Clinical


Fig 1


Typical presentation of dental decay in an older patient. (Photo supplied by Dr Gerald McKenna)


Fig 2


Biotène Oral Rinse (GlaxoSmithKline)


Fig 3 Duraphat 2800ppm Fluoride Toothpaste (Colgate)


after lunch or dinner may be suggested as a suitable time. Older adults experience


faster plaque accumulation than younger adults, due to the duel effects of gingival recession and reduced sali- vary function. Since the work of Loë in ı970, a succession of studies have proven the effectiveness of chlorhexidine 0.2 per cent mouthwash in plaque inhibition. Chlorhex- idine mouthwash is used in hospitals and nursing homes throughout the world to aid oral hygiene and, despite the potential for staining, is a very useful adjunct in elderly patients who have difficulty in maintaining adequate plaque control through brushing alone. Chlorhexidine works best on a plaque-free surface to prevent plaque reforming, but it can also be effective in the presence of plaque (Clarke et al., ı99ı). Chlo- rhexidine mouthwash should be used at a different time to tooth brushing, as many brands of toothpaste contain sodium laurel sulphate – a detergent which inactivates chlorhexidine. High fluoride toothpaste


containing 2800ppm is avail- able on prescription in Ireland (Fig 3). A meta-analysis of six randomised controlled trials (Lu et al., ı987, Ripa et al., ı988, Stephen et al., ı988, Marks et al., ı992, Stookey et al., 2004) demonstrated that 2800ppm toothpaste resulted in a significantly lower caries increment than a ıı00ppm control (Bartizek et al., 200ı). As patients are well used to using toothpaste, a change to a high-fluoride toothpaste such as Colgate Durpahat 2800ppm should be easily tolerated. High-strength fluoride tooth- pastes should be kept out of reach of young children and patients should be encouraged to expectorate after brushing. A topical paste containing


bio-available calcium and phosphate has been commer- cially developed as Recaldent, which is sold for professional use as Tooth Mousse or as MI Paste Plus (in combination with 900ppm fluoride) (Figs 4 and 5). As it is derived from milk casein, all potential users of Recaldent products should be be asked if they ever have any allergic reactions when drinking milk.


However, older patients


with lactose intoler- ance can use Recaldent products, as they do not contain lactose. These products can be applied at night time after tooth-brushing and the manu- facturers advise application of a pea-sized amount to each arch using a clean dry finger. The paste must be held in the mouth at least three minutes as the longer it is maintained in the mouth with saliva, the more effective it is. After spitting out, patients are advised not to eat or drink for 30 minutes and rinsing is to be avoided. For older patients with a high


caries rate or poor compliance with oral hygiene instruc- tion, there are a number of surgery-based interventions to reduce caries risk. The incorporation of chlorhexidine, fluoride and sodium diamine fluoride (SDF) varnishes in the control of dental caries in older patients is a relatively recent development (Fig 6). All have been shown to be effective at reducing the risk of future root caries in randomised controlled clinical trials. The application of varnishes is simple, quick and non-invasive


and can be used in a domi- ciliary setting. Furthermore, it reduces dependence on patient compliance for success, and treatment can be provided by a dental hygienist. It is essential for dentistry to


adapt to the changing age profile of our patients. A reduc- tion in the future incidence of caries in the elderly is dependent on changing their oral hygiene and dietary patterns. As a profession, we need to consider the changing oral hygiene needs of our patients as they move into old age and to implement caries prevention measures in a timely fashion.


ABOUT THE AUTHOR


Dr Martina Hayes qualified from Cork University Dental School and Hospital in 2006. She went on to complete the General Professional Training programme in Scotland, during which time she completed her MFDS examinations. In 2008, Martina returned to Ireland and enjoyed working in Abbeytrinity Dental Practice in Tuam, Co Galway. Martina is currently a clinical fellow in restorative dentistry and is completing a PhD in the area of dental decay in the elderly.


Fig 4


GC Tooth Mousse incorporating Recaldent (GC Dental)


Fig 5


GC MI Paste Plus incorporating Recaldent (GC Dental)


Fig 6


Cervitec Plus chlorhexidine varnish preparation (Ivoclar Vivadent)


Ireland’s Dental magazine 23


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