by caries or improper diet.

Reparative dentin – Secondary dentin.Retinopathy – Any disorder of the retina.Rheumatoid arthritis – An acute and chronic

arthritis, characterized by inflammation, musclesoreness and stiffness, and pain in joints and associ-ated structures; can affect any joint in the body.

Root caries – Caries on the root of the tooth,which is more susceptible to decay than the rest ofthe tooth due to the lack of an enamel covering, dif-ficulty in maintaining a clean surface, and lack ofpreventative therapies.

Secondary – Produced by a primary cause.Sjogren’s syndrome – A chronic, progressive

autoimmune disorder, characterized by dry eyes andmouth, and recurrent salivary enlargement.

SnF2 – A fluoride compound used in the preven-

4

tion of caries.Streptococcus mutans – A species of streptococ-

ci that has been implicated in dental caries andendocarditis.

Tachycardia – An abnormal rapidity of heartaction, usually defined as a heart rate greater than100 beats per minutes in adults.

Vasoconstrictors – An agent that causes con-striction of the blood vessels; found in some localanesthetics.

Xerostomia – Dryness of the mouth caused byabnormal reduction in the amount of salivarysecretion; may occur in diabetes, hysteria, acuteinfections, and some types of neuroses and may beinduced by certain drugs such as atropine andnicotine.

OLDER ADULT POPULATIONFor persons born in the United States, the life

expectancy has increased constantly during the lastcentury, with the greatest increasing segment beingpersons over sixty years of age. Greater numbers ofolder individuals are consequently seeking dentaltreatment. These patients require a full range of den-tal care: crown and bridge work, endodontics, peri-odontics, oral surgery, and restorative work.Although many of these individuals appear to be ingood health, it is important to remember the possi-ble presence of other physical disabilities and theyare much less able to tolerate the stresses normallyinvolved in planned treatment. Gerontologists havedivided the study of the older population into sever-al categories based on age:

• New-old (55-64 years)• Young-old (65-74 years)• Middle-old (75-84 years)• Old-old (85-plus years)Whatever terms are used to define your patients,

two very important facts exist. Foremost, characteri-zations of age should be based on ability, notchronological age; and second, the majority of olderadults perform at a high degree of independent func-tion. The majority of older adults with functionallimitations and compromised health are over the ageof 75 years. Chronological age refers to age as mea-sured by calendar time since birth, while functionalage is based on performance capacities. Although acalendar may signify a particular age, functionalability should be the standard that differentiates anindividual’s capability to maintain activity.

Table 1 lists the many changes frequentlyencountered in the geriatric patient. Decrease in tis-sue elasticity is a primary physiological change that

has a consequential effect on organs throughout thebody. For example, at 75 years of age, cerebralblood flow is around 80% of what it was at age 30;cardiac output has declined to 65% of what it previ-ously produced, and the renal blood flow hasdecreased to 45% of its former volume. Thisdecrease in renal perfusion has a potentially signifi-cant bearing on the actions of certain drugs, primari-ly those in which urinary excretion is a principalmode of removing the drug and its metabolites fromthe body. Drugs such as penicillin, tetracycline, anddigoxin exhibit greatly increased beta half-lives inthe older patient. Decreased tissue elasticity alsoaffects the lungs. Pulmonary compliance decreaseswith age.

MEDICAL HISTORYUpdating medical histories of the older adult

patient is crucial for diagnosis, treatment planning,treatment, and prognosis. For a new older adultpatient, a medical history form should be sent outbefore the initial visit, so the patient does not feelrushed in filling out the form. If there is not enoughtime to mail out a form, asking the patient to bring alist of any medications and dosages can be veryhelpful to both the patient and dental team. It isoften best to interview the patient alone in the treat-ment room, but for those with compromised mentalhealth, a relative or caregiver should accompany thepatient into the treatment room. In some instances,the patient may not be aware of all of the medica-tions that he or she is taking, and it may be neces-sary to confer with the primary caregiver or physi-cian before rendering treatment. Medical historiesshould be as specific as possible and consultationwith the patient’s physician may be necessary toresolve any questions that may arise from the med-ical history. All consultation notes must be docu-mented in the patient record.

Prescription medications and all over the countermedications, vitamins, and herbal supplementsshould be listed with the medical history. With olderadults being the leading consumers of multiple typesof medications for various health conditions, thepharmacological implications of successful dentaltreatment must be carefully assessed. Certain med-ications may interact with some of the drugs used inthe dental office, creating potential medical emer-gencies, especially if the dental team is unaware ofthe medication being taken. (See Appendix 1:Potential Drug Interactions) A complete and precisereview of the medical history should be done at eachappointment before treatment, even if the patient was

5

in two weeks ago. Medications and medical condi-tions can change frequently; therefore, it is importantto update the history at the start of each visit.

Many routine dental procedures, including ordi-nary brushing and flossing of teeth can release bac-teria into the bloodstream. In most instances, the

resulting bacteremia poses no threat and the body'snatural defenses attack and eliminate the invadingmicroorganisms. Even in individuals who are endo-carditis- susceptible, the bacteremia is usually elimi-nated by natural defense mechanisms. However,certain heart patients and joint replacement patients

Cardiovascular System

• Coronary artery disease

— Angina Pectoris

— Arrythmias

— Myocardial infarction

— Decreased contractility

• High Blood Pressure

— Cardiac disease

— Cerebrovascular disease

— Renovascular disease

Central Nervous System

• Alzheimerism

• Cerebral arteriosclerosis

— CVA

— Decreased memory

— Emotional changes

• Parkinsonism

• Responses to stimuli – all autonomic reflexesare slower

• Sleep patterns – less restful sleep, possibleinsomnia

• Voice – decreased range, may become higherpitched

Endocrine System

• Decreased response to stress

• Maturity – type two adult-onset diabetes mellitus

Gastrointestinal System

• Mastication – impaired due to loss of teeth or ill-fitting appliances

• Swallowing – more difficult as salivary secretionsdecrease

• Digestion – decreased due to reduction in pro-duction of digestive enzymes

Genitourinary System

• Decreased renal blood flow

• Decreased number of functioning glomeruli

• Decreased tubular reabsorption

• Benign prostatic hypertrophy

• Increased urination frequency

• Incontinence

Hearing

• Decrease in hearing capacity – may wear hear-ing aids

Integumentary System

• Texture – skin loses elasticity, wrinkling, dryness

• Color – face paler, spotty pigmentation

• Temperature – extremities cooler, decreasedperspiration

Hair – decreased growth, thinning, graying

Nails – decreased growth, increased ridges

Olfactory System

• Decrease in sense of smell (will affect the senseof taste)

Oral Cavity

• Bone – darker in color, stained, attrition, weak-ened under load

• Circumoral tissues – stiffen

• TMJ – muscle tone decreases

• Mucous membranes – dry, shiny, more fragile

• Periodontium – recession, redness, swelling,deterioration of bone

• Tongue – increase in the number of lingualvariscosities

• Salivary glands– decreased production, especial-ly by some medications

Respiratory System

• Arthritic changes in thorax

• Interstitial fibrosis

• Pulmonary problems related to pollutants

• Senile emphysema

• Anatomic structure- increased anterior-posteriordiameter

Vision

• Decrease in peripheral vision

• Sensitivities to bright lights

• Glaucoma

• Cataracts

Table 1: Pathologic and Physiologic Changes in Geriatric Patients

6

are vulnerable to the invading bacteria. Bacteremiain these patients can lead to infective endocarditis, aserious and often fatal condition. Even with theadvancements of medical science, we are unable topredict with absolute certainty which patients willdevelop endocarditis or which procedures will beresponsible for the infection. Therefore, every den-tal team member must identify patients with predis-posing conditions and take measures to protect themfrom this condition. It is important to know whichmedical conditions put patients at risk and the rela-tive severity of the risk. In the past, many dentalpatients were premedicated with antibiotics prior tocertain dental procedures.

