Geriatric

Geriatric : An overview. Part I. Pretreatment considerations Anthony M. Iacopino* /William F. Wathen**

A rising geriatric population remains dentate and requires more dental care to maintain dental health and function. This article discusses psychological aspects of aging and considerations of age-related changes of teeth, oral tissues, nutrition, and metabolism in the elderly Aging affects all ti.ssues and systems, as do nutritional and metabolic factors. Numerous factors alter healing, host resistance, digestion and absorption, mastication, metabolic competency renal and hepatic function, and excretory capabil- ity. Complex drug regimens further confuse clear diagnoses. Full consideration must be given these factors before treatment plans are fortmilated. (Quintessence Int 1993:24:259-266.)

Introduction treat this population. The geriatrically oriented is vital by virtue of education, training, and elinieal Tiie geriatric population is rising as many people reach skills. This paper provides an overview of elements the age of 70 with a prospeet of 20 years ahead.'"^ This necessary for diagnostic, managerial, and therapeutic current increase has resulted from improved social competence in geriatric dentistry. These elements fall conditions and advances in medical care. Concurrent into two domains; (I) management of teeth and eden- efforts by families, communities, and heaith care pro- tulous spaces as well as the delivery of supportive fessionals provide comfort, compassion, and health dental eare; and (2) management of the psychological, care for this population. However, a high proportion physiologic, and nutritional aspects of aging. Attempts of elderly suffer from dental disability.''•^ In geriatric at the flrst domain will surely fail without understand- settings, advice on oral care often is provided by the ing the second. These prerequisites can be collectively physician as part of total medical care. Neglect of oral called "pretreatment considerations." hygiene and increased are commonly seen, and it is often difficult to flnd dental practitioners to care for these individuals.''^ Understanding the elderly Thus, a current challenge for dentistry is to provide Discussions about elderly patients conjure up a stereo- adequately trained geriatric professionals who will type in most practitioners; unsteady, stiff, slow, vision- and hearing-impaired, confused, fearful, forgetful, and the cause of lengthy delays in the day's appoint- ments,"'^ The physiologic processes of aging and the gradual diminution in acuity of the flve senses are facts, but the rate at which they occur shows great Assistant Professor, Deparlmcnls of Biomédical Sciences and variation among individuals. Each patient should be Prosthodontics. Director. Molecular Biolugy, Baylor College of regarded as an individual. Older people who are retired Dentislry, 3302 Gaston Avenue, Dallas,Texas 75246, Private Practice in General Dentistry, Fort Worth, Texas; Assis- may feel a loss of personal signitlcance and will feel tant Professor, Department of General Dentistry, Director, further diminished by condescending attitudes. General Practice Fellowship Program, Di redor. Deparltnent of Continuing Education, Baylor College of Dentistry. Elderly people may become severely depressed by

Quintessence Internationai Volume 24, Number 4/1993 259 Geriatrie Dentistry such losses as failing physical health, death of family to the patient. Although it may take up an entire ap- and friends, decreased earning capacity and financial pointment, total listening involves sensitivity to all ver- independence, and reduced possessions or status. bal and nonverbal communications from the patient so Against this background, the prospect of tooth loss that nothing is missed,'* may hold disproportionate horror as loss of yet another The dentist-patient relationship must be one of part of oneself."