GERODONTOLOGY

GERODONTOLOGY

GERODONTOLOGY

GERODONTOLOGY

INTRODUCTION

Aging is a normal, genetically dictated physiological processs.It is a state

of interplay between the physiologically contractile and pathologically

destructive metabolic process. It is a process of morphological and

functional involution that affects most organs of the body. It leads to

gradual impairment in performance of various systems, hence of the

individual as a whole

The increase in life expectancy is the result of improved hygiene,

prevention and control of infections in childhood, development of new

drugs and better dietary habits.

One of the problems of aging is that some of bodily functions do not

maintain their efficiency. The cells, tissues, and organs do not age at the

same rate. To obtain successful results with complete dentures in the

postmaturation group of patients, the dentist must understand these bodily

changes. He must anticipate the time at which they will occur and

recognize the symptoms in the diagnostic phase of his procedures.

There is high degree of variability in the functioning of the aged. Aging

rates vary among populations and among individuals in the same

populations. The oral cavity, like the rest of the body, undergoes gradual

aging changes, although senescence does not follow the same pattern in

all people. It is almost impossible to find two geriatric patients who are

exactly alike in all aspects.

Because of high degree of variability among geriatric individuals, each

patient must be evaluated individually by knowing 1) why the changes

occur, 2)how the changes are related to the physiologic and psychologic

status of the patient,and 3)what influence the changes will have on the

prosthodontic procedures.

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Jamieson wrote that “fitting the personality of the aged patient is often

more difficult than fitting the denture to the mouth.” Success in geriatric

dentistry can be the result of building up the patient’s confidence in the

dentist, regardless of the quality of the final prosthesis. The important

factor is to persuade or condition the patient to accept the dentures, to

wear them, and to use them. The emotional and psychologic make up of

the patient must be kept in the mind during the entire procedure.

The patient must be educated to understand and accept the reduced

efficiency of the artificial dentition. The prosthodontist must realize that

treatment of the aging can be difficult. When the dentist does not have the

impatience, or knowledge to treat the geriatric patient, he should refer the

patient to a dentist who has these qualifications. The prosthetic dental

problems of the geriatric patient should not be arbitrarily placed in the

untreatable category.

Overall, the management of problems encountered in the aging

population can seem like a series of objectionable compromises, but

adaptation is the hallmark of successful aging, and coping with

difficulties is an acceptable part of everyday life. Life at any age does

have pleasant surprises and rewards.

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DEFENITIONS:

Geriatrics: o The branch of medicine or dentistry that treats the problems

peculiar to the ageing patient,including the clinical problems of

senescence and senilit .

Gerodontics:

o The treatment of dental problems of aging persons or problems

peculiar to advanced age.

Gerodontology:

o The study of the dentition and dental problems in an elderly

person. People who are above the age of 65 years are termed as

geriatric persons.

Aging:

o The aging process may be defined as the sum of all morphological,

functional alterations that occur in an organism, and lead to

functional impairment, which decreases the ability to survive

stress.

o Aging is manifested at all levels

o The changes seen are not dramatic, but with time leads to

exponentially increasing mortality rate at the population levels.

o The origin of this complex aging phenomenon is at the “biological

level”

GERODONTOLOGY

REVIEW OF LITERATURE:

Different theories of aging:

Researchers1 postulated the concept of error catastrophe as a cause of

cellular aging by self amplification of errors is based on the feedback of

infidelity of information transfer, including DNA replication. Since this is

one of the few theories of aging for which specific predictions are test

able, it has received much attention

Some researchers2 in history of gerodontology mentions that a large

number of theories exist which claim that a single organ or organ system

is responsible for aging of organisms. They include thyroid, hypophysis,

adrenals, gonads, blood vessels, diencephalon and reticuloendothelial

system.

Researchers3 claimed that a genuine physiological aging process must be

o Universal :detectable in all number of species,

o Intrinsic :proceeding independently of outside influences,

o Progressive :developing gradually and irreversibly, and

o Deleterious :harmful to the survival of the organism

Studies5 lead to the discovery of another possible mechanisms for active

genetic regulation of aging involves the loss of DNA sequences

“repeated in tadem”.The genes coding for the formation ribosomal RNA,

normally present in numerous copies, are depleted markedly in human

nerve cells and other postmitotic cells: by the age 100 years

approximately 70% of the gene are lost . Similar depletion of copies of

certain genes has been reported from invitro studies on late passage cells

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i.e. those which have gone through many population doublings; here

kinetochorial DNA , associated with cell division was affected.