In 2007, the American Heart Association (AHA)published new guidelines for antibiotic prophylaxis,thus eliminating the need of short-term antibiotics asa preventative measure for most of these patientsbefore their dental treatment. The new AHA guide-lines are based on a growing quantity of scientificevidence that shows the risks of taking preventiveantibiotics outweighing the benefits for mostpatients. The risks to the patient include adversereactions to antibiotics that range from mild topotentially severe and, in very rare cases, death.Inappropriate use of antibiotics can also lead to thedevelopment of drug-resistant bacteria, a growingconcern in the healthcare community. Research hasalso found no convincing evidence that taking pro-phylactic antibiotics prior to a dental procedure pre-vents infective endocarditis in patients who are atrisk of developing a heart infection. Their hearts arealready often exposed to bacteria from the mouth,which can enter their bloodstream during necessarydaily activities such as brushing or flossing. Thenew AHA guidelines are based on a comprehensivereview of published studies that suggests infectiveendocarditis is more likely to occur as a result ofthese daily activities than from a dental procedure.(See Appendix 2: Endocarditis Risks) The newAHA guidelines are designed for patients whowould have the greatest threat of an adverse out-come if they developed a heart infection.

Knowing which dental procedures pose the great-est threat to susceptible patients is also important.Reduce the risk factor with careful planning and byeducating the patient. The dentist in consultationwith the patient's physician will then choose theantibiotic regimen most appropriate for each patient.(See Appendix 3: Prophylactic Regimens)Occasionally, a patient with a total joint prosthesismay present to the dentist with a recommendationfrom his or her physician that is not consistent with

the new guidelines; this could be due to lack offamiliarity with the guidelines or to special consid-erations about the patient's medical condition thatare not known to the dentist. In this situation, thedentist is encouraged to consult with the physicianto determine if there are any special considerationsthat might affect the dentist's decision on whether ornot to premedicate, and may wish to share a copy ofthese guidelines with the physician if appropriate.Following this consultation, the dentist may decideto follow the physician's recommendation or, if inthe dentist's professional judgment antibiotic pro-phylaxis is not indicated, may decide to proceedwithout antibiotic prophylaxis.

The dentist is ultimately responsible for makingtreatment recommendations for his or her patientsbased on the dentist's professional judgment and anyperceived potential benefit of antibiotic prophylaxismust be weighed against the known risks of antibi-otic toxicity; allergy; and development, selectionand transmission of microbial resistance. Generally,patients with joint replacement are premedicated forup to 24 months following placement, during whichthey are most susceptible to infection.

Under the new 2007 AHA Antibiotic Guidelines,preventive antibiotics prior to a dental procedure areadvised for patients with the following heart condi-tions:

l artificial heart valves l a history of infective endocarditis l certain specific, serious congenital

(present from birth) heart conditions, including:

u unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduits

u a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure

u any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device

l a cardiac transplant that develops a problem in a heart valve.

7

Under the new guidelines, patients who havetaken prophylactic antibiotics routinely in the pastbut no longer need them prior to dental treatmentinclude patients with:

l mitral valve prolapse l rheumatic heart disease l bicuspid valve disease l calcified aortic stenosis l congenital heart conditions such as ventricular

septal defect, atrial septal defect and hypertrophic cardiomyopathy.

For patients who are not sure whether they needto be premedicated, a telephone consultation withthe physician is necessitated. Before the conclusionof the consultation, the dentist should ask for writtendocumentation from the physician in the form of aletter to be kept with the patient chart. When apatient forgets to premedicate, the antibiotic shouldbe given in a single dose 30 to 60 minutes beforetreatment. This time period is recommended so thatthere will be high blood levels of antibiotic at thetime bacteremia occurs; if the antibiotic accidentallyis not administered, the dosage may be given up to 2hours after the procedure. However, it is importantto note that the recommendation is to give theantibiotics 30-60 minutes before treatment.3

Infective endocarditis is one of the most seriouscomplications that can occur following a dentalappointment. Although the percentage of affectedpatients surviving endocarditis has greatly increasedthrough the years, prevention is the best way tomanage the disease.

AGING OF THE DENTAL TISSUES

The enamel of our teeth endures both chemicaland morphological changes through the years. Thesetissues become less hydrated and experiences super-ficial increases in fluoride content with age, espe-cially with the uses of dentifrice and tap water.Thickness of the enamel does change over time,especially on the facial, proximal contacts, andincisal and occlusal surfaces due to the many chew-ing cycles and cleaning with abrasive dentifrices.The disappearance of the outer layer of enamel overtime changes the way in which the tissue interactswith acidic solutions. The volume of dentin increas-es through the apposition of secondary dentin on thewalls of the pulpal chamber and because of caries ordental excavation. Aged dentin is more brittle, lesssoluble, less permeable, and darker than it was earli-er in life. The size of the pulp chamber and volumeof the pulpal tissue decreases with reparative and

secondary dentin. The odontoblastic layer surround-ing the pulp changes progressively from a multi-layer organization of active columnar cells to a sin-gle layer of relatively inactive cuboidal cells.Calcification of the nerve canals increases with age,and the cementum volume within the alveolusincreases gradually over time, notably in the apicaland periapical areas.

Aging affects the potential diagnosis and subse-quent treatment planning by altering the radiograph-ic appearance of teeth. Teeth that appear pulplessusually are not, making the instrumentation duringan endodontic procedure a challenge. Furthermore,radiographs of older teeth that appear to predict animpending coronal pulp exposure may be mislead-ingly pessimistic. Apposition of apical cementumhas been shown to alter the association between theapical foramen and the radiographic apex.

DENTAL TREATMENTThe incidence of root caries in the older adult has

been estimated at approximately 1.6 root surfacesper 100 root surfaces at risk. The nature of the rootcaries appear to be more severe in males and mostlikely to affect the molar regions. Significant factorsassociated with root caries include decreased sali-vary flow, impaired manual dexterity, and systemicconditions requiring medications that decrease sali-vary flow. Other risk factors influencing the higherincidence of root caries among the older patientinclude abrasion at the cementoenamel junction,fixed bridgework, removable partial dentures, long-term institutionalization, and soft diets consisting ofrefined sugars and sticky, fermentable carbohy-drates. Root caries prevention and therapy includeapplication of topical fluoride, dietary counseling,plaque control, and prevention of gingival recession.

Restorative dental treatment for the older patientmust take into account dental, functional, and med-ical considerations if the quality of care provided isto be equal to that of younger patients. The dentalteam must keep in mind the changes that have takenplace in the tooth structure as well as the impact ofmedical conditions when planning and deliveringrestorative care to their patients. Due to the nature ofincreased brittleness of the clinical crown, numerouspre-existing restorations and general recession, thedental practitioner may be especially challengedwhen treatment planning the restoration of cariouslesions in the mouths of older patients. Highly rein-forcing restorations such as onlays and full crowncoverage enhance the durability and strength andreduce the likelihood of non-restorable tooth frac-

8

tures. Extending the crown preparation apically andplacing the margins subgingivally is indicated occa-sionally to reduce the likelihood of developing pri-mary or secondary and recurrent root caries on theexposed surfaces of the teeth. Smoothing the com-promised root surface, improving access to oralhygiene, and applying a topical fluoride may suc-cessfully treat shallow root caries. Deeper compro-mised surfaces need to be cleaned out and restoredwith a restorable dental material.

There are four types of materials currently usedto restore carious lesions on the root surfaces: amal-gam; composite resins; auto-cured and dual-curedglass ionomer cements; and dentin bonding materi-als. However, restorative techniques and materialsdeveloped for and proven in the mouths of youngerpatients should not be assumed to perform identi-cally in the older dentition.

Amalgam is an ideal restorative material thatrequires mechanical undercuts and adequate con-densation, two factors that may be difficult to meetwhen restoring carious root lesions. Due to the lackof fluoride release and esthetics, and the need forconventional retention form, amalgam is not alwaysthe material of choice for root area restorations.However, amalgam works remarkably on surfacesthat act as anchor teeth for removable partial den-tures.

