Geriatric Exam 2

what kind of meds help treat osteoporosis

bisphosphonates
reduces the risk of fractures in those with osteoporosis
*can also prevent with regular exercise and adequate calcium and vitamin D

story about the 72 yr old pt undergoing hemodialysis

previously had severe osteoporosis (from renal osteodystrophy)
lower left mandibular region had many fractures
diagnosed with stage 3 medication-related osteonecrosis of the jaw
anticoagulant was changed to nafamostat mesylate to help reduce intraoperative bleeding
bone regeneration was seen after 6 months
*oldest case of mandibular regeneration ever reported

nutrition in old age (reading)

inadequate nutrition can contribute to an accelerated physical and mental degreneration
loose painful teeth or ill fitting dentures decreases their want to eat
decrease in caloric intake and insufficient levels of calcium, iron and zinc (more often in females) \n dentures contribute to higher carb diets \n diminished salivary gland function

what 2 things affect health and adequate nutrition in the elderly?

missing dentition and ill fitting dentures
*causes difficulty in chewing and perception of taste of foods

how do elderly pts taste buds change

there is a reduction in the total number
in younger people, they reproduce approx every 10 days, but is slower in the elderly (especially women with estrogen deficiency)

3 nutritional issues

missing dentition/dentures
diminished function in saliva
mouth dryness and dental caries have been attributed to reduced salivary flow

how do dentures change diets?

they will eat softer foods
these usually end up being high in fermentable carbs
can contribute to development of root caries

does smoking affect the sense of taste?

yes
it diminishes the taste of food, and makes flavorful foods taste flat and unappetizing

GERD

seen in about 20% of elderly (and young)
chronic disorder
increase in symp with an increase in the duration of the disorder

enviornmental factors that can contribute to higher prevalence of GERD and complications

change in salivary bicarbonate secretions
delayed gastric emptying
sedentary lifestyles
increase in meds predisposing the person to reflux disease
decrease sensation in esophagus

where is GERD more severe?

in the elderly
due to reduced or delayed recogniztion

tx for GERD

tx symptoms (antiacid, proton pump inhibitors) \n heal esophagitis \n maintain remission \n laparoscopic or endoscopic surgery (long term)

anorexia in elderly

happens more often than we think
usually unintentional (poor appetite, decreased physical activity, dont care for food as much) \n occurs bc of poor digestion, nutrients and calories \n calories are not absorbed as well \n can also be due to physical handicaps making and digesting the food

concerns of anorexia

dry mouth caries periodontal disease poor dentition in general ill fitted dentures mental illness loss of energy to do normal tastes loss of body fat and muscle mass

what is one of the most commonly diagnosed infection in adults?

urinary tract infection (UTI)
more common in women (30% aged 85+ reported having one in the last 12 months)
genetic factors can predispose people to have recurrent infections

ways to prevent UTI's

drink cranberry juice
check briefs every 2 hrs
careful cleaning after using the restroom

common symptoms of UTI

burning or painful urination
constant urge to urinate
cloudy urine
foul odor
pelvic pain

kidney stones

hard deposits of minerals and acid salts that stick together in concentrated urine can be painful to pass, but dont cause perm damage

common disease

prevalence and incidence has increased in the elderly

what are 2 key roles in the formation of kidney stones?

diet and obesity

ways to prevent kidney stones

stay hydrated
watch the diet
exercise
monitor medications
maintain regular follow-ups with healthcare providers

potential benefits of bisphosphonate drugs on osteoporosis in post menopausal women

better outlook than estrogen dosing, vit D and calcium supplements

3 bisphosphonates that were studied

etidronate
alendronate
risedronate

what were the 3 purposes for studying bisphosphonates?