Postulated6 causes for the deterioration of such genetic functions during

aging include

o insufficient repair of spontaneously damaged DNA,

o mutations in somatic cells ,and

o self-amplifications of errors, “error catastrophe”

A researchers7 discovered that with aging there is a loss of neurons in

several key areas of the brain and dendritic regression. The latter is

claimed to lead to “ progressive destructions of the dendritic domain.”

Studies8 found that the metabolic rate is more complicated in

homoiotherms. A classic experiment showed that in rats food restriction

prolongs in life span. This observation does not necessarily imply a

retardation of the aging processes, but could be due to

o Delayed maturation,

o Slowed growth,

o Reduced body fat,

o Reduced metabolic rate,or

o Changed metabolic patterns.

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Physiological changes in aging:

Some authors8 discovered that to carry out it’s functions effectively, the

kidney requires a large blood flow. In young people at rest 20% of the

cardiac output flows through the kidneys. However , with increasing age

there is a progressive decline in renal blood flow with flow in 90 years

olds being about one half of that in 40 year olds.

A study9 declared that cerebral metabolism and the blood flow related to

it are accepted indices of neural activity. Although there has been

considerable debate on the effects of age on these indices, it seems likely

that neither changes significantly with age at least up to age 70. Cerebral

blood flow does appear to decrease during the eighth decade even in

people free of brain disease; evidence for a decrease in cerebral

metabolism in healthy people over 80 years of age is less clear.

The author10 summarized the prodigious research from his laboratory

depicting physiological changes with age. This research shows a decline

in function in a broad spectrum of physiological process. The extent of

change varies from process to process with the conduction velocity of the

nerve impulse slowing only slightly to and marked decline observed in

renal and respiratory functions.

Research11 found that residual volume, which is the volume in the lungs

after maximal expiratory effort, increases with age. This is probably due

to a decrease in strength of the expiratory muscles, an increase in the

outward recoil force of the chest wall and increased tendency of small

airways to collapse and trap air in the alveoli with increasing age.

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Studies12 found that with advancing age, alveolar ducts and respiratory

bronchioles enlarge at the expense of the surrounding alveoli. As a result

a larger fraction of lung volume is contained in the alveolar ducts and

smaller volume in the alveoli. Alveolar surface area also decreases with

age. There is a loss in elastin fibers from the walls of the alveoli.

Researchers13 discovered that there does seem to be a small decrease in

plasma thyroxine(T4) concentrations in humans with advanced age . The

plasma concentration of free T3 does not change with age and this also

appears to be true of free T4,although there is one report of a significant

fall in plasma –free T4 with age. The rate of removal of T4 from the

circulation decreses with advancing age in humans. The reason that this

does not cause the plasma T4 concentration to increase is that the rate of

thyroid hormone secretion by the thyroid decreases proportionately.

Researchers14 discovered that there is loss of neurons with advancing age

but the loss is far from the uniform. Several cranial nerve nuclei shows

no age related loss of neurons. Locus cerulus and substantia nigra

undergo marked neuron loss.

Researchers15 documented that recent serial computed tomography

examinations of Japanese subjects provide rather strong support for the

concept of a decrease in brain weight with age with particularly striking

changes occurring after age 60.

It was found16 that in humans, plasma cortisol concentrations and its

diurnal rhythm remain unchanged even at very advanced ages.

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Nevertheless , the rate of secretion of cortisol does decrease with age but

there is a proportional decrease in the metabolic rate of disposal of

cortisol nor is there any evidence that the ability to secrete ACTH and

thus cortisol in response to stress is diminished with advancing age.

There is a marked decrease with advancing age in the plasma

concentrations of adrenal androgens, i.e. of the sulphate conjugates of

dehydroepiandrosterone and of androsterone. Elderly subjects do have a

diminished adrenal medullary response to stresses such as insulin

hypoglycaemia and vasomotor conditioning. Also there is a change in the

response to epinephrine at least at some target sites. Cessation of

reproduction in women occurs at menopause and appears to relate to a

primary loss in ovarian function. Plasma concentrations of luteinizing

hormone and follicle stimulating harmone increase in men with age.

