Geriatric Dentistry by MikeJenny

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									       Geriatric Dentistry




     Abdel Rahim Mohammad, DDS, MS, MPH, FAAOM
     Abdel Rahim Mohammad, DDS, MS, MPH, FAAOM
Professor and Director of Geriatric Dentistry and Community
Professor and Director of Geriatric Dentistry and Community
            Outreach & Engagement Programs
            Outreach & Engagement Programs
       The Ohio State University College of Dentistry
       The Ohio State University College of Dentistry




       Cases in Geriatric
          Dentistry




   Case 1(Alzheimer’s Disease)

• 65 y.o. Caucasian female with a diagnosis of
 severe early onset Alzheimer’s disease.
• C.C.: none verbalised
• PMH: Patient had a total joint arthroplasty
 2.5 years ago. She has unstable diabetes
 type II. She suffers from dysphagia and has
 a gastric tube.
            Medication History

    Medical             Drug           Oral Effect
   Condition
  Alzheimer’s     Aricept                 None
                  (Donepezil)
    Diabetes      Glucophage              None
                  (Metformin)
     Severe       Haldol                Tardive
    Delerium      (Haloperidol)        dyskinesia




                 Oral Status

• Teeth Present:
x| x |3| 4 |5 | 6 | 7 |8 9 |10|11| x |x | x |x |x
x|31|P|29|P|27|26|25 x |x |22|21|x |19|x |x

• Documented dental history of bridge from
 27 to 31. Tooth number 21 +3 mobility. Teeth
 number 4, 5, 6, 8, 11, 25, root caries.




               Behavioral Signs

• Patient is moaning and her hand is
 either over her abdomen or in her
 mouth.
      Overall Recommendations for
    Treatment of Alzheimer’s Patients
•   Medications may cause salivary gland dysfunction,
    hypotensive episodes, and may adversely interact
    with epinephrine.

•   Caregivers must be trained to assist with daily oral
    hygiene.

•   Aggressive prevention programs including topical
    fluorides must be initiated.

•   More frequent recall appointments are needed.

•   Short acting anxiolytic benzodiazepines (e.g.
    diazepam, lorazepam, oxazepam) administered
    before dental treatments may be helpful.




     Early Stage Recommendations
•   Treatment plan should anticipate
    accelarated oral health decline , therefore:
    1)Eliminate potential sources of pain, pathology, or sites of acute
    infection
    2)Restore function as soon as possible.
•   Provide routine dental care with minor
    modification
    Moderate Stage Recommendations
•    Expect uncooperative behavior.

•    Short appointments may be less stressful for the
     patient and clinician.

•    A thorough extraoral, intraoral, and radiological
     examination may not be possible: therefore the
     caregiver role is necessary to provide symptomatic
     or objective relief.

•    Advise caregivers that daily oral hygiene will be their
     responsibilities.

•    Treatment plans should not be complete
     rehabilitation (e.g. reline rather than remake
     dentures). But designed with minimal changes.




        Late Stage Recommendations

•    Avoid complex and time-consuming dental
     treatment.

•    Intra-venous (IV) sedation or general
     anesthesia for necessary dental care.

•    Treatment must focus on :
•    Removing unrestorable teeth
•    frequent oral hygiene measures.




     Treatment Planning Assessment
        of the Alzheimer’s Patient

        Mild Disease          Moderate Disease            Severe Disease

    Aggressive prevention     Aggressive prevention     Fluoride gels or
    program including         program using topical     varnishes. High risk of
    topical fluorides         gels. Mouth rinses with   aspiration
                              caution.
    Short appointments        Short appointments,       Short appointments
                              anxiolytics prn           with sedation

    Treatment aimed at        Restore function, but     Treatment aimed at
    restoration of function   less aggressively.        emergency and
                              Modify toothbrushes       maintenance care
        Case 2 (Osteoporosis)
• Mrs. H is 78 y.o. Caucasian
• C.C.: “Teeth need fillings”
• Med Hx.: Knee replacement 3 yrs. Ago
             Scoliosis of spine, Rheumatoid
             Arthritis, Osteoporosis,
             Hypertension, GERD




              Medication History
     Drug                 Dose              Indication

Calcium            400 mg               Calcium sup.
Pantoloc           40 mg                GERD
Apo-               200 mg               R.A.
hydroxyquin
Synthroid          0.112 mg             Hypothyroid
Calcitonin         2 nose sprays        Osteoporosis
Fosamax            70 mg                Osteoporosis
Evista             60 mg                Osteoporosis
Novamilor          55mg                 Diuretic




                   Oral Status
• Intra Oral Exam:
 X|X| 3 | 4 | 5 | 6 | 7 | 8 | 9 |10|11|12|13| P|15| X
  X|X|30|29|28|27|26|25|24|23|22|21|20|19| X |X

• Teeth 19,20 severe caries. #29 +3 mobility
• Supragingival calculus noted
    Case 3 (Medically Complex Conditions)
• Patient is a 76 y.o. Caucasian male
    C.C.: Aphasic, none verbalized. Son felt that his father was
    in pain. Esthethics was not an issue.
    PMH: Left CVA resulting in a right-sided hemiplegia, and
    aphasia.
•     cardiomyopathy, CHF, diverticulitis. Prostate ca. 5 yrs
    ago treated by surgery and radiation. He has dysphagia
    and has a gastric tube.


• Vital signs and Lab. tests
• BP 110/60, Temp. 37    o C.,   Resp. rate 12
• INR 2.4




       Patient/Family Expectations

• As patient was aphasic, all expectations
    were expressed by his son.

• His son hoped that the rehabilitation of his
    father’s mouth would lead to the removal of
    the gastric tube and reversal of his
    dysphagia.

• The son admitted that esthetics were not of
    major concern.




          Patient/Family Expectations
               Dental Response

• It was clearly stated to the son and father
    that the treatment prognosis was guarded.

• He was also informed jointly by the speech
    pathologist/physician/dental team that even
    with rehabilitation of his oral cavity, the
    dysphagia may not be reversible.
                             Current Medications




                  Oral Examination
Oral Examination
         x | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 |10| x |12|13|14| x | x
         x |31| FPD |28|27|26|25|24|23|22|21| FPD |18 | x

• Plaque and calculus levels were abundant on all remaining
    teeth.

• Teeth 8, 9 were root tips
• Caries noted on teeth 7, 13 and 31. Abutment teeth 18,21
    and 28and 31 were all carious.

• All molars had furcation involvement. The two fixed
    bridges had a mobility of +1

• Xerostomia




              Treatment Considerations
•   Patient’s CHF
    –  Patient became short of breath when stressed, the use of N2O
       was used to both ↑ oxygen delivery as well as axiolytic.
    –  Dental chair was not reclined as per normal patients to assist
       respiration.

•   Patient’s Anticoagulation
    –  INR’s were checked prior to scaling or oral surgery

                     Dental Treatment
•   Bridges removed to evaluate caries status. Teeth were filled with
    glass ionomer/composite laminate

•   Teeth 7, 8, 9 were extracted.

•   Partial acrylic dentures were made to replace missing teeth.
         Treatment – Oral Hygiene

• Patient was able to follow simple directions.
  Due to his right hemiplegia, oral hygiene
  measures had to be modified.




                   Case 4

• “A Tooth is piercing through
  the lip”




April 6, 2006




                                 June 12, 2006
Oral Hygiene in Institutionalized
            Patient
MINI IMPLANTS
                                September 22, 2003


               March 22, 2006




Case

The Patient:
• 77 y/o female with h/o
  cerebral aneurysm
• Is dependent in ADLs;
• Now lives her husband; married 50 yrs
• Modest cognitive impairment; follows
  simple commands; but has verbal
  disinhibitions
Case

Medical History
• Aneurysm – remote
• Dependent in ADLs
• Medications:
    – OTC analgesic




Case

Dental History
•   Has not seen a dentist in 10 yrs
•   Moderate to poor oral hygiene
•   Fractured, carious teeth
•   Periodontal disease
•   Ill-
    Ill-fitting maxillary RPD
•   No RPD in mandible
•   Abfracted lesions




Case
     Case

    Dental expectation:
    • Cc: Needs a check up and teeth fixed
       – Husband requests implants for her maxillary teeth
                                                                        for
       – Is willing to commit to bringing the patient 70 miles each way for
         treatment because no one else will care for her.




     Case
Rational Care Planning
• Medical:                        Post aneurysm with paralysis &
                                  cognitive deficits
• Medication:                     NA
• Functional Status:              Dependent status for
                                  some ADLs
• Psychological:                  Moderate cognitive impairment
                                  with social disinhibition




     Case
Rational Care Planning
• Behavioral:                            Pleasant, cooperative
• Financial:                      Spouse has insurance
• Social:                         Socially inappropriate on
                                  occasion; Need realistic
                                  plan for care
•    Caregiver:                   Husband
•    Motivation                   Well-
                                  Well-intentioned
•    Provider:                    NA
•    Quality of Life:             Opportunity; with challenges
    Case
Treatment Plan:
•   Extract maxillary teeth
•   FUD
•   Restore mandibular caries
•   Preventive plan
    – 3 month recall
    – 1.1 % Sodium fluoride gel




    Case

    Case Notes:
    • Dental care must be functional,
      manageable, setting realistic goals
    • Ease of appliance use with regards
      to paralysis
    • Esthetically pleasing (care-giver)
    • Maintainable (Prevention)
    • Oral care = Quality of Life




    Case

    Case Notes:
    • Education: essential in developing
      a workable plan that the family could
      consent to.
    • Challenge: Will the patient be able
      to manage a maxillary denture with
      her cognitive and functional status?
  Case

  The Patient:
  • 90 y/o female with AD for 10 years
  • Cared for by her dentist grandson
  • Medical History
     – Hypertension
     – Depression
     – Adenoma of the colon
  • Medications
     –    HCTZ
     –    Elavil
     –    Tacrine




  Case




  Case
Dental History:
PFM Crowns: 8, 9, 10
Maxillary partial denture
Mandibular overdenture:
         - 22, 27 endodontically tx
         - gold dome posts
Lost denture: late in disease
Case
• Case History
  –   AD: symptoms 1989
  –                     1989-
      Disease course: 1989-2001
  –   Early signs:
       • Naming difficulties
       • Suspicion
       • Place super glue in her eye, thinking it was eye
         drop
       • Left the bathtub running and forgot
       • Argumentative without fact
       • Disguised her deficits
       • At diagnosis: “I never thought I would have to do
                 myself.”
         this by myself.”




 Case
  Psycho-
• Psycho-social Issues
  –   Family denial
  –   Moves from independent living difficult
  –   Assisted Living 7 years
  –   Skilled nursing 7 months
  –   Fractured Hip: survived surgery




 Case
• Case History
  Mid-
• Mid-stage:
  –              mix-
      Seasonal mix-up
  –   Distinguish her favorite people
  –   Short term memory problems
  –   Distanced from conversation
  –   Hoarding
  –   Gait disturbance: risk of falls
 Case
• Case History
  Late-
• Late-stage:
  –   Unable to walk
  –   Blank face
  –   Didn’
      Didn’t recognize anyone
  –   Total dependence




 Case
• Case Issues
    Psycho-
  – Psycho-social issues critical
     • Family education
     • Support
  – Medical referral for evaluation early
     • Plan for management
     • Legal issues of consent




 Case
• Case Issues
  – Dental Care
     • Preventive regimen standard of care
        – 1.1 % neutral sodium fluoride in custom trays, if
          possible
        – Chlorhexidine gluconate, if appropriate
        – Other adjuncts to oral care giving
  – Lessen learned:
     • Duplicate all casts for removable partial dentures
           Improving Edentulous Patient’s Diets with Implant Retained Overdentures
    • ABSTRACT
    •The aim of this study was
    to compare the impact of                                                                            HISTORY:68 year old female with
    customized dietary advice                                                                           several missing teeth, non
    on patients' satisfaction                                                                           restorable teeth, periodontitis and
    with their dentures and                                                                             bone loss. She says she wants
    oral health-related quality                                                                         dentures. She has a bad ‘gag
    of life (OHRQoL) in                                                                                 reflex’. Initially approached dentist
    patients wearing implant-                                                                           with questions about implants.
    supported mandibular over                                                                           Medical history is fair. She has
    dentures (IOD) or                                                                                   arthritis and GERD. Patient is taking
    conventional dentures(CD)                                                                           Celebrex and Nexium.

    •REVIEW OFLITERATURE
                                                                                                         DIAGNOSIS: ?
    •The delivery of customized
    dietary advice to edentulous
    patients impacts differently on
    their satisfaction with denture
    comfort, stability and chewing
    ability depending on the nature of
    their prosthesis. This re-
    evaluation of satisfaction occurs
    when edentulous patients
    challenge themselves to consume
    more fruits, vegetables and fibre-
    rich foods. The IOD group                     •BIBLIOGRAPHY
    reported an increased level of                •_*J. Jerome Smith, DDSIMPLANT DENTISTRY
    satisfaction and perceived                    IN BLACK AND WHITE FOR GP’S
    chewing ability whereas it                    •*Ellis JS, Elfeky AF, Moynihan PJ, Seal C,
    appeared that CD wearers may                  Hyland RM, Thomason M.Clin Oral
    have had their awareness of the               Implants Res. 2010 Jan 22. [The impact of
    shortcomings of this sort of                  •dietary advice on edentulous adults'
                                                  denture satisfaction and oral health-related
    prosthesis reawakened.                        quality of life 6 months after intervention.




           Improving Edentulous Patient’s Diets with Implant Retained Overdentures
    • ABSTRACT
    •The aim of this study was
    to compare the impact of                                                                            HISTORY:68 year old female with
    customized dietary advice                                                                           several missing teeth, non
    on patients' satisfaction                                                                           restorable teeth, periodontitis and
    with their dentures and                                                                             bone loss. She says she wants
    oral health-related quality                                                                         dentures. She has a bad ‘gag
    of life (OHRQoL) in                                                                                 reflex’. Initially approached dentist
    patients wearing implant-                                                                           with questions about implants.
    supported mandibular over                                                                           Medical history is fair. She has
    dentures (IOD) or                                                                                   arthritis and GERD. Patient is taking
    conventional dentures(CD)                                                                           Celebrex and Nexium.

