Conservative Treatment of Geriatric Patients with Worn Dentition

You're listening to The Dr. Phil Klein Dental Podcast from Viva Learning.com. Welcome to Dental Talk. I'm Dr. Phil Klein. The fastest growing age group today is 80 and over. Geriatric dentistry is a reality and could very well be a hidden production area in your practice. Today we'll be discussing conservative treatment of the anterior worn dentition with incisal abfractions and exposed dentin, typical conditions of our aging patients. Our guest is Dr. Arthur Tomaro. a member of the Catapult Education Speakers Bureau, and presently practices in Chicago, Illinois. He has dedicated his entire career to the advancement of dental education and has published numerous articles in national and international publications. Dr. Tomaro, it's a pleasure to have you on Dental Talk. Thank you for having me, and it's going to be a fun time today. Yeah, so the fastest growing population group today is 80 and over. There's data showing 85 and over. which makes me feel good because I'm no youngster anymore. So if that's popular age group, I got some years left. So what are some of the issues the dental clinicians have to address considering this demographic data that's coming through? Being in practice today, you realize that when you start looking at your demographics of your patient pool, all of a sudden you notice that you no longer can address certain situations as ideal dentistry that perhaps we learned in dental school. or that we do on someone that's 50 that has many years left. As the population grows older, there are several things we have to look at. One is, what is the situation at hand? Is it decay? Is it gum disease? Where are we at with this patient? So what happens is that you have to come up with protocol. In other words, no treatment plan is the same. So one of the situations that arise is that we see the wear of teeth we've all seen those teeth in the aging population where for instance you look on the lower anterior incisors and you can actually see where the canal used to be the warm dentition the chip incisal edges or you look on the maxillary anterior teeth and you see the enamel worn away and you have a stain or some slight decay along that incisal line so we want to somehow maintain the integrity of that tooth. We don't want the patient to continue wearing on that tooth. So one of the ways that we have developed to come up with this is to use, without anesthetic, of using a flowable composite. Now there's a lot of flowable composites out there today. One of the buzzwords of dentistry today is bioactive. Bioactive, what that refers to is there's some type of recharge ion. whether it be fluoride, strotinium, sodium, aluminum, silicate, and borate. These are the ions that, for instance, the company Shofu call their gymers. And what the science shows is that, one, it is proven to inhibit plaque, two, to neutralize acid, and three, to eliminate secondary decay. So if I'm placing a filling nowadays, and i'm placing a geriatric patient and we all know one of the issues we have that geriatric patients have is dexterity keeping their teeth clean how many times we have these patients in every three to four months and there's plaque everywhere broad contacts dark triangles and it's just filled with plaque so i want to be able to provide that extra that i can provide in a filling material to help them fight off these issues that they battle every day as well. So let me ask you this, doctor. Incisal fractions are typical conditions of the aging population. What is one of the main causes for this? And describe what they actually are and how this flowable composite handles that kind of situation. You know, there's been lots of studies about this. Never in the history of dentistry. I've been in dentistry a long time, in fact. 40 years plus. Still love it. Still get excited about new products. Still test new products every day that I can. One of the observations, and I have not done a poll, but I would say well over 80% of our patient pool clenches or grinds their teeth. And if you look at it, when someone has had their teeth, adult teeth, for 60 years plus, there's going to be some wear and tear. There's no question. And so you'll see this chipping along the incisal edges. In fact, it's almost hollowed out where the enamel has worn away. And, you know, usually the maxillary incisors are flat and you have this hollowing on the mandibular incisors. So the nice thing about it is nowadays we have these fantastic products. As I mentioned, Gyamer and the Shofu Flowable, the Beautifil Flow Plus and the Beautifil Flow Plus X with this Gyamer in there. Now, the neat thing about it is these procedures, as you clean out the decay or the dentin, because usually in this aging population, the nerves have receded or they're cal spiked. But in most cases, in fact, I've never had to anesthetize one, even along the incisal edges of them. maxillary incisors if i remove decay because i'm using like a fissure out of me birth little 330 bird just to clean that decay or or just to clean that stain out