Studies17 found that the mean maximum heart rate during exercise also

decreases considerably with age. The cardiac output in the reclining

position decreases with age but in the sitting position at rest there is no

significant effect of age on cardiac output. Cardiac output increases

during exercise with work load in the young and the old. An increase in

resistance to blood flow occurs in many organs with increasing age

i.e.there is an increase in peripheral resistance with age.

Some studies18 found that although it is generally believed that central

nervous system functions decline markedly with age, this impression is

based more on observing the performance of individuals with disease

(e.g.senile dementia of the Alzheimer type) than on the careful

evaluation of individuals undergoing normal aging. Indeed , in the

absence of disease, most aged people remain altert with intact intellectual

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capabilities, sound judgement and creativity and with only a modest

decrease in mental agility.

Researchers19 discovered that the gastric glands decrease their secretion

with age and this includes volume and concentration of HCL, intrinsic

factor and pepsin. There may also be some reduction in the secretion of

pancreatic enzymes with age but more work is needed to be certain.

There is no evidence of a major change in biliary secretion with age.

A study20 claimed that a major consequence of the age related changes in

the cardiovascular systems is that the maximum cardiac output and

oxygen consumption during dynamic exercise decline with advancing

age in apparently normal people. They suggest that the two major

reasons, for this age related decline are the loss in responsiveness of the

heart to catecholamine and the increased vascular input impedance.

Some studies21 found that changes in sleep commonly occur with aging.

These changes involve a shortening of total sleep time at night,increasing

multiple brief awakenings and a shift to an earlier time of going to sleep

and awakening each day.

Cellular changes in aging:

A study22 mentioned that the first hint that mormal T cell functions might

decline with age came from the findings of morphologists who showed

that the thymic lymphatic mass decreased with age primarily as a result of

atrophy of the cortex

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.

As author23 mentioned that the human fibroblast model used to study

cellular aging has permitted the systematic study of events caused by

serial cell divisions. The first event observed was a decline in the

maximal density at confluence when growth stops. This permitted the

constructions of a survival curve for human fibroblasts, which was later

widely used to express their life span and as a reference to correlate

functional changes with the number of generations completed.

Some studies24 extensively studied DNA repair capacity as a function of

aging. A considerable amount of experiments show that ultraviolet-

induced repair and DNA strand rejoining are performed with the same

efficiency in old as in young cells.

Researchers25 conducted experiments on effects of ionizing radiation on

aging with the goal of checking somatic mutation theory. This led to a

new hypothesis to explain the aging of dividing cells. According to

them ,DNA strand switching, chromatin exchanges, chromosome

rearrangements, etc will destroy the interactions between various

domains,leading to aging.

Age changes in oral mucosa and periodontium:

The author26 did extensive studies on human preiodontium and observed

that width of periodontal ligament space of non-functional teeth is

narrower than functional teeth. This ,in future years paved the path for

some researchers to claim that teeth in elderly people have decreased

width of periodontium since they are not functional.

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Researchers27 observed the clinical changes associated with the tongue in

elderly people. The tongue shows loss of filiform papillae and

disturbance of sensory elements resulting in deterioration of taste

sensation and also burning sensation occasionally.

Studies28 found that with age the oral mucosa has been reported to

become increasingly thin, smooth and dry, to have a satin like, edematous

appearance with loss of elasticity and stippling, and to be more

susceptible to injury.

Studies29 found that among reported structural changes in human oral

epithelia associated with age are a thinning of the epithelial cell layers,

diminished keratinisation ,and alterations in the morphology of the

epithelium connective tissue interface.

Some studies30 mentioned that a decrease in width of periodontal

ligament with advancing age could be due to continuous deposition of

cementum on the root surface.

Some researchers31 worked on the classification of periodontal disease.

Periodontal disease has been divided in to 4 stages namely, the initial

lesion, the early lesion, the established lesion, and the advanced lesion.

Each lesion has characteristics that suggest an immunological response.

Characteristics of periodontal lesions .

