Common Dental Questions answered by Dr. S.N White

Hippocrates, the father of modern medicine, recorded a collection of facts about the elderly and old age. Among them was the idea that older persons need to consume less food to be healthy. Having fewer teeth, of course, is not necessarily a dividend in that respect for those who lose their teeth through age. Dr. S.N White explains the attention and care for the special patient whose changing biological structure is quite different from that of the younger patient, requiring a particular expertise and consideration for dental problems peculiar to the later years.

Q. In what ways are teeth different when we get older? 

A. Teeth do change as we age. Older people have different problems in keeping their teeth and mouths healthy than do younger people. The older you are, the more likely it is that you will suffer from advanced periodontal disease, root caries, tooth wear, shrinking jawbones, and even cancer of the mouth. A good general dentist who combines modern technology with an understanding of the special biological problems of the elderly will help to see that such conditions do not get out of control.

Q. What are the special problems or conditions of the elderly patient? 

A. First, there is periodontal (gum) disease. This condition, which affects virtually the entire population in some degree, tends to be more prevalent and severe in older populations. Red, swollen, and inflamed gums (gingivitis), when untreated, can lead to destruction of the bone surrounding the teeth (periodontitis). If sufficient bone support is lost, the teeth can actually feel loose. Periodontal disease is the major cause of tooth loss after middle age.

Q. You listed root caries. Does this afflict the same age level?

A. Cavities at the roots of the teeth are more likely to occur among persons 70 and over. Good care in brushing and flossing is particularly essential to prevent the problem. A fluoride rinse on a regular basis has also been shown to be of some benefit. Prompt treatment of this type of decay is important because of its particularly rapid advance through the tooth root.

Q. What can be done about natural wear and usage over a period of many years? 

A. At advanced ages, dental patients will often show greater tooth wear on the chewing surfaces. This becomes a problem when teeth become very sensitive or when the wear is enough to affect the way a person's teeth come together when chewing food. Coatings and desensitizing drugs are available, which help in some instances. With shrinkage of jawbones (maxillary or mandibular resorbtion), it has been shown that the presence of natural teeth stimulates the formation of new bone in the jaws, even in old age. It is for this reason that even a few natural teeth should be preserved for as long as possible. When all of the teeth are lost, a certain amount of jaw shrinkage occurs every year. Old patients who have been without natural teeth for many years may have severely resorbed jawbones, which can make denture wearing difficult. A loose denture does not always have to be remade. In some cases, modifications to the old denture are less costly and require a shorter adjustment period.

Q. What are the signs of cancer of the mouth? 

A. While a dentist generally does not treat this disease, he or she can often help spot it so that medical attention can be obtained early, when cure is most likely. Red or white spots in the mouth that bleed or do not heal in two weeks are cause for suspicion. They can be easily and quickly checked by a dentist.

Q. What are the particular aging changes that need special attention other than the usual ones of growing old such as getting gray, slowing down, or economic problems? 

A. The other aging changes that exist are changes in tissue tolerance, your ability to accommodate something new. Actually, many of the things you can manage to bear at a younger age become much more difficult at an older time in life such as reduced salivary flow and altered pain threshold. For example, with aging there are many benign changes, your hair gets a little grayer, your hearing begins to deteriorate, and you walk a little slower. You may be more depressed than usual, especially today, if you are on a fixed income. That's quite understandable. These are benign changes.

Q. I think they are malignant changes. 

A. That's a good point. However, this wouldn't directly affect the way you treat a patient in that category.

Oral Health and Cardiovascular Disease

Q. Aren't technological advances in dental equipment and procedures reducing the problems of dental care and dentistry, especially for the elderly? For example, there was a time when we had to go through frightening experiences with the use of standard drills. Now, with highpowered drills that you can't hear or feel, the dentist's chair is half pleasant. Doesn't this kind of development ameliorate the treatment, as you put it, of benign problems that accrue in old age? 

A. That is precisely what we are trying to explain in geriatric treatment. The problems of biology and age are not really solved by a lot of the technological advances that we have. Much more important in the care of the aging patient is to consider the actual needs of a patient, the ability to tolerate a prosthesis, or the ability to take a certain amount of care.

Q. What is an aging patient? At what point do we know? We just don't all of a sudden at 65 stop being what we were at 64. When do we know that we're in the category of an elderly patient requiring geriatric care?

A. Again, it's not clear. The 65 number is one that's been used for legal purposes. However, the aging process doesn't have a number. We have patients who are 85 who may look 60 years old, who may have an emotional level or think of themselves as a 25 year old. That type of patient obviously presents certain problems in management. And the practitioner should have the ability to recognize that.

Q. Suppose they are young physiologically and appear to be in excellent condition? 

A. It has been reported in studies that there are actually three different kinds of aging. There's the chronological age, the physiological age, and the emotional age. And these three ages in the normal individual should jibe. When we have marked discrepancies among these three categories, then we have a patient who is more difficult to manage and treat.

Q. If we have established what is considered to be an elderly patient requiring that specialized treatment, would it come at a particular age figure? How would the problem be identified through chronological examination? 