Retention of currently available restorative mate-rials should continue to use macromechanicalstrategies even as micromechanical and chemicaladhesive mechanisms provide bonding to dentinthat amplifies tensile strength and refines the mar-ginal seal. Undercuts and increased surface areathrough grooves and boxes enhance the restorativesuccess of bonded restorations and can be usedmore freely in older teeth without risking pulpalinvolvement. Pulpal sensitivity is usually greatlydecreased or lacking altogether in older teeth. Mostrestorative procedures can be done with no discom-fort in the absence of local anesthetic or with mini-mal infiltration of anesthetic, with the patient’s con-sent. Excluding the anesthetic is especially advanta-geous for patients with neurological diseases suchas stroke or dementia, as they may traumatize theirtissues inadvertently after the appointment whilethe soft tissues are still anesthetized.

Currently, glass ionomer cements are the pre-ferred restorative materials for carious root lesionsbecause they provide a long-term seal againstmicroleakage, continuous fluoride release, requireminimal cavity preparation and are well tolerated bythe pulp and gingival tissue. A sandwich technique

involving the use of glass ionomer cements as aliner under resin composite restorations optimizesthe benefits of both products. The concomitant useof dentin bonding agents allows for more conserva-tive tooth preparation and improved marginalintegrity. Acid etching of enamel is more effectivein the older tooth, requiring a shorter time for aretentive bond, and should be used with all types ofrestorative materials. Research states that there islittle need to base a restoration in the older patientother than to create an environment toxic to remain-ing bacteria when, to avoid an exposure, the clini-cian has made a decision to leave behind infecteddentin. Most bonding agents work well as liners andtherefore there is little need for application of a sep-arate product.

Dental restorations should be designed to beproactive as well as reactive with respect to theincreasing prevalence and extent of root exposure.Preventative approaches should be targeted specifi-cally toward root caries, and periodontal andrestorative therapies aimed toward maintaining gin-gival height in order to lower the number of poten-tial sites susceptible to root caries attack. Patientswith recurrent root caries need to be educated aboutdiet, use of fluoride, recare frequency, and other pre-ventative measures. When caries are present,perigingival margins should be extended slightlysubgingivally whenever feasible, in order to reducethe chance of recurrence. Restorative materials forcarious lesions on the root surfaces that featurebonding to the dentin and enamel will minimizemarginal leakage, but their optimal performancerequires careful isolation during the procedure.

To harmonize with adjacent, unrestored teeth,esthetic restorations should use lower-value shades,smoother facial contours, flattened incisal and inter-proximal areas, and overall greater translucency.Strategically placed fine opaque white lines canmimic natural blemishes found in older enamel andintensify the perceived translucency of the neigh-boring less-opaque restorative material. Incisaledges enhanced with violet stain effectively imitatethe appearance of enamel worn thin by use, withoutrequiring the physical reduction of the facial-to-lin-gual dimension that could undermine strength andreduce the lifetime of the restoration.

Bleaching of the older dentition can be done thesame as for younger teeth, providing that all areasof decay and root sensitivities are filled and theradiographic examination does not show any pulpalinvolvement. The patient needs to be informed thatamalgam, resin, gold, and porcelain restorations,

9

denture and partial teeth will not bleach, and thatsome anterior restorations may need to be replacedwith a more esthetically pleasing shade when thebleaching process is complete. For the patient witha removable appliance, an impression for thebleaching trays should be done with the applianceout of the mouth. There are many brands of takehome bleaching materials available to dentaloffices, with varying concentrations. A 10% – 16%carbamide peroxide solution is usually sufficientfor bleaching of the darker dentition. Writteninstructions should be given along with the verbalinstructions, and a follow-up telephone call oroffice visit a week after receiving the materials ishelpful for the patient. Approximately two weeksshould be allowed after completing bleachingbefore progressing with any resin bonding proce-dures in order to allow for any rebound in the shadeof the bleached teeth.

Recent studies have shown that a significantnumber of dental practitioners have increased thelength of their typical dental appointment.Although appointments of less than 60 minutes arestill widespread, many practitioners now schedule1- to 3-hour treatment sessions. Dental therapy isstressful to the patient and longer appointmentsare more stressful than shorter appointments.Medically compromised patients are more likelyto react adversely when subjected to longer treat-ment times. Patient anxiety remains an importantfactor in the delivery and outcome of dental care.Three tips for calming an anxious patient includeremaining calm, reassuring the patient continuous-ly, and making sure the anesthetic is effectivewhen being used. Patients can be reassured byproviding information about the treatment, allow-ing time for questions, not rushing to begin treat-ment, and paying attention to the individual’sneeds and feelings while providing an environ-ment conducive to communication, understanding,and patient education.

PATIENT POSITIONING FORCOMFORT AND EFFICACY

Aging patients may have impaired physicalmobility or sensory perception. Breathing patternsmay be irregular, causing the patient to become easi-ly winded. Escorting the patient slowly down thehall, matching their gait, and offering an arm forthem to grab onto will help make the patient feel abit more relaxed. For those traveling by a walker,walk ahead of the patient slowly. For those traveling

by wheelchair, slowly push the chair to the treat-ment room and, depending upon the dental chairposition, either back into the room or go forwardthrough the doorway. Line the wheelchair up withthe dental chair for easier transfer of the patient.

Some older adults find it difficult to sit forextended periods in the dental chair, or may objectto being placed in a supine position, while othershave difficulties with support and balance. Pillowsor rolled towels may be placed underneath knees orbehind necks and backs to prevent muscle spasmsand provide additional support during treatment.Always ask the patient before moving the chair oradjusting supports, and frequently ask if the patientis still comfortable. Most patients can be treatedsuccessfully within the dental office with a fewadaptations. Ideally, patients should be treated in thedental chair, but occasionally a patient in a wheel-chair may be unable to transfer to the dental chair.In this case, the dental team can move the wheel-chair as close to the dental unit as possible, andwork standing up. Patients who remain in the wheel-chair during treatment will need additional headsupport in the form of a portable headrest. For thosepatients treated in the dental chair, care must betaken at the completion of the appointment so thepatient is not brought abruptly for a supine positionto an upright sitting position. Orthostatic hypoten-sion is a frequent occurrence in the older adult withquick positional changes. Allowing the patient to sitfor a minute or two before escorting the patient tothe reception area helps them regain their balance.

MANAGEMENT FORPARTICULAR CONDITIONS

Alzheimer’s DiseaseAlzheimer’s disease is a type of dementia that is

progressive and a chronic degeneration of cognitivefunction. The etiology is unknown and onset canbegin as early as the fourth decade of life. In mostcases, the progression of the disease is a slow deteri-oration lasting for 15 years or more. The disease canbe divided into three stages:

Stage 1 – the mild impairment or forgetful-ness phase (2-4 years), in which the individ-ual experiences noticeable changes inmood, loss of judgment and memory.Neglect of appearance, denial of deficits,and inability to perform complex routineactivities is usually noted.Stage 2 – the moderate impairment or con-fusional phase (2-10 years), in which the

10

individual has increased episodes ofextreme irritability and confusion.Wandering, constant motion with repetitivemovements, and unclear speech is usuallynoted.Stage 3 – the severe impairment or demen-tia phase (1—3 years), in which the individ-ual becomes severely disoriented andbehavior difficulties become quite apparent.Confinement to bed or chair, incontinence,seizures, and a higher susceptibility toinfections is common.

The goals of dental treatment for these individu-als are to restore and maintain oral health, and toprevent the progression of oral disease. Due to thedegenerative nature of this disease, the first visitrepresents the best cognitive functioning level of thepatient. For this reason, the treatment plan should bedesigned to restore oral function quickly and toestablish an intensive prevention program.Appointment times should be scheduled with anawareness of the patient’s best time of day. Thepresence of a familiar caregiver in the treatmentroom will often ease the patient’s fears.

