Restorative considerations in the dental treatment of the older patient

The older person and his or her dentition will have a clinical presentation and a reaction to treatment that is influenced by his or her unique blend of aging and disease processes. Changes seen in enamel, dentin, pulp, and cementum of the older patient are described in terms of their causes and the impacts of the changes on clinical presentation and treatment choices.

Treatment of an edentulous patient with a dry mouth

Dental health professionals are being asked to care for a growing number and range of medically compromised patients living with chronic health problems. Although tooth loss overall has declined in the United States, millions of persons, particularly those of more advanced age, still require treatment for the edentulous condition. Particular challenges are faced when this oral state is combined with a complex medical history. The primary learning objective for this case is to increase your general knowledge of and skills in the dental management of the complete denture patient with a dry mouth.

Denture hygiene: a review and update

Growth in the aging population has resulted in an increasing number of older persons requiring dentures. The microporous surfaces of an acrylic denture provide a wide range of environments to support microorganisms that can threaten the health of a physically vulnerable patient. The maintenance of denture prostheses is important for the health of patients and to maintain an esthetic, odor-free appliance. Mechanical, chemical, and a combination of mechanical and chemical strategies are available to patients to facilitate denture hygiene. Brushing is an ineffective method of denture disinfection. Household bleach or vinegar are effective as are the commercial, effervescent products sold for denture soaking. A new denture cleaner contains silicone polymer that provides a protective coating for dentures as a final step in the cleaning process. The coating helps to minimize the adhesion of accretions to the denture throughout the day until the next cleaning. Dental professionals must have a current knowledge of denture cleansing strategies in order to maximize the service offered to denture patients.

Root caries in the elderly: an update for the next century

Root caries is an emerging challenge to the dental professions because of the growing number of increasingly aging adults who have retained many or all of their teeth. Risk factors for developing root caries point to both intraoral and environmental factors, making the management of root caries complex and multidisciplinary. Prevention is the most desirable approach for management, but patients who have developed caries of the roots can be treated with remineralization strategies or a variety of restorative approaches. Dental professionals need to keep abreast of new approaches emerging for the management of root caries.

Prosthodontic considerations for the older patient

The elderly have both the greatest level of need for prosthodontic services of any age group, and the greatest degree of complicating dental, medical, and behavioral factors. Issues arise in daily practice of whether or not to replace a missing tooth or teeth for a patient of advanced age and a wide variety of challenges-dental/oral and others-face the dentist who is considering replacing some or all of an older person's teeth. This article focuses on clinical approaches and techniques that have proven particularly important and useful for providing prosthodontic care to the older adult.

Root caries in the older patient: significance, prevention, and treatment

Root caries is an emerging challenge to the dental professions because of the growing number of increasingly aging adults who have retained many or all of their teeth. Risk factors for developing root caries point to both intraoral and environmental factors, making the management of root caries complex and multidisciplinary. Prevention based on a composite of risk factors is the most desirable approach for management. Patients who have developed caries of the roots can be treated with remineralization strategies, recontouring techniques, intracoronal restorations of a variety of established and recently introduced materials, or extracoronal restoration. Dental professionals need to keep abreast of new approaches that are emerging for the management of root caries.

How much physical activity is needed to minimize weight gain in previously obese women?

Exercise is frequently identified as a predictor of weight maintenance after elective weight loss in retrospective studies of treatments for obesity. We conducted a prospective study to test whether physical activity measured soon after weight loss predicted weight maintenance and to determine how much physical activity was required to optimize maintenance. Thirty-two women [mean (+/- SD) age, 38 +/- 7 y; body mass index (in kg/m2), 24 +/- 3] were recruited through local advertising within 3 mo of reaching their target for weight loss (23 +/- 9 kg). Total energy expenditure (TEE) was measured by the doubly labeled water method. Postabsorptive resting metabolic rate (RMR) and postprandial RMR [expressed as thermic effect of a meal (TEM)] were measured by respiratory gas exchange. Women in the physically active group (ratio of TEE to RMR = 1.89 +/- 0.08) gained 2.5 +/- 3.1 kg during the 12 mo after reaching their target for weight loss, moderately active women (TEE:RMR = 1.64 +/- 0.05) gained 9.9 +/- 10.5 kg, and sedentary women (TEE:RMR = 1.44 +/- 0.08) gained 7.0 +/- 5.9 kg (P < 0.01). Retrospective analyses of weight regain as a function of energy expended in physical activity indicated a threshold for weight maintenance of 47 kJ x kg body wt(-1) x d(-1). This corresponds to an average of 80 min/d of moderate activity or 35 min/d of vigorous activity added to a sedentary lifestyle.