1. determine fracture prevention efficacy on those with osteoporosis
2. determine impact of the drugs on increasing bone mineral density
3. determine effectiveness of preventing further fractures for those who have already had previous injuries

what is osteoporosis known as?

a silent disease
develops slow without causing noticeable symptoms until a fracture occurs

3 most common fracture sites in elderly

hip (neck of femur), spine, wrist \n occurs once 30% of bone mass is lost \n \*60% of women at age 60 have a high probability of fracture (men at 65)

ideal conditions for bone regeneration

good health
young age

what is the biggest risk factor for using bisphosphonates?

osteonecrosis of the jaw (first reported in 2003)
usually appears after dentoalveolar surgery
*increase in bisphosphonates also increases BRON (bisphosphonate-related osteonecrosis)
*white phosphorus has a link

does having arthritis make you more likely to have more dental concerns?

yes you may be more likely to need a crown or root canal inflammation can make your gums pull away from your teeth, and leave them vulnerable to plaque and acid attacks that cause cavities \n \*they are also less likely to visit a dental professional

diode laser therapy

can be used in dental offices for gum health and to kill the harmful bacteria in your mouth

how can immunosuppresives help and hurt?

they are used to help tx rheumatoid arthritis increase the risk of opportunistic infections, delayed wound healing and prolonged bleeding

what is one cause for TMJ dysfuntion?

osteoarthritis cartilage disc degenerates results in uncomfy TMJ or altered occlusion

how can you help people with arthitis?

meds (corticosteroids or bisphosphonates)
include OHE with caregivers
antimicrobial mouthrinses
special toothbrushes
*monitor the pt when they are in your chair (maybe schedule more time)

what is used to tx breathing disorders?

oral appliances
oral myofunctional therapy

CPAP effects on the oral cavity

extreme dry mouth
nasal congestion
weakened throat muscles

advancements used in airway dentistry

cone-beam CT-3D (CBCT)
expansion appliances (vivos)
myofunctional therapy

characteristics that increase pts risk for obstructive sleep apnea

scalloped tongue
mallampati score
buccal exostoses
tori
attrition
abfraction
narrow "v" shaped maxillary arch
high BP
mouth breathing
nasal congestion
smoking

ways to treat obstructive sleep apnea

hygienist: take appropriate xrays and review pts anatomy dentist: read CBCT and scans, review pt morphology, recommend pt to therapy and ortho \n physician: oder sleep study before and after tx

does tx of airway issues (thru expansion) have negative effects on the oral health?

No!
they have less long term affects

how does sleep apnea affect the oral cavity?

they tend to brux more (leading to bone and gum loss)
dry mouth prevents the mouth from healing properly, remineralizing, and destroying harmful pathogens \n may increase risk for periodontitis

how do diabetes affect your feet?

50% of all people with diabetes also have some kind of nerve damage (usually feet/legs)
it lowers ability to feel pain, heat or cold \n this puts pts at risk for developing foot ulcers that can get infected and not heal

what is one of the most common complications for pts who have uncontrolled diabetes mellitus?

diabetic foot ulcers
mainly located on toes and heels
about 5% of pts that have foot ulcers will end up with an aputation

most kinds of lesions that occur on diabetic pts feel

ulcers
calluses
dry cracked skin
*happens bc of reduced blood flow

what can be done to prevent nerve damage

follow a healthy eating plan (more fruits/veggies, less sugar/salt) \n keep blood sugar in your target \n 10-20 min of physical activity daily is better than 1 hr per week \n take your meds

tips for healthy feet

check your feet every day
wear shoes that fit
wash you feet everyday in warm water
trim your toenails
keep the blood flowing

do foot ulcers increase the chance for mortality?

yes
the outcome is related to duration of diabetes, comorbidity, ischemia and infections (not chronic age)

what is a sign of comorbidity with diabetes?

foot ulcers
sometimes to be considered the first sign of the dying process

T/F: pts with diabetes are at *increased* risk of influenza infection and serious complication

true
diabetes \= having more instances of high blood glucose \= hinders white blood cells ability to fight infection
aging + diabetes can weaken the immune system

when is the best time to get the flu shot?

beginning of September (before flu season)
the shot takes about 2 weeks to take effect - important to develop immunity before being exposed to the virus

why should geriatrics with diabetes get their vaccines?

to reduce their risk of getting sick (like everybody else)
helps reduce the severity of infections if they DO get infected
*every person with diabetes needs a flu shot every year

how can diabetic geriatric pts live a healthy lifestyle?

