Dental Health for Specially-Needed Populations
بسم الله الرحمن
الرحيم
صدق الله العلي العظيم
Dental health for
specially needed
population
Dr. Rihab Abdul Hussein Ali
B.D.S , M.Sc. , PhD.
Dental health of disabled and
medically compromised child
•
Disability
:
It refers to any
restriction
or
lack of
ability
to perform an activity.
•
A disabled individual
is a person who has one
or more
physical, medical, mental, or emotional
problems that result in a
limitation
of the
ability
to
function
normally
in fulfilling the
activities of daily
living
(
ADLs
).
•
Disability includes
all handicapping
conditions or
combinations
and could be
developmental
in origin
or
acquired
.
Classification of disabling conditions
:
•
Physical
disability such as
cerebral palsy
.
•
Mental
disability such as
Down syndrome
and
mental retardation
.
•
Sensory
disability like
deafness
and
blindness
.
•
Medical
compromise disability like
diabetes
and
Acquired Immune Deficiency
Syndrome
(
AIDS
).
Oral health status
:
•
Oral health may show
differences
between
normal
and
disabled
people. It had been found
that disabled individuals have tended to have
more teeth missing, more untreated decay
and
fewer teeth restored
.
•
Dental care
is often generated as an
emergency
.
With few exceptions,
preventive
care has
not
been emphasized in the way
as it should
. The
two
most important oral health
problems
among
disabled patients are
dental caries
and
periodontal disease
.
The issues regarding the delivery of care
to people with disabilities:
•
Normalization
.
•
Lack
of
funding
for training in the
Community
Dental Service
.
•
Cost
of
specialist services
and
facilities
.
•
Unwillingness
of some
general
dental
practitioners
to provide
dental services
to
some groups in the
community
.
•
Consent
and
restraint
.
It is important for dental providers to follow a
few simple steps when treating these patients:
•
Medical
,
dental
and
health history
should be
assessed.
•
Vital signs
should be taken.
•
Communicate clearly
with a patient who is
able
to
do so
. Otherwise, refer
questions
to the
person’s
caregiver
.
•
Obtain
consent
for
treatment
and possible
medical
stabilization
.
•
Assess
the patient for
possible complications
during
dental treatment
and utilization of
medical
stabilization
if
necessary
.
•
If medical
stabilization
is
needed
,
document
clearly the
time
patient utilized
medical stabilization and the
purpose
for
which it was utilized.
•
Document
the
patient’s tolerance
for
procedures.
•
Note
any
complications
during treatment.
•
Document
the procedures
performed
and
those
needed
in
future
appointments.
•
Sign
your
name
and
professional title
.
Dental management and preventive measures among disabled
individuals:
There are
general ways
to
promote
the
oral health
of people
with disabilities
before
consideration of
specific techniques
and
modalities
of dental care. They include:
•
To have an
advocate
someone to
ensure
that the individuals
concerned
receive
the
care
they
need
if they are
not
in a
position to
demand
it
themselves
. This relies on
caregivers
being
aware
of
potential needs
.
•
Ensuring
that
financial barriers
to dental care are
removed
is
vital
.
•
Services
themselves need to be
offered flexibly
.
•
People with
limitations
of
movement
needs
safe
and
effective
positioning
and may extend to the
use
of
conscious sedation
or even
general anesthesia
as an
adjunct to care
.
The risk factors for dental caries among
disabled individuals include:
•
Dietary
constituents
and
form
.
•
Liquid oral medicines
.
•
Poor
oral
clearance/stagnation
.
•
Resistance
to mouth
cleaning
.
•
Infrequent attendance
.
•
Attitude of caregivers
.
Preventive and treatment services should
evident to maintain oral health at higher level
by:
•
Application
of
topical fluoride
for those who
may be at
higher risk
for the development of
carious lesion
.
Administration
of
such
agents
can be
difficult
in a
severely
intellectually
impaired person.
•
Conventional
dental
treatment
may
not
be
appropriate
for
all patients
. For
some
groups,
the
only
way is with the
aid
of
general
anesthesia
. For
other
patients, an
alternative
approach to
managing carious
lesion using
simple
a traumatic restorative technique
(
ART
).
•
Dietary consideration
for people with disabilities may
need to be
different
. For
severely impaired
people,
food
is often
liquidized
or fed in
semi-solid
state after
mashing
. Some
very
disabled children and adults need to
take
high calorie
supplements in order to
maintain
nutritional status
. A
proper diet
is essential for a
good
preventive program
for disabled child, to
reduce
the
cariogenic potential
, so it is necessary: to
restrict
between meal snacking
.
Limit use
of
highly cariogenic
food.
