What Constitutes "Ideal Dentistry" Today?

 

Is dentistry tougher now than in years past? Absolutely.

Not that long ago, dentistry was a much simpler profession. Most practices were "drill and fill" offices where cavities occurred more frequently than now. Elective dentistry was not in high demand and comprised only a fraction of the average dental practice’s schedule. A limited range of cosmetic dentistry options was geared more for the rich and famous than for the average patient. Even orthodontics was something more for children of the well-to-do.
Things have clearly changed. In recent decades, dentistry has seen an explosion in technology and the number of services available to patients. Many of these services are in demand from the general public and are affordable for a growing number of patients.
All of this technical innovation, combined with shifting patient perceptions toward elective dentistry, has created a pressing question for dentists: What services are appropriate for their patients? Perhaps a larger issue needs to be addressed: Has the definition of "ideal treatment" become blurred?

 

Defining "Ideal Treatment"

I have always been a strong advocate of doctors offering ideal treatment to patients based on a comprehensive evaluation of their immediate and long-term oral health requirements. Before it can be determined whether patients will be interested in or have the financial capability to accept treatment, the ideal treatment plan should be developed and presented. In the process, patients will come to understand that the dentist has their best interests in mind.
Presenting ideal treatment also serves to:

Contemporary Concepts in the Diagnosis of Oral and Dental Disease

Dental clinics of North America
January 2011 issue
       Diagnosis is the essential first step in the provision of health care. A patient presents to a health care provider for a routine evaluation or with a specific complaint requiring attention. The provider will review the health history, ask pertinent questions about the history and symptoms, and then examine the patient. This will be followed by the use of other diagnostic procedures and tests, which can include radiographic studies and analysis of biologic fluids and tissue samples. Arriving at the correct diagnosis allows for selection of appropriate treatment, with minimal time delay. Health care providers must continually seek to improve their diagnostic acumen.
download

Essentials of Microbiology for Dental Students

Book information
Paperback: 348 pages
Publisher: Oxford University Press, USA; 2 edition (February 2, 2006)
Language: English
ISBN-10: 0198564899
ISBN-13: 978-0198564898
Product Dimensions: 10.8 x 8.7 x 0.9 inches
download

AGE RELATED CHANGES-2

Salivary glands
             Complaints of a dry mouth (xerostomia) and diminished salivary output are common in older populations.Estimates of xerostomia and salivary hypofunction indicate that approximately 30% of the population in 65 years and older experience these disorders and their accompanying oral and pharyngeal consequences.
  Older adults experience dry mouth for a variety of reasons.Interestingly,output from the major salivary glands does not undergo clinically significant decrements in healthy older people.As clinicians we should not attribute complaints of a dry mouth in an older person simply to their age:an appropriate diagnosis is required.
   The most common cause of salivary disorders is the use of prescription and non-prescription medications.Reports indicate that 80% of the most commonly prescribed medications can cause xerostomia, with more than 400 medications associated with salivary gland dysfunction as anadverse side-effect.Because elderly people are more likely than the rest of the population to take medications and are more vulnerable to their side-effects, medication-induced xerostomia is not uncommon.
  Drugs with anti cholinergic effects are most likely to produce complaints of diminished salivary output and dry mouth.Furthermore, drugs that inhibit neurotransmitters from binding to salivary gland membrane receptors, or that preturb ion transport pathways in the acinar cell, may adversely affect the quality and quantity of salivary output.Common categories of these drugs include;
-Tricyclic antidepressants
-Sedatives and tranquillizers
-Antihistamines
-Antihypertensives
-Cytotoxics; and
-Anti-Parkinsonism drugs
     One treatment for head and neck cancers is external beam radiation, which causes severe and permanent salivary hypofunction and results in persistent complaints of xerostomia.Radiation-induced destruction of the serous-producing salivary cells occurs via apoptosis.Within one week of the start of irradiation,a patient's salivary output may have declined by 60-90%, with no recovery occurring unless the total dose to salivary tissues is less than 25 Gy.Most patients receive therapeutic dosages that exceed 60 Gy, therefore their salivary glands undergo atrophy and become fibrotic.
   Numerous systemic medical conditions, including :
-Sjogren's syndrome
-Diabetes mellitus
-Alzheimer's disease: and
-Dehydration
      can cause or contribute to salivary gland diseases.Sjogren's syndrome is one of the most frequently encountered chronic autoimmune connective tissue disorders and is the most common systemic condition associated with xerostomia.Sjogren's syndrome occurs in primary and secondary forms.Those patients with primary have salivary and lacrimal gland involvement, with an associated decreased production of saliva and tears.In secondary form, the disorder presents with other autoimmune diseases, such as rheumatoid arthritis,systemic lupus erythematosis and scleroderma.