of there the beauty of this is our adhesives that we have nowadays we have universal adhesives these incisal of fractions what defines and an incisal of fraction what does it actually look like is that the hollowing out you're talking about or is it actually yeah it's a great question phil what it looks like and we've all seen them it looks like there's a hollowing out and the mesial distal lingual and facial of the tooth has enamel on it but the inside is actually looks like a crater if I can use that word properly. But it does. It looks just like a moon crater. And you look down in there, and if you're an endodontist, you couldn't miss that canal. You can actually see it sometimes down in there. I am an endodontist, actually. So you would see, yeah, you'd visually see the canal. But in many cases, that canal would be receded and calcified to the point where it's almost closed off on its own naturally. Now, you treat these often without anesthesia. You just go in there with a low-speed burr and... a hand instrument and just, if there is decay, just scrape it out? I do. And, you know, what I do is, and it's very well put, we turn down the speed. We're obviously not using 200,000 RPMs. And just make sure that that surface is clean and no anesthetic, none whatsoever. And so when I mentioned that the adhesive is universal adhesive, what makes a universal adhesive is, one, you can use it in a self-etching. You can use it in a selective etch and you can use it in a total etch. Let me define those. So total etch is obviously you etch the dentin and enamel. We still, in my hands, I prefer selective etch or total etch. And the reason for that is selective etch is when you just etch the enamel with the phosphoric acid etch and then you use the adhesive to etch the dentin. Why do I not use the universal adhesives? on the enamel and the reason for that is we still i believe we have not reached that point where the universal adhesives can break down the inorganic matrix to establish a good bond on the enamel so my two my personal is either selective etch or total etch and then you will apply that adhesive and you want to scrub that on there good to get a nice etch on there if you're doing the self etching or if you did the total etch you want to get those dental tubules impregnated with that and then you dry air, dedicated air. We use dedicated dry air. In other words, that syringe is only for dry air in our office. And then you're going to cure that adhesive. And then after that, you're putting on a bioactive composite on top of that? Yes, I'm using a flowable. And here's the key. When I first started doing these some time ago, we didn't have the shade selection that we have. Well, as you can imagine, Phil, for 60 years those teeth are not always the whitest teeth in the mouth in fact you know that you're looking at some seed shades at a beta c shade or d right shade so when i first started using that i go whoa you know i had to stand back it's like these fillers are pretty light but now the beauty what for instance Companies have done, especially Shofu, is they have given us C shades and D shades just for that reason. Just for the reason that patients obviously are living longer, patients' teeth age, and with aging comes discoloration. So all I do is apply the flowable, I cure it, and then I check the occlusion. What would be nice if we could build these teeth up? But as you know, when someone bites into CO, you want to make sure they have clearance that they're not hitting on these. teeth and their posterior teeth aren't coming together. So you have to maintain the occlusion. But it'd be wonderful if we could build them back up, obviously. And the beauty of this is, one, the patient didn't have to get numb. And the patient are tickled pink that, hey, I finally have something in there that's not chipping my teeth. You stop the chipping. You stop the wear on the teeth. You slow the wear down, I should say. And that they just absolutely love it. And no time at all. 30% of our practice here in Chicago is over the age of 80. So let me ask you this about root conditions. You talked about the incisal edge. You talked about fractions, mainly in the incisal area. What about the recession of the gingiva and any kind of conditions that are going to take place on the root surface itself? How do you handle that? And what are you seeing? Just today, I had a patient, a geriatric patient. And as you know, Bill, the... carries is a huge issue in our geriatric patients. The beauty of, again, with the gymer and the bioactivity is it is such a help to fight this once we place the fillings to inhibit the plaque and neutralize the acids. What I do is over time you see the fractions on the facial, on the cervical area, and we now know pretty much that this is due to clenching grinding over years and you see that recession and we know that with recession roots become exposed they're more prone to decay so again with this bioactivity we're able to place fillings sometimes access as i had today access is very difficult to get to but yet by these improved materials