SUPPORT FOR THE ELDERLY SUBJECT
PERIODONTAL CARE
MANAGEMENT OF THE ELDERLY SUBJECT PERIODONTAL CARE
PLAN
-Introduction
I-Senescence of the periodontium
II-Specificities of oral alterations in the elderly: At the periodontal level
III-Periodontal treatments
-Conclusion
INTRODUCTION :
Periodontal diseases are infectious, inflammatory diseases. In the elderly patient, the host’s defense capacity and healing capacity are often reduced by chronic pathologies and polymedication rather than by age itself.
I-SENESCENCE OF THE PERIODONTAL:
The alveolo-dental ligament and the cementum: a loss of elasticity, a smoother appearance, and increased fragility to attacks, particularly microbial and mechanical.
Histologically, the gingival epithelium presents a thinning of approximately 30% compared to the young adult and the connective tissue is characterized by a decrease in the number of fibroblasts and their synthesis capacity.
Alveolar bone: increased number of resorption cavities and decreased proliferation of osteogenic cells. These alterations result, in the elderly, in reduced remodeling, healing and adaptation capacities of the alveolar bone.
However, these modifications do not appear to have significant consequences on the functionality of the periodontium.
The nearly 25% reduction in the thickness of the alveolo-dental ligament over the course of life appears to be more the result of the physiological decrease in masticatory forces with age.
Morphological and physiological changes in periodontal tissues during aging play a major role in the defense and healing capacities of these tissues against microbial aggression.
II-SPECIFICITIES OF ORAL ALTERATIONS IN THE ELDERLY: AT THE PERIODONTAL LEVEL
According to PAGE, periodontal diseases in the elderly are slowly progressive adult periodontitis.
2-1-IMPACT OF AGING ON THE DEVELOPMENT OF PERIODONTAL DISEASES:
The greater frequency and severity of periodontal diseases observed with aging would rather be the result of prolonged exposure of periodontal tissues to plaque than a direct consequence of senescence.
2-2-IMPACT OF AGE ON ETIOLOGICAL FACTORS:
- BACTERIAL PLAQUE: Some particularities specific to elderly subjects should be noted:
-Gingivodental anatomy: leaving wider interdental spaces promotes food retention.
-Salivary flow is reduced: Diet also has its influence.
-In fact, these patients generally have chewing difficulties which lead them to modify their diet, favoring carbohydrates which constitute an energy source favorable to bacterial multiplication.
-The composition of the bacterial flora also varies with age: the bacterial flora stabilizes from a certain age.
- HOST’S ANSWER:
-The protective role of cellular immunity is reduced.
-At the local level, transmission is less well carried out due to the reduction in the number of LANGERHANS cells.
– LANGERHANS cells play, at the periodontal level, a role of antigen presentation to immunocompetent cells and can influence the evolution of the inflammatory process.
- GINGIVAL RECESSIONS:
-Their incidence increases with age.
-It is usually the consequence of periodontal diseases linked to unfavorable anatomical factors and especially the consequence of an aggressive brushing technique.
-Recent data show that root denudations are more frequent in people with good oral hygiene. The role of traumatic brushing would therefore be major.
III-PERIODONTAL TREATMENT: The treatment of the elderly patient must be adapted to his general state of health and his own progress in the process of senescence.
The practitioner will often have to make a therapeutic compromise to optimize the response to the request for care.
Thus, a patient in good general health, showing moderate progress in the senescence process, will often be treated in a comparable way to a young patient.
On the contrary, a patient whose general state of health is weakened and who presents disorders linked to the aging process must be treated in a reasoned manner in order to offer him only therapeutic alternatives compatible with his evolution.
3-1-PLATE CHECK:
In the elderly, physical and mental deterioration linked to senescence has direct consequences on the effectiveness and compliance (medical observance in terms of following the instructions or recommendations made by the doctor to the patient) of the patient with oral hygiene strategies.
Any musculoskeletal disorder (polyarthritis, etc.) can lead to physical deficits that are incompatible with providing the care necessary to maintain good oral health.
The decrease in sensory abilities (visual, tactile, proprioceptive or olfactory) leads to a decrease in the ability to detect dental plaque and therefore a decrease in the patient’s ability to maintain a good plaque index.
The presence of root caries linked to this lack of oral hygiene, to the salivary physiophysiological changes and to the modification of the diet can lead to the persistence of areas that retain dental plaque.
Of all the techniques used, the approach consisting of initial information of the patient about his pathology and follow-up with regular filling of a “follow-up notebook” is the one which seems to bring the most success in maintaining the low plaque index and the complaint.
In residents placed in institutions – long-term care units, retirement homes, dependent elderly accommodation facilities, plaque control has been shown to be less than optimal due to:
(1) a lack of consideration for oral care by healthcare staff,
(2) a lack of staff time,
(3) a lack of information on the part of the latter regarding the oral consequences of aging,
(4) lack of cooperation from residents.
It is then the responsibility of the dentist to reveal these shortcomings and to adapt plaque control techniques to the capabilities of patients and their caregivers.
- MATERIAL:
The oscillating-rotating electric toothbrush is known for its effectiveness in removing plaque.
It is all the more interesting because it simplifies the movements required to perform effective oral cleaning and its shape (large handle, small head) is adapted to the needs of the elderly.
The use of dental floss mounted on a floss holder and interdental brushes with a suitable handle promotes plaque control by the patient.
