Clinical examination in the elderly
- Introduction :
The clinical examination in an elderly person follows the same steps performed when examining patients of other age groups. However, given the physiological particularity of the oral environment in the elderly, the practitioner will direct his clinical and complementary explorations in a way that targets the pathologies or anomalies most frequently observed in the elderly. The practitioner must also investigate the history of general and stomatological history in a meticulous manner in order to arrive at an accurate diagnosis of the pathology at the origin of the reason for consultation.
- Goals :
- Assess the level of dependency of the elderly person
- Presence or absence of malnutrition or undernutrition
- Patient’s oral hygiene habits
- The general condition of the patient and the impact of general diseases on aging in the person examined
- Dental pathologies
- The means and course of the examination
- This systematic evaluation even for people who do not complain
- Done gently and completely because the patient can sometimes refuse violently
- Assessment of oral health:
- Systematic assessment of oral health
- To look for possible interferences of aging of dental and mucosal tissues on oral diseases.
Example: A deep cavity in an elderly person presents different symptoms than those caused by the same cavity in a young person.
- Exoral clinical examinations:
- observe the condition of the skin which is a real indicator of aging and of the integuments
- perform a temporomandibular joint examination
- assess existing vertical dimension and lip positioning
- distinguish between physiological and pathological alterations linked to tooth loss, for example
- perform a lymph node palpation to look for cervicofacial adenopathies.
- Intraoral clinical examinations:
- salivary quantity and quality often reduced in elderly patients taking multiple medications and possible mycotic foci
- assess the state of the tongue, which is often smooth and depapillated when it presents taste disorders
- THE OAG (ORAL ASSESSMENT GUIDE) GRID:
Goals :
- Standardize oral health assessment practices within institutions
- Assess the initial oral condition and its evolution
- Evaluate the effectiveness of hygiene control measures
Terms of Use:
When admitting the patient
The frequency of follow-up will be established according to the clinical situation.
Clinical examination in the elderly
| Weighting | score | |||||
| Indicator | Measuring tool | Method of measurement | 1 | 2 | 3 | |
| the voice | hearing | talk with the patient | Normal | dry and hoarse | difficulty speaking | |
| swallowing | observation | ask the patient to swallow | Normal | pain when swallowing | lack of swallowing | |
| lips | The look and the palpation | Observe | smooth, pink and moist | dry and cracked | ulcers or bleeding | |
| the language | the gaze and palpation | observe and touch the fabrics | pink and moist presence of the taste buds | pasty, less taste buds with glossy appearance | less colored cracked, swollen | |
| saliva and tongue | observation and for language | fold the tip of the tongue downwards which triggers saliva production | Transparent | viscous, thick, poor quality | Absent | |
| mucous membranes | the look | observe the appearance of the tissues | pink and wet | inflammatory, with inclusion of white plaques no ulceration | ulcerations and/or bleeding | |
| gums | the look and the tongue | press the gums with the tip of the tongue | pink, firm and well-defined | inflammatory, edematous | spontaneous bleeding or bleeding when pressure is applied | |
| teeth | the look | observe the appearance of the teeth and the entire dentition | clean and free of debris | well-localized plaque and debris (between the teeth) | plaque and debris spread throughout the gums and damaged teeth | |
The total score is calculated by value X/24
(Oral Health Assessment Scale developed by the University of Nebraska Medical Center at Buffalo and tested by J. Eilers)
Using the score allows you to monitor progress and assess the results of
care. The ideal score is 8/24.
Clinical examination in the elderly
Therapeutic attitudes
- Therapeutic attitude according to the degree of dependency of the elderly person:
There are three types of clinical situations:
- Independent and cooperative elderly patient:
Able to easily get to the dental office and able to properly maintain their own oral hygiene hygiene on their own and properly . Cooperative when their oral hygiene is satisfactory and they are regular at their appointments.
Procedure: All treatments are possible in the office, provided general precautions are followed.
- Dependent, cooperative, non-isolated elderly patient:
Presenting a beginning of loss of physical autonomy and a decrease in the power of adaptation. In most cases, he cannot go to the dental office alone and cannot ensure his oral hygiene effectively alone. The non-isolated patient is surrounded by a spouse, family or home help.
Procedure: All treatments are possible while respecting general precautions and ensuring the systematic presence of an accompanying person who can follow and re-explain the advice given by the practitioner and carry out post-operative monitoring.
Limit the number of treatment sessions as much as possible and adapt oral hygiene measures to the patient’s physical and/or mental capacities.
- Isolated and/or uncooperative dependent, polypathological and polymedicated elderly patient:
The patient is physically or cognitively dependent and has a loss of autonomy. This is referred to as a “multi-pathological patient”. Isolation is the observation of a situation in which an individual is separated, willingly or by force, from the rest of their usual environment.
On average, a subject over the age of 75 takes 5 to 6 medications per day. These prescriptions often cause side effects.
Action to be taken: In this latter case, the care must be limited to the strictly necessary procedures, taking into account the benefit/risk ratio.
- treatment of various injuries common in the elderly:
- Treatment of cervical caries:
Banting et al. in 1980 proposed a therapeutic classification based on the stage of development of root caries:
– In stage 1, there is a question of an early cavity that must be remineralized using fluoride gel such as Duraphat® by the dentist and by daily topical fluoridation by the patient using a fluoride toothpaste.
– In stage 2, the caries is superficial, the dentist performs the carious eviction and a retentive cavity, then makes a filling with glass ionomer cement which releases fluorides.
– In stage 3, the caries has formed a cavity, the dentist will proceed in the same way as for stage 2.
– In stage 4, the caries has reached the pulp, it is then necessary to assess whether the tooth can be preserved and whether it is possible to carry out endodontic treatment.
- Periodontal senescence and frequency of ankylosis; During dental extractions, alveolectomy is often necessary.
- Healing: when a mucosal injury is observed. These injuries persist longer, generating a difficulty in differential diagnosis, particularly with malignant diseases.
For the same condition in a young subject, the elderly subject presents more intense and more problematic post-operative consequences.
- Ulcerations: In the event of any ulcerative lesion persisting for more than 15 days, after elimination of traumatic factors, the diagnosis of oral squamous cell carcinoma should be considered.
- In the case of elderly people refusing to receive treatment (due to dementia or altered psychological profile), the practitioner may resort to conscious sedation with MEOPA or moderate conscious sedation with Midazolam, sometimes even general anesthesia.
- Clinical examination in the elderly
Conclusion :
A meticulous clinical examination that allows to establish a link between the effects of aging on oral health and the possible involvement of general diseases and their treatment. This also allows the practitioner to evaluate the cooperation of the elderly patient as well as the effectiveness of the tissue response during healing. The practitioner, and based on these elements and results, will be able to evaluate the benefit/risk ratio which will allow him to make the most appropriate therapeutic decision for his elderly patient.
Clinical examination in the elderly
Baby teeth need to be taken care of to prevent future problems.
Periodontal disease can cause teeth to loosen.
Removable dentures restore chewing function.
In-office fluoride strengthens tooth enamel.
Yellowed teeth can be treated with professional whitening.
Dental abscesses often require antibiotic treatment.
An electric toothbrush cleans more effectively than a manual toothbrush.