* It is no wonder that attention and intimacy and trust. Practitioners should make their sympathy is sought subconsciously and that a regular availability and willingness to see the patient abun- visit to a sympathetic dentist or physician is part of a dantly clear. The need for respect, concern, and com- "game" that keeps an individual going. passion cannot be overemphasized. If the dentistry must provide titne and attentive listening to does not take place within this type of relationship, geriatric patients. Time is money, but practitioners accomplishment will be diminished and the patient must be wifling to bear the financial burden of an will be dissatisfied. unhurried consultation. They must be able to modify their temperament to suit these patients and be relaxed enough to listen and fully undersland their problems." Aging in teeth and oral tissues Briskness, formality, and ultraefficiency must be re- Two major damaging influences are particularly as- placed by cheerfulness, warm optimism, and physical sociated with aging: (I) increasing brittleness that pre- closeness. Elderly patients often wait many anxious disposes to cracks, fractures, and shearing of tooth days for the visit, thinking and wori"ying about little substance; and (2) progressive apical migration of else, while to the dentist, it is a brief encounter in a soft tissue attachment, leading to root exposure and busy day. Older patients have an increasing dislike of diminished bony support.'^"' While each of the con- being hurried or rushed in any way. The successful stituent attachment tissues is capable of true regener- geriatrician proceeds slowly and explains adequately. ation, integrated repair of epithelium, fibers, and con- Stress resistance is greatly redticed in some older nective tissue is not easily achieved. The regenerative people. Shorter appointments and longer recovery capacity of soft tissue is not as brisk in as it is times are needed.^'^ in youth and is often extremely limited. Vanity does not fade with age. Loose or clicking den- Hard tissues tures can cause older people to increasingly withdraw from social contact. Many elderly people, especially is subject to , abrasion, and those residing in institutional settings or who have erosion (now termed ab fraction).^''•^'' Attrition results been treated unkindly by relatives, have a tenuous from frictional wear during repeated contact with hold on self-respect.' They may feel they have lost opposing teeth (occlusal attrition) and adjacent teelh their physical attractiveness. It can make an enormotis (proximal attrition). It is greatly influenced by diet difference to an individual's self-esteem to know that (gritty foods), parafunction (bruxism), and salivary his or her appearance and personality can give pleasure secretion (diminished lubrication). Abrasion is loss of to others. Dentists and staff must remember this during tooth substance by friction other than mastication treatment and continuously provide patients with pos- (improper toothbrush ing, for example). This usually itive signals relative to appearance. When older people manifests as transverse scoring of the enamel (canines come for treatment, it may be necessary to retain their and premoiars are most frequently affected at the cer- basic appearance, not only for prosthetic reasons but vicobuccal regions) and tends to be asymmetric. Where for social reasons as well, A substantial alteration of gingival recession has occurred (usually the case in facial and/or oral appearance may change relationships elderly patients), abrasion of the and dentin with grandchildren and friends for the worse." is more marked than is that of the enamel and is essen- Some older people have difficulty atticulating secon- tially capable of severing the crown from the tooth dary to mental and physical compromise. Clarity of root. Erosion designates loss of enamel from ingested speech is very important, particularly for those elderly or regurgitated acids. The main source of ingested acid residing in institutional settings. If a patient's speech is is citrus fruit and fruit products,'^ while regurgitated slow, we may be tempted to end sentences for him or acids are the result of gastrointestinal upsets, commoti her, often incorrectly. This is very frustrating to pa- in the elderly.''' Reduced salivary secretion also exacer- tients. It is difflcult to hsten while patients "wander," bates this process because of the loss of protective but it is imperative in learning how to be most useful salivary bnffering. The areas of erosion are usually