•
Liquid oral medicines
taken can be
damaging
for the
dentition
especially in
chronic users
, a
regular mouth
cleaning
using
fluoride toothpaste
is recommended. If
the patient will
not tolerate
the use of the
toothpaste
,
then a
toothbrush dipped
in
fluoride mouthwash
(
0.2%
sodium fluoride)
as a part of the mouth
cleaning routine.
People with physical (neurological) impairment:
1.
Periodontal diseases and caries
are both
more
widespread
in
cerebral palsy
(
CP
).
Enamel
hypoplasia, mouth breathing,
and
food retention
in the mouth
all
contribute to the
increased rates
of
periodontal disease
and
caries
.
Physical
constraints
of the patient with
CP
can make
proper
oral hygiene difficult
. For these reasons, the
patient
or
caregiver
should use
•
A
unique, individualized
dental care
plan
.
•
In a
person
who can
not tolerate extensive,
rehabilitative
dental care then it may be
necessary
to remove
badly worn
and
sensitive
teeth.
•
Pureed diets
are recommended for
cerebral
palsy
patients who have
difficulty in swallowing
.
•
For patients who have
difficulty grasping
a
conventional, slim-handled brush
,
manual
toothbrush with an
enlarged handle
,
elastic cuff
can be used
caregiver-directed
plaque control
measures.
Electric
toothbrushes are
not
recommended for those
severely disabled
individuals due to their
increased weight
,
difficulty in using on/off switch
as well as these
devices can cause
considerable damage
to the
hard and soft tissue
in a
short time
.
2.
Several
cases of
gingival hyperplasia
can be seen among
those disabled individuals.
3. The
malocclusion
is due to
skeletal problems
and the
common habit
of
tongue
thrusting
, and
bruxism
due to
increased rate
of
temporomandibular joint
(
TMJ
)
disorder.
Severe bruxism
can cause
wear
of tooth, tooth
fractures
, and
possibly pulpal exposure
of teeth. If
reasonable
for the individual,
orthodontics
could be
considered. A
mouth guard
could help
reduce
the
effects
of
the
prolonged clenching
.
4. Patients with cerebral palsy also tend to have
hyperactive
bite
and
gag reflexes
. If the gag
reflex
becomes a
problem
for the
dental provider
, keeping the patient in a
semi
upright
position with
chin down
.
Immobilization
of
uncooperative
physically disabled patients need
papoose
board
for
stabilization of body
,
adjustment of head
by
head
positioner
, and
strap and tape
for
extremities
.
Visual Deficits:
It may
range
from
correctable deficiencies
to
total
blindness
.
Chair
side
instructions
of
tooth brushing
and
flossing
should be demonstrated on:
•
Oversized models
of the
dentition
with a
giant-sized
toothbrush
.
•
Red floss
can help when
demonstrating
flossing to
those with
visual impairment
who have
difficulty
seeing
white floss
.
Green
floss is also
available
and
can be
used
, but
red
is
easier
for the
aging eye
to see.
Once the
flossing technique
is
understood
and
visual
acuity permits
, the patient may
switch
to
white
floss
for
regular home use
. This allows the patient to
check
the
color
of the floss for
possible gingival bleeding
.
•
An
adequate assessment
of the patient's
dexterity
and
ability
to
understand
the
technique
must be
determined before
flossing is
introduced
. For some
compromised
patients,
flossing can be performed
regularly
if a
floss-
holding device
is
used
.
•
Some
patients who have experienced
cerebrovascular accident
,
lack
the
skills
necessary to
use
a
mirror
. For these people, using
a mirror causes
confusion
and therefore is
contraindicated
.
•
The patient must be
sensitized
by "
feeling
" and
"
smell
" of a
clean mouth
to test the
success
of
oral
hygiene measures
.
Hearing problems:
•
They can occur in
all age
groups. The
most
common
problem
is
communicating
with the hearing disabled;
however, communication can
occur
when the
speaker
is
directly
in front of
the patient, at the
same eye level
and
face to face
. The hearing disabled patient also
relies
on the
communicator's facial expression
and
body language
.
•
Communication
may be by:
•
Clipboard
and a
red felt-tipped
pen should be used when
writing
information.
•
Nonverbal
communication is recommended, such as
smiling, hand holding,
and
shoulder touching
, plays a
role in the
clinician-patient
interaction, it becomes
extremely
significant
when there is
no alternative
.
Mentally retardation
:
For patients who
resistant
to mouth
cleaning
,
caregivers
could use:
•
Powered toothbrush
.
•
If disabled individuals
refused
this
type of brush
,
a
super brush
could be used instead, that allow
three teeth surfaces
cleaning to be involved.