we're fighting that it's an ongoing battle with aging in other words as i mentioned earlier hygiene dexterity, trying to get the patients to keep their teeth as clean as they did 40 years ago. That is a battle in itself. But quite honestly, Phil, it's a reality. Every one of our practices today, we need to address this. One of the courses I teach is on geriatric and how to handle different situations. What it comes down to is the treatment you deliver is directly related not only to age, but they're systemic. If you have an 80 -year-old patient, it's incredible health the charts show she's going to live another 15 to 20 years if she loses a tooth should you do anything at all doing nothing is an option should you place an implant or should you do a bridge or a partial so when we do geriatric evaluations we definitely relate it to their systemic condition and how good their overall health is to determine treatment So in this age group, how interested are these patients to move forward with dental work that is conservative versus bigger things like implants or crowns or veneers? Are they happy that you have a solution for them that barely requires them to get anesthesia? They could be out of there in one visit and these various incisal abstractions can be handled with the materials you're talking about? It's a great question because you see two different, multiple situations, I should say. One is... We have patients that are 85 years old that have chosen to live a quality life. What does that mean? They don't want dentures. They don't want partials. If they're in good health, they will want the implant. We allow them. I always teach dentists when I'm lecturing. I'd never tell a patient they need anything unless there's infection involved because if I tell them they need something, I own it. If they decide they want it, They own it. And we all know that people can live without teeth. That's another story. But the bottom line is, is that most of these patients, they want an incredible quality of life to the day they die. And what that means is that, again, we look at their systemic health. And, you know, if you have someone that has terminal cancer that maybe has a year left, obviously we're not going to do extensive dentistry. We're going to maintain as best as we can. But if you have someone that's 80, years old that is in the upper part health wise and finances is not an issue and that's another situation at that age finances can be a situation that determines treatment but if that's not an issue they're going to choose what they want to choose for a great quality of life you know what's interesting is as we wrap up this podcast i do want to mention typically we hear doctors talking about glass ionomers for you know pedo patients and geriatric patients but In this case, the condition is actually caused by what you said earlier in this podcast, grinding and bruxing and basically wearing their incisal edges down. And based on their 60 years of having these teeth in their mouth, just the normal activity of what's going on in their occlusion wore right through their enamel and these teeth were worn down. So glass ionomers may not be the best solution because they're not very wear resistant. Glass ionomers has its place in geriatric dentistry. It's just that now with the development of these bioactives like the Gymer and the Shofu Flow Plus and Flow Plus X, I'm the first to say science will show this over years. Like I said, it's the buzzword. We've been using it for some time now. And everything I see, I mean, I try to be the biggest critic of my own dentistry. We want to... make the clinician aware that we have a choice out there, that you can do these restorations. You don't have to use anesthetic. The patients will love you. You stop chipping. And it actually does strengthen the tooth. Dr. Tomaro, it's been a pleasure having you on the show. Thank you very much. I would say one last thing. I just want to promote the hands-on in January. Just look at it on Shofu's Facebook, if you don't mind me adding that. No, go ahead. We're going to do a hands-on with exactly what we talk about. We're going to send out the... to the doctor and some flowable. And we're just going to spend a little time together and go over the protocol for doing this. These are hidden treatments that are in your patient records right there, just waiting for you to do it. And the patients, they don't disagree. They like this treatment because they see such it being itself. an advantage to them could very well be a hidden production area in the practice exactly so it's it's it's a service to the patient it's a service to the to the community and it certainly could be a boost to your revenue of your practice yeah and to our listeners please visit Shofu S-H-O-F-U and check out the hands-on class that Dr. Tomaro is talking about. You can sign up for that. And in the comfort of your own home or office, you can actually do these procedures with Dr. Tomaro leading the way via the internet. So that's the age we live in right now. Thanks again. You take care. Have a great night.