Oropharyngeal candidosis in the older patient

Colonization of the oral and pharyngeal regions by Candida spp., particularly C. albicans, is extremely common in humans, particularly in early and late life. A variety of local and systemic conditions predispose the transformation of the benign colonization to a pathological state, which may have severe local or serious systemic consequences. The finding of oropharyngeal candidosis in an older patient, therefore, merits investigation of the likely host factors responsible for the organism adopting its pathogenic behavior. This paper provides non-dental clinicians managing older patients a review of the clinical characteristics, risk factors, diagnosis, and management of oropharyngeal candidosis in older adults.

Use of a microtiter plate assay to detect the rate of killing of adherent Candida albicans by antifungal agents

OBJECTIVES

Candida albicans may become adherent to prosthetic devices of various kinds and thereby produce infections that are difficult to treat with standard antifungal therapy. The objective of the present work was to study the effectiveness of antifungal agents against adherent C. albicans yeast cells.

STUDY DESIGN

A microtiter plate assay was developed to assess the time required for killing of the fungal cells by three antifungal agents.

RESULTS

The assay initially was validated by demonstrating that the percentage of organisms adhering to the test wells was relatively constant and that exposure to the antifungal agents caused only minimal dislodgement of viable organisms from the plates. In studies that used this assay to determine the time required for killing the adherent yeast cells, chlorhexidine was found to be the most effective; in fact, in comparing the minimal lethal concentrations of the agents for exposures of 2 minutes versus 4 hours, a ratio of 2.9 was obtained for chlorhexidine versus 1050 for amphotericin B and 556 for nystatin.

CONCLUSION

The microtiter plate assay used in these studies may therefore be useful as a screening test to determine which antifungal agents have the most rapid fungicidal effects on adherent fungal organisms.

The importance of oral health in the older patient

Oral health is important to general health because stomatologic disease affects more than the mouth. Increasing preservation of teeth among present and future cohorts of older people has increased their risk for serious disease from oral pathogens. The intent of this paper is twofold: first, to alert non-dental health personnel to the significance of oral health and oral disease in the older adult; and second, to recruit the assistance of non-dental professionals in helping patients to achieve and maintain an optimal oral condition. Normative aging processes alone have little effect on the oral cavity, but common disease processes affecting oral health include tooth loss, dental caries, periodontal diseases, and oral mucosal diseases (including candidiasis and squamous cell carcinoma). Systemic diseases and their treatments frequently affect salivary, oral motor, and oral sensory functions. As a result of bacteremia or aspiration of oral contents, organisms of oral origin can be responsible for serious nonstomatological infections. Clinicians caring for older people need to recognize the importance of stomatological health, include an oral component in the multidisciplinary geriatric assessment, support the education of patients on aspects of dental health, and advocate the expansion of personal and public oral health benefits for older adults.

Analytic requirements for the doubly labeled water method

The doubly labeled water method is the first method that accurately measures total daily energy expenditure in free-living subjects over periods of days to weeks. Validations have indicated that the method can be performed with a coefficient of variation of between 3% and 5%. This precision, however, is dependent on the quality of the isotopic analyses. A recent interlaboratory comparison has indicated that there is a wide variation in the accuracy and precision with which deuterium and 18O enrichments are measured. This reduces the accuracy and precision with which a laboratory will perform the doubly labeled water method and in some cases may limit the application of this technique. Herein we review the analytical requirements for optimal use of the method and some of the potential sources of error in the stable isotope analysis.

Dental management considerations for institutionalized geriatric patients

The elderly in general and the residents of nursing home facilities in particular are increasingly frail, old, and dentate. Dentists should be prepared to manage the oral health needs of elderly clients who are afflicted with complex medical, functional, and dental disabilities. Proper dental management requires a commitment to provide treatment of quality despite myriad obstacles. From the outset of evaluation, there must be recognition of the likelihood of compromised self-care and the development of proactive strategies to address dependence in oral care.

Relative dilution spaces of 2H- and 18O-labeled water in humans

The doubly labeled water method for measuring energy expenditure can be very sensitive to small differences in the ratio of the 2H to 18O isotope dilution spaces. Recently it has been suggested that the average ratio is higher than the 1.03 we previously recommended. We therefore combined the data from 99 recently studied subjects. Subjects (85 females and 14 males) were between the ages of 4 and 78 yr (mean = 34 yr) and between 10 and 52% (mean = 35%) fat. The average 2H-to-18O dilution space ratio was 1.034 +/- 0.014, which was very similar to the original assumption. As in recent reports, we did find that most of the variance (60%) was due to random analytic error and that there was no correlation between the dilution space ratio and age or body fat. However, in contrast to recent reports we found no evidence of a gender difference. Use of the constant dilution space ratio of 1.034 to recalculate CO2 product in published validation studies demonstrated improved accuracy, and thus the value of 1.034 is suggested for use in future studies.