•
For
severely disabled
or
mentally retarded
patients, a caregiver can provide
CHX
applications by
various means
and improve the
periodontal
condition.
Medically compromised patients:
•
For those
unable
to
swallow
,
mouth care needs
to
be carried out for the
patient in bed
,
aided
with an
aspirating toothbrush
.
•
If the person is
unable to tolerate
the
foamy
toothpaste
,
dipping
the
toothbrush
into
fluoride
mouthwash
.
•
In
older patients
,
gingival recession
is a
common
experience. If the gingival recession has occurred to
the extent that the
papilla no longer fills the
interdental space
, an
interproximal brush
may be
beneficial
.
•
The
gingival status
in
disabled
individuals is going to be
affected
by the
poor levels
of
oral hygiene
and to some extent an
alteration
in the
immune system
was recorded. For
certain
subgroups, like people with
Down syndrome
,
periodontal
disease has been noted to be
more prevalent
, due to
combination
of
poorly controlled plaque
levels and an
alteration
in
phagocytosis of neutrophils
. If gingival health is
poor
,
chlorhexidine gel
can be
swapped
around the
mouth
either on a
brush
or onto
gauze
. Chlorhexidine gel can be swapped around
the mouth. Alternatively,
chlorhexidine
can be
inserted
into the
gingival sulcus
area in a
varnish form
.
•
Disclosing
products should be suggested to
visualize plaque
when a patient has
difficulty
in
plaque removal
.
Single-dose
packaging
of
disclosing solution
with its
own cotton-swab
applicator has become
available
and may prove
practical
for
weekly plaque removal effectiveness
checks in
institutional
settings
.
Specialized Equipment for disabled
patient management:
•
Mouth Props.
•
Headrests.
•
Soft Ties.
•
Body Wraps
and Other
Limb Stabilizers.
•
Dental care for Institutionalized disabled
individuals
1- The
most common
role for the
dental provider
in an
institutional
setting is
consultant
.
2- The
dental clinician
should provide
educational
training programs
for the
nursing staff
. This requires
an
ongoing training
program because of
frequent
turnover
of
nurses' aides
in such facilities. Training
aids may include
videotape
recordings
of the important
aspects of
preventive care
.
3- The
administration
and the
staff
must be kept
aware
of the
importance
of
routine oral-health
care.
Dental health of
Geriatric population
•
Aging
is a
normal physiological
process that
every living organism has to go through and is
considered to be
inevitable
in the cycle of life.
•
Geriatric dentistry, or Geriodontics
is the
delivery
of dental care to
older adults
involving
the
diagnosis, prevention,
and
treatment
of
problems associated with
normal aging
and
age-
related diseases
.
•
On average, people
above
the age of
65 years
are
expected to
suffer
from
one
or
more chronic
medical
conditions that
require consideration
before
initiating any
dental treatment
.
The "elderly" segment of the population is
diverse and has been subdivided into the
following categories:
•
People aged
65- 74
years are the
new or young
elderly who tend to be
relatively healthy
and
active
.
•
People aged
75 - 84
years are the old or
mid-old
,
who
vary
from those being
healthy and active
to
those
managing
an
array
of
chronic diseases
.
•
People
85
years and
older
are the
oldest-old
, who
tend to be
physically frail
.
The aging process gives major results:
a) A
reduced physiologic reserve
of many body
functions (i.e.,
heart, lungs, kidney
).
b) An
impaired homeostasis
mechanism by
which
bodily activities
are
adjusted
(i.e.,
fluid
balance, temperature control
and
blood
pressure control
).
c) An
impaired immunologic
system, as well as
related
increased incidence
of
neoplastic
and
age-related autoimmune
conditions.
Functional Status
: functional assessment evaluates
one's ability
and
limitations
to complete
basic tasks
of
daily life
.
•
Health Status
: The study of aging includes
not only diseases
that cause
morbidity and mortality
but also the conditions that
cause
disability
and
decline
in
independent functioning
.
•
Activities of Daily Living
(
ADLs
): it defined the
functional
status
. Activities of daily living are those
abilities
that are
fundamental
to
independent living
, such as
bathing, dressing,
toileting, transferring
from
bed or chair
,
feeding
and
continence
.
•
Instrumental Activities of Daily Living
(
IADLs
): are
more
complex
daily activities such as
using the telephone, preparing
meals
and
managing money
.
The individual's
ability
to complete
ADLs
and
IADLs
will affect
the
person's ability
to access and maintain their
oral health care
regimen.
Common oral manifestation
•
Oral manifestations are classified into
physiological
changes and
pathological
conditions.