A. The tissue changes do occur gradually. The 65 year old individual may have tissues that are quite young. And so that person, for all practical purposes, would be treated as a younger individual. We see things in the oral structures, though, with the passage of time that do not escape any individual. We have an increase in periodontal disease as we get older, as we do with our eyesight. We become less meticulous with oral hygiene.

Q. What is the negative outcome of lessened salivary flow? 

A. Saliva is an essential ingredient for oral health. We don't realize it, but saliva does bathe the dentition and help keep the teeth clean. With diminished salivary flow, there is a great buildup of food debris around the dentition or, if there is a prosthesis, around that. Salivary flow is very important from an oral hygiene point of view, and as the years go by we do tend, as the euphemism states, to dry up. Drying up has been made out to be a humorous situation, but it does have ramifications in the oral cavity. If a patient has a prosthesis, saliva tends to keep the prosthesis in place. We need a certain amount of fluid to effect some kind of a suction in an upper denture. These are common problems for the older patients: the lack of saliva, the lack of water the cells typically lose water as they age.

Q. At what age do we begin to have a salivary flow problem? 

A. It's difficult to say. It can happen in a 50 year old, but we see some 85 year olds with excellent salivary flow. One of the things we have to be very careful of with the aging patient is to do a careful assessment of his or her medical condition. Most people after the age of 65 have many medical problems that may be at subclinical levels; that is, they are not active problems, but they are existing. These include arthritis, cardiovascular problems, and emotional problems. Many of these patients are seeing physicians, and many are taking drugs.

Q. Is nutrition an important factor? Would you recommend therapeutic doses of vitamins in middle age with regard to tissue efficiency in the elderly? Tissues are made up of collagen, for example, and vitamin C is thought to be a good builder of collagen. Have studies been made recommending massive dosages of vitamin C or E? What is your position regarding that element as part of overall preventive care? 

A. Certainly, it's a very good point, and nursing homes do give vitamin supplements routinely to patients. One of the big problems with the aging patient and the one who has chronic degenerative disease is that the vitamins that are essential are available, but they are not being utilized. Certain tissues in the body are breaking down, and reactions within the body are preventing utilization of essential ingredients because of other breakdowns. So we have to get into very sophisticated studies of immune reaction and breakdown of tissue. It is not simply a question of putting large amounts of essential ingredients in place. We have tried that, and it doesn't always work. Certainly there are nutritional deficiency cases, but the problem is much more sophisticated and complicated than that. If that were the only problem, then we could assure people of living much longer lifespans than they do.

Q. You describe the elderly as special patients. What are these special problems that derive from special patients? What are the prevalent ones for most of the elderly? 

A. Some of the most difficult and frustrating problems are in the area of prosthetics, meaning the replacement of missing parts and missing teeth. Sometimes we find a patient whose expectations may be unrealistic. They want and expect, and maybe not unjustifiably, a prosthesis to function as the natural dentition did.

Q. Why should that not be an expectation in this day of modern technology? We are told by dental specialists that teeth implantation is now at the point where it works very well, as good as new. 

A. We have made great advances in technology. People expect complete success in all medical procedures. In many cases we can't quite live up to some of the expectations. We do the best we can in many instances; for example, if we treat a patient without a natural dentition, an implant will provide that patient with a more retentive denture than a removable one that just rests on the tissues. However, all of the problems of tissue tolerance still exist. We have a framework on an implant that can fail for the same reasons that the individual's natural dentition failed. Why should we assume that something that we make is any better than what the patient was given biologically that didn't work out? The same train of events that lead to failure in natural biological situations are also operating in the artificial, and this is the most difficult thing to get patients to accept.

Q. Although this may not be a major problem, some people are concerned about it. The glue or cement that holds dentures in place contains harmful chemical residues that would affect the health of their systems. Is that a serious concern? 

A. These are all excellent points, because these are questions that are asked all the time. One problem we are having in this field is that so little interest has been shown within recent years in geriatrics. No study has been done to date that will document the effects of the denture adhesives over the long term in the oral cavity. What I'm speaking of now is the regular dental paste. We do know that some of the commercially available denture liners do cause a lot of harm because they exert undue pressure on sore tissues and can cause further breakdown. As far as the denture adhesives go, we don't really know what they do over the long term, but it is a recognized problem. We have a retention problem, and we have an area where people are desperate to try something, and the over the counter remedies are a great temptation. Usually the experienced prosthedontist can help these cases with proper extension of the dentures into the critical areas. No matter how much tissue is lost, there are usually places in the mouth where we can get additional retention. However, if we do have an aging patient and there is very little saliva flow, even an anatomically perfect prosthesis will give the patient the feeling of looseness.

Q. Is the medical and dental profession developing more sensitivity to the problems of treating the elderly? Are they becoming more patient and understanding? 

A. Yes, many of the schools have instituted programs whether they are called geriatric dentistry, or whether they go under the title of community dentistry. Students are taught in different ways to be more cognizant of the needs of elderly patients. It is, however, very difficult to get these courses into the curricula because of time slots, but the educational institutions are coming around.

Q. If you have two teeth missing on the bottom with a third one going and you don't like dentures, can anything be done for this condition? 

