October 3, 2014

The older patient
• Not a homogenous group but a large growing group. 1 in 6 people alive today are likely to live to 100 (Guardian 2010).
• Increasingly with high expectations.
• May not need to regard the elderly as a special group when considering treatment options.

How much of a problem is periodontal disease?
• ADHS (2009) – there are flaws with the study but because they use the same methodology every year it reveals good comparisons.
• Number of adults with visible plaque and calculus has dropped dramatically. Mild-moderate periodontitis has reduced. Intriguingly, severe periodontitis has increased by about 50%.
• Hugoson (2008) – globally the prevalence of severe periodontitis adjusted for age has 11-12% of severe periodontitis.
• Improving plaque control, improves gingival health and improves the prevalence of mild-moderate disease but not severe.
• Why? Dentists don’t take out as many teeth now and perhaps other aetiological factors are more common? Also effects of ageing population is likely to skew this.
• Impact – tend to think of periodontitis as a silent disease but it isn’t really. Patients complain of significant impacts of periodontal disease on their quality of life (function, appearance, aesthetics and general well-being).
• Severe periodontitis is relatively uncommon in the working population but relatively common in the older patient. Incidence appears to increase significantly over 65 years. This can be explained by other risk factors including smoking, genetics, systemic disease etc.

The well elderly
• Will still be taking lots of medications (that are keeping them well) and these can impact on their periodontal health. We need to understand these to help us manage these patients better.
• Be aware of the possibility of new periodontal disease even in the elderly.
• Complex medical history may impact significantly on periodontal status.

Diabetes
• Prevalence increasing rapidly.
• Total number in the UK is just past 1 million people.
• 95% of those affected are type II diabetics.
• 65 years and over then the prevalence rates are already approaching 15%. These people are also at risk of complications of diabetes that have a severe impact on their quality of life.
• 50% of people with type II diabetes don’t even know they have it!
• Periodontal disease is the 6th complication of diabetes.
• Diabetes causes increased prevalence and severity of periodontitis and can result in rapid periodontal breakdown (200-300%). The risk is related to glycaemic control. 7% HbA1C then normal risk of periodontal disease i.e. relative risk of 1. As glycaemic control deteriorates expotential rise of risk.
• What does it look like to the dentist? No particular characteristic appearance, increased pocketing and sometimes recurrent periodontal abscesses.
• Periodontal treatment may help their diabetic control but certainly adequate diabetic control will help their periodontal treatment.
• GDP can refer to GMP if suspect perio. If severe may refer to specialist.

Calcium channel blockers, drug induced gingival overgrowth and other drugs
• One of the main classes of drugs of choice for managaement of hypertension. Include Amlodipine, Nifedipine, Diltliazem.
• Are taken by 2 million in the UK.
• Recognised as having risk of drug induced gingival overgrowth.
• In affected cases, withdrawal of the drug often results in rapid improvement in periodontal disease.
• Is it okay to switch to another drug? Sometimes it is useful to contact GMP to see if this is feasible. In a newly diagnosed patient with hypertension (not post-MI), consider asking the GP to change.
• Other hypertensives: Ace inhibitors (e.g. ramipril), beta blockers (propanol), diuretics (bendroflumethiazide).
• Drug induced gingival overgrowth also with phenytoin and cyclosporin.
• In general, host responses may be affected by drugs through immunosuppression, neutrophil suppression and other host modifiers.
• Other drugs that can affect the periodontal tissues and can have uncertain effects: statins (anti-inflammatory and evidence that statins may be protection of periodontal disease), nonsteriodal anti-inflammatory drugs, anti-cytokine therapies, some new anti-cancer drugs.
• If in doubt – look things up, talk to your medical colleagues and advice from secondary referral. When referring be as specific as you can.
• Keep medical up to date and be prepared to provide extra supportive periodontal care.

Ageing
• Ageing per se does not increase disease susceptibility and does not seem to impair healing responses.
• Not a good reason to treat someone differently to another patient – doesn’t rule out e.g. regenerative surgery.
• Periodontal treatment works and alleviates quality of life issues

Implants
• Livin (2013) – periodontal treatment works as well as implants.
• No evidence that implants are better for the older patient than treating their periodontal disease.
• Implants are a viable treatment and good treatment for replacing missing teeth but not a reason to extract.

Periodontal disease and systemic health
• Many studies have shown associations between periodontal disease and risk of various other factors.
• Associations – may be causal, may be related by additional common factors, may be related by residual confounding or may be spurious.
• Studies – difficult to prove causality so the debate goes on!
• But clear we should regard dental and periodontal as part of general health.

Summary
• There is a markedly increased prevalence of periodontitis in the older patient.
• Periodontitis has significant impact on patients’ well being and quality of life.
• ‘Normal’ periodontal treatments are equally applicable to the older patient.
• Risk factor assessment and possible systemic effects need to be considered carefully.
• We need further information on how systemic factors impact on periodontal disease.

Periodontology

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