1- Physiological changes:
include changes in
teeth
structure
and changes in
soft tissues
.
A- Changes in teeth structure:
•
Enamel: increase
the
fluoride content
in the
superficial enamel
. The
thickness
of the enamel
decrease
over time, due to the
many chewing cycles
and
cleaning
with
abrasive dentifrices
.
•
Dentin
: The
volume
of dentin
increases
due to the
apposition of secondary
dentin on the
walls
of the
pulpal chamber
and because of
caries or dental
excavation
. Aged dentin is
more brittle
,
less
soluble, less permeable,
and
darker
than it was
earlier in life.
•
Pulp
: The
size
of the pulp
chamber
and
volume
of the pulpal
tissue
decreases
with
reparative
and
secondary
dentin.
•
Cementum: Calcification
of the nerve
canals
increases
with age, the cementum volume
within
the alveolus
increases
gradually over time,
notably in the
apical
and
periapical
areas.
B- Changes in oral soft tissues
:
•
Mucus membrane
generally
atrophies
with
age; the
rate
of atrophy depends on
diet,
habits, dentures wear
and
oral hygiene.
•
Increase keratinization
of
cheek
and
lips
.
•
Decrease keratinization
of
palate
.
•
Thinning
in
oral mucosa
make it more
easily
damages
and
penetrated
by
some substances
in
food
, which may give rise to
etching or
burning
.
2-
Pathological condition
: the
most common
oral
diseases and disorders associated with aging are:
root
caries, periodontal diseases, oral mucosal lesions,
Xerostomia
and
Oral cancer
.
A- Root Caries
•
Root caries
differs
from
coronal caries
(
enamel and
dentin
) in several aspects (
mineralization and
bacterial invasion
).
•
It appears to be
more severe
in
males
than
females
.
•
Most likely to affect the
molar regions
.
•
Risk factors:
1.
Gingival recession
.
2.
Physical disabilities
.
3.
Existing restorations
or
appliances
.
4.
Decreased salivary flow
.
5.
Medication
.
6.
Cancer therapy
.
7.
Low socioeconomic status
.
8.
Abrasion
at the
cementoenamel junction
.
9.
Soft diets
consisting of
refined sugars
and
sticky,
fermentable
carbohydrates.
•
Root caries prevention and therapy include:
1. Application of
topical fluoride
.
2.
Dietary counseling
.
3.
Plaque control
and prevention of
gingival recession
.
•
Restorative dental treatment:
•
Shallow root caries
1.
Smoothing
the
compromised
root surface.
2.
Improving
access to
oral hygiene
.
3.
Applying
a
topical fluoride
.
•
Deeper compromised root caries:
Need to be
cleaned out
and
restored
with a
restorable
dental material
. There are
four
types of materials currently
used to restore carious lesions on the root surfaces:
1.
Amalgam
.
2.
Composite resins
.
3.
Auto-cured
and
dual-cured
glass ionomer cements
.
B- Periodontal disease:
•
Reduction
in
vascularity, elasticity,
and
reparative
capacity are some of the
most common
underlying
causes
of periodontal diseases among old people.
•
Increased
number of
gram-negative bacteria
associated with
gingivitis and periodontitis
including
P. gingivalis
and
Fusobacterium nucleatum
.
•
Diabetic mellitus, tobacco smoking,
dementia/Alzheimer’s disease, arthritis,
Parkinson’s disease,
and
coronary artery disease
have all been
linked
to periodontal
disease
and should
be noted in the
health history
.
C- Oral Mucosal Lesions:
•
as
burning mouth syndrome, candidiasis,
Geographic tongue (benign migratory glossitis),
Epulis fissuratum, Hairy tongue, Herpes
simplex, Herpes zoster (shingles), Leukoplakia,
Lichen planus, aphthous
and others are the
most
common
oral mucosal
lesions
among
geriatric
patients.
•
However,
any mucosal lesion
that does
not
respond
as expected within an
appropriate
period
of time or that
persists
despite all attempts
to
resolve any underlying etiology
should be
biopsied
to determine the
diagnosis
.
D- Xerostomia:
•
It is a
subjective
sensation of
oral dryness
and it may be
associated with
salivary gland hypofunction
and
changes
in salivary
composition
. It may result in
avoidance
of
certain foods
that may lead to
social avoidance
and
compromise nutritional
status.
•
There is
no cure
or
single treatment
approach that is
effective
for
all patients
with symptoms of
dry mouth
and/or
salivary hypofunction
. The management for the
majority
of these patients is primarily
symptomatic
with
goals to:
1. Prevent
deleterious consequences
of
decreased
or
insufficient
amount of saliva.