Identifying the needs of the elderly dental patient. The geriatric dental assessment

The dentist's first obligation to a patient of any age or status is to provide professional expertise on the state of the oral cavity. For the older patient, the contention has been made in this article that, in assembling the battery of information on which a comprehensive plan of oral care is based, the dentist must then go beyond the oral cavity. Through identification of diagnoses, their pharmacologic managements, and related polysystemic functional limitations, the dentist gains insights into potential treatment pitfalls and the patient's ability to contribute to different facets of care. Potential misunderstanding can be avoided and patient orientation enhanced through early identification and involvement, as appropriate, of the decision maker and other interested parties. When all pertinent clinical data are gathered, the provider needs to work with the patient to establish the plan of care that best addresses the dental needs and the medical and functional limitations, given fiscal realities.

Use of a new assay technique for quantification of antifungal activity of nystatin incorporated in denture liners

Denture-induced stomatitis with concurrent candidal infection is the most commonly encountered intraoral abnormality among individuals who wear dentures. The institutionalized elderly demonstrate increased susceptibility and could benefit from its management with a fungicidal denture liner. As an integral part of the prosthesis, the efficacy of the fungicidal liner would be independent of patient compliance and/or nursing involvement and would provide a predictable therapeutic modality. In this study a "slant agar assay" was developed to evaluate the in vitro antimycotic activity of Visco-gel and Lynal liners impregnated with various concentrations of nystatin over a 14-day period in nonaqueous and aqueous environments. The results were as follows: preparations incorporating higher concentrations of nystatin resulted in greater inhibition of Candida albicans growth; Visco-gel liner-nystatin preparations exhibited a greater fungicidal activity than equivalent Lynal preparations; loss of potency by all of the reline-nystatin preparations consisted of an initial rapid loss between days 0 and 2, followed by a plateau during which the preparations gradually continued to lose inhibitory activity; and 1 million units of nystatin were necessary to maintain an adequate level of antifungal activity in an aqueous environment, where the liners demonstrated decreasing antifungal activity proportional to the duration of exposure to water.

Protective immunity against Onchocerca volvulus and O. lienalis infective larvae in mice

Acquired resistance to both Onchocerca volvulus and O. lienalis infective larvae, implanted within micropore chambers, could be induced in mice following immunization with irradiated L3 larvae. In experiments with O. volvulus in BALB/c and BALB/c. By mice, consistent levels of protection (61-75% reductions compared to challenge controls) were achieved with challenge infections of 2 week duration. In DBA/2 mice, levels of protection against O. lienalis were lower and more variable (42-63%): Moreover a 3 week period between challenge and recovery was required before significant reductions in larval recovery became detectable in vaccinated animals. Immunization of CBA or BALB/c mice with O. lienalis microfilariae, or CBA mice with normal or irradiated O. lienalis L3 larvae, failed to induce killing or growth retardation of developing larvae. Preliminary characterization of the effector mechanisms and cytokines associated with protective immunity against O. volvulus infective larvae revealed elevated levels of eosinophils in peripheral blood and within micropore chambers during challenge infections in vaccinated mice. Spleen cells from the same animals stimulated with parasite antigen induced significant levels of IL-5, IL-4 and IFN gamma. These cytokines were barely detectable in antigen stimulated cells from challenge control mice.

Identifying and addressing the challenges of oral care for the elderly patient

Growth in the proportion of elderly in the US population and the dropping rate of edentulousness are resulting in an increasingly diverse geriatric dental population. This paper focuses on oral hygiene provision in older patients, because the provision of effective daily oral care is a key factor for rehabilitative and maintenance plans. Both intraoral and extraoral impediments to oral care are discussed with reference to the older patient. Strategies to address these impediments are offered, including specific suggestions for the involvement of other family members and other health care providers.

General dental care for the elderly

In order to provide the highest level of quality medical care, the physician must be knowledgeable about problems related to the oral cavity. In particular, the physician should understand how to identify specific oral and dental problems such as caries, periodontal disease, and mucosal lesions, refer to and consult with dental health professionals regarding oral health issues, and be aware of the range of dental treatment modalities for oral and dental problems.

