General pathologies of the elderly

INTRODUCTION :

Aging gives some people abilities that are maintained at an optimal level, for others it leads to the extreme loss of all autonomy and ultimately death, hence oral health care is specific to each patient.

1. RHEUMATOID ARTHRITIS (RA):

Rheumatoid arthritis (RA) is a chronic, progressive inflammatory disease with major functional, psychological, social and professional repercussions for the patient.

Inflammatory synovitis is the basic lesion responsible for joint destruction.

1. MECHANISM:

It is still poorly understood. The mechanism would be as follows:

The starting point is a very significant immune reaction at the level of a joint which will cause local inflammation.

This inflammatory invasion is made up of cells (polymorphonuclear cells) and substances (cytokines, interleukins, interleukins 1 beta, TNF). This “unjustified” inflammation is responsible for the progressive destruction of the joint where the inflammation has developed.

2. SYMPTOMS:

Joint manifestations:

• Joints are swollen, stiff and painful
• There are also tenosynovitis of the fingers (inflammation of their sheath).
• In the feet, the deformations cause the toes to overlap.
• spinal cord compression Non-articular manifestations:
• Nodules form under the skin without seriousness. breathing difficulties.
• Neurological disorders.
• The damage may be cardiovascular: pericarditis.
• Pleuropulmonary involvement 1-3-TREATMENT:

Treatment should be multidisciplinary

• Treatment of flare-ups: this is done using anti-inflammatories including corticosteroids. They reduce the signs of inflammation (pain and swelling).
• Physiotherapy care.
• Rehabilitation.
• Surgery
• Classic background treatments: Some treatments are called “classic

“They were intended to slow the onset of subsequent attacks: Methotrexate

• Biomedicines: thiopronin, anti-cytokines (they counteract the action of local joint inflammatory factors).

4. Oral manifestations:

A- This mainly involves damage to the temporomandibular joint (TMJ):

After 3 to 4 years of development, joint pain appears with a cracking sensation when opening the mouth. This pain becomes symmetrical and is accompanied by cracking.

The patient is forced to gradually eat semi-liquid food. Five stages are distinguished in classical radiology:

• Stage sa: slight radiological damage but no clinical signs.
• Stage SI: mild joint narrowing with or without osteoporosis.
• Stage S2: irregularity on the mandibular condylar surface.
• Stage S3: multiple erosions, notches, geodes.

Stage S4: deformation, candy cane or sharpened pencil appearance, flattening of the condyle.

At the ATM level, three types of treatments are considered:

• infiltration of the painful joint,
• rehabilitation through physiotherapy and static and dynamic balancing of the occlusion,

-surgery (removal of the ATM in case of permanent constriction).

B-Rheumatoid arthritis and periodontitis:

Patients with rheumatoid arthritis suffer from earlier, more frequent, and more severe forms of periodontitis than the rest of the population.

In addition, the pathogenesis of periodontitis and rheumatoid arthritis presents similarities, particularly in the mechanisms of bone resorption leading to erosions in the case of rheumatoid arthritis and to alveolysis in the case of periodontitis.

5. The consequences of drug treatment: A-Infectious accidents:
   • The anti-inflammatory properties of corticosteroids can cause severe and serious infections such as osteomyelitis.
   • The promoting role of corticosteroids in candidiasis of the oral mucosa.
   • Prolonged administration of gold salts can result in a blue-gray deposit in areas of skin exposed to light and a purplish appearance of the gums. (Gold salts are drugs used in the basic treatment of rheumatoid arthritis (intramuscularly)
   • Gold salt stomatitis affects any part of the oral mucosa but the lower surface of the tongue and the floor of the mouth seem to be most affected.
   • The burning sensation is intense and a metallic taste may appear.

B- Local risk due to risk of osteonecrosis:

• The main risk of osteonecrosis linked to biotherapy is due to the RANKL inhibitor. This antibody blocks the binding of RANKL to its receptor, which in particular allows the activation of osteoclasts.
• Bone resorption is then blocked, an interesting action in the context of osteoporosis or bone metastases. However, even if the mechanism of action is totally different, we find the same undesirable effects as those observed with bisphosphonates in the oral cavity.
• Patients treated with anti-RANKL will be at risk of osteonecrosis of the jaws.

6. Oral health:

• The problem of oral hygiene:

It is linked to the inability or difficulty of handling a toothbrush as well as the limitation of mouth opening making brushing of the posterior teeth impractical.