keep up on their vaccines
control their diabetes

what drug can help reduce risk of oral cancer for pts with type 2 diabetes?

metformin!!
used to tx high blood sugar levels (type 2 diabetes)
produces anticancer effects (especially when longer than 21.5 mo)
*inhibits growth of squamous cell carinoma

which country has the oldest population?

germany
35% of them have removable prosthesis

3 S's of dental prosthesis

Simple (have spouse/nurse help them get it in and out)
Stable (hold up if dropped)
Solid (tx plan, pts know what will be happening and when)

what considerations and things should you consider when creating a tx plan for prosthesis?

asses and understand the pts limitations
involve informed consent and autonomy
*have the pt involved in the tx plan

are implants a good idea for geriatric pts?

yes

they can be predictable and safe \n age doesn't appear to affect prognostic significance in tx of implants \n they can facilitate oral function, comfort and quality of life \n can be used as a fixed implant-supported or removable implant-supported prosthesis

difficulties that can be associated with placing implants

hemorrhage
neurosensory abnormalities
tissue emphysema (air trapped beneath tissue)
infection
failure of wound healing (would dehiscence)
aspiration or swallowing of equipment
post op pain

mechanical problems based

overdenture clip/attachment fracture
porcelain veneer fracture on fixed partials
overdenture fracture and opposing prosthesis fracture
acrylic resin base fracture

prosthetic complications

material failure

gingival recession, blunted papillas, incomplete regeneration \n occlusal mismanagement \n incompletely seated prosthetic components \n adjustment to tissue-fitting surface of the prosthesis

overdenture complications

inadequate crn heigh space
poor osseous angulation
non-ideal implant positioning
retention loss overtime
o-ring failure
bar try in resulting in pain
gingival inflammation around bar
over denture fractures
food impaction

T/F: studies suggest that there are more implant failures due to bone loss in geriatric pts

true, but there are conflicting studies \n some say that older pts have equivalent or better results compared to younger edentulous pts

does alzheimers disease affect pain after dental procedures?

yeah, kinda \n episodes of delusion and intense pain can start after implant placements \n \*health status should be considered before planning any dental tx, talk to family or caregivers

when would dementia pts need IV sedation?

behavioral issues during dental tx
pts in the study also had 1+ comorbidities (circulatory, respiratory disease, hypertension, chronic pulmonary disease)

how did dementia pts respond to propofol in low level invasive procedures?

they had greater sensitivity to it
these procedures took more time (and more propofol)
ex: crn prep, cavity prep \n \*high level procedures like extractions took less time, and had more pre-op complications

water usage during IV sedation

associated with longer tx times
when possible

limit usage

complications during IV sedation

respiratory complications occurred 52.9% of time during ext
circulatory complications occurred 63.3% of the time during ext

when is IV sedation best for geriatric tx?

best for behavioral management in tx of outpts helped prevent dental accidents from abnormal behavior (observe for aspiration of retained fluids, airway obstructions, and monitor respiratory inhibition and/or circulatory variation) \n \*likely to see increase of dementia pts needing sedation for tx

how did alzheimers affect saliva in the case study?

flow of stimulated saliva as well as protein concentration were significantly lower than the control group
poorer hydration of vermillion zone and buccal mucosa were seen

redox imbalances

a result in pts with alzheimers

imbalance is toward oxidation reactions

general disturbances do not coincide with salivary redox balance disturbances (meaning they occur independently)

what glands fail in pts with alzheimers?

the parotid glands
submandibular glands are responsible for understimulated salivary secretion
\*reflected in poorer hydration of vermillion zone

risk factors of osteoporosis

low peak bone mass lack of estrogen smoking inactivity white/asian ethnic origin excessive alcohol or caffeine consumption \*1/4 pts die within a year of their first fracture, 1/2 of the remaining people will require nursing care

3 systemic diseases that affect bone

osteopososis
osteoarthritis
periodontal disease
*low bone mass influences clinical prognosis of tx

when does bone growth stop?