260 Quintessence International Volume 24, Number 4/t993 Geriatrie Dentistry saucer shaped and most eommonly are seen OR the There is clear evidenee to suggest that the deposition labial surfaces of maxillary anterior teeth. Erosion is or résorption of cementum ean be provoked by external usually a more painful process than either attrition or stimuli." A succession of low-grade insults over many abrasion. Wear patterns are important aspects of treat- years may account lor the frequency of hypercementosis ing teeth or temporomandibular joint (TMJ) problems in elderly teeth. When this is particularly prominent at when restorative proeeduies are planned. Botb normal the root apex, a "ball and socket" arrangement results, function and idiosyneratie habits must be considered.'" making it extremely diffieult to extract these teeth. TheTC is a diminished incidence of enamel (coronal) Root caries is unique in the elderly population."'''^ caries in the elderly."'""There are two theories for this Root suifaee cavitation differs in many respects from deerease. One proposes that there is a reduction in caries that starts in enamel. It is seen predominantly in susceptible sites because attrition aud absorption of the elderly because extensive areas of the tooth root fluoride and other ions by the enamel result in a more are rarely exposed in earlier years. Whereas in coronal acid-resistant surface. The other proposes that elderly caries vertical penetration precedes lateral extension, patients have acquired immunity to cariogenic micro- the lesion in root caries is usually broad and shallow organisms and claims that the time involved is eonsistent (probably because of the difference in mineral content with the slow acquisition of immunity to an organism between enamel and eementum). The pathogenesis of of low immunogenicity, such as Streptococcus niutans. root earies is not precisely understood, but there is Dentin undergoes different changes than the enamel, evidence that actiuomycetes rather than streptococci because of secondary dentin deposition."' Secondary are the principal causative organisms.- Once cemen- dentin ean be laid down for as long as the tooth pulp tum has become exposed to the oral environment, it remains vital, although paradoxically, it infringes on must be scrupulously maintained. Since cementum is the pulp chamber and ultimately leads to obliteration far less resistant to mecbanieal injury than enamel, of the pulp. This secondary dentin protects the pulp however, overly vigorous brushing ean be expected to from noxious stimuli and exhibits a pattern of dentinal result in damage no less undesirable than root earies tubuies that is much less orderly than the original or itself. Use of abrasives should be omitted in these primary dentin. Secondary dentin can take the form of areas. translucent zones and dead tracts. Translucent zones Bone is a conspicuously labile tissue, Resorption and are a protective response, and they owe their translu- deposition occur syncbronously in the process of growth cency to tubular occlusion via mineral salt deposition, and remodeling, an essential phenomenon for balanee whIcb changes the refractive index. !f the response is between structure and function. Once growth is com- more rapid, dead tracts will form due to loss of the plete, bone is notably less labile, although homenstatic odontoblastic process, Fnipty dentinal tubules yield a regulation necessitates some degree of continuing ré- bizarre opacity on transillumination. sorption and deposition. As physical activity diminishes, Dental pulp undergoes age-related changes in quality so does the demand for new bone formation and, by afld size.'"-' Tbe pulp ehamber and canals become the time old age is reached, atrophy has resulted from progressively reduced in size by the deposition of sec- slow, uncompensated résorption."' '^ Increasing fragility ondary dentin and another form of calcification called of elderly bone is not merely a consequence of atrophy. pulp stones. Pulp stones are dysplastic mineralized tis- Bone eomposition gradually alters, resulting in reduced sue existing in concentrically laminated masses with an resilience and increased brittleness. It is estimated that as yet undefined physiologic cause. With age the pulp the mineral content is reduced by 50% in women and becomes less cellular, less vascular, and more fibrous. 40% in men by age 75."'' Microseopically, the cellular The pulpal nerve fibers are substantially reduced in component diminishes progressively as age advances lengtb, diameter, and degree of myelination, leading so that the bone appears to be sclerotie and surviving to a decrease in dentinal sensitivity," The odontoblasts osteoeytes appear to be shrunken. Above all, however, lining the pulpal aspect of the dentin are less numerous the quantity of mineralized tissue is conspicuously re- and shrunken in appearance. There is also a gradual duced botb in eortical and trabecular bone. diminution in the diameter of the apical foramen, which may account for the progressive loss of vascularity and Soft tissues degenerative changes in aging pulps, Cementum, like The periodontium shows some age-related changes." " dentin, is gradually deposited throughout life and is Loss of the alveolar bone that normally surrounds the principal cause for narrowing of the apieal foramen. tooth roots and affords anchorage for the fibers of the