2. Attempt to
stimulate salivary flow
.
3. Alleviate
symptoms
in order to
improve
the patient’s
quality of life
.
4.
Saliva substitutes
can be used.
E- Oral Cancer
:
•
Person
65 yrs
of age and
older
are
7 times
more likely to
be
diagnosed
with oral cancer than those
less than 65
years
of age. They require
follow up
every
six months
to:
1-
Intra and extra
oral
examination
.
2- Receive a
thorough questioning
regarding
changes
in
oral conditions
and
habits
.
3-
X- Rays
should be taken
periodically
.
4- When
redness, irritation, bleeding, soreness, sensitivity
to temperature changes and/or chewing
is present to such a
degree that it
interferes
with
daily routine
or
persists
for
more
than
2 weeks
, the problem should be
investigated
.
With
early diagnosis
, the
prognosis
is much
improved
.
•
Preventive measures:
1.
Dietary modifications
that limit
sugar
intake
only
to
meals
.
2.
Elimination
or
decrease
of
between meal
snacking
.
3.
Maintenance
of
meticulous oral hygiene
.
4. Use of
patient-
and
professionally-applied
topical fluorides
(
rinses, gels, and varnishes
).
0.02%
sodium fluoride daily mouth rinse
and
0.4% stannous fluoride gel
. For patient with
Xerostomia
, it is recommended to
rinse twice daily
with a
nonprescription
0.05% sodium fluoride
mouth rinse
.
5.
Frequent dental visits
.
6. Patients with
salivary gland hypofunction
(
SGH
)
are
more susceptible
to
Candidiasis
, so
antifungal
drugs should be
prescribed
. It should be noted that
many oral
antifungal medications
contain
high
amounts of
sucrose
and are
cariogenic
. Therefore,
high caries-risk
patients should use
nystatin tablets
,
which contain
lactose
instead of
sucrose
.
7. Patients who wear
complete
or
partial dentures
and
have
oral candidiasis
should instructed to
wear
their
prosthesis
only
in the
daytime
,
clean
them with a
denture
toothbrush
and
disinfect
them by
soaking
overnight
in a
nystatin suspension
or
0.12%
chlorhexidine gluconate
.
Dental health for individuals with disabilities and medical compromises requires special care and attention. The challenges in delivering dental care, issues faced, and key steps to ensure proper treatment are discussed. Understanding disabilities, types of disabilities, oral health status, and the importance of preventive care are emphasized. Addressing concerns like consent, funding limitations, and normalization in dental services is crucial for improving access and quality of care for disabled individuals.
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Dental health for specially needed population Dr. Rihab Abdul Hussein Ali B.D.S , M.Sc. , PhD.
Dental health of disabled and medically compromised child
Disability: It refers to any restriction or lack of ability to perform an activity. A disabled individual is a person who has one or more physical, medical, mental, or emotional problems that result in a limitation of the ability to function normally in fulfilling the activities of daily living (ADLs). Disability includes all handicapping conditions or combinations and could be developmental in origin or acquired.
Classification of disabling conditions: Physical disability such as cerebral palsy. Mental disability such as Down syndrome and mental retardation. Sensory disability like deafness and blindness. Medical compromise disability like diabetes and Acquired Immune Deficiency Syndrome (AIDS).
Oral health status: Oral health may show differences between normal and disabled people. It had been found that disabled individuals have tended to have more teeth missing, more untreated decay and fewer teeth restored. Dental care is often generated as an emergency. With few exceptions, preventive care has not been emphasized in the way as it should. The two most important oral health problems among disabled patients are dental caries and periodontal disease.
The issues regarding the delivery of care to people with disabilities: Normalization. Lack of funding for training in the Community Dental Service. Cost of specialist services and facilities. Unwillingness of some general dental practitioners to provide dental services to some groups in the community. Consent and restraint.
It is important for dental providers to follow a few simple steps when treating these patients: Medical, dental and health history should be assessed. Vital signs should be taken. Communicate clearly with a patient who is able to do so. Otherwise, refer questions to the person s caregiver. Obtain consent for treatment and possible medical stabilization. Assess the patient for possible complications during dental treatment and utilization of medical stabilization if necessary.
If medical stabilization is needed, document clearly the time patient utilized medical stabilization and the purpose for which it was utilized. Document the patient s tolerance for procedures. Note any complications during treatment. Document the procedures performed and those needed in future appointments. Sign your name and professional title.