    •REVIEW OFLITERATURE
    •The delivery of customized
                                                                                                        DIAGNOSIS:
    dietary advice to edentulous                                                                        Complete edentulism
    patients impacts differently on
    their satisfaction with denture                                                                     TREATMENT PLAN: :
    comfort, stability and chewing                                                                      1) Implant retained dentures using
    ability depending on the nature of
                                                                                                        Locator housing attachments
    their prosthesis. This re-
    evaluation of satisfaction occurs                                                                   2)immediate dentures fabricated to
    when edentulous patients                                                                            be inserted at the time of
    challenge themselves to consume                                                                     extractions,
    more fruits, vegetables and fibre-
    rich foods. The IOD group                     •BIBLIOGRAPHY                                         3) immediate implant placement
    reported an increased level of                •_*J. Jerome Smith, DDSIMPLANT DENTISTRY              along with mini implant placement to
                                                  IN BLACK AND WHITE FOR GP’S
    satisfaction and perceived                                                                          help stabilize the immediate
                                                  •*Ellis JS, Elfeky AF, Moynihan PJ, Seal C,
    chewing ability whereas it                                                                          dentures.
                                                  Hyland RM, Thomason M.Clin Oral
    appeared that CD wearers may                  Implants Res. 2010 Jan 22. [The impact of
    have had their awareness of the                                                                     ALTERNATIVE TREATMENT
                                                  •dietary advice on edentulous adults'
    shortcomings of this sort of                  denture satisfaction and oral health-related          PLAN: Conventional dentures
    prosthesis reawakened.                        quality of life 6 months after intervention.




  -A 63 year old Caucasian female presented
          for dental treatment-10 medical
          diagnoses, one of which is Type II                                                                      History:
          Diabetes -Poly-medicated with 23                                                                        -Chief Complaint: “My dentures hurt.”
          prescription medications-She is a                                                                       -History of Present Illness: Hazel has been
          Medicaid patient and resident of                                                                               wearing her existing dentures for 10
          Columbus -Healthcare Center -The                                                                               years.
          treatment plan chosen involved the                                                                      -Past Medical History:
          fabrication of new upper and lower                                                                             -Coronary Artery Disease
          dentures-The alternative treatment                                                                             -Hypertension-Type II Diabetes
          plans involved implant therapy and                                                                             -Hypothyroidism-Pneumonia
          the focus this case report will be                                                                             -Depression-Insomnia
          review of a diabetes as a relative                                                                             -Chronic Pain-Anxiety-Psychosis
-         contraindication to implant therapy.
-10 non-diabetics and                                                                                            Medications:        Medications (continued):
                           -Only 57.1% of implants placed in
20 type II diabetics                                                                                             -Aspirin-Cymbalta -Oxycodon HCl
                           poorly controlled diabetics returned
were evaluated                                                                                                   -Docusate Sodium -Paroxetine
                           to or exceeded baseline stability
following implant                                                                                                -Ferrous Sulfate    -Polythylene Glycol
                           levels after 16 weeks
therapy                                                                                                          -Gabapentin         -Prilosec
                           -This report suggests that
-Implant stability was                                                                                           -Klor-Con           -Simvastatin
                           hyperglycemias effect on implant
                                                                                                                 -Levothyroxine      -Spiriva
assessed by resonance stability is directly related to:
frequency analysis         1.Microvasculature complications
                                                                         Bibliography                            -Lisinopril         -Torsemide
                                                                  Oates, T.W. “Glycemic Control and Implant      -Lorazepam          -Warfarin
over 4 months              at HbA1c > 8%                          Stabilization in Type 2 Diabetes Mellitus.”
-Glycemic control was                                                                                            -Meloxicam          -Zolpidem Tartrate
                           2.Inhibition of osteoblastic cell      Journal of Dental Research. Volume 88. Issue
determined by Well                                                4. April 2009. Pages 367-371.                  -Metroprolol        -Novolin
                           proliferation and collagen
controlled = HbA1c 6.1                                                                                           -Mucinex            -Symbicort
                           production during callus formation
– 8.0%Moderately           3.Reduced bone formation and                                                           Diagnosis ?
controlled = HbA1c 8.1     mechanical properties of the bone
– 10.0% Poorly             via increased apoptosis of bone-
controlled = HbA1c ≥       lining cells in hyperglycemic state
10.1%Patients with         -In retrospect, implant therapy in
HbA1c ≥ 8.1% had a         poorly controlled diabetics results
greater decrease in        in diminished osseointegration and
stability and required a increased failure rates. Caution
longer time for healing    should be utilized in placement of
-The time required for     implants in diabetic patients with
healing for poorly         poor glycemic control.
controlled diabetics to
the controlled diabetic
group levels required
double the time
   -A 63 year old Caucasian female presented
          for dental treatment10 medical
          diagnosis, one of which is Type II                                                                              History:
          Diabetes -Poly-medicated with 23                                                                                -Chief Complaint: “My dentures hurt.”
          prescription medicationsShe is a                                                                                -History of Present Illness: Hazel has been
          Medicaid patient and resident of                                                                                       wearing her existing dentures for 10
          Columbus -Healthcare Center -The                                                                                       years.
          treatment plan chosen involved the                                                                              -Past Medical History:
          fabrication of new upper and lower                                                                                     -Coronary Artery Disease
          dentures-The alternative treatment                                                                                     -Hypertension-Type II Diabetes
          plans involved implant therapy and                                                                                     -Hypothyroidism-Pneumonia
          the focus this case report will be a                                                                                   -Depression-Insomnia
          review of diabetes as a relative                                                                                       -Chronic Pain-Anxiety-Psychosis
-         contraindication to implant therapy.
-10 non-diabetics and      -Only 57.1% of implants placed in
20 type II diabetics       poorly controlled diabetics returned
were evaluated             to or exceeded baseline stability
following implant          levels after 16 weeks
therapy                    -The research report suggests
-Implant stability was     hyperglycemias effect on implant
assessed by resonance stability is directly related to:
frequency analysis         1.Microvasculature complications
                                                                                  Bibliography
                                                                        Oates, T.W. “Glycemic Control and Implant
over 4 months              at HbA1c > 8%                                Stabilization in Type 2 Diabetes Mellitus.”
-Glycemic control was      2.Inhibition of osteoblastic cell            Journal of Dental Research. Volume 88. Issue
determined by Well                                                      4. April 2009. Pages 367-371.         Alternative Treatment Plans:
                           proliferation and collagen
controlled = HbA1c 6.1                                                                                        1)Place 5 conventional implants in the
                           production during callus formation          Diagnosis ?
– 8.0%Moderately                                                                                                     maxillary alveolar ridge and 4
                           3.Reduced bone formation and                Complete Edentulism
controlled = HbA1c 8.1                                                                                               conventional implants in the
                           mechanical properties of the bone
– 10.0% Poorly                                                                                                       mandibular alveolar ridge. Following
                           via increased apoptosis of bone-            Treatment Plan: Remake upper and
controlled = HbA1c ≥                                                                                                 an adequate healing period, hybrid
                           lining cells in hyperglycemic state               lower complete dentures
10.1%Patients with                                                                                                   dentures with frameworks could be
                           -In retrospect, implant therapy in                utilizing resin and poly-
HbA1c ≥ 8.1% had a                                                                                                   fabricated.
                           poorly controlled diabetics results               urethane teeth. This process 2)Construct conventional upper and lower
greater decrease in        in diminished osseointegration and                would involve initial
stability and required a increased failure rates. Caution                                                            dentures followed by placement of 5
                                                                             impressions, border molding             mini-hybrid implants placed in the
longer time for healing    should be utilized in placement of                and final impressions, wax rim
-The time required for                                                                                               maxillary and mandibular alveolar
                           implants in diabetic patients with                try-in, esthetic try-in, denture
healing for poorly                                                                                                   ridges. Locator attachments could
                           poor glycemic control.                            delivery,
controlled diabetics to                                                                                              then be placed in the dentures to allow
the controlled diabetic                                                                                              for denture retentiveness.
group levels required                                                                                          2)Do nothing.
double the time




         Increased Candida Infection in the Elderly
                                                                                                                       History
  Abstract                                                                                                             • CC of patient: “My false teeth don’t fit”
  A prominent etiologic factor of                                                                                      • History of present illness: Patient
  denture stomatitis is a fungal                                                                                       presented with an ill-fitting upper denture
  infection such as Candida. The                                                                                       that the patient has had for several years.
  pathogenicity and progress of this                                                                                   Under the maxillary denture is a
  disease involves understanding its                                                                                   red/inflammed area.
  adherence to surfaces, cell surface                                                                                  • Past Medical History: Patient’s medical
  hydrophobicity, and patients saliva.                                                                                 diagnosis included, dementia, diabetes, high
  Review of Literature                                                                                                 blood pressure, and other past illnesses.
  Surface properties of dentures, cell         Graph 1: Phagocytosis of viable         Graph 2: Detection of              Medications: Patient is on a multitude of
                                               Candida albicans by salivary and        the cytokines in the
  surface hydrophobicity and saliva are        blood neutrophils from patients         saliva from patients
                                                                                                                       medications such as aspirin, Warfarin,
  all factors that play into infection of      with Candida-related denture            with Candida-related            Nitroglycerin, Amoxicillin (previous
                                               stomatitis and controls                 denture stomatitis and
  Candida. Candida shows that it can                                                   controls
                                                                                                                       infection), Fluoxetine, and Avapro are
  directly adhere to the denture base                                                                                  among the many.
  acrylic allowing it to colonize and                                                                                  Diagnosis ?
  cause an infection. Evidence has also
  shown that the more hydrophobic
  micro-organisms are ,the more able to
  adhere better to acrylic surfaces. The
  human saliva has natural cleansing
  properties and several innate defense
  molecules that helps to prevent fungal
  infections. Xerostomia is prominent in
  the elderly not allowing this innate
  defense to protect them from otherwise
  harmless pathogens. Other factors
  having an effect on fungal infections
  include proper cleaning of the denture
  and leaving it out of the oral cavity.      Bibliography: Arendorf TM, Walker DM. Denture stomatitis: review.
                                              J Oral Rehabil. 1987;14:217-27. , Tatiana Pereira-Cenci;
                                              Altair Antoninha Del Bel Cury; Wim Crielaard; Jacob Martien
                                              Ten Cate. Development of Candida-associated denture stomatitis: new
                                              insights. J. Appl. Oral Sci. vol.16 no.2 Bauru Mar./Apr. 2008.




         Increased Candida Infection in the Elderly
                                                                                                                       History
  Abstract                                                                                                             • CC of patient: “My false teeth don’t fit”
  A prominent etiologic factor of                                                                                      • History of present illness: Patient
  denture stomatitis is a fungal                                                                                       presented with an ill-fitting upper denture
  infection such as Candida. The                                                                                       that the patient has had for several years.
  pathogenicity and progress of this                                                                                   Under the maxillary denture is a
  disease involves understanding its                                                                                   red/inflammed area.
  adherence to surfaces, cell surface                                                                                  • Past Medical History: Patient’s medical
  hydrophobicity, and patients saliva.                                                                                 diagnosis included, dementia, diabetes, high
                                                                                                                       blood pressure, and other past illnesses.
  Review of Literature
                                               Graph 1: Phagocytosis of viable         Graph 2: Detection of           • Medications: Patient is on a multitude of
  Surface properties of dentures, cell         Candida albicans by salivary and        the cytokines in the            medications such as aspirin, Warfarin,
  surface hydrophobicity and saliva are        blood neutrophils from patients         saliva from patients
                                               with Candida-related denture            with Candida-related            Nitroglycerin, Amoxicillin (previous
  all factors that play into infection of      stomatitis and controls                 denture stomatitis and          infection), Fluoxetine, and Avapro are
  Candida. Candida shows that it can                                                   controls
                                                                                                                       among the many.
  directly adhere to the denture base
  acrylic allowing it to colonize and
  cause an infection. Evidence has also                                                                                Diagnosis
  shown that the more hydrophobic                                                                                      • Xerostomia
  micro-organisms are able to adhere                                                                                   • Denture Stomatitis with Candida
  better to acrylic surfaces. The human
  saliva has natural cleansing properties                                                                              Treatment Plan
  and several innate defense molecules                                                                                 • Have the patient use a product such as
  that helps to prevent fungal infections.                                                                             Biotene for the dry mouth ,reline the denture
  Xerostomia is prominent in the elderly                                                                               to insure proper fit and use a denture cleaner
  not allowing this innate defense to                                                                                  on it. For the Candida an antifungal agent
  protect them from otherwise harmless                                                                                 will be given, such as Nystatin.
  pathogens. Other factors having an
  effect on fungal infections include                                                                                  • Alternative Plan: Just to treat the
  proper cleaning of the denture and                                                                                   patient’s chief complaint of the ill-fitting
  leaving it out of the oral cavity.          Bibliography: Arendorf TM, Walker DM. Denture stomatitis: review.        denture, however this would not resolve any
                                              J Oral Rehabil. 1987;14:217-27. , Tatiana Pereira-Cenci;
                                              Altair Antoninha Del Bel Cury; Wim Crielaard; Jacob Martien              of the other obvious problems.
                                              Ten Cate. Development of Candida-associated denture stomatitis: new
                                              insights. J. Appl. Oral Sci. vol.16 no.2 Bauru Mar./Apr. 2008.
                 Drug inuced Gingival Hyperplasia
-A 73 year old Caucasian male present for dental
       treatment-Various medical diagnoses, one
                                                                                                                 History:
                                                                                                                 -Chief Complaint: “My teeth and gums hurt.”
       of which is epilepsy                                                                                      -History of Present Illness: This patient has and history
-Poly-medicated with 21 prescription                                                                                      of tooth pain periodontitis and gingival
       medications-He is a Medicaid patient and                                                                           hyperplasia.
                                                                                                                 -Past Medical History:
       resident of Canal Winchester nursing
                                                                                                                          -Coronary Artery Disease
       home .Patient has been having issues                                                                               -Hypertension
       with his teeth several have been                                                                                   -Type II Diabetes
       extracted; also complains of pain in his                                                                           -Pneumonia
                                                                                                                          -Depression
       gums. For this patient his immediate
                                                                                                                          -Insomnia
       concerns have been taking care of                                                                                  -Anxiety
       symptomatic teeth. Now that symptomatic                                                                            -Psychosis
       teeth have been taken care of he would                                                                             -Epilepsy
                                                                                                                          - Obstructive Bowel Disorder
       like his gums looked at
   Review of Literature
   .                                                                                                         Medications:
   -Aarli’s study consisted of 35 children under                                                             -Dilantin           ):
                                                                                                                                 -Paroxetine
   the age of 16 and 49 adults that were being                                                               -Aspirin
                                                                                                             -Cymbalta           -Polythylene Glycol
   treated for epilepsy. The control group                                                                                       -Prilosec
                                                                                                             -Docusate Sodium
   consisted of 16 children and 15 adults. His                                                               -Ferrous Sulfate    -Simvastatin
   study analyzed low serum levels and salivary                                                              -Gabapentin         -Spiriva
                                                                                                                                 -WTorsemidearfarin
   levels of IgA and the connection to gingival                                                              -Klor-Con
                                                                                                             -Lisinopril         -Zolpidem Tartrate
   hyperplasia. This study shows that in certain                                                                                 -Novolin
                                                                                                             -Meloxicam
   patients phenytoin/dilantin inhibits
                        -
                                                                                                             -Metroprolol        -Symbicort
   production of IgA, this deficiency leads to                                                               -Mucinex
   increased susceptibility to gingival
   inflammation which is likely to be a                                                                      Diagnosis:?
   predisposing factor for gingival hyperplasia.
   - Kim’s study analyzed the treatment of
   cyclosporin, induced gingival hyperplasia with
   the use of Azithromycin. In the study Kim
   looked specifically at the effect of
   azithromycin on cell proliferation.
                                                             Bibliography
   Azithromycin helped to elevate                        Aarli, John A. “Oates, Phenytoin-Induced
   metalloprotienase MMP -1 and MMP-2 in                 Depression of Salivary IgA and Gingival
   fibroblasts which control proliferation. The          Hyperplasia.” Epilepsia. Volume 17. Issue 3.
   results of this study show that azithromycin          May1976. Pages 283-291
                                                         J.-Y. Kim. “Mechanism of Azithromycin
   treatment may help reduce gingival                    Treatment on Gingival Overgrowth.” Journal of
   hyperplasia by reactivating growth regulating         Dental Research. Volume 87. Issue 11. 2008.
   enzymes.                                              Pages 1075-1079.