• Problems encountered during care:

The only difficulty that the practitioner may encounter is ankylosis of the ATM, that is to say the more or less significant limitation of the mobility of the joint, then leading to a reduction in the opening of the mouth.

In these patients, dental prostheses will be poorly tolerated. 1-7-Management:

• Long-term corticosteroid treatment:

-The risk of infection is increased when the daily dosage is greater than 10 mg per day and an invasive surgical procedure must be performed. It will then be necessary to implement an anti-infective protocol that includes:

• Prophylactic antibiotic therapy: a single dose of 2g of Amoxicillin (or 600mg of Clindamycin in case of allergy) one hour before the procedure to be performed
• Curative antibiotic therapy: Amoxicillin 2g per day in two doses for 7 days when the procedure performed results in mucosal or bone healing
  • Methotrexate treatment:

-An infectious outbreak is an emergency and must be eliminated.

-For patients with good oral health, treatment should be as conservative as possible, with the reinforcement of preventive measures.

-If an invasive procedure must be performed, the dental surgeon must first discuss with the prescribing physician the need for antibiotic prophylaxis.

• Treatment with biomedicines:

The dentist will discuss in advance with the prescribing physician to determine the need for antibiotic prophylaxis associated with a possible cessation of treatment 2 to 4 weeks before the procedure.

In addition, even if the patient is not yet undergoing this type of treatment, it will be necessary to investigate whether the initiation of biotherapy is planned. In this case, the FIBDs will have to be eliminated beforehand.

2. THE DEMENSE:

Currently, more than 55 million people worldwide are affected by dementia. Each year, there are nearly 10 million new cases.

Dementia results from various diseases and injuries that affect the brain. Alzheimer’s disease is the most common cause of dementia, estimated to cause 60 to 70% of cases.

Dementia syndrome can be caused by a number of diseases that, over time, destroy nerve cells and damage the brain, usually leading to a deterioration in cognitive function (i.e., the ability to process thoughts).

1. Overview:

The term “dementia” covers several diseases that affect memory, thinking, and the ability to perform everyday tasks.

Factors that increase the risk of dementia include:

• age , high blood pressure
• high blood sugar (diabetes) , overweight or obesity

• Smoking , excessive alcohol consumption
• lack of physical activity
• social isolation, depression 2-2-Signs and symptoms:

-Mood and behavior changes sometimes appear before memory problems.

-Symptoms get worse over time.

-As the disease progresses, the need for help with personal hygiene increases.

• People with dementia may not be able to recognise family members or friends, have difficulty moving around, experience urinary or faecal incontinence, have difficulty eating and drinking and experience behavioural changes, such as aggression, which are distressing for both the person with dementia and those around them.

2-3-Common forms of dementia:

-Alzheimer’s disease is the most common form and is thought to be the cause of 60 to 70% of cases.

• Other common forms include vascular dementia, dementia with Lewy bodies (abnormal protein deposits inside nerve cells), and several other diseases that result in frontotemporal dementia (degeneration of the frontal lobe of the brain).

-Dementia can also develop after a stroke or in the context of certain infections such as HIV, or nutritional deficiencies.

2-4-Dementia and oral health:

-There are many reasons for the decline in oral health in people with dementia: dementia leads to a reduction in independence, and a sick person brushes their teeth less regularly than before.

-Not brushing your teeth after a snack can also cause changes.

-In addition, people with dementia often reduce visits to the dentist or dental hygienist, which can negatively impact their oral health.

3. ALZHEIMER’S DISEASE:
4. Definition :

Alzheimer’s disease is a progressive and irreversible neurodegenerative disease that is part of dementia.

2. Symptoms:

COGNITIVE DISORDERS	PSYCHO-BEHAVIORAL DISORDERS
Memory disorders. Language disorders. Practical disorders (disorder of gestures). Gnostic disorders (recognition disorder). Disruption of executive functions.	Behavioral disorders (agitation, delusional syndrome, aggressiveness, etc.). Anxiety-depressive syndrome. Eating disorders. Sleep disorders with inversion of the nycthemeral rhythm (day/night).