ArthritisRheumatoid arthritis is a systemic disease of

unknown etiology, characterized by inflammation ofthe joints that become chronic and progressive,often causing gross deformities and limited motionin the involved joints. The temporomandibular jointmay be affected by this disease, resulting in limita-tions in opening of the mouth and holding open forextended periods. It is important to be aware ofwhat type of medications this patient may be taking,as aspirin, which is most commonly prescribed forrheumatoid arthritis, can extend bleeding times. Thepatient may also be taking corticosteroids, whichmay cause a potential drug interaction with somedental drugs. It is best to consult with the patient’sphysician before prescribing any medications postoperatively. Dental appointments should be kept asshort as possible and preferably during the latterpart of the day, when gradual use of the joints andmuscles throughout the morning has diminishedstiffness.

Cardiac conditionsCardiovascular disorders comprise a variety of

conditions including acquired and congenital heartdisease, such as atherosclerosis, congestive heartfailure, and rheumatic heart disease. These patientsmay be taking a variety of drugs and treatment

should be planned in collaboration with the patient’sphysician. Patients with cardiovascular disordershave an increased predisposition to developing bac-terial endocarditis and may be required to take pro-phylactic antibiotic therapy before certain treatmentprocedures. Individuals who are treated with amonoamine oxidase inhibitor for hypertension,should not receive a local anesthetic containing epi-nephrine, nor should the use of vasoconstrictors forgingival retraction and hemostasis be used.

DiabetesIt is estimated that approximately 7% of the U.S.

population have diabetes mellitus, but only half ofthem have been diagnosed. Over 18% of persons 65and older have diabetes. Diabetes mellitus is a dis-ease of metabolic disregulation that develops fromeither a deficiency in insulin production or animpaired utilization of insulin; there is no cure.There are two types of diabetes, and either type mayoccur at any age. Type I diabetes is also known asinsulin dependent diabetes (IDDM). It was formerlycalled juvenile-onset diabetes and results from thedestruction of insulin producing cells of the pan-creas, which may involve autoimmune or a virally-mediated destructive process. Control of this form ofdiabetes is dependent upon the administration ofinsulin. Type II diabetes, also known as non-insulindependent diabetes (NIDDM), was formerly calledmaturity-onset diabetes. It results from either defectsin the insulin molecule or from altered cell receptorsfor insulin and represents insulin resistance ratherthan deficiency. In the majority of the cases, Type IIis controlled through diet and oral medication. Untilrecently, Type II has been seen as a disease of genet-ic susceptibility triggered by environmental factors.The environmental trigger is the change in lifestyleto inactivity and in diet to overalimenation, especial-ly more carbohydrates and fats. The fundamentalbiochemical basis of diabetes is still unknown, andType II is not just a single entity. There are severalforms of late onset, Type II diabetes currently beingresearched. Currently, there is a global epidemic ofType II diabetes with morbidity and mortality of anenormous magnitude. In both cases, the oral mani-festations are similar and include:

• Acetone breath. This has the odor of decay-ing apples or stale cider.

• Alveolar bone loss. Severe loss of the sup-porting bone structure and the periodontalligaments results in the loosening of the teeth.

• Dehydration of the mucosal soft tissues.This results from the diminished production

11

of saliva. The dryness is uncomfortable andthe tongue may have a burning sensation.

• Delayed healing. This is accompanied by agreater susceptibility to infection.

• Irritated gingiva. These can be red, swollenand painful. As the age advances, the gingi-va becomes fibrotic and hypovascular.

• Toothache in clinically sound teeth. This isdue to the arteritis occurring throughoutthe body.

Diabetes mellitus frequently is associated with aclassic group of complications including cardiovas-cular disease nephropathy, neuropathy, periodontaldisease, and retinopathy. Periodontal disease is con-sidered the sixth greatest complication of diabetes.The incidence of periodontal disease appears toincrease in the diabetic population with age, and tobe more severe in those individuals with other sys-temic complications. Prolonged exposure to hyper-glycemic conditions results in decreased fibroblastproliferation and collagen synthesis, and basementmembrane alteration and thickening, to name a few.

Appointment scheduling of the diabetic patient iscrucial because diabetics receiving insulin therapymust consume carbohydrates every three hours dur-ing their waking hours. It is best to give thesepatients early morning hours so they are not keptwaiting, because the stress of waiting may result inan adverse reaction. The patient should be advisedto eat and adjust their insulin intake before theappointment. For the diabetic who wears a remov-able appliance, care must be taken to check theappliance for pressure points, because any pressureor roughness from the appliance can result in grossinflammation of the mucous membranes.

Parkinson’s DiseaseParkinson’s disease is a chronic, progressive dis-

order caused by the pathological changes in thebasal ganglia of the cerebrum, resulting in the defi-ciency of dopamine. Characteristics include exces-sive salivation and drooling, involuntary tremors,loss of postural stability, muscle rigidity, and slow-ness of spontaneous movement. Tremors in lips andtongue, and difficulty swallowing are common,making treatment somewhat of a challenge.Adaptive aids and enlarged toothbrush and flosshandles should be provided to these individuals tofacilitate self-care and consequently self-determina-tion whenever possible. Special consideration isneeded when positioning the patient for treatment,and at the conclusion of treatment when the dentalchair is brought to an upright position. Balance and

equilibrium are often affected, either by medicationsor the disease itself. It is crucial to remember that apatient with Parkinson’s usually has no impairmentin intellectual function.

Sensory impairedA patient who is visual or hearing impaired will

often come to the office with a friend or familymember who plans to aid with communication. It isimportant to allow the patient to be as independentas possible. A visual impaired patient communicatesthrough other senses, such as hearing, smell, tasteand touch. It is very helpful and beneficial to thepatient to have the treatment explained as theappointment progresses and mention to the patientwhen something may taste unpleasant. Inform thepatient before moving the chair position. It may alsobe helpful to touch the patient reassuringly as thechair is being positioned.

A hearing impaired patient sometimes has lessobvious needs. They may or may not read lips, andmay nod or smile and appear to understand out ofpoliteness. If the patient does read lips, stand infront of the patient, and speak slowly without overenunciating the words with your mask removed,keeping instructions as simple as possible. It is bestto have a pen and paper handy to aid with communi-cation if needed. Some patients may come to theappointment with an individual who knows sign lan-guage. In this situation, speak to the patient directlywith your mask off while the signer is off to the sidesigning. When giving post-operative instructions, besure to include a written copy for the patient.

Loss of speech acuity may account for some ofthe difficulty a hearing impaired individual mayhave in adjusting to speaking with a new removableappliance. The sibilant sound “s” will be particularlydifficult. If the patient is compliant, after the appli-ance is properly adjusted to permit proper soundproduction, have the patient practice difficult soundsuntil he or she is able to make an acceptable sound.Since the patient can no longer depend on auditoryself-monitoring of their speech for self-correction,he or she must learn to judge production by theplacement and feel of the tongue against the appli-ance. Allowing a little extra appointment time forboth visually and hearing impaired patients is help-ful to both the patient and the dental team.

StrokeA cerebrovascular accident (CVA) or stroke is the

result of damage to part of the brain and is usuallycaused by a sudden interference of the blood supply

12

to the brain. Although stroke can occur at any age,the greatest incidence is among adults 60 years ofage and older. Severity of the stroke varies from oneindividual to another with little or no paralysis tocomplete paralysis. On occasion, the part of thebrain that controls speech is affected. Stroke patientsmay have difficulty in swallowing, chewing orwearing of removable appliances. Maintenance oforal hygiene often times diminishes. Stroke patientsshould be treated as an adult with respect.Temporary personality changes and display ofbehavior usually result from injury to the portion ofthe brain that controls these emotions. Appointmenttimes need to be short with frequent rest periods, asthe patient will tire quickly. Modification of tooth-brush and floss handles may be needed, dependingon the severity of the injury.