A. If you have just two or three teeth (lower teeth) missing in the front of your mouth and you have all of your other teeth intact, you can have what is called a fixed prosthesis, which means it doesn't have to be removed. However, you do need sound teeth bordering the space, so that the replacement teeth can be attached to them.

Q. How do you find a good dentist? 

A. The best way is to speak with friends whom you regard highly and for whom you have respect, and find out who their practitioner is.

Q. If dentures are made with silver or metal palates, what does the silver do to the denture?

A. Most complete upper dentures are made with all acrylic, which means all plastic. The metal palate attempts to lighten the case a little bit, and it also helps to transmit some of the temperature changes a little more accurately than the plastic does. It makes for a stronger denture if you have a very hard musculature. Sometimes we see fractures of all plastic complete dentures, so the complete denture made with a metal palate makes for a stronger case. One of the disadvantages of having a metal palate is that it is more difficult to add plastic to the inside to tighten it at routine visits, and it is a bit looser.

Q. Is it better to have the clear plastic? 

A. Under most circumstances, the all acrylic complete upper denture is simpler and easier to manage and is more amenable to adjustments than a metal palate case.

Q. What if you get a numbness in the lower chin from lower dentures? Is that a cause for concern? 

A. If you get a numbness, you may have excessive pressures on some of the nerves in what we call the mucobuccal fold, the denture may be overextended in certain areas, and it would be best to have your dentist check on the border extension of the lower prosthesis.

Q. If my teeth are loose from bone loss, can anything be done to save them from coming out? 

A. One of the great problems of dentistry today is the management of bone loss in periodontal disease. At what point do we recommend the removal of all teeth? That becomes a very difficult decision to make. A lot depends on who the patient is, his or her age, how badly he or she wants to keep his or her own teeth, and how much time, effort, and expense the patient wants to go through to maintain the remnants of a failing dentition.

Q. Is that a decision that one should always consider important enough to get the opinion of two or three dentists? 

A. By all means, but it should be carefully discussed with the patient on the basis of a very thorough diagnosis.

Q. Where there is loss of bone, does one ever grow new bone through electrical stimulation? 

A. It is very difficult to grow or regenerate new bone in the oral cavity once there has been deterioration. Research has been done on electrical stimulation, but it has not been carefully documented.

Q. Can loose teeth be tightened up again, and does having the flu affect the gums in this respect? 

A. In this case, the person probably has periodontal disease. This is an inflammation of the tissues around the teeth and possibly some bone loss. Any kind of systemic illness or low resistance will accelerate any existing disease that is present. What has happened is that the flu has exacerbated an acute reaction in a condition that was rather chronic previously. When the general health level is improving, then probably the severe and acute situation will subside, and a dentist should be seen to treat the chronic condition.

Q. In the case of a 22 year old, what would be the prognosis when an impacted third molar was extracted a short time ago, and the patient is left with numbness along the tongue and gum on the side of the extraction? Can anything be done? 

A. Usually, in our experience, that is a common occurrence in a difficult extraction of a third molar, because in order to remove some of these teeth, the roots of the third molar sometimes actually touch the main nerve trunk to the lower jaw. So it's almost virtually impossible to remove some of these teeth without damaging nerve fiber, and some of those fibers enervate the tongue or the skin around the lip. Usually there is a regeneration of that nerve and the fibers that were severed, but it may take several weeks or months or a year or longer, but in most cases the sensation does come back.

Dental Implant Problems and Solutions

Q. Can a precision removable denture that has been in the mouth for 25 years and is now loose be restored?

A. If it is a precision attachment case and it has lasted 25 years, you have done very well with it, and you've been very fortunate. In 25 years, a lot of changes take place in the mouth and in the tissues, and that prosthesis has been subjected to a lot of stress over 25 years of mastication. It might be time for a new one, but today it might not be made in gold as it was previously.

Q. Where dentures have been worn successfully for 30 years and a recent complete lower denture is put in, resulting in a painful experience and the necessity of having them realigned over a long period of time, what can be done to improve the condition? Can realigning help? 

A. Your disappointment in the complete lower denture is quite common. They are much more difficult to get used to and to accommodate than complete upper dentures. The fact that you wear the lower denture is a very good sign. It shows that you are motivated and are willing to bear discomfort in order to get used to them. The fact that the lower denture does move up and down is another problem. There are things that can be done to stop the movement of the lower denture, but perhaps the most important factor influencing the success of a complete lower denture is the ability of the patient's neuromuscular mechanism (which means the nervous system) to accommodate to the denture, and that is a very difficult phenomenon for most people. That is why we try to retain the remnants of the lower dentition as long as we can.

Q. What is a good tooth powder or paste, and is fluoride effective for the elderly?

A. Fluoride helps the elderly, but it is not as effective as it would be for the child. As far as using powders, they are generally more abrasive than paste, and if you are getting an abrasion erosion problem, brushing vigorously with a powder will tend to increase the abrasion and damage to the dentition. Avoid hard brushing, use a soft toothbrush, and tend toward a paste rather than any kind of powder. If there is a lot of acid, the best thing to explore is your diet.


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