A features of initial lesion

o Classic vasculitis of vessels subjacent to the junctional epithelium

o Exudation of fluid from the gingival sulcus

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o Increased migration of leukocytes in to junctional epithelium and

gingival sulcus

o Presence of serum proteins,especially extravascularly

o Alterations of the most coronal portion of the junctional epithelium

o Loss of perivascular collagen

Features of early lesion

o Presence and accentuation of the features described for the initial

lesion

o Accumulation of lymphoid cells immediately-sugjacent to the

junctional epithelium at the site of acute inflammation

o Cytopathic alterations in resident fibroblasts,possibly associated with

interactions with lymphoid cells

o Further loss of the collagen fiber network supporting the marginal

gingival

o Beginning proliferation of the basal cells of the junctional epithelium

Features of established lesion:

o Persistence of the manifestations of acute inflammation

o Predominance of plasma cells but with appreciable bone loss

o Presence of immunoglobins extravascularly in the connective tissues

and in junctional epithelium

o Continuing loss of connective tissue substance noted in the elderly

lesion

o Proliferation , apical migration, and lateral extension of the junctional

epithelium. Early pocket formation may or may not be present

Features of advanced lesion:

o Persistence of features described for the established lesion

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o Extension of the lesion in to alveolar bone and periodontal ligament

with significant bone loss

o Continued loss of collagen subjacent to pocket epithelium with

fibrosis at more distant sites.

Researchers’31 discovered that with respect to organic constituents in

parotid secretions, little change in total protein release has been reported. In

particular, when the secretion of granules, the anionic proline rich-protiens,

was evaluated, stable release was seen across the life span among both men

and women. These proteins, besides being useful markers for parotid

exocytosis, have an important physiologic role;that of maintaining calcium

and phosphate solubility.

Studies32 have evaluated submandibular salivary out put from healthy young

and elderly individuals and found severe impairment of more than 70% in

both unstimulated and citrate stimulated salivary flow in elderly.

Age changes in teeth

Studies33 reported that most characteristic age change in cementum is the

gradual increase in thickness. Cementum deposition occurs throughout life.

The total width of the cementum almost triples between the age of ten and 75

years.

Some researchers34 conducted studies on the composition of surface and

subsurface enamel and have clearly demonstrated difference in chemistry

between the two,for example in fluoride content. The crystal in surface

enamel are much thicker than those in the bulk of enamel.

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Some studies35 reported no significant differences in the density of enamel as

a function of age. However the nitrogen content increased with age .

Nitrogen content showed a gradual increase between 30 years to 60 years

and then a drastic rise.

Researchers36 mentioned that 6-7% of normal pulps exhibit mineralization’s

of various types while about 75% of the pulps from teeth with pathological

lesions showed changes. A 1:10 ratio of pulpal mineralization in non carious

teeth has been reported in young and individuals.

According to author37 under normal physiological conditions, only half the

dentinal tubules become completely obturated. Obturated dentin should be

considered as age change because it is not present in primary structures.

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Discussion

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Factors influencing aging

Genetic factors:o Mutationso Species specific life spanso Hybrid vigor o Sex o Parental ageo Twin studieso Premature aging syndromeo Cells in culture

Environmental factorso Physical and chemical components- radiationo Biologic factor- nutrition o Tropical countrieso Socio – economic factorso Low income groupso Bad housing o Poor working conditiono Stresses of life

Biologic theories of aging:

Genetic theories Non genetic theoriesError theories Immunologic theories

Somatic mutations free – radical theory

Reduncies Cross linking theory

Genetically programmed senescence Metabolic rate or wear and tear theory

Disposable soma theory

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Physiology of aging :

Physiological deteroration – increases with age

o It reduces physiological capacity and the ability to meet challenge

o It is progressive

o Major contributing factor to death of extremely old

Central nervous system:o Impairment of learning and memory after 70 years

o Slowing of central processing

o Decrease in the brain size and weight

o Deterioration of the motor systems

o Decrease function of the extrapyramidal system

Cerebellar function

Muscular strength

o Increase in the

Movement time

Reaction time

o Sensory systems loss of

Vibratory perceptions in lower extremities

Touch

Taste

Smell

Hearing

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Vision

o Sleep

Shortening of sleep time

Increased multiple brief awakening

o Neuro muscular system

o Loss of muscle mass

o Loss of muscle strength

o Loss of muscle performance

Cardio – vascular system :

o Decrease in

Intrinsic heart rate

Mean maximum HR during exercise

Cardiac out put

Oxygen consumption

o Increase in

Peripheral resistance

Muscle stiffness

Contraction period

Thickness of walls of aorta

Respiratory system :

o Increase in residual volume

o Decrease in expiratory reserve volume

o No change in total lung capacity

o Marked changes in air flow

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Kidney and body fluids:

o Loss of

Weight of kidney

Glomeruli

o Deterioration of function

Progressive declination in renal blood flow

GFR( glomerular filtration rate)