Ouintessence International Volume 24, tslutnber 4/1993 261 Geriatric Dentistry periodontal ligament is hastened by the extraction of likely to cause problems than is degenerative change teeth. Before extraction, this hone resorbs slowly in the TMJ articulation. Evidence of age-related disease along with gingival recession. The process is more in tht^ TMJ is sufficient to warrant its consideration rapid and irregular in the presence of periodontal when masticatory problems arise in older people. disease. Through its unique ability to attach at both Symptoms of TMJ dysfunction are fairly prevalent in the connective tissue and tooth interfaces, junctional older individuals. Thirty percent of patients greater epithelium forms a seal that protects the connective than 711 years old exhibit TMJ dysfunction, tenderness tissue of the periodontium from the oral environment." of the masticatory muscles, and abnormal joint sounds; Originally located at the cementoenamel ¡unction the mean age of patients with osteoarthrosis of the (CEJ), this seal may be hreached (masticatory stress, TMJ is 62 years.^'^= mechanical injury, or ) and then No dentist can enjoy an understanding of the geriatric renewed at a level slightly apical lo the CEJ. With patient's oral health or disease without a full apprecia- repeated wear and tear, the cycle continues this apical tion of the events and changes that underlie tissue progression. Epithelial rests of Malassez proliferate in aging. Elderly patients may be frustrated by difficulty response to injury and are thought to function as a re- in describing what is wrong. The practitioner must be serve of epithehal cells available for providing a new skilled in combining what the patient describes and seal as the gingiva recedes. These epithelial masses what is occurring in the tissues into a diagnosis. An decrease in number with age.''This cycle of wear and apparently unsubstantiated complaint about a denture tear produces slow, uniform, symmetrical recession. may bc related to changes in the tissues on which it Loss of periodontal attachment is compensated for rests. Cooperation with the elderly patient's physieian by additional deposition of cementum and increased is essential and it is the dentist"s responsibility to renew content of collagen in the periodontal ligament. Thus, and maintain this contact. well-worn teeth with advanced recession are usually surprisingly firm. Mobility and gingival bleeding are seen only when periodontal disease is present. Nutrition and nietuboiism in the elderly Oral mucosa possesses no singular feature related to The importance of nutrition in maintaining health in the effects of aging. The wrinkling of facial skin is old age is well documented, but nutrition remains matched by a less obvious slow atrophy and loss of the beset with myths and misconceptions. The nutritional oral mucosa, mostly reflective of a gradual deterioration status of geriatric patients directly affects their ability in bodily efficiency. Elderly patients suffer a loss of tis- to withstand trauma, to heal, and to respond to dental sue and oral fluids associated with reduced vascularity procedures. Mental and physical disability are related and salivary secretiou. This depletion is attributable to poor nutrition in the elderly.^' Elderly individuals to an age-related decrease in acinar tissue, compared will differ in a wide range of parameters (activity, social with ductal and connective tissues,'^"''•"^ resulting in class, habits, and type of work), necessitating assess- increasing vulnerability to minor injury. ment of nutritional status on a ease-by-ease basis. A Wound healing becomes progressively less rapid with common nutritional assessment method utilizes dietary advancing age because of decreased vascularity and history, clinical examination, and laboratory testing.