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.
