Conservative and endodontic care in the elderly
Plan :
Introduction
I-Reminders on the aging of dental structures and its implication in our therapies
II-Oral care specific to the elderly
1-Preventive care
1.1. Motivation for oral hygiene
1.2. Fluorine
1.3. Prosthetic care
1.4. Dietary advice
1.5. Hydration and treatment of hyposialia
1.6. Control and screening visits
2- Curative care
2.1. Diagnosis and therapeutic decision-making
2.2. Conservative care
2.3. Endodontic treatment
2.4. Endodontic surgery
2.5. Treatment of dyschromia
Conclusion
Introduction :
The effects of aging on the different orofacial tissues are expressed by very diverse pathologies.
The fragility of patients, the constraints and risks of their polymedication are all problems in the therapeutic care of elderly subjects.
Given the increase in life expectancy, awareness is required on the part of both practitioners and patients. This results in specific treatments that take into account the age and motivation of the latter.
I-Reminders on the aging of dental structures and its implication in our therapies:
- Physiological retractions of the gums are frequently observed,
Promoting exposure of dental roots.
- Root caries such as mylolysis, which are common in patients
aged, are characterized by dentin sclerosis which is accompanied by hypermineralization of the dental tubules which are then obliterated.
- Dentinogenic treatments used in carious decay
deep ones are not very useful because the pulp is retracted.
- Regarding endodontic treatments, the placement of the dam can be
sometimes made difficult or even impossible due to breathing or swallowing difficulties.
- Access to the pulp cavity should be done cautiously because of the risk of perforation
of the pulp floor is large due to pulp retraction.
- The narrowing of the pulp volume at the level of the canals, the presence of
Pulpoliths and obstruction of the dental apices are all elements that increase the difficulty of canal catheterization.
Conservative and endodontic care in the elderly
II-Oral care specific to the elderly:
1-Preventive care:
Several arguments explain the increase in cariosusceptibility:
- A diet rich in sugars and carbohydrates, of consistency
soft and adherent to the tooth (taste disorders);
- Decreased salivary flow, buffering capacity of saliva;
- Decreased manual dexterity and loss of autonomy represent
major barriers to practicing oral hygiene;
To be effective, all the preventive measures put in place must therefore result in a simultaneous attack on three fronts:
Protect the tooth,
Monitor the patient’s diet and hydration,
And fight cariogenic bacteria.
1.1. Motivation for oral hygiene:
1.1.1. Tooth brushing:
Ideally, this cleaning should be done twice a day: in the morning and in the evening.
The electric toothbrush can be of great service to people with teeth who are losing motor and intellectual autonomy and can become a basic tool for the daily oral hygiene of these people.
Dental hygiene protocol depending on the patient’s degree of dependency:
Independent person
It is done with a soft toothbrush and toothpaste, using a classic technique: going from the gum (pink) towards the tooth (white), sector by sector, face by face.
Dental floss, interdental brushes and mouthwash can be used after brushing for better cleaning of the mouth and teeth.
Person who is not or is not very autonomous but cooperative
These hygiene tips will be applied by those around the patient if they are at home, or by the healthcare staff if the patient lives in an institution.
If oral hygiene can only be ensured once a day, then evening brushing should be preferred.
Non-autonomous, non-cooperative person
This is the case for patients with dementia or Alzheimer’s disease…
Oral hygiene will be simplified, however: a folded compress held on forceps, soaked in chlorhexidine mouthwash, will be used.
If the patient suffers from hyposialia, alcohol-free mouthwashes, such as Paroex®, are preferred.
1.1.2. Cleaning dental prostheses:
Brushing is done using a prosthesis brush. It is best to use toothpaste. The patient gently rubs all sides of the prosthesis. The goal here is again to remove the coating of plaque and food residue, and to limit the appearance of candidiasis. The prosthesis must then be rinsed well before putting it back in the mouth.
In our opinion, the use of effervescent tablets should be limited to a soaking bath of 15 minutes maximum.
Once a week, the prosthesis can be immersed in chlorhexidine mouthwash, also limiting the soaking time to 15 minutes.
1.2. Fluorine:
Fluoride ion, both through general route (drinking water, supplements in the form of tablets or drops, salt), and through topical application (toothpaste, fluoride gel applied with or without the aid of a tray or fluoride varnish applied in the dental chair), has shown its ability to strengthen the superficial apatite crystal and thus protect the tooth against the leakage of its mineral constituents. Fluoride also has antimicrobial properties, particularly against streptococcus mutans.
Fluoride administration should be a high priority for all dependent older people, particularly those where oral hygiene is poor and difficult to achieve.
1.3. Prosthetic care:
Advancing age is often associated with tooth loss.
Replacing missing teeth with a dental prosthesis is very important.
In addition to restoring aesthetics, the prosthesis ensures functional support during swallowing and chewing by mechanically maintaining the lower part of the face.
In addition, it protects the teeth against wear and occlusal trauma due to the absence of this wedging.
1.4. Dietary advice:
The dentist can also play an advisory role in the diet of his patient. He must be able to guide the malnourished elderly person towards appropriate food choices based on the chewing abilities of each person and the recommended nutritional intake and, in more serious cases, towards a nutritionist or dietician.
A diversity of diet and sufficient quantities allow for a good balance of the main nutrients (proteins, lipids, carbohydrates) and ensure a correct intake of vitamins, minerals (calcium, iron) and fiber.
1.5. Hydration and treatment of hyposialia:
Ensure hydration:
For good hydration, you need to drink an average of 1.5 L of liquid per day. But 1.5 L of liquid does not necessarily mean 1.5 L of water. Fruit juices, infusions, broths, soups for example are all drinks likely to satisfy our daily water needs.
