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The Dental Prosthetist and their Future Role in Oral Health P2

We think about dementia. I said that there are a lot of causes of dementia. Alzheimer’s is the biggest one, particularly in the 85 and overs but mostly infect dementia is very common as well. Patients have these little small gaps in memory. Particular in short term in memory and that will cause them to forget   instructions. We will more likely to give them written instructions for example. The epidemic of  obesity many of you would have heard much of this in the press  is linked to reflux  that has drastic consequences  for the  dentition and also strongly linked to  sleepapnia and other issues in terms of  general health such as hypertension .

So these are big things happening at he  community level that affect the sort of patients  that  we are looking after and indeednmyight impact on our  own life. Diabetes because of its very strong two way association with periodontitis is a big factor to think about. We often think all teeth are lost in older patients from periodontitis and that’s not entirely true. The biggest single factor that causes teeth in older patients to be lost is the combination of mouldy factorial tissues around root service caries, periodontitis, what you could also call sometimes prosthetic convenience. In other words the tooth may not be able to be used to support a prosthesis. But you get lots of root carries, you get lots of aggressive periodontitis in patients like that.

If you sort of defocus form the filling narrow view of the dental profession for a moment and think about these big disease they share lots of common risk factors and this nice slide put together by Peter Dettinson just links to gather a whole range of these risk factors so that we can see that stress and diet link very many of these conditions together. So does alcohol and exercise. When we think about the  public health of this  aging community we have all these  little  many epidemics happening  that are interlinks so we will be  coming more used to  dealing with   patients who will care  more  of this burden of  disease as we  have a more aging population .

Just to return to dementia once you get the high levels of dementia you will obviously need a lot of care with activates of daily living and so on. We’ve now got patients who are outside of many of the windows of dental treatment and indeed a lot of the survey data we have in Australia doesn’t capture very well patients that are institutionalised. I recently reviewed a couple of papers for a major Australian journal looking at the dental health for people in different levels of dementia care in Australia. The figures there are much , much , worse ten you would  expect to get if  you  simply did the telephone  survey and aloe t of the data  in Australia airs based on  convenience an  telephone survey .
We  actually tend to under rate some of the e  severity of  oral  health and when you go on income of these facilities as  i know many of you do you see first-hand some  of the conditions that  are there. Some we have a population that is going from go-go , to slow-go , to no-go as the populations is able to live longer it carries more of the burden of life with it. So we need to adjust our mental barometers a little bit looking into the future.

Medications have I big impact on care and they will have an increasing impact on care in the future. Not just prescription medicines but all the over the counter, the natural, the herbal, rhea alternative, all these things can impact on oral health.  I thought i would just give you some simple examples, gingiva enlargement is one group of things and severe oral dryness, or zero stymie is another. Both of them have some important and interesting consequences   and there are some many other once and Gary will show you a nice example of traded dyskinesia tomorrow. So i won’t talk about that one with you. Hers some examples of gingival enlargement driven by the most commonly drug used for hypertension in Australia. A sort of typical nyphetomine class calcium chiding blocker causing some very nice enlargement. You can see here indicated by the arrows creating what looks like asked Uvula in the patient on the body in this large [Inaudible] tissue in the patient in the right. Both of which we removed surgically as you can see here.

Oral  dryness have  big impact and Avery , very common problem is  it would be unusual for me to  see  elderly  patient and now see oral  dryness in the area  of practise that i work in .  It has big impacts for how well lower dentures are lubricated and we’ve still yet to find and absolutely perfect replacement for saliva. It is such a simple yet complexed material.   That we are yet to have a perfect replacement and offer these patients both comfort and all the supporting roles that saliva plays in minting oral health today. It has a big impact on the type of mucosal disease that patients present  with and Michael will come back and talk about the problems of oral  fungal infection with you late ranchos conference but when we see these recurring dfubncal  infection in patients mouth associated with a  denture or not we need to think as  what environment is driving that  and are there things in he patients medical health   or things i n the medication that are  changing the saliva environment and changing the  patients ability  to heal  in the amount good immune  response .  I won’t give you the one hour lectures as much as  is would like  to on the drugs that causes  dry moth but there is a very  long list as you can see here and many of them  start with the word anti  which i guess gives you a little  bit of  a clue.