age 18
maximal overall bone mass is present
initially formed in utero
*bone mineral content and completion can increase thru 30's

when does age related decrease begin?

mid 40's

bone mass

80% is determined by heredity
5-8% can be increased via exercise and calcium (but lost when discontinued)
harder to regain bone mass the older you get

bone differences in gender

men have thicker cortical bone women have smaller bones, and rapid bone loss bc of estrogen deficiency, \*more at risk for fractures\* \n thinning of bone occurs in men and women, but men have compensatory increase (maintains resistance to fractures) \n trabecular bone mass is the same

osteoporosis

decrease in bone density
30% decrease from peak bone mass
1/3 women and 1/12 men over the age of 50 have osteoporosis

prevention of osteoporosis

consists of early intervention
high intake of calcium thru light (especially teens)
fluoride short-term can increase trabecular bone mass
therapies (bisphosphonates or hormone replacement)

oral bone loss is osteoporosis

max and mand bone loss increases with increased tooth loss
accelerated ridge loss seen in edentulous pts
seen in women 50+ and men 65+
might need modification in dental tx (ext and implants)

osteoblast

decrease as bone surface area and volume decrease active for shorter period and produces less matrix once trabeculae is lost they will not regenerate

osteoclasts

do not decrease with age
dimensions of resorption lacunae excavated by osteoclasts

how long does bone remodeling take?

doubles as you age
equilibrium between resorption and formation takes longer
new bone doesnt completely replace the amount of bone loss
*bone strength depends on size and shape

cortical bone

80% of our skeleton
most significant change in age (increases pores)
results in loss of strength and increased fragility
constantly remodeling

trabecular bone

horizontal struts decrease with age
vertical struts become thinner and perforated
most often seen in horizontal, which reduces the resistance to compressive forces, which increases probability to fracture \n \*loss of connectivity

osteonecrosis of the jaw

bisphosphonate-associated
most are associated with tooth extractions
higher in IV administration rather than oral administration

oral bisphosphonates

actonel (risedronate)
boniva (ibandronate)
fosamax (alendronate)

IV bisphosphonates

aredia (pamidronate)
zometa (zolendronic acid)
bonefos (clodronate)

clinical presentation of osteonecrosis

pain
soft-tissue swelling and infection
loosening of teeth
drainage
exposed bone
feeling of numbness
heaviness
dysesthesias (uncomfy sensation of touch)
*can stay asymptomatic for months

dental management of oral bisphosphonates

routine dental exam comprehensive exam before starting meds DDS should inform pt of the low risk of developing BON maintain OH risks, benefits and alternatives should be given in informed consent \n physician should be consulted prior to tx

dental management of IV bisphosphonates

avoid invasive dental procedures
dentists should check removable prosthesis to avoid soft-tissue injury
manage infections aggressively and non-surgically
pick RCT over ext

sarcopenia

muscle water, results in problems with simple muscle activity and things like posture contributing to falls and instability in older age

proteins

required for a variety of purposes including the maintenance of skeletal muscles as well as a source of energy

micronutrient intake

older people need to consume a more nutrient dense diet
higher fruits, veg and whole-grain content with appropriate amount of fat

2 ways vitamin D comes

skin synthesis (adequate exposure to the sun)
dietary intake

what vitamins are critical of mucosal integrity

iron
vitamin B
folate
*papilla will flatten and mucosal coverings reduce thickness and more red appearance

Iron deficiency

burning mouth syndrome
angular cheilitis
stomatits associated area
candida infections

how many days does it take for plaque to mature?

4 days \n once mature, it can metabolize carbs and produce acid

what is one of the key determinants that effect oral function?

edentulism
causes problems chewing and swallowing

how can taste and smell change in geriatric pts

likely associated with poorer release of tastants from foods that are not chewed as well
geriatric pts chew less (and stop eating chewy foods)
2/3 adults over 80 show a level of disturbance in smell (higher in men

nutrient density

amount of nutrients in a food relative to the number of kilocalories it provides

food patterns

develop during childhood and reflect their lifestyle
can change from cultural and ethnic differences
*be sensitive to food patterns when giving pts nutrition advice