Periodontium
          Epidemiological studies show that the prevalence and severity of periodontal disease increases with age.This is most likely the result of repeated episodes of active destruction occuring over time rather than an intinsic change associated with ageing process itself.Periodontal changes attributable solely to advancing age are not sufficient to account for tooth loss, especially in a healthy adult.Gingival recession has been considered as an age change, but it is now known to be a part of the clinical spectrum of periodontitis in  which plaque is the main aetiological agent.There is no evidence that the elderly are particularly susceptible to periodontal disease,although confounding variables such as systemic disease, reduced manual dexterity, oral factors and medications have an adverse effect on periodontal health.

Teeth
      Age changes in teeth include physiological wear with superimposed changes in morphology associated with pathology, including attrition and changes in the structure of composition of the dental hard tissue.

Enamel: The enamel tends to become more brittle and susceptible to chipping,cracking and fracture.it also becomes less permeable with age, reflecting the ionic exchange which occurs between enamel and the oral environment throughout life. Darkening of the enamel and staining has also been described and may be due to absorption of organic material.

Dentino-Pulpal Complex: Two main age-related changes in dentine are continued formation of secondary dentine,resulting in reduction in size and in some cases obliteration of the pulp chamber, and dentinal sclerosis associated with the continued production of peritubular dentine.Both of these processes are also associated with caries and tooth wear.Dentine sclerosis may affect the use of adhesive systems with dentine.Sclerosis of radicular dentine tends to make the roots brittle and they may fracture during extraction.It is also associated with increased translucency of the root.This starts at the apex in the peripheral dentine just beneath the cementum and extends inwards and coronally with increased age.
   Physiological changes are as a result of continued production of secondary dentine.This reduces the height of pulp horns,makes the pulp shrink out of the crown and anterior teeth, reduces the distance between chamber roof and floor in posterior teeth and causes the pulp to narrow concentrically in roots.The diminishing pulp space can be further complicated by the growth of irregular calcifications around degenerating blood vessels and nerve cells.These changes usually comprise spheroid  'pulp stones' in the coronal chamber and linear deposits in the canals. Radiographs may suggest that these changes complitely obliterate the pulp space, but they are usually interspersed with soft tissue that provides space and nutrition for microbial infection, whilst easing the path for operative disruption and entry.
  Pulps undergo physilogical and reactive changes as patients age.Changes are not, howeer,uniform and are not uniquely concentrated in the chronologically old.Pulp canals in the elderly are not necessarily narrow and difficult to manage, and reactive changes in the young and middle aged can be equally challenging.
   As the pulp ages, it becomes less vascular, less cellular and more fibrotic, resulting in a reduced response to injury and decreased healing potential.There is also a reduced nerve supply which, together with a greater thickness of dentine, makes vitality testing more difficult.The tissue is tougher and may not be penetrated as easily with files.The risk this presents is that entry, even to a seemingly large pulp, results in compaction of pulp tissue to form a dense collagenous plug that is as impregnable as any calcified deposit.There is special merit in the elderly of removing pulp tissue with barbed broaches and routine use of lubricants to allow instruments to glide through tissue rather than compacting it.

Cementum: Cementum continues to be formed throughout life, especially in the apical half of the root,resulting in a gradual increase ith the thickness to compensate for interproximal and occlusal attriton and in response to trauma, caries and periodontal disease.The amount of secondary cementum at the apex of a tooth is a factor that can be taken in to account in radiographic working length estimation in endodontics,and in forensic dentistry in age estimation.Increase amounts of cementum along with secondary and reparative dentine diminish tooth sensitivity and reduce perception to painful stimuli.

Conclusions
    A variety of oral changes may be observed in elderly patients.These changes can be attributed to variety of physiological and pathological processes which have developed over a lifetime.Clinically, it is important to recognize these changes and to develop planning strategies which take account of them.Emphasis must be placed on preventive regimes and treatment delivery which is sympathetic to changing needs of our existing elderly and ageing population
 

       This information was useful or not.Give your feed back in comments.
                 

        

AGE CHANGES

Age-related oral changes are seen in the oral hard and soft tissues as well as in bone, the temporomandibular joints and the oral mucosa. As older patients retain their natural teeth for longer, the clinical picture consists of normal physiological age changes in combination with pathological and iatrogenic effects.

Worldwide population demographics are changing rapidly and the proportion of older people is growing faster than any other age group.Approximately 600 million people are currently aged 60 years and over,and this number is expected to double by 2025.Globally,poor oral health among older people has traditionally been manifest in high levels of tooth loss,dental caries and periodontal disease experiance,as well as xerostomia and oral precancer/cancer.In addition,evidence of the relationship between oral health and poor general health continues to grow with links between severe periodontal disease and diabetes mellitus,ischamic heart disease and chronic respiratory disease the focus of much research.

        Age changes are manifest in oral and dental tissues.What is seen is a combination of physiological age changes with superimposed pathological and iatrogenic effects.