               Drug induced Gingival Hyperplasia
   -A 73 year old Caucasian male presented for
          dental treatment-Various medical
                                                                                                                 History:
                                                                                                                 -Chief Complaint: “My teeth and gums hurt.”
          diagnoses. one of which is epilepsy                                                                    -History of Present Illness: This patient has and history
          Poly-medicated with 21 prescription                                                                             of tooth pain periodontitis and gingival
          medications -He is a Medicaid patient                                                                           hyperplasia.
                                                                                                                 -Past Medical History:
          and resident of Canal Winchester
                                                                                                                          -Coronary Artery Disease
          nursing home .Patient has been having                                                                           -Hypertension
          issues with his teeth several have been                                                                         -Type II Diabetes
          extracted; also complains of pain in his                                                                        -Pneumonia
                                                                                                                          -Depression
          gums. -For this patient his immediate
                                                                                                                          -Insomnia
          concerns have been taking care of                                                                               -Anxiety
          symptomatic teeth. Now that                                                                                     -Psychosis
          symptomatic teeth have been taken care                                                                          -Epilepsy
                                                                                                                          - Obstructive Bowel Disorder
          of he would like his gums looked at.
       Review of Literature
                                                                                                             Medications:
   Aarli study consisted of 35 children under                                                                -Dilantin           ):
   the age of 16 and 49 adults that were being                                                               -Aspirin            -Paroxetine
   treated for epilepsy. The control group                                                                   -Cymbalta           -Polythylene Glycol
                                                                                                             -Docusate Sodium    -Prilosec
   consisted of 16 children and 15 adults. His                                                                                   -Simvastatin
                                                                                                             -Ferrous Sulfate
   study analyzed low serum levels and salivary                                                              -Gabapentin         -Spiriva
   levels of IgA and the connection to gingival                                                              -Klor-Con           -WTorsemidearfarin
   hyperplasia. This study shows that in certain                                                             -Lisinopril         -Zolpidem Tartrate
                                                                                                             -Meloxicam          -Novolin
   patients phenytoin/dilantin inhibits
                        -                                                                                                        -Symbicort
                                                                                                             -Metroprolol
   production of IgA, this deficiency leads to                                                               -Mucinex
   increased susceptibility to gingival
   inflammation which is likely to be a                                                                      Diagnosis: Gingival Hyperplasia
   predisposing factor for gingival hyperplasia.
   - Kim’s study analyzed the treatment of                                                                   Treatment Plan: Gingivectomy and modify use
   cyclosporin, induced gingival hyperplasia                                                                        of Dilantin.
   with the use of Azithromycin. In the study
   Kim looked specifically at the effect of
   azithromycin on cell proliferation.                       Bibliography                                    Alternative Treatment Plan:
   Azithromycin helped to elevate                                                                            -Treat with Azithromycin
   metalloprotienase MMP -1 and MMP-2 in                 Aarli, John A. “Oates, Phenytoin-Induced            -No treatment.
                                                         Depression of Salivary IgA and Gingival
   fibroblasts which control proliferation. The          Hyperplasia.” Epilepsia. Volume 17. Issue 3.
   results of this study show that azithromycin          May1976. Pages 283-291
   treatment may help reduce gingival                    J.-Y. Kim. “Mechanism of Azithromycin
                                                         Treatment on Gingival Overgrowth.” Journal of
   hyperplasia by reactivating growth regulating         Dental Research. Volume 87. Issue 11. 2008.
   enzymes.                                              Pages 1075-1079.




                           Xerostomia and Denture Retention
       Literature Review
       :Xerostomia, a decrease in the amount
       or quality of saliva, is an afflication                                                           •        History
       that affects about 30% of the elderly                                                                        –     CC-”My dentures don’t fit”
       population. This condition occurs                                                                            –     Hx of present illness-2+ years,
       primarily due to the multiple                                                                                      denture has gotten progressively
       medications used by patients. There                                                                                less retentive. Food also penetrates
       are over 1000 medications that can                                                                                 around under extended borders on
       cause xerostomia (2). Lack of saliva                                                                               denture.
       can result in changes in the oral                 Prevalence of reported xerostomia
                                                         symptoms in patients ranging in age from                   –     Past Med Hx-Diabetes (Type II),
       mucosa. In denture wearers, these                                                                                  Depression, Hypertension
                                                         20-80 by number of medications
       changes can cause instability in the
                                                                                                                    –     Medications-Atenolol, Furosemide,
       denture (1). This instability can cause
                                                                                                                          Nardil, etc.
       discomfort and sore spots in the
       edentulous maxilla. This leads to many
       complaints and can result in a patient                                                            •        Diagnosis :??
       no longer using the denture.
       Fortunately, in patients with
       xerostomia that wear removable
       dentures, additional steps can be                  Xerostomia in edentuous arch and
       taken to improve retention during                  tongue
       wear. Patients can use saliva
       substitutes to help wet the mouth and
       aid in mastication of food. Patients can
       also use denture adhesives to improve
       retention. Dentures should be wetted
       before insertion, even if the patient is
       not using adhesive. This will further
       increase retention and may also relieve
       some symptoms of xerostomia.
       Patients should also increase their
       dietary intake of liquids. Furthermore,
       decrease in saliva can lead to an
       increase in incidence of candidiasis. In                    Bibliography
       denture wearers, this incidence rises        1.   Sacchelli S., Calderini A.,
       even more (2). Fortunately xerostomia             Farronato GP., Spadari F.
       can be managed in a variety of                    “Problem of Xerostomia in
       methods, including altering                       Wearers of Complete Dentures.”
       medications, saliva substitutes, and
                                                         Dent Cadmos. 1989 Nov 30;
       increasing fluid intake, among others.
                                                         (57)18:38-43
       Understanding the causes of
                                                    2.   Turner, Jahangiri, Ship.
       xerostomia and its management is
                                                         “Hyposalivation, Xerostomia, and
       critical to treating the growing
                                                         the Complete Denture: A Systemic
       elderly population.
                                                         Review.” J Am Dent Assoc.
                                                         2008;139;146-150
                          Xerostomia and Denture Retention
    Literature Review :
    •Xerostomia, a decrease in the amount
    or quality of saliva, is an afflication                                                                            •     History
    that affects about 30% of the elderly                                                                                     – CC-”My dentures don’t fit”
    population. This condition occurs                                                                                         – Hx of present illness-2+ years,
    primarily due to the multiple                                                                                                  denture has gotten progressively
    medications used by patients. There                                                                                            less retentive. Food also penetrates
    are over 1000 medications that can                                                                                             around under extended borders on
    cause xerostomia (2). Lack of saliva                                                                                           denture.
    can result in changes in the oral                      Prevalence of reported xerostomia
                                                                                                                              – Past Med Hx-Diabetes (Type II),
    mucosa. In denture wearers, these                      symptoms in patients ranging in age from
                                                           20-80 by number of medications
                                                                                                                                   Depression, Hypertension
    changes can cause instability in the
    denture (1). This instability can cause                                                                                   – Medications-Atenolol, Furosemide,
    discomfort and sore spots in the                                                                                               Nardil, etc.
    edentulous maxilla. This leads to many
    complaints and can result in a patient                                                                             •     Diagnosis
    no longer using the denture.                                                                                              – Total edentulism and xerostomia
    Fortunately, in patients with
    xerostomia that wear removable
                                                                                                                       •     Treatment Plan
    dentures, additional steps can be                                                                                         – Remake denture with properly
                                                             Xerostomia in edentuous arch and                                      extended borders when medicaid
    taken to improve retention during
                                                             tongue                                                                allows
    wear. Patients can use saliva
    substitutes to help wet the mouth and                                                                                     – Treat xerostomia with a commercial
    aid in mastication of food. Patients can                                                                                       oral moisturizing gel such as
    also use denture adhesives to improve                                                                                          biotene mouthwash or XERO-lube.
    retention. Dentures should be wetted                                                                                           Brush gums with toothpaste.
    before insertion, even if the patient is                                                                                       Cleanse denture daily to prevent
    not using adhesive. This will further                                                                                          candidiasis. If xerostomia
    increase retention and may also relieve                                                                                        continues consider a prescription
    some symptoms of xerostomia.                                                                                                   saliva substitute; sodium
    Patients should also increase their                                                                                            carboxymethyl cellulose 0.5%
    dietary intake of liquids. Furthermore,                                                                            •     Alternative Treatment Plan
    decrease in saliva can lead to an                                                                                          – Do hard reline on denture to extend
    increase in incidence of candidiasis. In                          Bibliography                                                 borders
    denture wearers, this incidence rises         1.        Sacchelli S., Calderini A.,
    even more (2). Fortunately xerostomia
                                                                                                                               – Explain to patient the limitations of
                                                            Farronato GP., Spadari F.                                              retention of a denture, especially on
    can be managed in a variety of
                                                            “Problem of Xerostomia in                                              resorbed ridges and with
    methods, including altering
    medications, saliva substitutes, and                    Wearers of Complete Dentures.”                                         xerostomia
    increasing fluid intake, among others.                  Dent Cadmos. 1989 Nov 30;                                          – Consult with physician to decrease,
    Understanding the causes of                             (57)18:38-43                                                           alter, or substitute xerostomia
    xerostomia and its management is              2.        Turner, Jahangiri, Ship.                                               causing medications
    critical to treating the growing                        “Hyposalivation, Xerostomia, and
    elderly population.                                     the Complete Denture: A Systemic
                                                            Review.” J Am Dent Assoc.
                                                            2008;139;146-150




  Effect of Simvastatin on Residual Ridge Resorption
                                                                                                                             Historyy:
            Abstract                                                                                                         Chief Complaint: “I want dentures”
-A 62 year old Caucasian female                                                                                              History of Present Illness: Patient has had a
                                                                                                                             history of periodontal disease, caries, and
presented for dental treatment                                                                                               partial edentulism
-Multiple Medical diagnoses
-Patient is currently on twelve                                                                                              Past Medical History:
                                                                                                                                        -Coronary Artery dis.
prescriptions                                                                                                                           gastric reflux
-Patient has medicaid health                                                                                                            -Hypertension
insurance                                                                                                                               -Type II Diabetes
-The research study selected was the effect                                                                                             -CVA
                                                                                                                                        -Pneumonia
of simvastatin on remodeling of the alveolar
-                                                                                                                                       -Depression
bone following tooth extraction in the                                                                                                  -Insomnia
International Journal of Oral and Maxillofacial                                                                                         -osteoarthritis
Surgery.                                                                                                                                -Anemia
-The study used PLGA co-polymer to deliver                                                                                              -Hypercholesterolemia
the simvastatin due to it's biocompatibility
and biodegradability. Some PLGA had
simvastatin (variable) and other did not carry                                          Medications:
simvastatin (control). -Sixty male Wistar rats                                          -Actos 45 mg p.o. q.d.
were randomly divided into experimental and                                             -diovan 80 mg p.o. q.d.
control groups (n=30).                                                                  -folic acid 1 mg p.o. q.d.
-PLGA carrier were implanted into extraction                                            -metoprolol tartrate 100 mg p.o.
                                                                                        b.i.d.
sockets of right mandibular incisors. The rats                                          -nortriptyline hcl 50 mg p.o. q.d.
were killed at 1, 2, 4, 8 or 12 weeks after                                             -omeprazole 20 mg p.o. q.d.
implantation. The relative height of the                                                -sertraline hcl 100 mg p.o. q.d.
residual alveolar ridge was significantly                                               -simvastatin 80 mg p.o. q.d.
greater in the experimental compared to the                                             -acetaminphen 625 mg p.o. Prn
control group at 2, 4, 8 and 12 weeks.                                                  q6h
-The bone mineral density in the                                                        -diabetic tussin ex liquid 10 ml
experimental group was significantly higher                                             p.o.
                                                                                        -hydralazine 10 mg p.o. Q6h
than that in the control group at 4, 8 and 12
weeks.
-A larger newly formed bone island was
observed in the experimental group at 4
weeks, and higher bone formation rate and
quality were found than in the control group
                                                                        Bibliography
at different time points except 1 week.
                                                       The effect of simvastatin on remodelling of the alveolar bone
-The findings indicate that local application          following tooth extraction
of simvastatin would effectively preserve the          Z. Wu, C. Liu, G. Zang, H. Sun
residual alveolar bone by promoting bone               International Journal of Oral & Maxillofacial Surgery -
                                                       February 2008 (Vol. 37, Issue 2, Pages 170-176, DOI:
formation in the extraction socket.                    10.1016/j.ijom.2007.06.018)