^'' locally impaired hemodynamics, which arise from Dietary surveys determine what the patient eats, damage to and thickening of vessel walls. Decreased how much, and the state of dietary balance. Intake of immune response introduces yet another obstacle to protein, fat, carbohydrates, vitamins, essential ele- healing, and, perhaps most importantly, the capacity ments (calcium and potassium), and trace elements of ceils to undergo division can decline until the pro- (zinc and copper) is assessed. Dietary histories of food liferative response essential for repair is deficient.'^'' eaten during a fixed period (1 week or 1 day) are ob- tained by interview and questionnaire.^''This method Finally, there are age-related changes in the mastica- relies on the patient's memory (not ideal) and the skill tory musculature and TMJ. With age, muscle fibers of the interviewer. It is advisable to repeat this on decrease in size and number and are replaced by fat several different oecasions and to recruit a responsible and fibrous connective tissue."'"' Atrophy of mastica- party to assist the patient. It has been estimated that tory muscles is due in part to disuse, as less muscular 20% of the population greater than age 80 suffers from effort is required either because of a failing dentition, mainutrition.-^-* The major factors influencing nutritional a progressively softer diet, or both. The dwindling status are (1) quality and quantity of food intake, (2) power of the masticatory musculature is much less

262 Quintessence Inlernational Volume 2A. Number 4/1993 Geriatric Dentistry itigestion of food obtained (tnastication and swallow- Disorders of the GI tract may give rise to nutritional ing), (3) digestioti anti absorption, and (4) requirement deficieneies through loss of nutrients. Loss of iron as a of body tissues. result of bleeding {ulcers, hemorrhoids, and aspirinlike Food intake relates to a number of factors. House- drugs used to treat arthritis al! cause GI bleeding) bound individuals will show a decreased intake because is the most common cause of iron deficiency in the it is hard to go out and purchase food. Diminished elderly."' Intestinal motility is also impaired by age activity reduces tbe need for food intake: thus some and this may have effects on nutritional status. Current individuals may suffer from nutritional deficiency while fashion is to correct constipation by increasing the fiber they appear well nourished or obese. Lack of interest content of the diet. While this is undoubtedly effective in food and its preparation {senses of taste and smell in increasing stool bulk, iron, calcium, and magnesium decline witb age) can contribute to a dietary deficiency, ions attach to the fiber and are not absorbed, thereby as can a sbortage of money. Reduced intake is almost creating a potential deficiency, always multifactorial and many factors such as depres- Tbe requirements of body tissues have not been sion, bereavement, and alcoholism, are linked. Elderly shown to change because of the aging process itself, singles living alone are particularly prone to deficiency but in disease states common among the aged, protein states. Ignorance of food values also plays a part in requirements are doubled or tripled, and many ill, el- poor dietary habits among the geriatric population.^' '^ derly people are considerably undernourished.^' The Mastication and swallowing are vital to the ingestion need for essential amino acids may increase as a result process. The production of saliva diminishes with age of infection, fever (increases basal metabohc rate), and certain drugs (diuretics and antidcpressants) may protein loss due to GI disease, and recovery from a also decrease secietion. As a result, mastication be- surgical operation or trauma. Supplementation of the comes less efficient and swallowing more difficult. diet with appropriate proteins leads to better tissue re- Food may be chewed for long periods and then spat pair and more rapid recovery. out. Eating becomes a slow business and food becomes Poor nutrition may give rise to a variety of elinical cold and unpalatable. This problem is compounded by signs and symptoms that a skilled practitioner can pick a poor dentition. Tbe proportion of sohd foods ingested up during the clinical examination,^""*^ Complaints is closely associated with tbe presence or absence of related to difficulty with night vision may be indicative teeth," Disorders of neuromuscular coordination may of vitamin A deficiency. The