XerostomiaXerostomia refers to the sensation of a dry

mouth. Various factors can play a role in thepatient’s perception of xerostomia. Prescriptionmedications, surgical intervention, or chemotherapyand radiotherapy treatment of cancer intensifieschanges in salivary function. Commonly adminis-tered medications associated with xerostomiainclude anticholinergics, antihistamines, antihyper-tensives, antimetabolites, antiparkinsonians, diuret-ics, narcotic analgesics, quinolones, sedatives, andtranquilizers. Other common factors includingaging, diabetes, mouth breathing, smoking, andSjogren’s syndrome aggravate the condition. Salivaperforms a variety of functions in maintaining den-tal health. They include:

• Antibacterial and microbial action.• Assistance in swallowing.• Buffering of acids produced by oral bacteria.• Lubrication of tissues and aids in the break-

down of food.• Remineralization of tooth surfaces.

Xerostomia affects women more frequently thanmen, and is more commonly found in older individ-uals. Once the diagnosis of xerostomia or salivarygland hypofunction is made and the possible causesconfirmed, treatment for the condition usuallyinvolves the use of artificial saliva substitutes, andchewing gum and toothpaste formulated to treatxerostomia. In the more severe cases, such aspatients receiving radiotherapy for cancer of thehead and neck, or patients with Sjogren’s syndrome,a systemic cholinergic stimulant may be adminis-tered if no contraindications exist. In all cases, goodhydration is essential with water being the drink of

choice. Caffeine should be avoided as it is dehydrat-ing, as should sugared candies or cough drops,which aid in root caries.

Due to the complex nature of xerostomia, man-agement by the dental team is extremely difficult.Although the artificial saliva products do not stimu-late salivary production, the use of these products ishighly recommended for patient comfort.Xerostomia not only affects the mucous membranesof the oral cavity, it can greatly affect the rate ofcaries. Many of the products on the market are bal-anced in terms of pH so that no additional risk ofdental caries occurs. In patients with moderate tosevere xerostomia, or those individuals with a sus-ceptibility to caries, saliva substitutes can be used inconjunction with topical fluoride treatment pro-grams designed by the dentist to reduce the inci-dence of caries. Salivary substitutes may provide anallergic potential in patients who are sensitive tosome of the preservatives present in the artificialsaliva products. Furthermore, there is a risk ofmicrobial contamination by placement of the sali-vary substitute container in close contact with theoral cavity. Patient education regarding the use ofsaliva substitutes is essential. The patient withchronic xerostomia should be educated on the needfor regular recare visits, optimum performance inhome care, and the need to re-evaluate oral soft tis-sue pathology and any changes that potentiallycould occur long-term. (See Appendix 4: ArtificialSalivary Substitutes)

HOMEBOUND DENTISTRYMost operative techniques that are used in the

dental office can be adapted and employed to home-bound care of individuals confined to their homes,nursing homes, and hospitals. An assistant will usu-ally travel with the dentist. The patient shouldreceive the same consideration and quality of caregiven to patients in the dental office. Portable equip-ment is compact, lightweight, and relatively self-contained. The equipment should include a meansof positioning the patient’s head, adequate light,handpieces, and other instruments and materialsneeded for treatment. Portable radiographic materialis also available. Treatment sessions should beshorter than those in the office because the home-confined individual may tire more easily.

Home care aids and suggestionsThe instruction and home care regime of the

physically challenged patient will depend on thetype and severity of the disability. The individual

13

who has a mild physical or mental disability can betaught a simple brushing, such as the Fones or pressand roll method. Bicycle grips, tennis balls, andStyrofoam molds with the handle of the toothbrushplaced inside can be used as alternative brush han-dles for the patient with decreased manual dexterity.There are several types of toothbrushes on the mar-ket and some can be personalized to meet patientneeds. By bending a plastic handle under hot water,the angle of the brush can be adjusted to counterbal-ance the disability. Supervision by the parent orcaregiver may be required at one of the daily brush-ings, preferably the evening one. The more seriouslyimpaired patient may be instructed in the use of anelectric toothbrush. (See Appendix 5: MechanicalToothbrushes) The patient should be encouraged tobrush his or her own teeth during the day. This willhelp to reinforce the concept that the teeth should becleaned twice daily and to give the patient a sense ofresponsibility for his or her own care.

If the patient has the necessary interest and skills,flossing can be taught or reinforced. A floss holdercan be a useful device if the patient’s manual dexter-ity is limited, or a mechanical flossing device is alsoacceptable. Floss holders can also be inserted intoalternative handles. (See Appendix 6: AutomatedFlossers)

Flouride treatmentsFor the caries prone patient, the use of fluoridated

toothpaste is essential. It is recommended that olderadults use either a monofluorophosphate (0.76%MFP; Colgate) or sodium fluoride paste (0.24%NaF; Crest). These two dentifrices contain 1000-1100 ppm fluoride. For patients with extensive den-tal work or for those with a higher decay rate, overthe counter and prescription mouth rinses, gels, ortoothpastes may be indicated. (See Appendix 7:Fluoride Therapy)

Concentrated topical fluoride applications follow-ing dental prophylaxis has been evaluated andapproved by the American Dental Association andthe Food and Drug Administration. There are threetypes of fluoride in-office delivery systems consid-ered safe and effective:

• 8% SnF2 – is contraindicated for patientswith anterior demineralization due to thestaining potential.

• 1.23% APF – has a pH 3.5, contain hydro-fluoric acid, and has a potential to etchporcelain and glaze surfaces. It is con-traindicated for patients with crown andbridge work. (A sodium fluoride can be

used instead).• 2.0% NaF – can be safely used with porce-

lain and resin restorations.

For the older individual with little or no decay,one or two fluoride applications annually followinga prophylaxis is recommended. For patients withmore extensive decay, a more aggressive regime offour to six applications over four to six weeks tocontrol the caries process may be in order. Multiplesurface root caries can be managed as an infectionusing a combination of an antimicrobial agent(0.12% chlorhexidine) to control bacterial growthand topical fluoride to protect the exposed root sur-faces. While chlorhexidine is primarily used as anantimicrobial agent for treating gingivitis and peri-odontal disease, it is very effective in controllingand eliminating microorganisms responsible forcaries formation, specifically streptococcus mutansand the actinomyces organisms.

CONVEYING POST TREATMENTINSTRUCTIONS

Communication with patients, especially geriatricpatients, is the most essential element in a success-ful dental practice. Communication is more thantalking; it is listening and understanding. For thehearing impaired individual, a clipboard with apiece of paper and a pencil is especially helpful forconveying messages. Written post-operative instruc-tions are recommended, in addition to verbalinstructions. The patient may be too fatigued fromthe treatment to understand clearly what they arebeing told. For hearing impaired individuals, it isespecially helpful to have instructions written out. Ifthe treatment was particularly taxing for the patient,a quick telephone call by a dental team member inthe early evening is a nice gesture.

When scheduling dental appointments, it is essen-tial to ask the patient what time of the day they pre-fer. Special circumstances and patient needs shouldbe taken into consideration. Some older patientshave frequent dosing schedules for their medica-tions, while others tend to do better at different timesof the day. Arthritic patients tend to do better in theafternoons. When scheduling an appointment at thecompletion of treatment, it is helpful to provide thepatient with a clearly written appointment card list-ing the date, day, and time of their next appointment.When a series of appointments is needed, it is help-ful to the patient if the appointments are scheduledon the same day of the week and time of the day. Ifthe patient is making an appointment over the tele-

14

phone and the appointment is over a week away,mail an appointment card to the patient as a friendlyreminder. Confirmation calls the day before are alsohelpful reminders to our older patients.

SUMMARYWith the ever-increasing elderly population, new

challenges will be presented as this group of indi-viduals continues to live longer, retain more of theirnatural dentition, and present with specific types ofneeds for preventative and restorative care. Treatingand meeting these requirements of our older patientsin the dental office is a challenge at times, but trulya rewarding experience. Dental team members canbetter prepare themselves to meet these demandsthrough a thorough knowledge of the needs andtreatments specific to these special individuals.