  Effect of Simvastatin on Residual Ridge Resorption
                                                                                                                       Historyy:
            Abstract                                                                                                   Chief Complaint: “I want dentures”
-A 62 year old Caucasian female                                                                                        History of Present Illness: Patient has had a history
                                                                                                                       of periodontal disease, caries, and partial
presented for dental treatment                                                                                         edentulism.
-Multiple Medical diagnoses                                                                                            Past Medical History:
-Patient is currently on twelve                                                                                                    -Coronary Artery Dis, gastric reflux
                                                                                                                                   -Hypertension
prescriptions                                                                                                                      -Type II Diabetes
-Patient has medicaid health                                                                                                       -CVA
insurance                                                                                                                          -Pneumonia
-The research study selected was the effect                                                                                        -Depression
                                                                                                                                   -Insomnia
of simvastatin on remodeling of the alveolar
-                                                                                                                                  -osteoarthritis
bone following tooth extraction in the                                                                                             -Anemia
International Journal of Oral and Maxillofacial                                                                                    -Hypercholesterolemia
Surgery.
-The study used PLGA co-polymer to deliver
the simvastatin due to it's biocompatibility
and biodegradability. Some PLGA had                                                                                                  Diagnosis:Complete edentulism
simvastatin (variable) and other did not carry
simvastatin (control). -Sixty male Wistar rats                                          Medications:                                 Treatment Plan: Full mouth extractions
were randomly divided into experimental and                                             -Actos 45 mg p.o. q.d.                       followed by healing and alveloplasty if
control groups (n=30).                                                                  -diovan 80 mg p.o. q.d.                      needed. Make complete upper and
-PLGA carrier were implanted into extraction                                            -folic acid 1 mg p.o. q.d.                   lower tissue supported dentures. This
sockets of right mandibular incisors. The rats                                          -metoprolol tartrate 100 mg p.o.
                                                                                        b.i.d.
                                                                                                                                     process would involve initial
were killed at 1, 2, 4, 8 or 12 weeks after                                             -nortriptyline hcl 50 mg p.o. q.d.           impressions, border molding and final
implantation. The relative height of the                                                -omeprazole 20 mg p.o. q.d.                  impressions, wax rim try-in, esthetic
residual alveolar ridge was significantly                                               -sertraline hcl 100 mg p.o. q.d.             try-in, denture delivery, and post
greater in the experimental compared to the                                             -simvastatin 80 mg p.o. q.d.                 delivery check.
control group at 2, 4, 8 and 12 weeks.                                                  -acetaminphen 625 mg p.o. Prn
-The bone mineral density in the                                                        q6h
experimental group was significantly higher                                             -diabetic tussin ex liquid 10 ml         Alternative Treatment Plan:
than that in the control group at 4, 8 and 12                                           p.o.                                     No treatment
                                                                                        -hydralazine 10 mg p.o. Q6h
weeks.                                                                                                                           Maxillary and mandibular implants
-A larger newly formed bone island was                                                                                           followed by the construction of a
observed in the experimental group at 4                                                                                          hybrid maxillary and mandibular
weeks, and higher bone formation rate and
quality were found than in the control group
                                                                        Bibliography                                             denture.
                                                                                                                                 Mini implants placed on the maxilla
at different time points except 1 week.
-The findings indicate that local application          The effect of simvastatin on remodelling of the alveolar bone             and mandible in order to allow for
                                                       following tooth extraction
of simvastatin would effectively preserve the          Z. Wu, C. Liu, G. Zang, H. Sun                                            locator attachments to be placed in the
residual alveolar bone by promoting bone               International Journal of Oral & Maxillofacial Surgery -                   resin of conventional dentures.
                                                       February 2008 (Vol. 37, Issue 2, Pages 170-176, DOI:
formation in the extraction socket.                    10.1016/j.ijom.2007.06.018)
                                               Removing teeth in a Geriatrics patient
                             Abtract
      . The patient is a 78 yr old female                                                                                                                                                                                                                             History
      with moderate health problems                                                                                                                                                                                                                                      CC: “My left side has been
      including dementia and
                                                                                                                                                                                                                                                                      hurting”
      hypertension. Her chief
      complaint was pain on the left                                                                                                                                                                                                                                     PI: Pt went to outside dentist and
      side of her mouth. On the day of                                                                                                                                                                                                                                they did nothing. Dentist gave her
      the appointment there was no                                                                                                                                                                                                                                    Amoxillin and Vicodin and sent her
      pain present. So she decided                                                                                                                                                                                                                                    away. Pt just knows that her teeth were
      that she would like her two                                                                                                                                                                                                                                     hurting
      broken teeth (#4 and 5) extracted
      while she was there.                                                                                                              References                                                                                                                         PMH: Dementia, HTN, Diabetes,
                                Review of Litrerature                                                                                   (1)    Healthcare proxies of nursing home                                                                                     Anxiety,
                                                                                                                                               residents with advanced dementia:
     In this case one of the woman’s health problems was                                                                                       decisions they confront and their                                                                                      Depresion, B12 defiency, osteoporosis
    dementia. This is interesting because the patient                                                                                          satisfaction with decision-making.
    presented with pain, but was having no pain at the time.                                                                                   Givens JL, Kiely DK, Carey K, Mitchell                                                                                    Medications: Norvase (5mg).
                                                                                                                                               SL. J Am Geriatr Soc. 2009                                                                                             Lopressor (25mg), Amoxicillin (500mg),
    When asked about the pain, she could not remember                                                                                          Jul;57(7):1149-55. Epub 2009 May 21.
    exactly how bad it was or how long she had it. Also,       (2)                                                                             Tooth loss and associated factors in
                                                                                                                                                                                                                                                                      Almopidine Besylate (5mg), Aricept
    ,none of the nurses knew how long she had it. After                                                                                        long-term institutionalised elderly                                                                                    (10mg), Aspirin (81mg), Chlorhexidine
    reviewing an article by Givens JL, it seems that many                                                                                      patients.Tramini P, Montal S, Valcarcel                                                                                gluconate (.12%), Meloxicam (7.5mg),
                                                                                                                                               J.Gerodontology. 2007 Dec;24(4):196-                                                                                   Metoprolol (25mg), hydrocodone
    dementia patients are not happy with decisions they                                                                                        203.
    make and would like more help from health care             (3)                                                                             Systemic diseases among patients with
                                                                                                                                                                                                                                                                      (5/500mg), Diabetic Tussin, Alprazolam
    providers in making them (1). Another issue I would like                                                                                   and without alveolar bone loss.Al-Emadi                                                                                (.25mg), Acetemenephin (325mg) prn
    to address is that you will see that our patients is                                                                                       A, Bissada N, Farah C, Siegel B, Al-                                                                                   pain
                                                                                                                                               Zaharani M.Quintessence Int. 2006
    recommended to have full mouth extractions since she                                                                                       Nov-Dec;37(10):761-5.                                                                                                  Diagnosis: Chronic periodontitis with
    has been in the nursing home. She said before she got
                                                                                                                                                                                                                                                                      most teeth non-restorable.
    to the nursing home she regularly saw a dentist and had
    good oral health care. She said that since she has been
    in the home, she has been losing more teeth. A study
    done by Tramini P. Suggests that “General health
    problems as well as a poor oral condition were
    significant risk indicators for tooth loss among the long-
    term institutionalised elderly” (2).
     Finally, my patient also had hypertension and diabetes
    which can have an effect on how a patient is treated and
    responds to dental surgery. In an article I found there is
    said to be a correlation between systemic disease such
    as diabetes and hypertension, and alveolar bone loss (3).
    This could also be why my patient was starting to lose
    more of her teeth.




                                               Removing teeth in a Geriatrics patient
                             Abtract
      . The patient is a 78 yr old female                                                                                                                                                                                                                             History
      with moderate health problems                                                                                                                                                                                                                                      CC: “My left side has been
      including dementia and
                                                                                                                                                                                                                                                                      hurting”
      hypertension. Her chief
      complaint was pain on the left                                                                                                                                                                                                                                     PI: Pt went to outside dentist and
      side of her mouth. On the day of                                                                                                                                                                                                                                they did nothing. Dentist gave her
      the appointment there was no                                                                                                                                                                                                                                    Amoxillin and Vicodin and sent her
      pain present. So she decided                                                                                                                                                                                                                                    away. Pt just knows that her teeth were
      that she would like her two                                                                                                                                                                                                                                     hurting
      broken teeth (#4 and 5) extracted
      while she was there.                                                                                                              References                                                                                                                         PMH: Dementia, HTN, Diabetes,
                                Review of Litrerature                                                                                   (1)    Healthcare proxies of nursing home                                                                                     Anxiety,
                                                                                                                                               residents with advanced dementia:
     In this case one of the woman’s health problems was                                                                                       decisions they confront and their                                                                                      Depresion, B12 defiency, osteoporosis
    dementia. This is interesting because the patient                                                                                          satisfaction with decision-making.
    presented with pain, but was having no pain at the time.                                                                                   Givens JL, Kiely DK, Carey K, Mitchell                                                                                    Medications: Norvase (5mg).
                                                                                                                                               SL. J Am Geriatr Soc. 2009                                                                                             Lopressor (25mg), Amoxicillin (500mg),
    When asked about the pain, she could not remember                                                                                          Jul;57(7):1149-55. Epub 2009 May 21.
    exactly how bad it was or how long she had it. Also,       (2)                                                                             Tooth loss and associated factors in
                                                                                                                                                                                                                                                                      Almopidine Besylate (5mg), Aricept
    ,none of the nurses knew how long she had it. After                                                                                        long-term institutionalised elderly                                                                                    (10mg), Aspirin (81mg), Chlorhexidine
    reviewing an article by Givens JL, it seems that many                                                                                      patients.Tramini P, Montal S, Valcarcel                                                                                gluconate (.12%), Meloxicam (7.5mg),
                                                                                                                                               J.Gerodontology. 2007 Dec;24(4):196-                                                                                   Metoprolol (25mg), hydrocodone
    dementia patients are not happy with decisions they                                                                                        203.
    make and would like more help from health care             (3)                                                                             Systemic diseases among patients with
                                                                                                                                                                                                                                                                      (5/500mg), Diabetic Tussin, Alprazolam
    providers in making them (1). Another issue I would like                                                                                   and without alveolar bone loss.Al-Emadi                                                                                (.25mg), Acetemenephin (325mg) prn
    to address is that you will see that our patients is                                                                                       A, Bissada N, Farah C, Siegel B, Al-                                                                                   pain
                                                                                                                                               Zaharani M.Quintessence Int. 2006
    recommended to have full mouth extractions since she                                                                                       Nov-Dec;37(10):761-5.                                                                                                  Diagnosis: Chronic periodontitis with
    has been in the nursing home. She said before she got
                                                                                                                                                                                                                                                                      most teeth non-restorable.
    to the nursing home she regularly saw a dentist and had
    good oral health care. She said that since she has been                                                                                                                                                                                                           Treatment Plan:
    in the home, she has been losing more teeth. A study
    done by Tramini P. Suggests that “General health                                                                                                                                                                                                                     Extract all teeth and make upper
    problems as well as a poor oral condition were                                                                                                                                                                                                                    and lower denture-pt did not want this
    significant risk indicators for tooth loss among the long-                                                                                                                                                                                                        option, she said none of them hurt so
    term institutionalised elderly” (2).                                                                                                                                                                                                                              she wants to keep them Instead
                                                                                                                                                                                                                                                                      cleaning was done and she was put on
     Finally, my patient also had hypertension and diabetes                                                                                                                                                                                                           6-month recall # 4 and 5 are broken-and
    which can have an effect on how a patient is treated and                                                                                                                                                                                                          were extracted .
    responds to dental surgery. In an article I found there is
    said to be a correlation between systemic disease such                                                                                                                                                                                                            Alternate plan: Do nothing
    as diabetes and hypertension, and alveolar bone loss (3).
    This could also be why my patient was starting to lose
    more of her teeth.




               ILL FITTING DENTURES AND DRY MOUTH: CAUSES ,SOLUTIONS AND
                         POSSIBLE ALTERNATE TREATMENT MODALITIES
                   Abstract                            History:
   -A 82 year old Caucasian female presented for dental                                                                                                                                                    Flow rate of parotid and                          -Chief Complaint: “My dentures don’t fit and mouth is
                                                                                                                                                                                                           submandibular-sublingual
   Treatment with 9 medical diagnoses, Hx of SC Ca with                                                                                                                                                    (SM/SL) saliva as a function of time                       dry.”
   Radiation. She is Poly-medicated with 19 prescription                                                                                                                                                   after start of radiotherapy
                                                                                                                                                                                                                                                             -History of Present Illness: The Pt has had these
                                                                                                                                                                                                           (conventional fractionation schedule,
   Medications, is a Medicaid patient and is a resident of                                                                                                                                                 2Gy per day, 5 days per week, total                        dentures for past 9 years and has had radiation
   Delaware Court                                                                                                                                                                                          dose 60-70 Gy). The parotid,
                                                                                                                                                                                                           submandibular, and sublingual                              for Sq Cell Ca 3 yrs ago.
   -The treatment plan consists of fabricating a new upper                                                                                                                                                 glands are located in the treatment               -Past Medical History:
                                                                                                                                                                                                           portal. Initial flow rates were set to
   and lower conventional complete denture.                                                                                                                                                                100% (modified after Burlage et al.,                       -Squamous Cell Carcinoma
   -The alternative treatment plans could involve implant                                                                                                                                                  2001).
                                                                                                                                                                                                                                                                      -Hypertension
   supported complete denture prosthesis.or relining the                                                                                                                                                                                                              - Alzheimers
   old denture and/or using denture adhesive for retention.                                                              TABLE                                                                                                                                        -Hypothyroidism
                                                                                                                                                                                                           The use of denture adhesives on ill-
   -The case report will be a review of the after effects of                                            RESULTS OF RADIOTELEMETRY MEASUREMENTS

                                                                                                                  Total Chews    Total Pressure                     Total time
                                                                                                                                                                                                           fitting dentures and new dentures will                     -Depression
   radiation on salivary flow ,consequent adjuvents                                        Conditions
                                                                                                                 per Test
                                                                                                                      Food Piece   (kg/cm2)
                                                                                                                                                Mean Pressure per Chew
                                                                                                                                                      (kg/cm2)
                                                                                                                                                                            T me per Chew
                                                                                                                                                                            (sec) (sec)                    allow patients to increase the force
                                                                                                                                                                                                                                                                      -Insomnia
                                                                                           Old dentures
                                                                                                                                                                                                           they can apply to foods in chewing. In
   that can be used to increase saliva flow and the use of                                 No adhesive
                                                                                           Adhesive (one
                                                                                           application)
                                                                                                                        63