In addition to combating dehydration, it is necessary to have sufficient water intake to avoid dry mouth. Do not hesitate to use artificial saliva (salivary substitutes and salivary stimulants) and to contact a doctor to replace certain medications responsible for hyposialia.
Management of hyposialia:
Saliva is a protective element of the oral cavity, which becomes considerably scarcer with advancing age.
Identifying additional causes, of pathological and/or drug origin, is essential to adapt the treatment.
Indeed, the latter varies according to the degree of hyposialia. The treatment protocols can be schematized by the figure
Conservative and endodontic care in the elderly
1.6. Control and screening visits:
Annual check-ups are mandatory. This allows us to monitor the dental condition, the fit and stability of the prostheses and to prevent a pathological condition from developing and developing.
2- Curative care:
In the elderly, the factors influencing therapeutic decision-making are complex.
2.1. Diagnosis and therapeutic decision-making:
Medical condition (and management of infectious and hemorrhagic risk):
The dentist will be particularly vigilant in the face of certain conditions, very common in elderly individuals, often associated and weighing on the therapeutic decision.
The pathologies to be considered as a priority are: cardiovascular disorders in the broad sense (from valvular disorders to rhythm disorders, including a history of heart attacks and hypertension); diabetes; rheumatic disorders and mental disorders.
Conservative and endodontic care in the elderly
The risk of infection will be present in the case of poorly controlled diabetes, corticosteroid therapy or chemotherapy, for example, or when there is a risk of endocarditis. Antibiotic prophylaxis is then essential. In patients at risk, consultation with the treating physician or specialist is of great help, particularly in defining the extent of the risk and conducting the necessary additional examinations.
The risk of bleeding is present as soon as a patient takes antiplatelet agents or antithrombotics (antivitamin K, heparin). The new recommendations are to no longer stop antiplatelet treatments (aspirin). Similarly, there is now a tendency to no longer stop treatments with antivitamin K, as long as the patient is within a therapeutic window of INR of 2-3.
2.2. Conservative care:
The senescent tooth, as we have already described, is often abraded and presents pulp sclerosis, due to the apposition of secondary or even tertiary dentins.
Like any tooth, an old tooth can be decayed. The decay of the elderly is often characteristic: cervical, root, …
It is also very common to observe cavities on the faces adjacent to an edentulous area or at the end of a hook arm.
Apart from that, these are just “normal” cavities. As such, the treatments will not be any different from usual.
2.2. Conservative care:
The treatment technique is chosen based on the patient’s state of dependence and cooperation.
Atraumatic Restorative Treatment (ART),
Minimal Invasive Dentistry (MID)
And the sandwich technique
ART technique “Atraumatic Restorative Treatment”
Does not involve rotating instrumentation.
The cavity will be cured with an enamel chisel or excavator.
Debridement of the cavity and filling should be done as quickly as possible.
Conventional glass ionomer (GIC) cements will be preferred
MID “Minimally Invasive Dentistry” technique
Uses rotating instrumentation (green ring contra-angle and “ball” burs).
There is time to intervene, the patient is more or less cooperative.
The cavity will be sealed with light-curing CVIs.
Sandwich technique:
Is implemented to avoid damaging a tooth too much. Two types of materials are used: composites and CVI.
The dentin is reconstituted with a CVI and the enamel with a composite, the latter protecting the CVI. This technique optimizes the properties of each of the materials used.
Other materials: biodentine + composite
2.3. Endodontic treatment:
These treatments are greatly complicated by pulp retraction. The pulp chamber, narrower and more remote, is difficult to access. The canals are narrow, requiring a long preparation time. The benefit/risk balance must therefore be carefully evaluated.
Any general pathology sensitive to the risk of bacteremia requires either treatment in one session or extraction of the tooth, all under antibiotic prophylaxis.
In this case, endodontic treatments will mainly be considered on single-rooted teeth. But to this must be added:
• strong motivation of the patient to keep his tooth;
• good tolerance to the treatment: the patient must be able to keep their mouth open long enough to allow treatment ;
• good cooperation during treatment.
2.4. Endodontic surgery:
Minor surgery procedures can commonly be considered in the elderly.
The operative risks will often be the same as for extractions.
If the patient is at medical risk, only extraction and ridge regulation are considered. On the other hand, in healthy patients or those with well-balanced chronic pathologies, everything can be considered at any age.
2.5. Treatment of dyschromia:
Tooth color varies greatly from person to person and becomes darker with age. As we age, the dentin (located under the enamel and naturally more yellowish) becomes more and more exposed due to the gradual thinning of the enamel layer that protects the teeth. The teeth therefore become more yellow or grayish over time.
You can do “hydrogen peroxide” lightening treatments and get very good results. There is no age limit for an elderly person, but it remains one of the easiest situations to correct.
The installation of dental veneers is also a possible solution, especially when the dyschromia is very significant or the lightening does not give a satisfactory result.
Conservative and endodontic care in the elderly
Conclusion :
Oral well-being should certainly not be neglected in gerontology; indeed, the human organism is composed of a multitude of interdependent units. Therefore, the alteration of one of the parts potentially compromises the functioning of the whole.
The dentist helps maintain this balance through prevention, monitoring and oral rehabilitation.
To do this, he must determine the impacts of normal and pathological general aging on the individual’s body, establish an appropriate treatment plan and ensure good care.
Dental crowns are used to restore the shape and function of a damaged tooth.
Bruxism, or teeth grinding, can cause premature wear and often requires wearing a retainer at night.
Dental abscesses are painful infections that require prompt treatment to avoid complications. Gum grafting is a surgical procedure that can treat gum recession. Dentists use composite materials for fillings because they match the natural color of the teeth.
A diet high in sugar increases the risk of developing tooth decay.
Pediatric dental care is essential to establish good hygiene habits from an early age.