BIBLIOGRAPHYCottone, James A., Terezhalmy, Geza T., and

Molinari, John A Practical Infection Control inDentistry. Media, PA., Williams & Wilkins, 1996;84-122.

Johnson, Dr. Kenton: notes from continuing educa-tion lecture: Treating the geriatric patient. NorthSuburban Dental Assistants Society; March 15, 2001.

Malamed, Stanley F. Medical Emergencies in theDental Office. St. Louis, Mosby-Year Book, Inc.,1993; 3-9, 121-134, 227-249, 262-449.

Shapira, Eric Z., MS, DDS, MAGD. "ElderAbuse: Society’s forgotten issue." GeneralDentistry, Vol. 48, number 5, September/October,2000; 490-492.

Wynn, Richard L., Ph.D. "The Top 50Prescription Medications Dispensed in Pharmaciesin 1999." General Dentistry, Vol. 48, number 5,September/October 2000; 494-498.

Brisack, Nancy J., RDH, BS. "CPR News:Sedentary Lifestyle: A Modifiable CardiovascularRisk Factor." The Journal of Practical Hygiene,Vol.9 number 4, July/August 2000; 28-30.

Cameron, Carroll, RDH, MA; "Endocarditis";Miami, Home Study Educators, Inc. 1996; (7-8,30).

Reynolds, Elizabeth, RDH, MS. "TheImmunocompromised Patient." The Journal ofPractical Hygiene, Vol.9 number 4, July/August2000; 33-34.

Ship, Jonathan A., DMD and Chavez, Elisa, M.,DDS. "Management of Systemic Diseases andChronic Impairments in Older Adults: Oral HealthConsiderations." General Dentistry, Vol. 48, num-ber 5, September/October 2000; 555-563.

Wynn, Richard L., Ph.D. "New Drug Approvals

in 1999." General Dentistry, Vol.48, number 4,July/August 2000; 380-384.

Zunt, Susan L., DDS, MS. "Oral Candidiasis:Diagnosis and Treatment." The Journal of PracticalHygiene, Vol.9 number 5, September/October 2000;31-36.

Krejci, Charlene B., DDS, MSD and Bissada,Nabil F., DDS, MSD. "Periodontitis – The risks forits development." General Dentistry, Vol.48, num-ber 4, July/August 2000; 430-434.

Little, James W., DMD, MS. "Cancer awarenessand dentistry." General Dentistry, Vol.48, number4, July/August 2000; 462-465.

Niessen, Linda C., DMD, MPH and Gibson,Gretchen, DDS, MPH. "Aging and Oral Health forthe 21st Century." General Dentistry, Vol. 48, num-ber 5, September/October 2000; 544-549.

Berg, Rob, DDS, MPH, MS, MA; Garcia, LilyT., DDS, MS; Berkey, Douglas B., DMD, MPH,MS. "Spectrum of Care Treatment Planning:Application of the Model in Older Adults."General Dentistry, Vol. 48, number 5,September/October 2000; 534-542.

Small, Bruce W., DMD, MAGD. "Esthetic andFunctional Reconstruction of the Geriatric Patient."General Dentistry, Vol. 48, number 5,September/October 2000; 506-509.

Trushkowsky, Richard D., DDS. "TreatmentConsiderations and Options for ContemporaryTooth Whitening." The Journal of PracticalHygiene, Vol.9 number 4, July/August 2000; 44-47.

Shay, Kenneth, DDS, MS. "RestorativeConsiderations in the Dental Treatment of the OlderPatient." General Dentistry, Vol. 48, number 5,September/October 2000; 550-553.

Waldman, H. Barry, DDS, MPH, Ph.D. andPerlmann, Steven P., DDS, MScD. "ProvidingGeneral Dentistry for People With Disabilities: ADemographic Review." General Dentistry, Vol. 48,number 5, September/October 2000; 566-569.

Weiner, Arthur A., DMD, Forgione, Albert,Ph.D., Wiener, Lori K., Hwang, Joseph, DMD."Potential fear-provoking patient experiences duringtreatment." General Dentistry, Vol.48, number 4,July/August 2000; 466-471.

Jacobs, James Q. "Non-Insulin-DependentDiabetes Mellitus: Thrifty genotype or ThriftyPhenotype?"; 1999 Internet article (http://www.geoci-ties.com/jqjacobs/southwest/diabetes.html)

Alexander, Roger E., DDS and Gage, Tommy W.,BS, DDS, Ph.D. "Parkinson’s Disease: An Updatefor Dentists." General Dentistry, Vol. 48, number 5,September/October 2000; 572-580.

15

Darby, Michele Leonardi BSDH, MS and Walsh,Margaret M. RDH, MS, MA, EdD Dental HygieneTheory and Practice. Philadelphia, W.B. SaundersCompany, 1995; 873-924.

Finkbeiner, B.L. and Johnson C.S.Comprehensive Dental Assisting: A ClinicalApproach. St. Louis, Mosby-Year Book, Inc., 1995;106, 458-459, 642, 657-658.

Jahn, Carol, RDH, MS. "Review of AutomatedPlaque Removal Products." The Journal of PracticalHygiene, Vol.9 number 5, September/October 2000;48-52.

Meiller, Timothy F., DDS, Ph.D. and Wynn,Richard L., Ph.D. "Drugs and Dry Mouth."General Dentistry, Vol. 49, number 1,January/February 2001; 10-14.

GSC Homestudy Course "Geriatric Dentistry:Dental Issues for the Aging Population; 2000.

Jacobs, Marie C., DDS, "Addressing SpecialNeeds of Older Adults in the Dental Office".American Dental Assistants Association; 1993.

1 American Heart Association: AntibioticProphylactic Guidelines (as published in the April2007 Journal of the ADA) retrieved January 16,2008 from http://www.qualitydentistry.com/dental/information/abiotic.html

2 Advisory Statement: Antibiotic Prophylaxis forDental Patients with Total Joint Replacements.JADA, Vol. 134, July 2003. Retrieved on January16, 2008 from http://www.ada.org/prof/resources/pubs/jada/reports/report_prophy_statement.pdf

3 Infective Endocarditis-Frequently AskedQuestions. American Dental Association. RetrievedJanuary 16, 2008 from http://www.ada.org/prof/resources/topics/infective_endocarditis_faq.asp

16

Appendix 1: Drug Interactions

Dental Drug Patient Drug Adverse Effect

Tetracycline Antacids Reduced serum concentration andefficacy of tetracycline

Tetracycline Penicillin Impaired efficacy of penicillin

Erythromycin Penicillin Impaired efficacy of penicillin

Erythromycin Theophylline (Bronchodilator) Nausea, vomiting, seizures

Erythromycin Carbamazepine (Tegretol) Carbamazepine toxicity – blurred vision, nausea

Erythromycin Triazolam (Halcion) Triazolam toxicity – psychomotorimpairment and memory dysfunction

Erythromycin HMG-Co-A reductase Muscle weakness and muscleinhibitors (Lipitor) breakdown

Erythromycin Terfenadine (Seldane) Cardiotoxicity – ventricular arrhythmias

Azole antifungals HMG-Co-A reductase Muscle weakness and muscleinhibitors (Lipitor) breakdown

Metronidazole Alcohol Tachycardia, sudden death

Ketoconazole Terfendaine (Seldane) Cardiotoxicity – ventricular arrhythmias

Ketoconazole Alcohol Increased respiratory rate, tachycardia

NSAIDS Coumadin Increased prothrombin time

Vioxx Coumadin Increased prothrombin time

Vioxx Methotrexate Increase plasma concentrationsof methotrexate

Ibuprofen Oral anticoagulants Increased prothrombin time

Ibuprofen Lithium Lithium toxicity – mental confusion

Aspirin Oral coagulants Increased bleeding

Aspirin Probenecid (Benemid) Inhibition of uricosuric action of Probenecid

Epinephrine Tricyclic antidepressants (Elavil) Hypertension

Epinephrine Synthroid, Levoxyl Increased sensitivity of myocardium

Epinephrine Monoamine oxidase inhibitors Hypertension(Nardil, Parnate)

Narcotic analgesics Cimetidine (Tagamet) Increased CNS effects of the narcotic

Morphine Alcohol Increased sedation

Benzodiazepines (Valium) Alcohol Ataxia, respiratory depression

APPENDICES

17

High Risk Conditions

• Previous history of endocarditis

• Prosthetic cardiac valves

• Surgically constructed systemic-pulmonaryshunts or conduits

Moderate Risk Conditions

For the following moderate risk patients, prophylax-is is not usually required. Consultation with thepatient's physician is recommended if a conditionis in question.