                                                                                                                         68
                                                                                                                                        6.6

                                                                                                                                        11.2
                                                                                                                                                           0.1

                                                                                                                                                            0.2
                                                                                                                                                                              41.1

                                                                                                                                                                              42.4
                                                                                                                                                                                               0.7

                                                                                                                                                                                                0.6
                                                                                                                                                                                                           the instance of old, ill-fitting dentures,                 -Fibromyalgia
                                                                                                                                                                                                           this increase may be considerable.
   adhesives on the old ill-fitting dentures and their                                     Adhesive (two
                                                                                           applications)               100              13.1                0.1               60.1              0.6
                                                                                                                                                                                                           Adhesives allow much greater total                         -Anxiety/ Psychosis
                                                                                           Gel                          62              14.2                0.2               37.9              0.6
   influence on oral microorganisms.                                                       New dentures
                                                                                           No adhesive                  60             12.0                0.2                39.5               0.7
                                                                                                                                                                                                           pressure to be applied to the mucosa
                                                                                                                                                                                                                                                                      -Deep Vein Thrombosis
                                                                                           Adhesive (one                                                                                                   during the chewing of a given quantity
                                                                                           application)                  58             17.0                0.3               37.8                   0.6
                                                                                                                                                                                                           of food. The time taken to chew the
                                                                                                                                                                                                                                                                                         Medications (continued):
         Review of Literatures                                                             Adhesive (two
                                                                                           applications)
                                                                                           Gel
                                                                                           Note: Information obtained from under complete maxillary denture when chewingstandard carrot test food.
                                                                                           Vol 50 No. 4
                                                                                                                        56
                                                                                                                        65
                                                                                                                                       17.5
                                                                                                                                       18.1
                                                                                                                                                           0.3
                                                                                                                                                           0.3
                                                                                                                                                                              37.4
                                                                                                                                                                              41.1
                                                                                                                                                                                                     0.6
                                                                                                                                                                                                     0.6
                                                                                                                                                                                                           foods does not vary substantially            Medications:
                                                                                                                                                                                                                                                        -Aspirin
                                                                                                                                                                                                                                                                                         -Aricept
                                           -Quantitative changes include                                                                                                                                                                                                                 -Nexium
-Research report selected was Oral                                                                                                                                                                                                                      -Effexor
                                               a. p H ↓ from 7.0 to 5.0                                                                                                                                                                                                                  -Simvastatin
Sequelae Of Head And Neck                      b. ↓ buffering capacity because of ↓in                                                                                                                                                                   -Zoloft
                                                                                                                                                                                                                                                                                         -Warfarin
Radiotherapy                               bicarbonate concentration in parotid saliva                                                                                                                                                                  -Docusate Sodium
Vissink, J. Jansma, F.K.L. Spijkervet,         c. ↑ In Na , Cl, Mg , Ca concentration                                                                                                                                                                                                    -Lyrica
                                                                                                                                                                                                                                                        -Ferrous Sulfate
F.R. Burlage, and R.P. Coppes                  d. ↑ in immunoproteins (IgA, lactoferrin,                                                                                                                                                                                                     -Zolpidem Tartrate
-Dutch researchers gathered                Lysozyme) but because ↓ in overall quantity                                                                                                                                                                  -Gabapentin
                                                                                                                                                                                                                                                                                             -Lorazepam
information from experiments done on       of saliva flow rate there is a significant                                                                                                                                                                   -KCl 20
rats and follow up on post radiation       immunoprotein deficit.                                                                                                                                                                                                                            -Furosemide
                                                                                                                                                                                                                                                        -Synthroid
head and neck cancer patients.             -There is a pronounced ↑ in acidogenic,                                                                                                                                                                                                           -Carvediol
-The clinical consequences of              cariogenis microorganisms like S. mutans,                                                                                                                                                                    -Oxycontin
                                                                                                                                                                                                                                                                                             -Lisinopril
radiation therapy include mucositis        Lactobacillus and Candida species.
and taste loss which are reversible,       -Efficiency of Denture Adhesives and their
hyposalivation (dry mouth) and             Possible Influence on Oral Microorganisms
radiation caries which are irreversible    G.D. Stafford and C. Russell
and osteoradionecrosis and radiation       -Clinical tests done on 60 CD wearing pts
caries which are a life long threat        -Materials and Methods: Miniature
-4 phases of hyposalivation post           inductance pressure transducer and
radiation                                  radiotelmetry circuit
   a.0-10 days –rapid ↓ in flow rate       -Ill fitting dentures and 2 sets of new
without changes in amylase secretion       dentures made.
or acinar cell #                           -measurements taken by pressure gauge at
   b. 10-60 days-↓ amylase secretion       base of palatal surface of maxillary denture
and acinar cell #                          midway b/w midline and artificial teeth in
   c. 60-120 days- no change in any of
the three
   d. 120-240 days- further
                                           first molar region on left side
                                           -test food used was std cylinder of fresh
                                           carrot cut by cork borer into 1 inch pieces
                                                                                                                                                                  Bibliography
deterioration of gland function            -2 denture adhesives shosen- gel and paste
-A rapid ↓ in salivary flow rate during    -4 denture pwdr and 2 pastes were tested
                                                                                                        Oral Sequelae Of Head And Neck Radiotherapy
first week of radiotherapy followed by     for microbial growth by inoculating for 2                    Vissink, J. Jansma, F.K.L. Spijkervet, F.R. Burlage, and R.P.
gradual decrease to less than 10% of       days with at 37 C after sterilizing and                               Coppes
initial flow as depicted in above graph    adding 1 % sucrose and adjusting p H 6.8                              Critical Reviews in Oral Biology & Medicine, May
-- Parotid gland is more effected than     Refer to table for test modalities and                                2003; vol. 14: pp. 1
submandibular gland but the                results depicting ↑ force on chewing and                     Efficiency of Denture Adhesives and their Possible
submandibular gland is more sensitive      comfort in wearing ill fitting dentures and
to post radiation effects because of its
                                                                                                                 Influence on Oral Microorganisms
                                           that the adhesived supported growth of S.
inability to restore/ correct damage       mitis and C. albicans but not N. pharyngis.                  G.D. Stafford and C. Russell
                                                                                                                 Journal of Dental Research, Jul 1971; vol. 50: pp.
                                                                                                                 832 - 836 99 - 212
               ILL FITTING DENTURES AND DRY MOUTH: CAUSES ,SOLUTIONS AND
                         POSSIBLE ALTERNATE TREATMENT MODALITIES
                   Abstract                            History:
   -A 82 year old Caucasian female presented for dental                                                                                                                                                    Flow rate of parotid and                          -Chief Complaint: “My dentures don’t fit and mouth is
                                                                                                                                                                                                           submandibular-sublingual
   Treatment with 9 medical diagnoses, Hx of SC Ca with                                                                                                                                                    (SM/SL) saliva as a function of time                       dry.”
   Radiation. She is Poly-medicated with 19 prescription                                                                                                                                                   after start of radiotherapy
                                                                                                                                                                                                                                                             -History of Present Illness: The Pt has had these
                                                                                                                                                                                                           (conventional fractionation schedule,
   Medications, is a Medicaid patient and is a resident of                                                                                                                                                 2Gy per day, 5 days per week, total                        dentures for past 9 years and has had radiation
   Delaware Court                                                                                                                                                                                          dose 60-70 Gy). The parotid,
                                                                                                                                                                                                           submandibular, and sublingual                              for Sq Cell Ca 3 yrs ago.
   -The treatment plan consists of fabricating a new upper                                                                                                                                                 glands are located in the treatment               -Past Medical History:
                                                                                                                                                                                                           portal. Initial flow rates were set to
   and lower conventional complete denture.                                                                                                                                                                100% (modified after Burlage et al.,                       -Squamous Cell Carcinoma
   -The alternative treatment plans could involve implant                                                                                                                                                  2001).
                                                                                                                                                                                                                                                                      -Hypertension
   supported complete denture prosthesis.or relining the                                                                                                                                                                                                              - Alzheimers
   old denture and/or using denture adhesive for retention.                                                              TABLE                                                                                                                                        -Hypothyroidism
                                                                                                                                                                                                           The use of denture adhesives on ill-
   -The case report will be a review of the after effects of                                            RESULTS OF RADIOTELEMETRY MEASUREMENTS

                                                                                                                  Total Chews    Total Pressure                     Total time
                                                                                                                                                                                                           fitting dentures and new dentures will                     -Depression
   radiation on salivary flow ,consequent adjuvents                                        Conditions
                                                                                                                 per Test
                                                                                                                      Food Piece   (kg/cm2)
                                                                                                                                                Mean Pressure per Chew
                                                                                                                                                      (kg/cm2)
                                                                                                                                                                            T me per Chew
                                                                                                                                                                            (sec) (sec)                    allow patients to increase the force
                                                                                                                                                                                                                                                                      -Insomnia
                                                                                           Old dentures
                                                                                                                                                                                                           they can apply to foods in chewing. In
   that can be used to increase saliva flow and the use of                                 No adhesive
                                                                                           Adhesive (one
                                                                                           application)
                                                                                                                        63

                                                                                                                         68
                                                                                                                                        6.6

                                                                                                                                        11.2
                                                                                                                                                           0.1

                                                                                                                                                            0.2
                                                                                                                                                                              41.1

                                                                                                                                                                              42.4
                                                                                                                                                                                               0.7

                                                                                                                                                                                                0.6
                                                                                                                                                                                                           the instance of old, ill-fitting dentures,                 -Fibromyalgia
                                                                                                                                                                                                           this increase may be considerable.
   adhesives on the old ill-fitting dentures and their                                     Adhesive (two
                                                                                           applications)               100              13.1                0.1               60.1              0.6
                                                                                                                                                                                                           Adhesives allow much greater total                         -Anxiety/ Psychosis
                                                                                           Gel                          62              14.2                0.2               37.9              0.6
   influence on oral microorganisms.                                                       New dentures
                                                                                           No adhesive                  60             12.0                0.2                39.5               0.7
                                                                                                                                                                                                           pressure to be applied to the mucosa
                                                                                                                                                                                                                                                                      -Deep Vein Thrombosis
                                                                                           Adhesive (one                                                                                                   during the chewing of a given quantity
                                                                                           application)                  58             17.0                0.3               37.8                   0.6
                                                                                                                                                                                                           of food. The time taken to chew the
                                                                                                                                                                                                                                                                                         Medications (continued):
         Review of Literatures                                                             Adhesive (two
                                                                                           applications)
                                                                                           Gel
                                                                                           Note: Information obtained from under complete maxillary denture when chewingstandard carrot test food.
                                                                                           Vol 50 No. 4
                                                                                                                        56
                                                                                                                        65
                                                                                                                                       17.5
                                                                                                                                       18.1
                                                                                                                                                           0.3
                                                                                                                                                           0.3
                                                                                                                                                                              37.4
                                                                                                                                                                              41.1
                                                                                                                                                                                                     0.6
                                                                                                                                                                                                     0.6
                                                                                                                                                                                                           foods does not vary substantially            Medications:
                                                                                                                                                                                                                                                        -Aspirin
                                                                                                                                                                                                                                                                                         -Aricept
                                           -Quantitative changes include                                                                                                                                                                                                                 -Nexium
-Research report selected was Oral                                                                                                                                                                                                                      -Effexor
                                               a. p H ↓ from 7.0 to 5.0                                                                                                                                                                                                                  -Simvastatin
Sequelae Of Head And Neck                      b. ↓ buffering capacity because of ↓in                                                                                                                                                                   -Zoloft
                                                                                                                                                                                                                                                                                         -Warfarin
Radiotherapy                               bicarbonate concentration in parotid saliva                                                                                                                                                                  -Docusate Sodium
Vissink, J. Jansma, F.K.L. Spijkervet,         c. ↑ In Na , Cl, Mg , Ca concentration                                                                                                                                                                                                    -Lyrica
                                                                                                                                                                                                                                                        -Ferrous Sulfate
F.R. Burlage, and R.P. Coppes                  d. ↑ in immunoproteins (IgA, lactoferrin,                                                                                                                                                                                                     -Zolpidem Tartrate
-Dutch researchers gathered                Lysozyme) but because ↓ in overall quantity                                                                                                                                                                  -Gabapentin
                                                                                                                                                                                                                                                                                             -Lorazepam
information from experiments done on       of saliva flow rate there is a significant                                                                                                                                                                   -KCl 20
rats and follow up on post radiation       immunoprotein deficit.                                                                                                                                                                                                                            -Furosemide
                                                                                                                                                                                                                                                        -Synthroid
head and neck cancer patients.             -There is a pronounced ↑ in acidogenic,                                                                                                                                                                                                           -Carvediol
-The clinical consequences of              cariogenis microorganisms like S. mutans,                                                                                                                                                                    -Oxycontin
                                                                                                                                                                                                                                                                                             -Lisinopril
radiation therapy include mucositis        Lactobacillus and Candida species.
and taste loss which are reversible,       -Efficiency of Denture Adhesives and their
hyposalivation (dry mouth) and
radiation caries which are irreversible
                                           Possible Influence on Oral Microorganisms
                                           G.D. Stafford and C. Russell
                                                                                                                                                                                                                                                        Diagnosis:        Complete Edentulism with hyposalivation (dry
and osteoradionecrosis and radiation       -Clinical tests done on 60 CD wearing pts                                                                                                                                                                            mouth)
caries which are a life long threat
-4 phases of hyposalivation post
                                           -Materials and Methods: Miniature
                                           inductance pressure transducer and                                                                                                                                                                           Treatment Plan:           Remake upper and lower complete
radiation                                  radiotelmetry circuit                                                                                                                                                                                                dentures utilizing resin and poly-urethane teeth. Process
   a.0-10 days –rapid ↓ in flow rate       -Ill fitting dentures and 2 sets of new
without changes in amylase secretion
                                                                                                                                                                                                                                                                would involve initial impressions, border molding and final
                                           dentures made.
or acinar cell #                           -measurements taken by pressure gauge at                                                                                                                                                                             impressions, wax rim try-in, esthetic try-in, denture delivery,
   b. 10-60 days-↓ amylase secretion       base of palatal surface of maxillary denture                                                                                                                                                                         and post-operative check ( 24 and 72 hour check)
and acinar cell #                          midway b/w midline and artificial teeth in
                                                                                                                                                                                                                                                         Alternative Treatment Plan:
   c. 60-120 days- no change in any of
the three
   d. 120-240 days- further
                                           first molar region on left side
                                           -test food used was std cylinder of fresh
                                           carrot cut by cork borer into 1 inch pieces
                                                                                                                                                                  Bibliography                                                                           -Place 5 conventional implants in the maxillary alveolar ridge and 4
deterioration of gland function            -2 denture adhesives shosen- gel and paste
                                                                                                                                                                                                                                                                   conventional implants in the mandibular alveolar ridge.
-A rapid ↓ in salivary flow rate during    -4 denture pwdr and 2 pastes were tested
                                                                                                        Oral Sequelae Of Head And Neck Radiotherapy                                                                                                                Following an adequate healing period, hybrid dentures
first week of radiotherapy followed by     for microbial growth by inoculating for 2                    Vissink, J. Jansma, F.K.L. Spijkervet, F.R. Burlage, and R.P.
                                                                                                                                                                                                                                                                   with frameworks could be fabricated.
gradual decrease to less than 10% of       days with at 37 C after sterilizing and                               Coppes
initial flow as depicted in above graph    adding 1 % sucrose and adjusting p H 6.8                              Critical Reviews in Oral Biology & Medicine, May                                                                                        -Reline the existing denture and use denture adhesives for
-- Parotid lland is more effected than     Refer to table for test modalities and                                2003; vol. 14: pp. 1                                                                                                                              adequate form and retention provided that the dry mouth
submandibular gland but the                results depicting ↑ force on chewing and                     Efficiency of Denture Adhesives and their Possible                                                                                                         which is leading to irritation of the underlying mocosa is
submandibular gland is more sensitive      comfort in wearing ill fitting dentures and
to post radiation effects because of its   that the adhesived supported growth of S.
                                                                                                                 Influence on Oral Microorganisms                                                                                                                  controlled by medications/ pharmacological stimulants
inability to restore/ correct damage       mitis and C. albicans but not N. pharyngis.                  G.D. Stafford and C. Russell                                                                                                                               Pilocarpine HCl or Cevimeline HCl , sialogogues (Oral
                                                                                                                 Journal of Dental Research, Jul 1971; vol. 50: pp.                                                                                                Balance, Oralube, Biotene, Salivart etc)
                                                                                                                 832 - 836 99 - 212