presence of angular also make swallowing difficult (dysphagia). These may cheilosis, glossitis, dermatitis, diarrhea, and memorj' be associated with paralysis or dysfunction of the facial loss point to B-complex defieicncies. Delayed wound and masticatory muscles as well as those involved with healing can be related to lack of vitamin C, while a the control of the tongue and pharynx. These muscles generalized pattern of bone décalcification and muscu- are often affected by cerebrovast:ular accident. Slow lar weakness may be related to lack of vitamin D. Vit- movements (hypokinesia) associated with rigidity and amin K deficiency will lead to bleeding problems, and tremor compound the inability to swallow. Thus, pa- deficiencies of potassium, magnesium, and calcium tients with Parkinsons disease often suffer from poor may give rise to cardiac disturbances, muscle tremor nutritional status. Any disease process affecting the and tetany, and postural hypotension. Anemia, reduced upper gastrointestinal (GI) tract may interfere with resistance to infection, and atrophie buccal mucosa food ingestion.^^ may affect the may indicate depressed levels of iron, zinc, and copper. IMI, interfering with mastication, and, breathless ness The clinical diagnosis of nutritional deficiencies is dif- due to respiratory disease or associated with heart fail- ficult al best, and the problem is compounded by the tire may make swallowing difficult. fact that there may be a long latent period before tbe appearance of overt clinical signs. Biochemical and Age-related changes in digestion and absorption are hématologie testing are essential for proper diagnosis, due to mild, generaUzed atrophy of the GI tract. and arrangements should be made with the patient's Gastric hydrochloric acid secretion is reduced, leading physician for evaluation and testing whenever a nutri- to achloThydria. When illness or heart failure exist, tional deficiency is suspected. digestion will be impaired. Malabsorption is associated with a variety of conditions in the elderly (partial gas- Age-related cbanges in metabolism can affect renal trectomy, gastritis, coeliac disease, diverticulosis, and function, bepatic function, the endocrine system, and laxative drugs). Usually, tbe resuh is a poor absorption absorption and excretion processes. At the cellular of fats and fat-soluble vitamins (A, D, E, and K). level, it is likely that these changes can be attribufed

Quintessence International Volume 24, Number 4/1993 263 Geriatrie Dentistry to altered enzyme patterns (because of defective pro- Drug metabolism is of particular concern in aging tein synthesis or deereased enzyme adapiability and patients.''-''"'" The incidence of illness increases steadily induction), diminished cell sensitivity (dtie to reduced with age. More than 80% of people older than 65 target cell receptors), and impaired cellular immunity.'' years are taking at least one medication. ' The many It has been suggested that aging is regulated by the physiologic and biochemical changes associated with hypothalamic-hypophyscal endocrine system, and the aging alter body composition, and the efficiency of presence of an "aging clock" tnechanism situated in individual organs diminishes. Lean body mass is re- the hypothalamus has been postulated.'" The most duced and fat mass is inereased. Organ blood flow is notable impact of this regulation concerns the pituitaiy diminished. Reduced glomerular filtration rates alter glaud (hypophysis) and its relalionship to the adrenal body salt and water contents. Diminished hepatic gland (hypophyseal-adrenal axis). The sequelae of ab- metabolism impairs the "first-pass" effect. Changes in normal function of this axis are well described. The cell mcmhranes alter receptor functions and numbers ability to respond or adjust to stress declines with age of receptors may be lost. Nutritional deficiencies may (less efflcient production of glucocoiticoids and ad- lower plasma protein levels, thus affecting protein renalin). Vasoprcssin levels increase with age (causing binding of drugs. Once a drug has been prescribed it the rise in blood pressure found in aging patients). has to be taken, absorbed, transported to the end Hypofunction of ihe axis leads to increased pigmenta- organ, utihzed. metabolized, and excreted. Each one tion, loss of iron, obesity, lethargy, and mental confu- of these steps may be altered hy aging. sion (Addison's disease). Hyperfunction of the axis The more drugs an older person has to take, the leads to , muscle atrophy, fat deposition, and worse compliance is likely to be.'