• Valvular heart disease

– Rheumatic fever

• Mitral or aortic valvulitis

• Congenital heart disease

– Aortic stenosis

– Asymmetric septal hypertrophy

– Bicuspid aortic valve

– Coarctation of the aorta

– Complex cyanotic heart disease

– Hypermetropic astigmatism

– Idiopathic hypertrophic subaortic stenosis

– Mitral valve prolapse with insufficiency and/or holosystolic murmur

– Patent ductus arteriosus

– Post mitral valve surgery

– Primum atria septal defect

– Pulmonic stenosis

– Tetralogy of Falot

– Tricuspid valve disease

– Ventricular septal defect (unrepaired)

– Ventriculoatrial shunts for hydrocephalus

For the following low risk patients, prophylaxis isnot usually required. Consultation with the patient’sphysician is recommended.

Low Risk Conditions

• Angiography or cardiac catherization procedures

• Atherosclerotic heart disease

• Cardiac pacemakers and implanted defibrillators

• Coronary artery stenosis

• Functional or innocent heart murmur

• History of rheumatic heart disease (+5 yearselapsed) without clinical heart disease

• Uncomplicated atrial septal defect (secundumtype)

• Six months or longer after surgery:

– Coronary artery bypass graft

– Ligated patent ductus arteriosus

– Surgically closed atrial/ventricular septal defect (without prosthetic patch)

– Vascular natural tissue grafts

• In the absence of associated heart disease:

– Cystic fibrosis

– Previous Kawasaki disease without valvular dysfunction

– Sexually transmitted diseases (except HIV infection)

– Sickle cell anemia

– Well-controlled Diabetes

The following procedures are low risk and do not requireprophylaxis:

Low Risk Dental Procedures

• Application of fluoride

• Application of sealants

• Restorations above the gingiva

• Injection of local intraoral anesthesia (exceptintraligamentary)

• Orthodontic band adjustment

• Shedding of primary teeth

• X-rays

Appendix 2: Risk Conditions for Endocarditis

18

Appendix 3: Prophylactic Regimens for Dental Procedures for Adults

Situation Agent Regimen

Standard general prophylaxis Amoxicillin 2.0 g orally one hour before scheduled with no allergies procedure

Unable to take oral medications Ampicillin 2.0 g intramuscularly or intravenously 30 minutes prior to treatment

Allergic to penicillin Clindamycin OR 600 mg orally one hour before scheduled treatment

Cephlexin OR Cefadroxil 2.0 g orally one hour before scheduled treatment

Azithromycin OR Clarithromycin 500 mg orally one hour before scheduled treatment

Allergic to penicillin and Clindamycin OR 600 mg intravenously within 30 minutes unable to take oral medications prior to treatment

Cefazolin 1.0 g intramuscularly or intravenously within 30 minutes prior to treatment

Source: JADA Vol 128, Aug 1997

Appendix 4: Xerostomia Treatment Products*

Artificial saliva (OTC) Manufacturer

Biotene Oral balance gel, gum, toothpaste, mouthwash Laclede, Inc.www.laclede.com

Mouthkote oral moisturizer Parnell Pharmaceuticals, Inc. www.parnellpharm.com

Salivart synthetic saliva Gebauer Company www.gebauerco.com

Cholinergic Salivary Stimulants (By Prescription Only) Manufacturer

Cevimeline (Evoxac) Daiichi Pharmaceutical Corp.www.evoxac.com

Pilocarpine (Salagen) MGI Pharma, Inc. www.mgipharma.com

* List is not all-inclusive; additional products also may be available.

19

Appendix 6: Automated Flossers & Power Irrigators*

Flosser Manufacturer

Oral B Hummingbird® Oral B®

www.oral-b.com

One Step® Pro-Dentec®

www.prodentec.com

Waterpik Flosser® Water Pik, Inc.Various Models www.waterpik.com

Irrigator Manufacturer

Oral B® OxyJetTM Oral B®

Various Models www.oral-b.com

Interplak® Dental Water Jet Conair®

Various Models www.conair.com

Hydro Floss® Hydro Floss, Inc.www.hydrofloss.com

Waterpik Dental Systems® WaterPik, Inc.Various Models www.waterpik.com

* not limited to

Appendix 5: Mechanical Toothbrushes*

Toothbrush Manufacturer

Colgate® Colgate-Palmolive Co.®

(Various models) www.colgate.com

Crest® Church DwightSpin Brush www.churchdwight.com

IntelliClean System Philips Oral Healthcarewww.sonicare.com

Opticlean™ Plaque Remover Conair®

www.conair.com

Oral B® Oral B®

(Various models) www.oral-b.com

Sonicare® Philips Oral Healthcare (Various models) www.sonicare.com

Waterpik® Water Pik, Inc.(Various Models) www.waterpik.com

20

Appendix 7: Fluoride Therapy

Over-the-Counter Supplemental Fluorides for Home Use

Product Concentration Manufacturer

Reach Act®Fluoride 0.05% sodium fluoride Johnson & JohnsonAnti-Cavity Treatment Personal Products Co.

Fluorigard® Anti-Cavity 0.05% sodium fluoride Colgate-Palmolive Co.Fluoride Rinse

Listermint® with fluoride 0.02% sodium fluoride PfizerAnti-Cavity rinse

Phos-Flur® Rinse 0.044% sodium Colgate-Palmolive Co.and acidulated phosphate

Gel-Kam® 0.4% stannous fluoride gel Colgate-Palmolive Co.

Stanimax® 0.4% stannous fluoride SDI Laboratories

Prescription Fluorides for Home Use

Product Concentration Manufacturer

Phos-Flur® Daily Oral Rinse 2.2% neutral sodium fluoride Colgate-Palmolive Co.

Phos-Flur® Gel 1.1% sodium Colgate-Palmolive Co.and acidulated phosphate gel

PreviDent® Gel 1.1% neutral sodium fluoride Colgate-Palmolive Co.

PreviDent® 500 Plus Dental Cream 1.1% neutral sodium fluoride Colgate-Palmolive Co.

Thera-Flur® Gel Drops 1.1% neutral sodium fluoride Colgate-Palmolive Co.

Neutracare Home Topical 1.1% neutral sodium fluoride Colgate-Palmolive Co.

Gel-Kam® Oral Rinse 0.63% stannous fluoride Colgate-Palmolive Co.

PerioMed® 0.63% stannous fluoride 3M ESPE OMNI Preventive Care

Perio Maintenance® Rinse 0.63% stannous fluoride Dental Resources, Inc.

Pro-Dentx® Home Fluorides 0.63% stannous fluoride Professional Dental Technologies(Pro-Dentec)

Stanimax® 0.63% stannous fluoride SDI Laboratories

Gel-Tin® 0.4% stannous fluoride Young Dental Mfg., LLC

Pro-Dentx® Home Fluorides 0.4% stannous fluoride Professional Dental Technologies(Pro-Dentec)

OmniMed® 0.4% stannous fluoride 3 M ESPE OMNI Preventive Care

Point-Two® Dental Rinse 0.2% sodium fluoride Colgate-Palmolive Co.