                    Myofascial Pain Disorder in an Edentulous Patient
Abstract:
Myofascial pain in an edentulous                                                                                                                                                 Graphs:
patient is a problem that is                                                                                                                                                                                                                                       History
intensified by stress and poor                                                                                                                                                                                                                                        Chief Complaint: “My face 
muscle tone. It can be treated with                                                                                                                                                                                                                                muscles hurt”
well‐balanced dentures,                                                                                                                                                                                                                                               Present Illness: 82 y.o 
physiotherapy and drug therapy.                                                                                                                                                                                                                                    caucasian female. Patient has 
                                                                                                                                                                                                                                                                   had pain in right facial muscles 
  Review of Literature: 
                                                                                                                                                                                                                                                                   for 3 years off and on       
 Myofascial  pain disorders present 
                                                                                                                            Fig. 1. Trigger point analysis and                                                                                                     Past medical history:   Patient 
many clinical signs and symptoms                                                                                            palpation demonstration                                                                                                                has a left leg below the knee 
with muscle pain being the most 
                                                                                                                                                                                                                                                                   amputation due to trauma and 
common complaint. This pain is 
                                                                                                                                                                                                                                                                   depression
caused by stress, occlusal 
                                                                                                                                                                                                                                                                       Medications: Coumadin
interferences, and trauma. As people 
age, they lose muscle tone and a 
slight amount of strain to these 
muscles can cause discomfort and 
stiffness (2). After using trigger point 
analysis to determine which muscles 
are affected, treatment modalities can 
be considered. Physiotherapy is the 
most effective treatment next to 
occlusal splints and correction of oral                                                                                                                                               Bibliography
habits. This will allow the patient to                                                                        1.Faulkner, K., Mercado, M. Aetiological factors of 
strengthen muscles in order to limit                                                                          craniomandibular disorders in completely edentulous 
                                                                                                              denture‐wearing patients. Journal of Oral 
the discomfort during function. Drug                                                                          Rehabilitation. Vol 18, Issue 2. 2007.
therapy can also be effective to an                                                                           2.Keng, S.B. Myofascial PainDysfunction Syndrome. 
                                                                                                              Singapore Medical Journal. Vol 24, No 2. 1982
extent (1).




                    Myofascial Pain Disorder in an Edentulous Patient
Abstract:
Myofascial pain in an edentulous                                                                                                                                                 Graphs:
patient is a problem that is                                                                                                                                                                                                                                       History
intensified by stress and poor                                                                                                                                                                                                                                        Chief Complaint: “My face 
muscle tone. It can be treated with                                                                                                                                                                                                                                muscles hurt”
well‐balanced dentures,                                                                                                                                                                                                                                               Present Illness: 82 y.o 
physiotherapy and drug therapy.                                                                                                                                                                                                                                    caucasian female. Patient has 
                                                                                                                                                                                                                                                                   had pain in right facial muscles 
  Review of Literature: 
                                                                                                                                                                                                                                                                   for 3 years off and on       
 Myofascial  pain disorders present 
                                                                                                                            Fig. 1. Trigger point analysis and                                                                                                     Past medical history:   Patient 
many clinical signs and symptoms                                                                                            palpation demonstration                                                                                                                has a left leg below the knee 
with muscle pain being the most 
                                                                                                                                                                                                                                                                   amputation due to trauma and 
common complaint. This pain is 
                                                                                                                                                                                                                                                                   depression
caused by stress, occlusal 
                                                                                                                                                                                                                                                                       Medications: Coumadin
interferences, and trauma. As people 
age, they lose muscle tone and a                                                                                                                                                                                                                                   Diagnosis
slight amount of strain to these                                                                                                                                                                                                                                          Myofascial Pain Disorder
muscles can cause discomfort and                                                                                                                                                                                                                                          Edentulism
stiffness (2). After using trigger point                                                                                                                                                                                                                           Treatment Plan
analysis to determine which muscles                                                                                                                                                                                                                                     Proposed: Occlusal adjustment 
are affected, treatment modalities can                                                                                                                                                                                                                             of dentures, physiotherapy to 
be considered. Physiotherapy is the                                                                                                                                                                                                                                strengthen affected muscles, stress 
                                                                                                                                                                                                                                                                   reduction practices
most effective treatment next to 
                                                                                                                                                                                                                                                                       Alternative: Fabricate new 
occlusal splints and correction of oral                                                                                                                                               Bibliography                                                                 dentures, drug therapy using muscle 
habits. This will allow the patient to                                                                        1.Faulkner, K., Mercado, M. Aetiological factors of                                                                                                  relaxant flexeril
strengthen muscles in order to limit                                                                          craniomandibular disorders in completely edentulous 
                                                                                                              denture‐wearing patients. Journal of Oral 
the discomfort during function. Drug                                                                          Rehabilitation. Vol 18, Issue 2. 2007.
therapy can also be effective to an                                                                           2.Keng, S.B. Myofascial PainDysfunction Syndrome. 
                                                                                                              Singapore Medical Journal. Vol 24, No 2. 1982
extent (1).
                           Abstract
                 A 51 year old Caucasian male                                                                                                                     History:
                                                                                                                                                                   Chief Complaint: “I can’t eat very well. I need
                  presents for dental treatment                                                                                                                           some partials.”
                 Diagnosed with A-Fib, Right                                                                                                                      History of Present Illness: Loss of function for 2yrs.
                  Atrial Ablation 3/09                                                                                                                             Past Medical History:
                 Under Cardiologists care                                                                                                                                 •He has had recurrent episodes of Afib over
                  treated with Coumadin                            cardiac arrhythmia                                                                                      the last two years lasting a few days to more
                                                                                                                                                                           than 7 days.
                 The treatment plan includes
                  periodontal maintenance &                                                                                                                                •March 09 Right Atrial Ablation – Surgery –
                                                                                                                                                                           due to recurrent arrhythmia
                  fabrication of maxillary and
                  mandibular Removable                                                                                                                                     No known drug allergies
                  Partial Dentures.
                                                                                                                                                                           •Currently Under Cardiologist’s care
           Review of Literature                                                                                                                                            •Vitals: BP Usually around 120/65, HR. 60, RR
The specific bacterial pathogens that have been associated                                                                                                                 16, INR 3.0
with aggressive periodontitis are Actinobacillus
actionomycetemcomitans and Porphyromonas ginginvalis,                                                                                                            Medications
and neutrophil function abnormalities.1 Patients who have a
history of periodontitis are generally setup on a 3-month                                                                                                           Name                 Generic             Dose/Freq
recall system to eliminate the etiologic factors that can cause
recurrent periodontal disease. 2
His remaining teeth have poor crown-to-root ratios already
because of generalized horizontal bone loss, so anymore                                                                                                             Rythmol              Propafenone         325mg/         2x
bone loss could result in inability of his teeth to act as                                                                                                                                                   daily
abutments for his partials causing them to fail. However, a
new understanding of the periodontal inflammatory process                                                                                                           Metoprolol           Toprol XL           25mg/ 1 xdaily
has shown that a little bit of mobility can be tolerated when
supporting a prosthesis as long as inflammation is controlled                                                                                                       Coumadin             Warfarin            2.5mg/ 1x daily
and proper occlusion created.3       Fortunately, the patient is                                                                                                    Ultracet             Tramadol            40mg/ PRN
now motivated and has reasonable expectations, which will
only improve his prognosis.                                                                                                                                         Flexaril             Cyclobenzaprin      10mg/ PRN
Lesson Learned:                                                                                                                                                                          e
Not all treatment plans have an excellent or even good
prognosis. However, involving the patient in the treatment
                                                                                          Bibliography                                                              Zanaflex             Tizanidine          5mg/ PRN
planning process is key because their needs and concerns                                                                                                                                 Coenzyme Q10        100mg/ daily
                                                                   1. Parameter on Aggressive Periodontitis. J Periodontol
are different from the dentist’s. Knowing the alternatives
                                                                   2000;71:867-869.
available to them and the associated risks and costs of each
                                                                   2. Perio Maintenance (2003). J Periodontol 2003;74:1395-
alternative enables     the patient to make and informed                                                                                                                                 MultiVitamin        1 tab daily
                                                                   1401.
decision about their oral health.
                                                                   3. J Prosthet Dent. 1979 Jul;42(1):34-8.                                                                              Vitamin B12         1 tab daily




                           Abstract
                 A 51 year old Caucasian male                                                                                                                     History:
                                                                                                                                                                   Chief Complaint: “I can’t eat very well. I need
                  presents for dental treatment                                                                                                                           some partials.”
                 Diagnosed with A-Fib, Right                                                                                                                      History of Present Illness: Loss of function for 2yrs.
                  Atrial Ablation 3/09                                                                                                                             Past Medical History:
                 Under Cardiologists care                                                                                                                                 •He has had recurrent episodes of Afib over
                  treated with Coumadin                            cardiac arrhythmia                                                                                      the last two years lasting a few days to more
                                                                                                                                                                           than 7 days.
                 The treatment plan includes
                  periodontal maintenance &                                                                                                                                •March 09 Right Atrial Ablation – Surgery –
                                                                                                                                                                           due to recurrent arrhythmia
                  fabrication of maxillary and
                  mandibular Removable                                                                                                                                     No known drug allergies
                  Partial Dentures.
                                                                                                                                                                           •Currently Under Cardiologist’s care
           Review of Literature                                                                                                                                            •Vitals: BP Usually around 120/65, HR. 60, RR
The specific bacterial pathogens that have been associated                                                                                                                 16, INR 3.0
with aggressive periodontitis are Actinobacillus
actionomycetemcomitans and Porphyromonas ginginvalis,                                                                                                      Name                    Generic              Dose/Freq
and neutrophil function abnormalities.1 Patients who have a                                                                                                Rythmol                 Propafenone          325mg/      2x
history of periodontitis are generally setup on a 3-month                                                                                                                                               daily
recall system to eliminate the etiologic factors that can cause
                                                                                                                                                           Metoprolol              Toprol XL            25mg/ 1 xdaily
recurrent periodontal disease. 2
His remaining teeth have poor crown-to-root ratios already                                                                                                 Coumadin                Warfarin             2.5mg/ 1x daily
because of generalized horizontal bone loss, so anymore                                                                                                    Ultracet                Tramadol             40mg/ PRN
bone loss could result in inability of his teeth to act as                                                                                                 Flexaril                Cyclobenzaprin       10mg/ PRN
abutments for his partials causing them to fail. However, a                                                                                                                        e
new understanding of the periodontal inflammatory process                                                                                                  Zanaflex                Tizanidine           5mg/ PRN
has shown that a little bit of mobility can be tolerated when                                                                                                                      Coenzyme Q10         100mg/ daily
supporting a prosthesis as long as inflammation is controlled
                                                                                                                                                                                   MultiVitamin         1 tab daily
and proper occlusion created.3       Fortunately, the patient is
now motivated and has reasonable expectations, which will                                                                                                                          Vitamin B12          1 tab daily
only improve his prognosis.                                                                                                                                      Diagnosis: Recurrent Periodontitis on a reduced
Lesson Learned:
                                                                                                                                                                       periodontium & Partial Edentulism
                                                                                                                                                                 Treatment Plan: Maxillary Distal Extension RPD and
Not all treatment plans have an excellent or even good
prognosis. However, involving the patient in the treatment
                                                                                          Bibliography                                                                 Mandibular Tooth Supported RPD.
planning process is key because their needs and concerns
                                                                   1. Parameter on Aggressive Periodontitis. J Periodontol
are different from the dentist’s. Knowing the alternatives                                                                                                        Alternative Treatment Plan:
                                                                   2000;71:867-869.
available to them and the associated risks and costs of each                                                                                                      1. Implants Placed in Maxilla and Mandible
                                                                   2. Perio Maintenance (2003). J Periodontol 2003;74:1395-
alternative enables     the patient to make and informed                                                                                                          2. Implant supported mandibular RPD and maxillary distal
                                                                   1401.
decision about their oral health.                                                                                                                                          extension RPD.
                                                                   3. J Prosthet Dent. 1979 Jul;42(1):34-8.
                                                                                                                                                                  3. No Treatment




                             Combination Syndrome Correction Prior to Prosthodontic Reline or
                                                     Fabrication

                                                                                                                                                                       History
                           Abstract                                                                                                                                    Chief Complaint:
                                                                                                                      Figure    1.     Combination
                                                                                                                                                                         Female 70-year-old patient presented with chief
 Combination syndrome is a condition typically                                                                        syndrome,    resulting from                      complaint, “My denture doesn’t fit well at all, I’d
                                                                                                                      maxillary ridge resorption                       like a reline.” Patient reported that she had lower
 observed in patients who are completely edentulous                                                                   opposing natural mandibular
 in the maxillary arch but have anterior teeth in the                                                                 teeth.                                           anterior teeth opposing the current denture, but
 lower arch. A complete maxillary denture opposing                                                                                                                     subsequently had the lower teeth extracted and a
 the lower natural teeth results in the resorption of                                                                                                                  complete lower denture made to oppose the upper
 the anterior maxillary ridge. Fibrous tissue replaces                                                                                                                 complete denture
 the region formerly occupied by bone, and a so-                                                                                                                       .
 called flabby ridge results. This flabby ridge makes                                                                                                                  Medical history
 it difficult to fit a complete denture, and over time,              Figure 2. Surgery to remove                                                                       revealed several bowel surgeries to correct
 additional resorption of the maxillary bone will                    excessive fibrous tissue                                                                          motility and bolus incarceration issues.
 render a complete denture less stable due to                        below the gingiva but above
                                                                     the    ridge    bone    was
 foundation mobility. Patients often visit their dental              performed.
 practitioners, requesting a complete upper denture                                                                                                                    medications:
 reline. Such was the case with a patient in Jackson,                                                                                                                  Simvastatin for cholesterol, Lisinopril for
 Ohio.                                                                                                                                                                 hypertension, and Citalopram SSRI for depression.