Dental management and preventive measures among disabled individuals: There are general ways to promote the oral health of people with disabilities before consideration of specific techniques and modalities of dental care. They include: To have an advocate someone to ensure that the individuals concerned receive the care they need if they are not in a position to demand it themselves. This relies on caregivers being aware of potential needs. Ensuring that financial barriers to dental care are removed is vital. Services themselves need to be offered flexibly. People with limitations of movement needs safe and effective positioning and may extend to the use of conscious sedation or even general anesthesia as an adjunct to care.
The risk factors for dental caries among disabled individuals include: Dietaryconstituents and form. Liquid oral medicines. Poor oral clearance/stagnation. Resistance to mouth cleaning. Infrequent attendance. Attitude of caregivers.
Preventive and treatment services should evident to maintain oral health at higher level by: Application of topical fluoride for those who may be at higher risk for the development of carious lesion. Administration of such agents can be difficult in a severelyintellectually impaired person. Conventional dental treatment may not be appropriate for all patients. For some groups, the only way is with the aid of general anesthesia. For other patients, an alternative approach to managing carious lesion using simple a traumatic restorative technique (ART).
Dietary consideration for people with disabilities may need to be different. For severely impaired people, food is often liquidized or fed in semi-solid state after mashing. Some very disabled children and adults need to take high calorie supplements in order to maintain nutritional status. A proper diet is essential for a good preventive program for disabled child, to reduce the cariogenic potential, so it is necessary: to restrict between meal snacking. Limit use of highly cariogenic food. Liquid oral medicines taken can be damaging for the dentition especially in chronic users, a regular mouth cleaning using fluoride toothpaste is recommended. If the patient will not tolerate the use of the toothpaste, then a toothbrush dipped in fluoride mouthwash (0.2% sodium fluoride) as a part of the mouth cleaning routine.
People with physical (neurological) impairment: 1. Periodontal diseases and caries are both more widespread in cerebral palsy (CP). Enamel hypoplasia, mouth breathing, and food retention in the mouth all contribute to the increased rates of periodontal disease and caries. Physical constraints of the patient with CP can make proper oral hygiene difficult. For these reasons, the patient or caregiver should use A unique, individualized dental care plan. In a person who can not tolerate extensive, rehabilitative dental care then it may be necessary to remove badly worn and sensitive teeth.
Pureed diets are recommended for cerebral palsy patients who have difficulty in swallowing. For patients who have difficulty grasping a conventional, slim-handled brush, manual toothbrush with an enlarged handle, elastic cuff can be used caregiver-directed plaque control measures. Electric toothbrushes are not recommended for those severely disabled individuals due to their increased weight, difficulty in using on/off switch as well as these devices can cause considerable damage to the hard and soft tissue in a short time.
2. Several cases of gingival hyperplasia can be seen among those disabled individuals. 3. The malocclusion is due to skeletal problems and the common habit of tongue thrusting, and bruxism due to increased rate of temporomandibular joint (TMJ) disorder. Severe bruxism can cause wear of tooth, tooth fractures, and possibly pulpal exposure of teeth. If reasonable for the individual, orthodontics could be considered. A mouth guard could help reduce the effects of the prolonged clenching. 4. Patients with cerebral palsy also tend to have hyperactive bite and gag reflexes. If the gag reflex becomes a problem for the dental provider, keeping the patient in a semi upright position with chin down. Immobilization of uncooperative physically disabled patients need papoose board for stabilization of body, adjustment of head by head positioner, and strap and tape for extremities.
Visual Deficits: It may range from correctable deficiencies to total blindness. Chair side instructions of tooth brushing and flossing should be demonstrated on: Oversized models of the dentition with a giant-sized toothbrush. Red floss can help when demonstrating flossing to those with visual impairment who have difficulty seeing white floss. Green floss is also available and can be used, but red is easier for the aging eye to see. Once the flossing technique is understood and visual acuity permits, the patient may switch to white floss for regular home use. This allows the patient to check the color of the floss for possible gingival bleeding.
An adequate assessment of the patient's dexterity and ability to understand the technique must be determined before flossing is introduced. For some compromised patients, flossing can be performed regularly if a floss- holding device is used. Some patients who have experienced cerebrovascular accident, lack the skills necessary to use a mirror. For these people, using a mirror causes confusion and therefore is contraindicated. The patient must be sensitized by "feeling" and "smell" of a clean mouth to test the success of oral hygiene measures.
Hearing problems: They can occur in all age groups. The most common problem is communicating with the hearing disabled; however, communication can occur when the speaker is directly in front of the patient, at the same eye level and face to face. The hearing disabled patient also relies on the communicator's facial expression and body language. Communication may be by: Clipboard and a red felt-tipped pen should be used when writing information. Nonverbal communication is recommended, such as smiling, hand holding, and shoulder touching, plays a role in the clinician-patient interaction, it becomes extremely significant when there is no alternative.