Of course today  we see patients how are very  frail and very much affected  by connective tissue diseases  , conditions  cut as shivering syndrome and  scleroderma  and not uncommon conditions to encounter and these patients  egret very much  challenged by  incredible  dryness of their oral tissue. That makes it very difficult to think about these patients having a removal of prosthesis whatsoever and it’s very hard for these patients to care for their teeth and for any appliances which we may construct for them. So today we have a whole range of protocol and materials and extra bits   and pieces that we have to use with these patients like some of these products here to try to work again ds or to reverse some of these terrible side effects of dry mouths in these patients.

Many of these patients need treatment to be changed a little bit and  some of these things will be about chair positions , some will be  about the  advice we give a patient , some will be about the timing we give an appointment. There’s a whole range of things we could go through for quite a long time which will all be little things that might help a patient to have a more comfortable experience when they are in the chair. I guess that  I’m flagging  here is that in the long  range planning for continuing education it would seem to me to be a great  area where dental procedures  could  understand besom of the medical  factors coming in their patients  background that would impact  upon care . That i guess sis flagging of this future needs in terms of learning for this professional group.

Certainly when i see h the see patients and i see the harder end of the scale obviously i have to go through the risk assessment and really work out how safe to treat in the chair is and who is not. It could be a radiation patient. This morning followed by a humiliate patient, followed by a dementia patient, followed by phobic. There is no sort of consistent   pattern of patience but they all need something adjusted just a little bit and this complexity of patients will be more a part of our professional land scape. I feel certainly of the rest of our practising lives if not beyond that.

So, having said all that, that’s sort of the medical l complexity what’s the side of the coin. I now want to talk about what would call the worries well, so the worried well are patients why are travelling very well medically. They are not so problemised but they are very demanding. I’m sure all the patients of this type don’t live in my wedding room. I’m sure they are fairly thick and fast in your wedding rooms as well where we know we can look objectively at an appliance they are wearing but it doesn’t quite seem to turn all their switches off. Because we know that all   the technical things are only part of a much bigger puzzle and that been very well described in the literature. We need to understand that some patients just want as this fellow said something to replace my missing front choppers, where this other patient wants something that replicates the natural pre-existing dentition almost perfectly in every way. Patients vary enormously and today we can see the expectations of patients growing in the community. If you look at a number of the studies done on patients satisfaction you can see that there is a group of patients who are continually satisfied and some who are more satisfied and a bunch of reasonably happy. Despite all the advances in techniques and technology we see the persistence of patients how are very, very difficult to treat and carry will talk some more about that topic when he goes though the examination go a new patient tomorrow.

Does it impact on oral health? That answer is absolutely. This is one if the first of about   a hundred, not really hundred its bout a hundred and three little graphs I’m going to share with you this afternoon. This is the difficulty in eating seo food in adults in Australia in 2002 from a phone survey. so if you look  at peel which are the purple  buyers and   the people who  have got  a four partial denture you can  see how the likelihood d of avoiding  some foods is  increased by  somewhere about a  third to a half  depending on  which group you’re looking at . So it does make a difference in real terms, in terms of food selection.

If you look at  people who  are aged 55 ears and above above rather than all of the adult  population you can see that having natural teeth only in purple , having a denture with  natural teeth an black  or having no natural  teeth at all in grey gives you  varying  degrees  of  difficulty in terms  of what you can function with . I think we need to realise that it is   really hard to meet the experimentation of complete functional replacement with the technology that we have today.  Those that cause food avoidance in that  same group well the answer is  absolutely yes and as you  would expect the group that have no  tooth  at all , complete  tooth loss, the black  bars show the highs across all the different  age groups .

They are clearly some issues seeing that. The missing part of this puzzle is that data like this fir a phone survey   doesn’t capture those one people how are in high care   dementia. It doesn’t capture in the low socio economic group who don’t have a telephone. It actually under represents the group that will actually have the worst diidessases. What have just shown you on those little graphs is actually the best case scenario. The situation is actually a lot worse than that. You need to remember that telephone surveys miss a lot of people in the population. We also need to remember  that this whole  access issue can patients actually access this care an d can they  afford it and will patients actually stay  on a waiting list for care if the waiting list  is so long they may   as well give up and go and do something else.

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