                     Review of Literature                                                                           Figure 3. Expected post-surgical
                                                                                                                    results – a stable bone base upon
 L. Tolstunov found that a multi-disciplinary                                                                       which the patient’s former
                                                                                                                    denture may be hard relined or
 approach might yield the best results when treating                                                                upon which a new complete
 a patient with combination syndrome. Patients may                                                                  maxillary denture may be made.
 opt for extraction of lower anterior teeth and an
 implant-supported mandibular complete denture.
 In the presence of lower anterior mandibular teeth,
 combination syndrome can be expected to progress.
 Denture relines will be necessary and will become
 more difficult with continued ridge resorption and                Figure    4.    A    panoramic
                                                                   radiograph may be used to show
 resulting fibrous tissue deposition.                              the extent of ridge and general
                                                                   mandibular           resorption.
                                                                   Extractions performed prior.
 E.M. Ahmet found that predictable correction of
 combination syndrome may be attained through
 flap reflection and undermining, but preserving, the
 buccal gingiva. Some palatal gingivae may be
                                                                    •References:
 removed in order to re-approximate the tissues for
 suturing prior to the soft reline of the maxillary                  References:
                                                                    •Ahmet EM. Combination Syndrome Rapid and Predictable
 denture.                                                            1. Wang YC and                                                           and
                                                                    Correction. Liou EJW. Comparison of the loading behavior of self-drilling2008;predrilled J
                                                                                     Diagnostic, loading. Am J Orthod Dentofacial Considerations.
                                                                     mini-screws throughout orthodonticProsthetic, & Surgical Orthop               133:38-43.
                                                                    Prosth. Dent. 2009.
                                                                     Acknowledgements:
                                                                    SSH acknowledges Dr. Tatakis for his assistance and support.
                                                                    •Tolstunov L. Combination syndrome: classification and case
                                                                    report. J Oral Implantol. 2007;33(3):139-51.
                        Combination Syndrome Correction Prior to Prosthodontic Reline or
                                                Fabrication

                                                                                                                                                       History
                      Abstract                                                                                                                         Chief Complaint:
                                                                                                            Figure    1.     Combination
                                                                                                                                                         Female 70-year-old patient presented with chief
Combination syndrome is a condition typically                                                               syndrome,    resulting from                complaint, “My denture doesn’t fit well at all, I’d
                                                                                                            maxillary ridge resorption                 like a reline.” Patient reported that she had lower
observed in patients who are completely edentulous                                                          opposing natural mandibular
in the maxillary arch but have anterior teeth in the                                                        teeth.                                     anterior teeth opposing the current denture, but
lower arch. A complete maxillary denture opposing                                                                                                      subsequently had the lower teeth extracted and a
the lower natural teeth results in the resorption of                                                                                                   complete lower denture made to oppose the upper
the anterior maxillary ridge. Fibrous tissue replaces                                                                                                  complete denture
the region formerly occupied by bone, and a so-                                                                                                        .
called flabby ridge results. This flabby ridge makes                                                                                                   Medical history
it difficult to fit a complete denture, and over time,     Figure 2. Surgery to remove                                                                 revealed several bowel surgeries to correct
additional resorption of the maxillary bone will           excessive fibrous tissue                                                                    motility and bolus incarceration issues.
render a complete denture less stable due to               below the gingiva but above
                                                           the    ridge    bone    was
foundation mobility. Patients often visit their dental     performed.
practitioners, requesting a complete upper denture                                                                                                     medications:
reline. Such was the case with a patient in Jackson,                                                                                                   Simvastatin for cholesterol, Lisinopril for
Ohio.                                                                                                                                                  hypertension, and Citalopram SSRI for depression.

              Review of Literature                                                                        Figure 3. Expected post-surgical             Diagnosis
                                                                                                          results – a stable bone base upon            combination syndrome secondary to maxillary
L. Tolstunov found that a multi-disciplinary                                                              which the patient’s former
                                                                                                                                                       denture opposing natural dentition for a number of
                                                                                                          denture may be hard relined or
approach might yield the best results when treating                                                       upon which a new complete                    years prior to mandibular anterior teeth being
a patient with combination syndrome. Patients may                                                         maxillary denture may be made.
                                                                                                                                                       extracted. Fibrous tissue provided an unstable base
opt for extraction of lower anterior teeth and an                                                                                                      for the patient’s 8-year-old denture, which had
implant-supported mandibular complete denture.                                                                                                         been relined previously.
In the presence of lower anterior mandibular teeth,
combination syndrome can be expected to progress.                                                                                                      Treatment Plan
Denture relines will be necessary and will become
                                                         Figure    4.    A    panoramic                                                                Proposed plan – Surgery to remove underlying
more difficult with continued ridge resorption and       radiograph may be used to show                                                                fibrous tissue on maxillary arch, soft reline of max.
resulting fibrous tissue deposition.                     the extent of ridge and general
                                                                                                                                                       denture.
                                                         mandibular           resorption.
                                                         Extractions performed prior.
E.M. Ahmet found that predictable correction of
combination syndrome may be attained through                                                                                                           Alternative plan
flap reflection and undermining, but preserving, the                                                                                                   Reline maxillary denture, neglecting the underlying
buccal gingiva. Some palatal gingivae may be                                                                                                           fibrous tissue.
removed in order to re-approximate the tissues for        •References:                                                                                 Patient elected for surgical removal of underlying
suturing prior to the soft reline of the maxillary        References:                                                                                  fibrous tissue on maxillary arch and subsequent
                                                          •Ahmet EM. Combination Syndrome Rapid and Predictable
denture.                                                  Correction. Liou EJW. Comparison of the loading behavior of self-drilling2008;predrilled J
                                                           1. Wang YC and
                                                           mini-screws throughout orthodonticProsthetic, & Surgical Orthop
                                                                                                                                    and
                                                                           Diagnostic, loading. Am J Orthod Dentofacial Considerations.  133:38-43.
                                                                                                                                                       denture soft reline.
                                                          Prosth. Dent. 2009.
                                                           Acknowledgements:
                                                          SSH acknowledges Dr. Tatakis for his assistance and support.
                                                          •Tolstunov L. Combination syndrome: classification and case
                                                          report. J Oral Implantol. 2007;33(3):139-51.




                                              associated disorders may cause the dental
                                              effects of xerostomia, caries and decreased
                                                            denture retention




                                              associated disorders may cause the dental
                                              effects of xerostomia, caries and decreased
                                                            denture retention
                                          Angular Cheilitis
       Abstract
                                                                                                 Case Presentation
       This is an inflammatory
          lesion at the corner of                                                                CC: “corners of my mouth
          the mouth. Deep splits                                                                    burn.
                                                                                                 History of PI: Denture teeth
          can form that ulcer and                                                                   are very worn down and
          then crust when the skin                                                                  corners of mouth are red
          is stretched. These                                                                       with a crust.
                                                                                                 PMH: Diagnosed with
          cracks can also become                                                                    depression, HBP, and
          infected with candida                                                                     diabetes type II..
          albicans worsening the                                                                 Meds: Fluoxetine, lisinopril,
                                                                                                    and metaformin.
          situation.
       Review of literature                             References
       etiology,                                        1.    James, William D.; Berger,
                                                              Timothy G.; et al. (2006).
             the intial onset is linked to                    Andrews' Diseases of the Skin:
                                                              clinical Dermatology. Saunders
            deficiencies in zinc, b12,                        Elsevier.
            riboflavin, and iron. Also due to           2.     Riboflavin deficiency, National
            reduction of vertical dimension                   Institute of Health.
                                                              www.medline.com
            of occlusion (worn dentures)                3.     Lu S, Wu H (2004). "Initial
            the skin tends to crease without                  diagnosis of anemia from sore
                                                              mouth and improved
            teeth height which keep skin                      classification of anemias by
            tight. Angular Cheilitis is treated               MCV and RDW in 30 patients".
                                                              Oral Surg Oral Med Oral Pathol
            with antifungals such as                          Oral Radiol Endod 98 (6): 679–
                                                              85.
            Nystatin ointment and
                                                        4.      www.mayoclinic.com
            construction of new dentures




Abstract

This is an inflammatory
   lesion at the corner of Angular                                   Cheilitis                   Case Presentation
                                                                                                 CC: “corners of my mouth
   the mouth. Deep splits                                                                            burn.
   can form that ulcer and                                                                       History of PI: Denture teeth
   then crust when the skin                                                                          are very worn down and
                                                                                                     corners of mouth are red
   is stretched. These                                                                               with a crust.
   cracks can also become                                                                        PMH: Diagnosed with
   infected with candida                                                                             depression, HBP, and
                                                                                                     diabetes type II..
   albicans worsening the
                                                                                                 Meds: Fluoxetine, lisinopril,
   situation.                                                                                        and metaformin.
Review of literature                                                                             Diagnoses: Angular Cheilitis
Unkown etiology, however                                                                             that may have been
                                                                                                     caused by decreased VD
the intial onset is linked to                                                                        of worn out dentures.
   deficiencies in zinc, B12,                                                                    Treatment plan:
                                                        References
Riboflavin,and iron. Also loss                          1.    James, William D.; Berger,         1. prevent further candidiasis
                                                              Timothy G.; et al. (2006).
   vertical dimension of                                      Andrews' Diseases of the Skin:         infection by providing
   occlusion (worn dentures)                                  clinical Dermatology. Saunders         patient with Nystatin-
                                                              Elsevier.
                                                                                                     triamcinolone acetonide
   has been implicated                                  2.     Riboflavin deficiency, National
                                                                                                     ointment and disinfect
                                                              Institute of Health.
   because the skin tends to                                  www.medline.com                        dentures and reline
   crease without teeth height                          3.     Lu S, Wu H (2004). "Initial
                                                              diagnosis of anemia from sore
                                                                                                     dentures
   which keep skin tight.                                     mouth and improved                 2. Construct new dentures .
                                                              classification of anemias by
   Angular Cheilitis is treated                               MCV and RDW in 30 patients".
                                                              Oral Surg Oral Med Oral Pathol
   with antifungalsuch as                                     Oral Radiol Endod 98 (6): 679–
                                                              85.
   Nystatin ointment and                                4.      www.mayoclinic.com
   construction of dentures.




   •     ABSTRACT
                               Improving Hygeine in Elderly Population
                                                                                            HISTORY: Patient is a female, 70
   •The aim of this case study                                                              years old. Med Hx reveals that she
   is to highlight the                                                                      is medicated for dementia as well as
   significance of oral                                                                     depression. Patient is confined to
   hygiene consideration to                                                                 wheel chair. She relies on her
   the treatment planning in                                                                healthcare workers to provide oral
   the institutionalized                                                                    hygiene. She is on a 3 month recall
   elderly                                                                                  program but was last seen for a
   population.Specifically                                                                  cleaning almost 1 year ago. She has
   those who cannot perform                                                                 a history of being a cooperative
   oral hygiene themselves                                                                  patient. She has no chief complaint.
   because of physical and/or
   mental limitations. The
   results show a lack of
   appreciation and concern
   for the oral hygiene of
   this population.
    •REVIEW OFLITERATURE
    •Literature shows that poor oral
    hygiene and its manifestations       •BIBLIOGRAPHY
    such as dental plaque                •Gerodontology Volume 10 issue
    accumulation and periodontal         2 Pages 109 - 113. Published Online:
    disease result from multiple         28 Jul 2006.
    factors. Some of these factors are   Community Dentistry and Oral
                                         EpidemiologVolume 15 Issue 2, Pages 85 - 89
    endogenous such as change in
                                         •Published Online: 29 May 2006.
    quantity and quality of salivary     Journal of Advanced Nursing Volume
    flow . Behaviors such as smoking     52, Number 4, November 2005 , pp. 410-419(10).
    also have direct correlations.        International Journal of Evidence-based
    Finally, the role of healthcare      Healthcare Volume 2, Number 3, April 2004 , pp.
                                         65-113(49)
    provider is essential, especially
    with the prevalence of dementia.
    •    ABSTRACT
                                      Improving Hygeine in Elderly Population
                                                                                                          HISTORY: Patient is a female, 70
    •The aim of this case study                                                                           years old. Med Hx reveals that she
    is to highlight the                                                                                   is medicated for dementia as well as
    significance of oral                                                                                  depression. Patient is confined to
    hygiene consideration to                                                                              wheel chair. She relies on her
                                                                                                          healthcare workers to provide oral
    the treatment planning in
                                                                                                          hygiene. She is on a 3 month recall
    the institutionalized                                                                                 program but was last seen for a
    elderly                                                                                               cleaning almost 1 year ago. She has
    population.Specifically                                                                               a history of being a cooperative
    those who cannot perform                                                                              patient. She has no chief complaint.
    oral hygiene themselves
    because of physical and/or
                                                                                                          DIAGNOSIS: Generalized Chronic
    mental limitations. The                                                                               plaque-induced Gingivitis
    results show a lack of
    appreciation and concern
    for the oral hygiene of                                                                               TREATMENT PLAN: As can be
    this population.                                                                                      seen, this patient suffers from very
                                                                                                          poor oral hygiene. The proper
    •REVIEW OFLITERATURE                                                                                  course of treatment is gross
    •Literature shows that poor oral                                                                      debridement followed by cleanings
    hygiene and its manifestations              •BIBLIOGRAPHY                                             every 3 months. In addition, it is
    such as dental plaque                       •Gerodontology Volume 10 issue                            essential to institute a daily hygiene
    accumulation and periodontal                2 Pages 109 - 113. Published Online:                      regimen such as CHX mouth
    disease result from multiple                28 Jul 2006.                                              wash.The importance of oral
    factors. Some of these factors are          Community Dentistry and Oral
                                                                                                          hygiene must be stressed to her
                                                EpidemiologVolume 15 Issue 2, Pages 85 - 89
    endogenous such as change in                                                                          care giver. Otherwise, her condition
                                                •Published Online: 29 May 2006.
    quantity and quality of salivary            Journal of Advanced Nursing Volume                        can lead to eventual tooth loss and
    flow . Behaviors such as smoking            52, Number 4, November 2005 , pp. 410-419(10).            subsequent complications affecting
    also have direct correlations.               International Journal of Evidence-based
                                                                                                          the patient quality of life.
    Finally, the role of healthcare             Healthcare Volume 2, Number 3, April 2004 , pp.
                                                65-113(49)
    provider is essential, especially
    with the prevalence of dementia.