Mentally retardation: For patients who resistant to mouth cleaning, caregivers could use: Powered toothbrush. If disabled individuals refused this type of brush, a super brush could be used instead, that allow three teeth surfaces cleaning to be involved. For severely disabled or mentally retarded patients, a caregiver can provide CHX applications by various means and improve the periodontal condition.
Medically compromised patients: For those unable to swallow, mouth care needs to be carried out for the patient in bed, aided with an aspirating toothbrush. If the person is unable to tolerate the foamy toothpaste, dipping the toothbrush into fluoride mouthwash. In older patients, gingival recession is a common experience. If the gingival recession has occurred to the extent that the papilla no longer fills the interdental space, an interproximal brush may be beneficial.
The gingival status in disabled individuals is going to be affected by the poor levels of oral hygiene and to some extent an alteration in the immune system was recorded. For certain subgroups, like people with Down syndrome, periodontal disease has been noted to be more prevalent, due to combination of poorly controlled plaque levels and an alteration in phagocytosis of neutrophils. If gingival health is poor, chlorhexidine gel can be swapped around the mouth either on a brush or onto gauze. Chlorhexidine gel can be swapped around the mouth. Alternatively, chlorhexidine can be inserted into the gingival sulcus area in a varnish form. Disclosing products should be suggested to visualize plaque when a patient has difficulty in plaque removal. Single-dose packaging of disclosing solution with its own cotton-swab applicator has become available and may prove practical for weekly plaque removal effectiveness checks in institutional settings.
Specialized Equipment for disabled patient management: Mouth Props. Headrests. Soft Ties. Body Wraps and Other Limb Stabilizers.
Dental care for Institutionalized disabled individuals 1- The most common role for the dental provider in an institutional setting is consultant. 2- The dental clinician should provide educational training programs for the nursing staff. This requires an ongoing training program because of frequent turnover of nurses' aides in such facilities. Training aids may include videotaperecordings of the important aspects of preventive care. 3- The administration and the staff must be kept aware of the importance of routine oral-health care.
Dental health of Geriatric population
Aging is a normal physiological process that every living organism has to go through and is considered to be inevitable in the cycle of life. Geriatric dentistry, or Geriodontics is the delivery of dental care to older adults involving the diagnosis, prevention, and treatment of problems associated with normal aging and age- related diseases. On average, people above the age of 65 years are expected to suffer from one or more chronic medical conditions that require consideration before initiating any dental treatment.
The "elderly" segment of the population is diverse and has been subdivided into the following categories: People aged 65- 74 years are the new or young elderly who tend to be relatively healthy and active. People aged 75 - 84 years are the old or mid-old, who vary from those being healthy and active to those managing an array of chronic diseases. People 85 years and older are the oldest-old, who tend to be physically frail.
The aging process gives major results: a) A reduced physiologic reserve of many body functions (i.e., heart, lungs, kidney). b) An impaired homeostasis mechanism by which bodily activities are adjusted (i.e., fluid balance, temperature control and blood pressure control). c) An impaired immunologic system, as well as related increased incidence of neoplastic and age-related autoimmune conditions.
Functional Status: functional assessment evaluates one's ability and limitations to complete basic tasks of daily life. Health Status: The study of aging includes not only diseases that cause morbidity and mortality but also the conditions that cause disability and decline in independent functioning. Activities of Daily Living (ADLs): it defined the functional status. Activities of daily living are those abilities that are fundamental to independent living, such as bathing, dressing, toileting, transferring from bed or chair, feeding and continence. Instrumental Activities of Daily Living (IADLs): are more complex daily activities such as using the telephone, preparing meals and managing money. The individual's ability to complete ADLs and IADLs will affect the person's ability to access and maintain their oral health care regimen.
Common oral manifestation Oral manifestations are classified into physiological changes and pathological conditions. 1- Physiological changes: include changes in teeth structure and changes in soft tissues. A- Changes in teeth structure: Enamel: increase the fluoride content in the superficial enamel. The thickness of the enamel decrease over time, due to the many chewing cycles and cleaning with abrasive dentifrices.
Dentin: The volume of dentin increases due to the apposition of secondary dentin on the walls of the pulpal chamber and because of caries or dental excavation. Aged dentin is more brittle, less soluble, less permeable, and darker than it was earlier in life. Pulp: The size of the pulp chamber and volume of the pulpal tissuedecreases with reparative and secondary dentin. Cementum: Calcification of the nerve canals increases with age, the cementum volume within the alveolusincreases gradually over time, notably in the apical and periapical areas.