3. Classification:

Stage 1: mild (MMSE > 20)	Stage 2: moderate (MMSE between 10 and 20)	Stage 3: severe (MMSE < 10)
Mild impairment of memory, language and comprehension. Active cooperation possible.	Personality and behavior disturbance. Difficulty understanding instructions. Inconsistent cooperation.	Reduced comprehension, reduced verbal expression. Difficulty performing orofacial movements. Forgetting minor instructions. Little cooperation, opposition.

(Mini Mental State Examination)

4. Medical management of the disease:

Non-medicinal	Medicinal
Objective : to preserve the patient’s abilities. Psychological support. Speech therapy. Physiotherapy, psychomotor skills. Occupational therapy. Environmental support (adaptation of the home).	Objective : reduce symptoms Cholinesterase inhibitor: donepezil (Aricept®), galantamine (Reminyl®), rivastigmine (Exelon®) NMDA receptor antagonist (N-Methyl-d-aspartate): mementin (Ebixa®). Antidepressants mainly SSRI (Selective Serotonin Reuptake Inhibitors). Anxiolytics. Anticonvulsants. Neuroleptics: (risperidone for example): if psychotic signs are present .

5. Oral effects:

Due to illness	Due to treatments
Decreased or even absent hygiene. Hyposialia Polycaries due to eating disorders, poor hygiene and hyposialia. Swallowing disorders (due to orofacial apraxia, loss of the swallowing reflex, etc.). In severe stages of the disease: Chewing disorders. Risk of severe bruxism causing pain and mobility. Difficulty handling removable prostheses (praxic disorders).	Hyposialia (antidepressants, anxiolytics) and its consequences : Caries. Dysesthesia, taste alteration. Periodontal diseases. – Mycoses. Oral ulcers.

3-7- Summary of potential risks in dentistry:

Type of risk	YES	NO
Infectious		√
Hemorrhagic		√
Anesthetic		√
Medicated	√		Risk of drug interactions
Others	√		Compliance issues

3-8-Care by the dental surgeon

• THE DEGREE OF COOPERATION OF PATIENTS WITH DEMENTIA:

It is essential to assess the patient’s behavior regarding his hygiene and his behavior regarding oral care. For this, different tests have been proposed:

-The Niessen et al. (1985) test

-The Nordenram et al. (1997) test

Does the patient brush his teeth or clean his dentures?	yes (0) with partial assistance (1) with full assistance (2)
Does the patient express his reasons for complaint?	yes (0) to some degree (1) no (2)
Does the patient follow simple instructions?	yes (0) occasionally (1) no (2)
Can the patient hold an x-ray in his mouth?	yes (0) sometimes (1) no (2)
Is the patient aggressive?	no (0) sometimes (1) yes (2)
Score	…/10

• The Niessen et al. (1985) test

It is a simple and quick observation test giving a score out of 10.

• The test score is between 0 and 3: patient cooperation is possible but inconsistent and the treatment may be adapted (limit the number of sessions, short sessions, reassure the patient).
• The score is between 4 and 7: patient cooperation becomes difficult and care must be adapted. The use of sedation care may be necessary for certain treatments.
• The score is between 8 and 10: patient cooperation is almost impossible. Treatment is carried out under sedation.
• CARE BY THE DENTAL SURGEON:

Adapted and/or assisted daily hygiene . Active prevention: check-up, fluoridation, regular scaling . Preservation/restoration of function: conservative care, prosthetic care .
Conventional conservative care or principle of minimal intervention . Prosthetic repair or rehabilitation . Possible care under conscious sedation .

Assisted daily hygiene . Emergency: Relieve pain, Fight infection, Readapt prostheses .
Rare conservative care . Frequent avulsions . Prosthetic rehabilitation. Care under conscious sedation .

Assisted daily hygiene . Emergency: relieve pain, fight infection, prevent bites. Abandon prostheses .
Avulsions . Care under conscious sedation .

CONCLUSION :

Oral health care for dependent elderly people involves a therapeutic compromise because mental, motor or psychomotor deficiencies prevent access to care .

The specific oral health needs of this population, such as monitoring oral hygiene and funding programs in institutions or at home.

General pathologies of the elderly

  Untreated cavities can lead to tooth loss.
Dental veneers restore a harmonious smile in just a few sessions.
Misaligned teeth can cause joint pain.
Dental implants are fixed into the bone for optimal stability.
Chlorhexidine mouthwashes treat gum infections.
Damaged baby teeth can affect speech and chewing.
A toothbrush replaced every three months ensures effective hygiene.
 

General pathologies of the elderly