Bone     Increasing age is associated with progressive reduction in bone mass resulting in osteoprosis.Age related osteoporosis is common and, in edentulous patients,may play a role in atrophy of alveolar and possible basal bone,although no clear relationship has been established.Atrophy of alveolar bone is related mainly to tooth loss.Its extent increases with age resulting, in the absence of denture, in loss of facial height with upwards and forwards posturing of mandible.Loss of alveolar bone is more extensive and occurs more rapidly in the mandible than in maxilla.

 Levels of cyclo-oxygenase 2 (COX2) enzyme.which plays an essential role in bone repair,decline rapidly with ageing.This may explain the delayed bone healing that occurs in older patients.Research is now being conducted to stimulate activity of the COX2 enzyme and subsequent bone healing.

Temporomandibular Joint

(TMJ)

   In the TMJ it is difficult to distinguish changes due to ageing from those related to osteoarthrosis.Excluding those changes due to osteoarthrosis,the main age changes are related to remodelling of articular surfaces and disc in response to functional changes following tooth loss.Remodelling may result in disc displacement,particularly anterior displacement.The retrodiscal tissues may show adaptive changes associated with decreased cellularity and vascularity, and increased density of collagen, and may eventually function as an articular disc.However, in some cases the displacement may lead to perforation of the disc, particularly of its posterior attachment, resulting in progressive joint damage

Nerves and musculature

Muscle function is depedent on the performance of the nervous system and both exhibit independent age-related changes.Nerve cells loss is universal in old age and is ehibited in the brain and spinal cord.There are also age related changes in neurotransmitters, resulting in motor dysfunction. Peripheral nerve functiondeclines with ageas there is a reduction in conduction velocity, increased latencies in multi-synaptic pathways,decreased conduction at neuromuscular junctions and loss of receptors.

Continued muscle function is a major requirement for the maintainance of speech and mastication.In all patients with advancing age there is a reduction in total muscle mass which occurs through a reduction in the number of muscle fibre rather than a major reduction in muscle fibre size. Electrophysiological studies have also shown a loss f motor units with age, particularly in those over the age of 60 years, which manifests as a reduction in muscle strength and reduced masticatory forces.Age induces a lengthening of the chewing process associated with reduction in muscle activity, suggesting that elderly patients adapt their chewing activity.

Evidence suggests that edentate patients exhibit an increased reduction in muscle mass and reduction in maximal bite forces compared with dentate patients.However, many edentate individuals successfully rehabilitated using complete dentures regard their masticatory function as satisfactory.

Oral mucosa

         The clinical appearance of oral mucosa in older patients is often indistinguishable from that of  younger patients.However,changes overtime including mucosal trauma, mucosal diseases, and salivary hypofunction can alter the clinical appearance and character of the oral tissues in older patients.

   The stratified squamous epithilium becomes thinner, loses elasticity, and atrophies with age.A declining immunological responsiveness further increases the susceptibility to infection and trauma.An increased incidence of oral and systemic disorders,along with increased use of medication,may lead to oral mucosal disorders in elderly patients.Elderly patients may develop vesiculobullous,desquamative,ulcerative,lichenoid and infectious lesions of the oral cavity.In addition, oral cancer is primarily a disease of ageing and associated cell dysregulation.It is estimated that more than 90% of all oral cancers in developed countries occur in individuals older than 50 years, with a mean onset during the sixth decade of life.Oral cancer is associated with high morbidity and a particularly poor survival raate of less than 50% after 5 years.

Sensory changes
         It is known that taste and smell sensitivities change throughout life and often decline with ageing.These changes can make food become tasteless thus resulting in a reduction in appetite.Such taste and smell dysfunctions may be due to a variety of contributing factors including oral diseases, systemic conditions and their associated treatments.Most studies suggest that the sense of smell is more impaired by ageing than the sense of taste.Olfactory cells which respond to smells are renewed much more slowly in elderly people.Olfactory acuity declines with age as the number of olfactory nuclei in the brain decline and the olfactory receptors in the roof of the nasal cavity regress.As a result, older people generally have greater difficulty differentiating among food odours than younger people.
   A diminution of taste results from the degeneration of taste buds and a reduction in their total number as renewal is much slower in elderly people.Elderly people have considerable differences in their sensory perceptionand capacity to detect the pleasantness of foods compared with younger people.
 This can lead to older people adding ingredients such as sugars or salt to food stuffs which can have adverse health effects.Whilst chemosensory deficits experienced by elderly patients generally can not be reversed, interventions including intensification of the taste and odour of foods, can compensate for age related perceptual losses.Amplified flavours increase the number of molecules that interact with receptors and compensate for sensory losses.Evidence shows that such amplification can improve food palatabillity and acceptance, increase salivary flow and immunity, and reduce oral complaints in both sick and healthy older patients.

          

      

EVIDENCE BASED DENTISTRY

download