*' Absorption may be depressed immune function (Cushing's disease). The inlluenced by the action of other drugs. Laxatives, for hypop h y seal-thyroid axis is also perturbed in tbe aged example, may speed GI transit so that absorption of and hypofunction of the thyroid (myxedcma) is com- the drug is reduced or, alternatively, other drugs (anti- mon in the elderly population."^ Symptoms of the con- cbolinergics) may slow transit time so that absorption dition inelude obesity, mental and physical slowing, is increased. Drugs may also interact to form less deafness, cold intolerance, loss of hair, constipation, absorbable complexes. Hepatic metabolism is less and limb pain. The high prevalence of hypothyroidism efficient for some drugs so that higher blood levels of is probably due to aheration of immune responses In drug are attained. This is probably due to reduced old age. Antithyroid antibody titers are higher than hepatic blood flow. Binding sites on plasma protein normal in 33% of those older than 85.''" The gonads molecules, especially albumin, are reduced with age. are also affected by age changes.*"" Ovarian function Thus more free drug will be available (particularly in eeases at menopause, so that female hormone levels the case of those drugs that are highly protein bound). decline and the estrogen-testosterone ratio begins to The possibility of adverse interactions between protein- change. This leads to the loss of secondary sex charac- bound drugs is very real. Changes in lean body mass teristics {breasts atrophy and facial hair increases). In and fat mass as well as body water lead to changes in the male, testosterone levels slowly decrease so that drug distribution with age. As a result, lipid-soluble the estrogen-testosterone ratio swings in the opposite drugs will have a larger distribution volume and a direction, leading to a tendency toward femini2ation. lower plasma level, while polar drugs have a small dis- The inability to handle a glucose load increases with tribution volume and a high plasma level. Considerable age so that 25 % of the elderly persons older than 70 evidence exists that end-organ sensitivity increases suffer from maturity onset diabetes.'''' It may be that with age and this seems to affect the nervous system the receptor cells arc less sensitive to the insuhn pro- preferentially. The glomerular filtration rate diminishes duced or that the insulin itself is less active. The because of reduced renal blood flow as well as reduc- complications that accompany this condition affect the tion In the number of glomeruli. Tubular reabsorption eye (retinopathy and cataracts), cardiovascular system is altered, and the net effect is that drugs are poorly (coronary artery disease), kidney (diffuse glomerular excreted, as are normal waste products. Consequently, sclerosis), and the nervous system (neuropathy and drug balflife is prolonged in the case of drugs that autonomie dysfunction leading to postural hypotension depend on renal excretion for their elimination (and or bladder and bowel disturbances). Thiazidc diuretics the elimination of their metabolites). have been shown to inhibit insuhn release and may actually aggravate the condition. Because of these changes, special care must be taken in prescribing drugs and doses must be adjusted to

264 Quintessence International Volume 24, Number 4/1993 Geriatrie Dentistry meet the individual needs of elderly patients. Patients 13. Weiner AA. The psych o physio logic eliology of anxiety in Ihe should be closely monitored, and the practitioner must geriatric dental patient. Spec Care Dent 19B5;3:172-177. 14. Brock AM. Communicating with the elderly patient. Spec know the pharmacology of tlie drug prescribed, whether Care Dent Iy85;3:t57-t59. it is metabolized in the liver or excreted unchanged in 15. Miles AEW. Age changes in dental tissues. In: Cohen B, the kidney, the fate and activity of its metabolites, Kriimcr tRH. Scientific Foundations of Dentistry. London: whether it is an acid or a base, whether it is lipid or Heinemann Medical, 1976:435^50. 16. Viidik A Biological aspects of aging, ln: Pedersen PN, Loe water soluble, if it is highly protein bound, and if it H (cds). Geriatric Dentistry. St Louis: Mosby, 1986:94-120. is likely to interact with other drugs that the patient 17. Cohen B. Aging in leeth and associated tissues. In: Cohen B, needs to take or is already taking. Thompson H (esd). Dental Care for the Elderly. London: Year Book, 1987:23-40. 