PreviDent® Dental Rinse 0.2% sodium fluoride Colgate-Palmolive Co.

Oral-B Fluorinse® 0.2% sodium fluoride Procter & Gamble

Oral-B NeutraCare® 1.1% sodium fluoride at neutral pH Procter & Gamble

Oral-B Stop® 0.4% stannous fluoride gel Procter & Gamble

PreviDent® 0.2% neutral sodium fluoride Colgate-Palmolive Co.

21

ABOUT THE AUTHORNatalie Kaweckyj currently resides in

Minneapolis, Minn., where she has worked clinical-ly, administratively and academically. She is cur-rently a faculty member at Herzing College as wellas a clinic manager at Children's Dental Services.She is a certified dental assistant, certified dentalpractice management administrator, certified ortho-dontic assistant, certified oral and maxillofacialsurgery assistant, registered dental assistant inrestorative functions in Minnesota, and a Master ofthe American Dental Assistants Association. Shegraduated from the ADA accredited dental assistingprogram at ConCorde Career Institute in 1993, andbecame a member of ADAA that same year.

She has graduated with degrees in biology andpsychology and is pursuing a doctorate in epidemi-ology. Natalie is a three-term past president ofMDAA, 7th District Trustee and has served as chairof the Councils on Legislation, Fellowship &Mastership and Governance. She has served asADAA secretary and ADAAF director, in additionto serving on the ADAA Council on Finance. Inaddition to her association duties, Natalie is veryinvolved with her state board of dentistry and statelegislature in the expansion of the dental assistingprofession, serves as the President of the MinnesotaEducators of Dental Assistants (MEDA) and sits onthe MN RDA Exam Committee in ExpandedFunctions. She is also affiliated with OSAP and theAmerican Association of Dental Practic Managers.She has authored several other courses for theADAA on a variety of subjects.

The Test

Now proceed to the test. All questions are constructed using a multiple-choice format.

Take the test by logging in at www.cdabc.org,

highlight My Desktop > My Events.

The test will be evaluated immediately after you click Grade Now and upon successful completion, verification of your continuing education credits will be forwarded to you immediately by email. A pass mark of 80% must be achieved to receive continuing education credits. Should you not obtain a passing score, you will be notified immediately and given the opportunity to complete the test again. A maximum of four attempts is provided. Credit/course refunds are not issued for courses not passed within four attempts.

22

0802GERIATRIC DENTISTRY: REVIEWING FOR THE PRESENT,

PREPARING FOR THE FUTUREPOST-TEST

Please choose the one best answer.

1. Root caries ____________________________.A. appear more severe in femalesB. appear more severe in malesC. are most likely to affect the premolar

teethD. are most likely to affect the lower

anterior teeth

2. Cardiovascular disorders include all of the fol-lowing except __________________________.

A. Rheumatic heart diseaseB. AtherosclerosisC. Rheumatoid arthritisD. Acquired heart disease

3. An example of a highly-reinforcing restoration would be a/an _____________________.

A. inlayB. MODB amalgamC. onlayD. posterior composite

4. __________________________ are dental pro-cedures associated with the lowest incidence of endocarditis.

A. Oral hygiene proceduresB. Sealant applicationsC. Oral surgery proceduresD. Periodontal surgeries

5. Xerostomia is directly associated with ______________________ in the older patient.

A. arthritisB. diabetesC. endocarditisD. periodontitis

6. ______________________ has had an impact on geriatric dentistry.

A. Medical advancementsB. EdentulismC. Variety of dental productsD. Better insurance

7. At 75, the renal blood flow has decreased to _____________________ of its initial volume.

A. 30 percentB. 45 percentC. 65 percentD. 80 percent

8. Bacteremia can lead to ___________________.A. deathB. periodontal diseaseC. root cariesD. secondary caries

9. __________________________ is associated with a higher incidence of root caries.

A. Increased salivary flowB. Lack of medicationsC. Wearing denturesD. Long-term institutionalism

10. Gerontologists have divided the older popula-tion into categories based on ______________.

A. physical healthB. number of teethC. chronologyD. ability

11. ______________________________ increases with age.

A. Enamel hydrationB. Enamel thicknessC. Volume of dentinD. Volume of pulp tissue

12. Physiological aging changes include _____________________________________.

A. increased peripheral visionB. increased contractilityC. type I diabetes mellitusD. type II diabetes mellitus

23

13. Medical histories should be updated _____________________________________.

A. only when there are new medicationsB. prior to any invasive treatmentC. at every appointmentD. when confirming the visit

14. The odontoblastic layer changes from a ____________ and _________ layer to inactive cuboidal cells.

A. multi-layer/inactiveB. single/inactiveC. single/activeD. multi-layer/active

15. The cementum volume increases ___________.A. incisallyB. periapicallyC. mesiallyD. occlusally

16. The _____________________ is not affected by age.

A. potential diagnosisB. radiographic appearanceC. subsequent treatmentD. need for radiographs

17. ________________________ are medications associated with xerostomia.

A. Narcotic analgesicsB. CholinergicsC. HistaminesD. Metabolites

18. _____________________is a common dental drug that can potentially interact with a med-ically compromised patient.

A. IbuprofenB. 3% carbocaineC. EpinephrineD. Dopamine

19. Stannous fluoride is contraindicated for patients with ________________________.

A. anterior demineralizationB. porcelain crown/bridge workC. posterior demineralizationD. root caries

20. Appointment scheduling should accommodate the patient's ___________________________.

A. dental needsB. financial needsC. medical needsD. social needs

21. Post operative instructions should be _____________________________________.

A. verbalB. writtenC. given to a caregiverD. both written and verbal

22. Home care products can be tailored to fit the patient's physical ability by _______________.

A. assessing the disabilityB. modifying brush handlesC. prescribing mechanical aidsD. all of the above

23. Root caries prevention and therapy includes _______________________.

A. prevention of periodontal diseaseB. adding soft foods to the dietC. dietary counselingD. fixed bridgework

24. __________________________ is not a factor for xerostomia.

A. Prescription medicationC. ChemotherapyC. Surgical interventionsD. Genetics

25. Multiple surface root caries can be managed as an infection by using a/an ________________.

A. antimicrobial agentB. antifungal agentC. topical fluorideD. antimicrobial agent and fluoride

26. For esthetic restorations next to unrestored teeth, the restorations should be ___________.

A. a higher-value shadeB. flattened interproximallyC. less translucentD. rougher facial contours

24

27. __________________ are clinical manifesta-tions of diabetes.

A. Hydration of the mucosal tissuesB. Increased healing timesC. ToothachesD. Cortical bone loss

28. ___________________________ is/are charac-teristics of Parkinson's Disease.

A. Involuntary tremorsB. XerostomiaC. Mental impairmentD. Postural stability

29. Patients with cardiovascular disorders have a predisposition to _______________________.

A. root cariesB. xerostomiaC. endocarditisD. failing restorations

30. The estimated incidence of root caries is approximately _____________ per 100 root surfaces at risk.

A. 1.6 surfacesB. 16 surfacesC. too few to countD. too high to count

31. The dental team member should categorize the older patient by ________________________.

A. ageB. functional abilityC. mental capacityD. number of teeth

32. Age _______ calcification of nerve tissue and the cementum in the alveolus ___________ with time.

A. increases/increasesB. increases/decreasesC. decreases/decreasesD. decreases/increases

33. A systemic cholinergic stimulant ___________.A. is an over the counter medicationB. comes in many formsC. is not to be used for Sjogren'sD. is a systemic medication

34. When developing a treatment plan, all but the following should be taken into consideration.

A. changes in tooth structureB. the patient's ageC. impact of medical conditionsD. functional abilities

35. Dental treatment modifications of the medical-ly compromised can include ______________.

A. home bound dentistryB. hospital dentistryC. neck and back supportsD. all of the above