B- Changes in oral soft tissues: Mucus membrane generally atrophies with age; the rate of atrophy depends on diet, habits, dentures wear and oral hygiene. Increase keratinization of cheek and lips. Decrease keratinization of palate. Thinning in oral mucosa make it more easily damages and penetrated by some substances in food, which may give rise to etching or burning.
2-Pathological condition: the most common oral diseases and disorders associated with aging are: root caries, periodontal diseases, oral mucosal lesions, Xerostomia and Oral cancer. A- Root Caries Root caries differs from coronal caries (enamel and dentin) in several aspects (mineralization and bacterial invasion). It appears to be more severe in males than females. Most likely to affect the molar regions. Risk factors: 1. Gingival recession. 2. Physical disabilities. 3. Existing restorations or appliances.
4. Decreased salivary flow. 5. Medication. 6. Cancer therapy. 7. Low socioeconomic status. 8. Abrasion at the cementoenamel junction. 9. Soft diets consisting of refined sugars and sticky, fermentable carbohydrates. Root caries prevention and therapy include: 1. Application of topical fluoride. 2. Dietary counseling. 3. Plaque control and prevention of gingival recession.
Restorative dental treatment: Shallow root caries 1. Smoothing the compromised root surface. 2. Improving access to oral hygiene. 3. Applying a topical fluoride. Deeper compromised root caries: Need to be cleaned out and restored with a restorable dental material. There are four types of materials currently used to restore carious lesions on the root surfaces: 1. Amalgam. 2. Composite resins. 3. Auto-cured and dual-curedglass ionomer cements.
B- Periodontal disease: Reduction in vascularity, elasticity, and reparative capacity are some of the most common underlying causes of periodontal diseases among old people. Increased number of gram-negative bacteria associated with gingivitis and periodontitis including P. gingivalis andFusobacterium nucleatum. Diabetic mellitus, tobacco smoking, dementia/Alzheimer s disease, arthritis, Parkinson s disease, and coronary artery disease have all been linked to periodontal disease and should be noted in the health history.
C- Oral Mucosal Lesions: as burning mouth syndrome, candidiasis, Geographic tongue (benign migratory glossitis), Epulis fissuratum, Hairy tongue, Herpes simplex, Herpes zoster (shingles), Leukoplakia, Lichen planus, aphthous and others are the most common oral mucosal lesions among geriatric patients. However, any mucosal lesion that does not respond as expected within an appropriate period of time or that persists despite all attempts to resolve any underlying etiology should be biopsied to determine the diagnosis.
D- Xerostomia: It is a subjective sensation of oral dryness and it may be associated with salivary gland hypofunction and changes in salivary composition. It may result in avoidance of certain foods that may lead to social avoidance and compromise nutritional status. There is no cure or single treatment approach that is effective for all patients with symptoms of dry mouth and/or salivary hypofunction. The management for the majority of these patients is primarily symptomatic with goals to: 1. Prevent deleterious consequences of decreased or insufficient amount of saliva. 2. Attempt to stimulate salivary flow. 3. Alleviate symptoms in order to improvethe patient s quality of life. 4. Saliva substitutes can be used.
E- Oral Cancer: Person 65 yrs of age and older are 7 times more likely to be diagnosed with oral cancer than those less than 65 years of age. They require follow up every six months to: 1- Intra and extra oral examination. 2- Receive a thorough questioning regarding changes in oral conditions and habits. 3- X- Rays should be taken periodically. 4- When redness, irritation, bleeding, soreness, sensitivity to temperature changes and/or chewing is present to such a degree that it interferes with daily routine or persists for more than 2 weeks, the problem should be investigated. With early diagnosis, the prognosis is much improved.
Preventive measures: 1. Dietary modifications that limit sugar intake only to meals. 2. Elimination or decrease of between meal snacking. 3. Maintenance of meticulous oral hygiene. 4. Use of patient- and professionally-applied topical fluorides (rinses, gels, and varnishes). 0.02%sodium fluoride daily mouth rinse and 0.4% stannous fluoride gel. For patient with Xerostomia, it is recommended to rinse twice daily with a nonprescription0.05% sodium fluoride mouth rinse.
5. Frequent dental visits. 6. Patients with salivary gland hypofunction (SGH) are more susceptible to Candidiasis, so antifungal drugs should be prescribed. It should be noted that many oral antifungal medications contain high amounts of sucrose and are cariogenic. Therefore, high caries-risk patients should use nystatin tablets, which contain lactose instead of sucrose. 7. Patients who wear complete or partial dentures and have oral candidiasis should instructed to wear their prosthesis only in the daytime, clean them with a denture toothbrush and disinfect them by soaking overnight in a nystatin suspension or 0.12% chlorhexidine gluconate.