Gastrointestinal system:

o Disordered contractions

o Spontaneous gastro – oesophageal reflex

o Slow gastric emptying

o Loss of fat absorption

o Very slight impairment of protein digestion

o Reduction in calcium absorption

o Decreased secretion by gastric glands- less volume and concentration of

HCL

Intrinsic factor

Pepsin

Endocrines:

o Adenohypophysis – secretion of tyrotropin is blunted

o Neurohypophysis – greater release of antidiuretic hormone

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o Thyroid – slight decrease in T4 ( thyroxine )

cortisol secretion is decreased

aldosterone decreased

o Insulin –decreased sensitivity of the target tissues to the action

Glucose intolerance

Reproduction:

o Men

Decline in sexual interest. Drive and vigor

Increase in plasma concentration of LH( leutenizing hormone) and

FSH( follicle stimulating hormone )

o Women

Marked decline in estrogen concentration after menopause

Miscellaneous

o Loss of lean body mass

o Body fat increase with age

o Decrease in BMR

o Reduced ability to maintain body temperature

o Immune system

Oral changes in aging:

Oral mucosa : The clinical picture is one that of atrophy

o Thin smooth dry – satin like

o Loss of elasticity and stippling

o More susceptible to injury

o Decreased repair potential

Frequent application of soft liners

Skin changes:

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o Wrinkled dry-patchy pigmentation

o Loss of elasticity and fine pattern

o Diminished bulk of muscles ,fat and connective tissue- drooping of skin

o Into folds and creases

Gingiva:

o Loss of stippling

o Oedematous appearance

o Thin keratinized layer

o Tissue is easily injured

Lips :

o Angular cheilitis

- Vit B deficiency

- Dehydration

Teeth

o Enamel

Attrition

Erosion

abrasion

o Fluoride content increases

o Enamel crackes-increases

o Enamel lamellae- increases

o Cementum increases in thickenss

o Dentin – secondary dentin formation

Obturation of dentinal tubules

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o Pulp : fibre increased

Blood supply- reduces

Pulpstones- increases

Salivary changes :

Salivary flow reduces

o Medication- Depression

-Insomnia

o Salivary gland atrophy

Consequences :

o Diminished functions like mastication

o Digestive problems

o Poor retention of denture

o Susceptibility of mucosa to frictional irritation from the movement

o Interference with patients ability to wear dentures

Excessive saliva :

Transient –on insertion of denture. No reduction in salivary output from

the parotid gland where as that of submandibular gland is reduced.

Sub mandibular gland: 45% of total output

o Changes in composition:

Ptyalin – decreases

Mucin - increase

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o Physical changes:

o Viscous ropy

- Plaque formation and growth of cariogenic bacteria

Treatment of xerostomia:

o Increase intake of water

o Frequent mouth rinses

o Lubricating jelly

o Silicone fluid

o Semisolid denture adhesives- Decrease irritation of the tissues

Temporarily increases denture retention

o Use of silogogues-pylocarpine hydrochloride or nitrate. 5 mg before

meals

o Sucking on sour candy

o Nicotinamide 250 to 400 mg tid for 2 weeks

Bone tissue:

o Compact or cortical bone

o Spongy or trabecular or cancellous bone

Effects of aging :

o Thinning of cortical bone

o Increase in porosity

o Loss of trabecular

o Cellular atropy

o sclerosis

Maxilla- narrower

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Manbible- wider posteriorly

Tongue and taste :

Smooth ,glossy or red and inflamed in appearance

Distuebed sensation – taste

soreness burning (post menopausal women)

Varicose vein on the ventral surface

Tongue size:

Does not vary with age but over development of intrinsic muscles hence

larger tongue ( loss of teeth mastication and to keep the loose denture)

Impact of environmental and social forces on gagging:

An older person’s life is basically roleless. Unstructuted by the society and

conspicuously lacking in norma.Rosow( 1974)

General medical aspects of aging:

Cardiopulmonary disorders:

o Valvular heart disease

o Cardiac arrhythmias

o Coronary artery disease/ischemic heart disease

o Hypertension

o Congestive heart failure

o Chronic bronchitis/emphysema

Nervous system disorders:

o CVA( cerebrovascular accidents) or strokes

o Parkinson’s disease

o Tardive dyskinesia

Rheumatologic disorders:

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o Temporal arthritis

o Osteoporosis

o Osteoarthritis

Miscellaneous disorders:

o Leukaemia

o Iron deficiency anaemia

o Diabetes mellitus

o Thyroid disorders

o Urinary incontinenc

Geropsychiatric disorders:

Situational disorders:

o Associated with emotional crisis or prolonged situational stress

o Improper oral hygiene

o Sustained muscular tension

Bruxism

Atypical facial form

o Burning mouth or tongue

o Such patients should be treated with compassion, respect and

willingness to comfort

Affective disorders:

o Depression :

Usually co-operative

Appear to forget clear instructions

Fatigue easily and require several short appointments

o Side effects of anti depressants

Burning mouth

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Postural dizziness

Excitemet

Tachycardia

Rapid speech

Confusion

o Anxiety disorders:

Apprehensiveness

Worry

Agitation

Tachycardia

Dizziness

Weakness

Visual ad gastro intestinal disturbance

Fatigue and headache

Insomnia

Sometimes depressive mood elements

o Treatment

Benzodiazepines

Tricyclic antidepressants

o Disorders of congestive function

Dementia , deliria and toxic confusional states

Premedications :

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o Aggressive , confused and frightened patients

o Haloperidol 1-2 mg

o Thiothixine 2-5 mg ,one hour before the treatment

o Thioridazine 25-50 mg the night before the procedure

Paranoid states:

Paranoid is a group of symptoms involving suspiciousness on others.

Chronic mental disorder persisting in to late life:

o Chronic schizophrenics who survive in to their 60 and 70 years

display no florid psychotic symptoms , showing only impoverishment

of social .intellectual and emotional life ,social and financial

dependency and occasional odd habits.They neglect even an extensive

oral disease

Aging And Nutrition

o The diagnosis of a nutritional deficiency- stomatitis must always be

consistent with a background of nutritional impairment and substantiated

by a conservative interpretation of the data derived from a careful and

complete diet survey, a probing medical history and physical

examination, and appropriate laboratory and roentogenographic

determination.

Etiology of dietary deficiency:

o Lack of proper food intake

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low income and lack of knowledge on how to spend the money

available for food to the best advantage.

Physical handicaps, lack of mobility which makes preparation of food

difficult

Poor facility

Poor dentitionor improper dentures

Depression boredom, anxiety and loneliness

o Disease which interfere with

Digestion

Absorption

Utilization of foods

Eg : oral cancers

Oral symptoms of nutritional deficiencies:

o The symptoms may antidate ,coincide with, or follow the appearance of

deficiency induced signs.

o They are represented by

Burning

Soreness

Tenderness

Dryness

Sialorrhea

Loss of diminution of taste ( ageusia or dysgausia)

o Soreness and burning of tongue:

Iron deficiency anemia

Vit B12 responsive pernicious anemia

o Stomatodynia :

Pellagra

Sprue

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Kwashiorkor

Scurvy

Nutritional microcytic anemia

o Xerostomia :

Vit A deficiency

Ariboflavinosis

Pellagra pernicious anemia

Iron deficiency anemia

Sprue

Dehydration

o Sialorrhea

Acute nutritional deficiency stomatitis

Acute pellagra

o Impairment of taste sense:

Pellagra

Pernicious anemia

Oral signs of nutritional deficiency:

o Cheilosis

o Gingivitis

o Glossitis

Lip lesions

o Deficiencies of riboflavin , niacin ,protein ,vitamin B12,folic acid, iron

pyridoxine, pantothenic acid and vitamin C.

Gingivitis

o Deficiencies of niacin, tryptophan, and vitamin C

Glossitis :

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o Niacin , folic acid ,vit B12, pyridoxine, protein, and iron deficiency

Treatment of nutritional deficiencies:

General principles:

o A well balanced high protein ( 120-150gm) diet should be administered

with adequate calories, vitamins, and minerals.

o Therapeutic amounts of specific nutrients should be added as a

supplements to the daily diet.