18. Touy?., LZ. Glasstnan RM. Citrus acid and teeth. J Dent Assoc Afr 198I;36:195-2O1. Conclusions 19. Nelson JB, Castell DO. The gastrointestinal system. In: Hazzard WR, Blass JB (eds). Principles of Geriatric Medicine When dealing with geriatric patients, the dentist must and Gerontology. New York: McGraw-Hill, 1990:58-64. show respect and genuine concern. Compassion con- 20. Adicr P, Ciirrelalion between dental caries prevalences at dif- sumes time, but it cannot be regarded as a luxury. It ferent ages. Caries Res 1968:2:79. 21. Symons NBB. Dentine and pulp. In: Cohen B, Kramer IRH. is, in fact, a genuine need. Sbort-term attitudes and Scientific Foundations of Dentistry, London: Heincmann treatment plans should be avoided for all elderly pa- Medical, 1976:423^33. tients and not merely those who are reluctant to accept 22. Fried K, Erdeiyi G. Changes with age in canine tooth nerve fibres of the cat. Arch Oral Biol 19a4;29:581-585. the prospect of old age. These patients need all the 23. Schu)ts-Haudl SD, Aas E. Dynamics of the periodontal tis- encouragement they can receive to make the best of sues. The connective tissue, OdontolTldskr l96l;69:431-435. their remaining years. The dentist is faced with frequent 24. Ibbetson RJ. Restorative needs and methods. In: Cohen B, complaints from elderly patients (many seemingly un- Thompson H {cds). Dental Care for the Elderly. London: Year Book, 1987:142-178. justified) but argument and anger are futile. Criticism 2.S, Fejcrskov O. Nyvad B. Pathology and treatment of dental must be absorbed and every effort made to help. 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Spec Care Dent 1985;4:244-247. 33. Morley JE, Nutrilion and aging. In: Hazzard WR, Blass JP 7. Meskin LH. Economic impact of dental service utilization by (eds). Principles of Geriatric Medicine and Gerontology. New older adults. J Am Dent Assoc 1990i 120:665-668. York: McGraw-Hill, t990:48-60. S. Kiyak HA, Milgrom P, Ratener P. Conrad D. Dentist's at- 34. Rubcnstein LZ. Comprehensive geriatric assessment. Annu titjdes toward and knowledge of the elderly. J Dent Educ Rev Gerontol Geriatr 1989,9:t45-t92. t982;46:226-273. 35. Chamber DW. Behavior modifieation. ln: Chamber DW 9. Anderson EG. Reflections on a praetice giiing geriatric. (ed). Diet, Nutrition and Dentistry. St Louis: Mosby, 19S1: 1989:44:91-92. 40^5. 10. Charatan FB. The gerophsychiatric patient. Spec Care Dent 36. Nelson JB and CasteM DO. Aging of the gastrointestmal sys- !985;3:2I3-216. tem. In: Hazzard WR, Blass JP (eds). Principles of Geriatric II Portnoy EJ Successful communicalion with older patients. Medicine and Gerontology. New York: McGraw-Hill. 19yO: Spec Care Denl 1985 ;3:180-182. 58-63, 12. Johns RB. Delivery of care. In: Cohen B,Thompson H (eds). 37. Werner 1. Nutritional characteristics ol the elderly. In: Platt D Dental Care for the Elderly, txindon: Year Book, 1987.123-125. (ed). Geriatries, vol 2. Berlin: Springer, 1983:352-365.

Quintessence International Volume 24, Number 4/1993 265 Geriatric Dentistry

38. Jollitïec N.Tht physical signs of tnaliiutritior. In: Jolliffce N 42. Jeffreys PM. The prevalence of thyroid dis(;iisi; in patients ad- (cd). Tho Control of Mil I nutrition in Mar. New York: Amer- mitied to a ¡jiíriatric tlepartmenl. Age Ageing ty72;l:33-37, ican Public Health Association, l%0:8-tt. 43. Davidson JM, Hormonal changes in sexual function in aging, 3y. SandsleaJ HD, Curter JP and Darby WJ, How to diagnose J Clin Endocrinol Metal) iy83;.';7:7l-7S. nulritional disorders in daily practice. Nutri Today 196y;4: 44. Smilh MJ, Hall MRP. Carbohydrate loleranee in the very 20-26. aged. Diabelologia ty73;9:387-39L 40. E.vton-Smith AN. Nutritional status: Diagnosis and preven- 45. Roy J. Medication for the elderly. Rep Royal CotI Physicians tion of malntitrition. ln: Estiin-Stnith AN, Caird Fl (eds). 1984;IS:7-17. Metabolic utid Nutritional Disorders in Elderly. Bristol, Eng- 46. Weintratib M. Compliance in the elderly. CHn Geriatr Med latid: Wright and Sons, 1^80:66-75. 4t. Sapolsky R. The neuroendocrinology of stress and aging. 47. Nolan L, O'Malley K, Prescribing for the elderly. J Am Endocr Rev iy86;7:2S4-2yO. Geriatr Soc 1988;.'i6:1.16-142. •

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