New programs for advanced training in dental geriatrics

The unprecedented increase in the number and percentage of Americans who are older than the age of 65 is presenting the health care system with unique diagnostic, therapeutic, fiscal, and ethical challenges. Chronic disease, complex pharmacotherapeutic regimens, and psychosocial and physical dysfunction are prevalent in this age group. The dental profession is faced not only with an increase in the number and complexity of older patients, but with the fact that growing numbers of older patients are retaining a greater proportion of their natural dentitions for longer periods. To help meet the need for increased professional skill to deal with these issues, the Health Resources and Services Administration of the Department of Health and Human Services is supporting 23 medical school based geriatrics training programs, designed expressly for physicians and dentists. The programs offer a mixture of experiences in: clinical care of the elderly in a variety of settings; design and conduct of research relevant to geriatric and gerontologic issues; enhancement of pedagogical skills; and program administration. Physicians and dentists share many of the training experiences, providing both groups with unique insights into the presentation and management of their patients' problems, and an enriched awareness of each other's contributions to the care of the elderly.

A follow-up report of occupational stress in urban EMT-paramedics

A survey completed by 280 nonvolunteer, urban emergency medicine technician (EMT)-paramedics revealed high levels of occupational stress. We used a four-component model of occupational stress in medical environments to show indications that much variation in the manifestation of stress was accounted for by the rank and job description of the EMT-paramedic, the district served by the EMT-paramedic, and the patient population served by the EMT-paramedic. Stress exhibited by field EMT-paramedics tended to manifest in more negative attitudes toward patients, whereas administrative-level paramedics exhibited more organizational stress. We noted that the age of the EMT-paramedic and the length of time employed as an EMT-paramedic correlated with the level of occupational stress (P less than .05). The recent occurrence of significant life events also was significantly related to the level of stress (P less than .05). An EMT-paramedic's gender, marital status, and number of calls per shift had no significant correlation to the level of occupational stress. Based on these results, we recommend tailoring occupational stress programs to meet the needs of individual EMT-paramedics. Special attempts should be made to identify and counsel EMT-paramedics who are undergoing stressful life events. Finally, we suggest that rotating EMT-paramedics through various districts on a regular basis may help alleviate the negative impact on patient care in areas that have been identified as particularly stressful. Further studies are needed to verify our hypothesis.

Integrating geriatric dentistry into general practice residency programs

As the proportion of elderly people in society increases, so will the general practitioner's professional contact with the geriatric patient. Such a change will necessitate an alteration in patterns of practice. The "new elderly" are presenting with complicated restorative needs, and they increasingly expect the high quality of dentistry they have received much of their lives. Their expectations will require an enhancement and refinement of the general practitioner's diagnostic and therapeutic skills in geriatric dentistry. Yet the predoctoral dental curriculum is unable to provide the depth of experience and knowledge required. The amount of information that must be assimilated and the type of supervised clinic activities that must be experienced to prepare a student adequately in geriatric oral health care are too extensive to be included in a four-year program. Under the existing dental educational system, the fully skilled, professionally secure, and clinically astute general practitioner capable of managing the complex needs of the elderly will emerge from the general practice residency.

The absence of an age effect on enamel solubility in phosphoric acid

The growing proportion of older Americans and the projections in declining edentulousness in future cohorts of elderly necessitate elucidation of the responses of the aging human dentition to existing restorative techniques. This study investigated the results of the acid etch process as a function of age of specimen donors as well as a function of race, tooth type, and time between extraction and etch. Statistical analysis of data showed no significant effect on solubility by age, race, or length of time from extraction until etch. Molars were significantly less soluble than other teeth. The most frequently observed microscopic texture was an irregular, granular configuration termed 3g. Widely textural variation was observed in each specimen. A possible explanation for the observations is the distribution of prismless enamel. The widespread belief that older teeth are less efficaciously etched may be based on the greater frequency of composite restoration failures in the elderly, which in turn is more likely a factor of restoration size and changes in intraoral environment than of age.

Margin placement of esthetic veneer crowns. Part IV: Postoperative patient attitudes

Ninety-one subjects with a total of 196 esthetic veneer crowns with visible gingival margins were surveyed. An esthetic analysis of crown margins showing with a normal smile and an exaggerated smile was performed and recorded. Patient satisfaction or dissatisfaction with the esthetic veneer crowns was assessed. The conclusions of this study support the results reported in the first three parts of this study, indicate that satisfactory results can be obtained on many individuals when the crown margins of esthetic veneer crowns are placed supragingivally, and support the philosophy that individual patient education and analysis are essential to the selection of optimum margin placement when esthetic veneer crowns are the treatment of choice.