Daily therapeutic dose:

Folic acid 5 to 10 mg

Niacin amide 150 to 250 mg

Riboflavin 10- 15 mg

Ascorbic acid 150- 300 mg

Vit A 25000-50000 units

Vit D 3000- 5000 units

Medicinal iron 200-400 mg (1.2 gm of ferrous sulphate)

Vit B12 10- 15 µg

o Coexisting diseases which cause secondary nutritional deficiencies or

increase the nutritional requirements must be controlled or eliminated

whenever possible.

o Symptomatic and supportive treatment should be given to get rid of and

comfort the patient in the presence of pain ,infection, vomiting, diarrohea

and dehydration.

PHARMOCOLOGY AND AGING:

General consideration;

o In general ,elderly people use 30% of all prescribed medications (Nielsen

et al 1981). Thus it is important to know if drug dosage has to be changed

when older persons are considered

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o Significant changes in pharmacokinetics and pharmacodynamics do occur

with increasing age

Compliance:

o The number of different drugs prescribed and

o The number of doses given per day of each drug

o More than 3 different drugs and more than 2 doses for a day of each drug

decrease compliance significantly

o Elderly patients are not necessarily more prone to non compliance than

younger patients

Absorption :

o A series of physiologic functions in the gastrointestinal changes with age.

o There is decrease in

Gastric emptying rate

Secretion of hydrochloric acid

Gastrointestinal mobility

Intestinal blood flow

Efficiency of many active transport systems

o As a result, a higher plasma drug levels are found in elderly patient

Volume of distribution:

o The total body weight declines steadily after the age 50 years, because of

loss of intracellular water and of lean body mass. While adipose tissue

mass is increased.

Clinical significance:

o The volume distribution of lipid soluble drugs is higher, where as that of

water soluble drugs is decreased

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Protein binding:

o The concentration of serum albumin decreased with advancing age.

In aged 3.5 g/ dl

Young adults 4-4.5 g/dl

o This causes on increased unbound fraction of drugs and influence the

distributution of drugs

Metabolism:

o The hepatic blood flow decreases with age and rate of metabolism of high

clearance drugs such as propranolol and lidocain whose elimination are

highly flow dependent is reduced in the elderly.

o The elimination of low clearance drugs depends primarily on the activity

of the hepatic microsomal drug metabolizing enzymes. The enzymes

activity per unit liver also decreased with advancing age.

Renal excretion:

o Renal function evaluated on the basis of inulin clearance or by

endogenous creatinine decreases considerably with age.

Young -20 to 22 mg/kg/24 hr

Old – 10 mg/kg/24 hr

o Dosage modifications are necessary primarily to drugs for which the

renal excretion of the parent compound or the active metabolites is the

major mechanism of elimination

Pharmacodynamics :

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o Reduced hepatic synthesis of blood clotting factors with a resulting

greater sensitivity to the action of oral anticoagulants

o Diazepam and nitrazepam (10 mg) appear to result in greater depression

of the central nervous system.

Adverse reactions :

o Frequency of adverse drug reactions is greater in the elderly . However

older persons take more medications and this must be taken in to

consideration.

DRUGS IN DENTAL PRACTICE:

Antibiotics:

o Water soluble antibiotics like penicillins , cephalosporins,

aminoglycosides, tetracyclins will be affected by the age –dependent

decrease in renal function.

o In contrst lipid soluble antibiotics like erythromycin, chloramphenicol are

primarily metabolized in liver resulting in more hydrophilic metabolites

which are subsequently excreted by kidneys.

Penicillins:

o Excretion of these drugs is much reduced in the elderly compared to

younger subjects.

o Because of high therapeutic index the modification of dosage to

compensate for reduced renal clearance is not necessary.

o In general normal doses of all penicillins can be safely prescribed to all

elderly patients regardless of age.

Erythromycin:

GERODONTOLOGY

o High therapeutic index

o Therefore normal dosages should be prescribed to all patients irrespective

of age

Metronidagole and tinidazole:

o It is advisable to use lower dosages of metronidazole in this age group to

avoid accumulation of active water soluble metabolites when kidneys

function is reduced.

o The excretion of tinidazole is unchanged in renal failure.

Sulfamethizole:

The half-life of sulfamethizole is significantly prolonged in the elderly

(181±13 min)as compared to younger subjects (10

GERODONTOLOGY