             Psychological Issues Faced by Patients with Tooth
                                   Loss        •History
                                                                                                           • A 68-yo female presents with the chief
                                                                                                           complaint: “I’m ashamed that I don’t have any
                •Abstract                                                                                  teeth.” Pt reports inadequate dental care as a
• Final tooth loss represents a dramatic                                                                   child, and no dental insurance throughout her
                                                                                                           adult life. Consequently, she lost many of her
event in the life of a person. Many patients
                                                                                                           teeth to caries, and has worn several
see their edentulism as a loss of youth and                                                                combinations of partial dentures. She recently
attraction, and feel ashamed of their           •Fig. 1 Categories describing alterations in               had the last of her teeth removed due to
appearance. Concurrently, these patients        self-image of newly edentulous patients1                   periodontal compromise.
face new challenges in eating and speaking,                                                                • Pt. reports that since this final tooth loss, she
and must learn to deal with a foreign                            Subcategories                             has avoided being seen in public for fear of
prosthesis in the mouth. Patients can                                                                      embarrassment while talking, eating, or laughing.
become depressed as they avoid social                                                                      She feels a great deal of guilt for not having taken
situations that bring them support and joy.       Becoming       Lack of dental awareness earlier in       better care of her teeth, and is overwhelmed by
                                                                 life                                      the thought of learning to use complete dentures.
Dentists must recognize these issues in the       a deviating
newly edentulous patient, address them in a       person         Feelings of shame and guilt               Without teeth, she says, she does not look or feel
compassionate manner, and know when to                                                                     like herself.
                                                                 Physical pain
refer appropriately for psychiatric
intervention.                                     Becoming       Category                                  •Medical History
                                                  an
                                                                                                           • Pt. has well-controlled diabetes and
                                                  uncertain
                                                                                                           hypertension. She is taking Metformin and
                                                  person
                                                                                                           Amlodipine, as well as Ibuprofen for rheumatoid
         •Literature Review                                      Social security                           arthritis.
                                                  Becoming
• Trulsson et al1 interviewed newly               the person     Regaining attraction
edentulous patients and described three           I once was
categories of self-image in patients during                      Good dental status
their treatment (Fig. 1). Tada et al2 related                    Feelings of gratitude
increased tooth loss to decreased physical      •1.Trulsson U, Engstrand P, Berggren U, Nannmark U,
activity, affecting health-related quality of   Bra˚nemark P-I. Edentulousness
life. Davis et al3 found that a deteriorating   •and oral rehabilitation, experiences from the patient
dentition leads to patients restricting food    perspective. Eur J Oral Sci 2002;110: 417–424.
choices for social reasons and enjoying         •2. Tada A, Watanabe T, Yokoe H et al. Relationship
food less, which may have consequences for      •between the number of remaining teeth and physical
the nutritionally compromised elderly.          •activity in community-dwelling elderly. Arch Gerontol
                                                •Geriatr 2003; 37: 109–117
Philling4 describes the mouth as “the most
                                                •3. Davis DM, Fiske J, Scott B, Radford DR. The
emotionally charged area of the body,” and
                                                emotional effects of tooth loss in a group of partially
as such, requires significant psychological     dentate people: a quantitative study. Eur J Prosthodont
adjustment when a change such as                Rest Dent. 2001 Jun;9(2):53-7
edentulism takes place. Until patients adapt    •4. Philling LF. Emotional aspects of prosthodontic
to this change, anxiety will be present.        •patients. J Prosthet Dent 1973; 30: 514




             Psychological Issues Faced by Patients with Tooth
                                   Loss        •History
                                                                                                           • A 68-yo female presents with the chief
                                                                                                           complaint: “I’m ashamed that I don’t have any
                •Abstract                                                                                  teeth.” Pt reports inadequate dental care as a
• Final tooth loss represents a dramatic                                                                   child, and no dental insurance throughout her
                                                                                                           adult life. Consequently, she lost many of her
event in the life of a person. Many patients
                                                                                                           teeth to caries, and has worn several
see their edentulism as a loss of youth and                                                                combinations of partial dentures. She recently
attraction, and feel ashamed of their           •Fig. 1 Categories describing alterations in               had the last of her teeth removed due to
appearance. Concurrently, these patients        self-image of newly edentulous patients1                   periodontal compromise.
face new challenges in eating and speaking,                                                                • Pt. reports that since this final tooth loss, she
and must learn to deal with a foreign                            Subcategories                             has avoided being seen in public for fear of
prosthesis in the mouth. Patients can                                                                      embarrassment while talking, eating, or laughing.
become depressed as they avoid social                                                                      She feels a great deal of guilt for not having taken
situations that bring them support and joy.       Becoming       Lack of dental awareness earlier in       better care of her teeth, and is overwhelmed by
                                                                 life                                      the thought of learning to use complete dentures.
Dentists must recognize these issues in the       a deviating
newly edentulous patient, address them in a       person         Feelings of shame and guilt               Without teeth, she says, she does not look or feel
compassionate manner, and know when to                                                                     like herself.
                                                                 Physical pain
refer appropriately for psychiatric
intervention.                                     Becoming       Category                                  •Medical History
                                                  an
                                                                                                           • Pt. has well-controlled diabetes and
                                                  uncertain
                                                                                                           hypertension. She is taking Metformin and
                                                  person
                                                                                                           Amlodipine, as well as Ibuprofen for rheumatoid
         •Literature Review                                      Social security                           arthritis.
                                                  Becoming
• Trulsson et al1 interviewed newly               the person     Regaining attraction
edentulous patients and described three           I once was                                               •Diagnosis
categories of self-image in patients during                      Good dental status
                                                                                                           • Situational anxiety secondary to complete
their treatment (Fig. 1). Tada et al2 related                    Feelings of gratitude                     edentulism
increased tooth loss to decreased physical      •1.Trulsson U, Engstrand P, Berggren U, Nannmark U,
activity, affecting health-related quality of   Bra˚nemark P-I. Edentulousness
life. Davis et al3 found that a deteriorating   •and oral rehabilitation, experiences from the patient
                                                                                                           •Treatment Plan
dentition leads to patients restricting food    perspective. Eur J Oral Sci 2002;110: 417–424.             • Well-constructed dentures made by a dentist
choices for social reasons and enjoying         •2. Tada A, Watanabe T, Yokoe H et al. Relationship        who will take time to explain their use and care.
food less, which may have consequences for      •between the number of remaining teeth and physical        Recommend counseling to help Pt. address the
                                                •activity in community-dwelling elderly. Arch Gerontol     psychological issues she is facing at this time.
the nutritionally compromised elderly.
                                                •Geriatr 2003; 37: 109–117
Philling4 describes the mouth as “the most
                                                •3. Davis DM, Fiske J, Scott B, Radford DR. The
emotionally charged area of the body,” and                                                                 •Alternate Treatment Plan
                                                emotional effects of tooth loss in a group of partially
as such, requires significant psychological     dentate people: a quantitative study. Eur J Prosthodont    • If patient complains of changes in weight or
adjustment when a change such as                Rest Dent. 2001 Jun;9(2):53-7                              sleep patterns, or feelings of intense
edentulism takes place. Until patients adapt    •4. Philling LF. Emotional aspects of prosthodontic        hopelessness, she should be referred for
to this change, anxiety will be present.        •patients. J Prosthet Dent 1973; 30: 514                   psychiatric evaluation.
              •Treatment Planning for the Geriatric Patient
•Abstract       Designing a treatment
plan for a geriatric patient is a more                                                         •86 y.o. male
complex procedure than if the same thing                                                       •CC: “I want my false teeth.”
is done for a middle-aged adult. Many                                                          •PI: Completely Edentulous
geriatric patients have some kind of
                                                                                               •Medical History: Diagnosed with
physical limitation that affects their
                                                                                               dementia in 2001, high blood pressure
ability to maintain their dentition.
                                                                                               diagnosed 1998, high cholesterol
Others have cognitive problems and
                                                                                               diagnosed 1998, no allergies
systemic conditions that make them less
capable of caring for themselves and                                                           •Medications: Atenolol, Lisinopril,
undergoing dental treatment. Geriatric                                                         Plavix, Galantimine, Risperidone, etc.
patients are also more likely to be taking
numerous medications to maintain their                                                         •After performing a geriatric
health. Thus, a thorough examination                                                           assessment test on the patient, it was
must be done for each patient before                                                           determined that he had severe
determining the best course of treatment.                                                      dementia. His nurse stated that he used
The goal when treating a geriatric                                                             to have dentures that he lost awhile ago
patient should be to create a stable oral                                                      but doesn’t have any problems eating
environment that the individuals are able                                                      currently.
to maintain.                                         •Mohammad, Abdel Rahim. Geriatric
•Literature Review                                   Dentistry. 5th edition Columbus, OH:
•Elderly people are more susceptible to              2008.
developing systemic problems as a result of an
                                                     •Yeh, Chih-Ko, Katz, Michael S.,
oral condition. So, it is important for these
individuals to receive dental treatment. The         Saunders, Michele J. Geriatric
goal of this treatment should be prevention of       Dentistry: Integral Component to
disease and maintenance of oral functions such       Geriatric Patient Care. Taiwan
as mastication and speech. There is no need to       Geriatrics & Gerontology 2008; 3(3):
take extravagant measures to save a hopeless
                                                     182-192.
tooth or to put them through complex
procedures such as dental implants or gingival       •Thomas-Weintraub, A. Dental Needs
grafts. At this point in their lives, these people   and Dental Service Use Patterns of an
are just concerned with being free of                Elderly Edentulous Population. J.
pain/infection and being able to live their lives
                                                     Prosthetic Dentistry 51: 164-168, 1985.
without having to worry about their teeth.




              •Treatment Planning for the Geriatric Patient
•Abstract       Designing a treatment
plan for a geriatric patient is a more                                                         •86 y.o. male
complex procedure than if the same thing                                                       •CC: “I want my false teeth.”
is done for a middle-aged adult. Many                                                          •PI: Completely Edentulous
geriatric patients have some kind of
                                                                                               •Medical History: Diagnosed with
physical limitation that affects their
                                                                                               dementia in 2001, high blood pressure
ability to maintain their dentition.
                                                                                               diagnosed 1998, high cholesterol
Others have cognitive problems and
                                                                                               diagnosed 1998, no allergies
systemic conditions that make them less
capable of caring for themselves and                                                           •Medications: Atenolol, Lisinopril,
undergoing dental treatment. Geriatric                                                         Plavix, Galantimine, Risperidone, etc.
patients are also more likely to be taking           •Mohammad, Abdel Rahim. Geriatric         After performing a geriatric assessment
numerous medications to maintain their               Dentistry. 5th edition Columbus, OH:      test on the patient, it was determined
health. Thus, a thorough examination                 2008.                                     that he had severe dementia. His nurse
must be done for each patient before                                                           stated that he used to have dentures that
                                                     •Yeh, Chih-Ko, Katz, Michael S.,
determining the best course of treatment.                                                      he lost awhile ago but doesn’t have any
                                                     Saunders, Michele J. Geriatric
The goal when treating a geriatric                                                             problems eating currently.
                                                     Dentistry: Integral Component to
patient should be to create a stable oral                                                      Diagnosis :Complete Edentulism in
                                                     Geriatric Patient Care. Taiwan
environment that the individuals are able                                                      patient with Severe Dementia
                                                     Geriatrics & Gerontology 2008; 3(3):
to maintain.                                                                                   Treatment Plan :fter assessing the
                                                     182-192.
•Literature Review                                                                             patient’s Dementia status, it was
•Elderly people are more susceptible to
                                                     •Thomas-Weintraub, A. Dental Needs
                                                     and Dental Service Use Patterns of an     determined that the best course of
developing systemic problems as a result of an
                                                     Elderly Edentulous Population. J.         treatment was to do nothing for the
oral condition. So, it is important for these
individuals to receive dental treatment. The         Prosthetic Dentistry 51: 164-168, 1985.   patient. This decision was based on the
goal of this treatment should be prevention of                                                 fact that the patient would be unable to
disease and maintenance of oral functions such                                                 handle the upkeep required for
as mastication and speech. There is no need to                                                 dentures and may not be able to give the
take extravagant measures to save a hopeless
                                                                                               feedback required during the
tooth or to put them through complex
procedures such as dental implants or gingival                                                 appointments needed to make them.
grafts. At this point in their lives, these people                                             Making dentures for this patient
are just concerned with being free of                                                          wouldn’t significantly improve his
pain/infection and being able to live their lives                                              ability to function and would probably
without having to worry about their teeth.
                                                                                               just be misplaced again.




                               THE END

                      “To Add Life To Years Not Just Years To Life”

								
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