However, it should be kept in mind that the use of oral hygiene equipment can be complex depending on the degree of loss of autonomy and cooperation of the elderly patient.
Due to the increased prevalence of cervical caries observed in the elderly, the use of a highly fluoridated toothpaste is recommended.
A minimum of two brushings per day is sufficient to maintain good oral health.
In the presence of periodontal disease, the use of toothpastes containing Chlorhexidine may be of interest due to its ability to limit the progression of these diseases in at-risk individuals.
3-2-NON-SURGICAL TREATMENT: Frequent visits are necessary to help the elderly person maintain their oral health and to adapt the plaque control equipment to the patient’s developments.
In the presence of xerostomia or degenerative diseases, visit intervals of 1 to 2 months are recommended for periodontal monitoring as well as in addition to initial treatment.
The weakening of patients and their reduced tolerance to pain require treatments in short sessions.
During scaling and root planing, root instrumentation should be limited so as not to be iatrogenic at the root surface level. Fluoride applications are then indicated.
3-3-SURGICAL TREATMENTS:
The patient’s age does not constitute a contraindication to periodontal surgery, unlike the general state of health.
The presence of systemic diseases (heart disease, pulmonary and rheumatological conditions, endocrine disorders), other physiological consequences of aging and polydrug treatment, mean that the elderly patient must be considered as a special case requiring precautions adapted to each pathology.
- MEDICAL RISK ASSESSMENT:
Before performing surgery on an elderly person, the practitioner must assess the risks of complications to which the patient is exposed.
This assessment concerns the risks associated with frequent pathologies, as well as the physiological and psychosocial changes of aging.
To do this, it is essential that a precise medical interview, as well as a careful clinical examination, be carried out and that certain biological tests be prescribed for the patient.
- The risk of infection
Assess the risk of infection.
Contact the attending physician.
Antibiotic prophylaxis is mandatory and if necessary.
- The risk of bleeding:
It is therefore necessary, before any surgical procedure, particularly in an elderly individual (patient taking antiplatelet agents or antithrombotics: antivitamin K, heparin) to explore the risk of hemorrhage.
In particular, the following will be requested: platelet count, prothrombin time, INR and TCA.
- Precautions when prescribing post-operative medication:
Elderly patients are often polymedicated. However, after a surgical procedure, the dentist will often be required to prescribe, even for a short period of time, analgesic and/or antibiotic medications, the action of which may be added to and/or interfere with that of the current medications.
- Anesthesia:
In the elderly, local anesthesia is often sufficient for minor procedures. In surgery, anesthetics with vasoconstrictors are preferable because they reduce the systemic absorption of anesthetics, increase their duration of action and ensure effective local hemostasis.
However, frequent systemic pathologies in these patients or current medications contraindicate certain molecules and require certain precautions.
- PERIODONTAL SANITATION SURGERY:
In the case of deep pockets, conservative treatment by scaling and root planing may be insufficient and surgical treatment for appropriate debridement or to ensure a gingival morphology that facilitates plaque control may be indicated.
- PRE-PROSTHETIC SURGERY:
– Mucogingival defects interfering with the stability and retention of a prosthesis.
– Floating ridges, retromolar trigones, floating tuberosities.
– Thick folds near poorly adapted prostheses.
– Significant gingival hyperplasia, often of traumatic origin (regularization of the ridge).
– Absence of attached gum in areas subject to prosthetic friction (gingival grafts).
- INCREASE IN ALVEOLAR RIDGE:
Progressive resorption of edentulous alveolar ridges leads to severe bone atrophy which results in instability of prostheses.
Surgical possibilities:
– Augmentation of the ridge by surface gingival graft or by buried connective tissue.
– Augmentation by bone graft
– Augmentation by guided bone regeneration techniques (particularly partially edentulous ridge).
Finally, it should be noted that the success of periodontal surgery depends on the control of bacterial plaque and professional monitoring.
Periodontal healing appears to be very little modified in the elderly despite the cellular modifications of senescence (reduction in fibroblastic activity, collagen formation rates, alterations in terminal vascularization).
However, healing times will be longer than in young patients.
3-4-IMPLANT TREATMENTS: Like periodontal sanitation surgery, the creation of implant-supported dental restorations appears to be a safe and lasting therapeutic possibility in the elderly. Many studies show implant success rates comparable to the success rates achieved in younger patients.
This approach allows a significant improvement in the patient’s bone mass, quality of life and nutritional status following the comfort obtained in terms of chewing. The placement of implants allows to increase prosthetic comfort, but also to perpetuate prosthetic restorations over time.
MANAGEMENT OF THE ELDERLY SUBJECT PERIODONTAL CARE
CONCLUSION :
In these patients, treatment of chronic periodontitis by ultrasonic debridement of the pockets allows in the majority of cases to restore a balance, maintained by attentive monitoring. Complementary surgical treatment of the pockets, however, retains its interest for deep pockets. The age of the patient requires us to be rigorous but does not allow us to abstain from therapy.
MANAGEMENT OF THE ELDERLY SUBJECT PERIODONTAL CARE
Untreated cavities can damage the pulp.
Orthodontics aligns teeth and jaws.
Implants replace missing teeth permanently.
Dental floss removes debris between teeth.
A visit to the dentist every 6 months is recommended.
Fixed bridges replace one or more missing teeth.