Operative notes
Fifth year
2023
Fall 2022
2021
1
Faculty vision:
The Faculty aspires to be a recognized educational institution, regionally
and internationally, by providing advanced educational programs,
innovative applied research, and sustainable community development.
Faculty Mission:
The mission is to prepare knowledgeable and well-trained dentists
committed to human values and professional ethics, by developing
advanced educational programs that correspond to the actual needs of the
local and global labor market. The Faculty is also committed to preparing
applied research in line with national strategies, as well as providing
sustainable community service following international quality standards
2
Intended learning outcomes of course (ILOs)
a. Knowledge and understanding:
By the end of this course the student should be able to
A1- Describe the different changes associated with aging
procedure and its implication on restorative dentistry.
A2- Explain the basic parameters of esthetics in restorative
dentistry.
A3- Clarify the appropriate techniques required for esthetic
building up of direct anterior resin composite restorations
b. Intellectual skills
By the end of this course the student should be able to
B1-Analyze different esthetic problems and propose an
appropriate treatment plan
B2- Integrate and link the information gained across the course
program with the problem solving in different clinical situations.
B3- Correlate between the data collected regarding age changes
and restorative treatment planning for elderly.
c.Professional and practical skill
By the end of this course the student should be able to:
C1- Perform different cavity designs clinically and restore them with
appropriate restorative materials efficiently.
C2- Demonstrate appropriate isolation methods during procedures.
3
C3- Demonstrate patient reception, dismissal and operating positions
to provide maximum accommodation and comfortable environment
for excellence of performance.
d.General and transferable skills:
By the end of this course the student should be able to
D1. Exercise effective communication methods with other health care
professionals and auxiliary personals to maximize patient benefits
and minimize the risk of errors.
D2. Motivate students by encouraging team work and leadership
activities and develop professional attitude.
D3. Manage Time and stress with the capability to prioritize work
load for better performance and management
D4. Recognize the basic concepts of quality assurance and practice
management
4
Anterior Direct Resin Composite Restorations
ILOs:
• Clarify the uses of direct resin composites
• Identify the keys for successs for anterior composite restoration
• Clarify the appropriate technique for shade mapping and shade reproduction
• Clarify the appropriate technique for shape mapping and shape reproduction Dental esthetics has become increasingly important during the last decade when
considering diagnosis and treatment planning. Nowadays, patients seek highly
aesthetic restorations especially when dealing with the smile zone requiring
more sophisticated techniques that meet with their demands.
Where can I use composite
Preserving the original shape of the tooth (Group I):
•
Replacing hard dental tissues loss due to caries, trauma, erosion, abrasion,
attrition
•
Correcting the minor tooth dysplasias
•
Correcting the labial surfaces
•
Altering tooth color
Altering the original shape of the tooth (group II)
• Correcting tooth shape in cases of pronounced dental malformation (e.g
hypoplasia, amelogensis imperfcata, peg teeth
5
• Altering tooth shape in cases of transportation(e.g when transporting a canine
orthodontically to fill the gap due to agencies of the lateral incisors
• Widening a tooth in cases of migration (“true migration” discrepancy
between the widths of the dental arch and individual teeth; “apparent
migration”e.g; missing individual teeth due to agenesis or trauma)
• Correcting tooth position with changes in the sagittal, transverse, and/or
vertical position
• Correcting of the tooth shape in cases of gingival recession (reducing “black
triangles”)
Key for success for anterior composite restoration:
• Shade reproduction (layering technique)
• shape reproduction (three dimensional shape reproduction)
• Maintenance (refer to third year notes)
A. Shade reproduction
For proper shade color reproduction, the operator should understand the opical
properties of tooth, properly select the shade, shade map of the required tooth to
be restored, then select the appropriate layering technique according to the
existing condition
a. Opalescence
b-fluorescence
c-Translucency
d-characterization
6
a.Opalescence: the incisal third has a translucent area among the dentin
mammelons-this area has a bluish effect under transmitted light, when light is
reflected through the enamel, it appears reddish orange.
b. Fluorescence : Dental hard tissues (particularly enamel and the ADJ) also
fluoresce when struck by invisible/short wave ultraviolet light, reflecting it back
as visible, bluish longer wavelengths.Therefore, for successful integration,
dental materials should possess fluorescent properties.
c. Translucency: for successful restoration integration, accurate replication of
translucency is considered to be almost as important as value. The translucency
of natural enamel (and restorative material) is strongly influenced by its
thickness
d. Characters:
•
Incisal ‘halo’ effect
•
Intensive white spots, clouds or bands
•
Chromatic spots or bands, eg amber, brown, white
•
Dentine lobes of varying color
2-Shade color selection for natural layering could be achieved:
Manually: using shade guides:
•
Classical
Vita
shade
guide;
arrangement
according
to
Hue/Chroma:A(Brown,1-4) B (Yellow,1-4) C (Grey,1-4)D(Reddish Grey,24)
Arrangement according to value (B1, A1, C1, D2, B2, A2, A3, D3, C2, D4,
C3, B3, B4, A3.5, A4, C4)
•
Supplied from the manufacturer, made from the same material
•
Use of composite beads may help
Color Recipe:
7
•
Shade wheel
•
Conversion chart
Performing a customized shade guide
3- Shade mapping of the tooth
4- Shade reproduction
•
Layering techniques:
a-Monochromatic layering technique:
Despite technological advances in contemporary composite systems, the
majority of practitioners use monochromatic materials for anterior composites.
Such techniques are ideally suited for small cavities but they may deliver suboptimal aesthetic outcomes in more aesthetically important areas : small class
III cavities with the preservation of the enamel shell
In large class III cavities “ Through and through” (i.e; no facial or lingual tooth
structure), class III restoration donot blend with the color and transluceny of
adjacent tooth structure. Layering technique should be employed with such case.
b- Dual-shade layering technique:
layering techniques by using two material shades, as this simplified technique is
reported to deliver an acceptable colour match in a large number of clinical
situations.
c- Polychromatic layering technique:
When aesthetic demands are high, the widely accepted stratification technique
proposed by Lorenzo Vanini is recommended. As each clinical situation
presents different aesthetic challenges, study of detailed atlases describing the
comprehensive range of layering options is highly recommended. The
fundamental principle of polychromatic layering technique is to use different
composite shades to replicate the layers seen in natural teeth.
8
Palatal
enamel
layer
A palatal ‘shell’ of translucent enamel composite is light-cured in place.
Dentine layer
To avoid a monochromatic appearance, dentine lobes are restored using
progressively chromatic increments. The dentine build-up should stop short of
the incisal edge and should be shaped into lobes, leaving room for the
incorporation of materials designed to replicate the appropriate optical
properties of the incisal third
Characterizations and intensives:
Intensives are used to recreate white spots or patches in teeth found
with hypoplastic and hypomineralization defects. White features vary in opacity
extent and lack opalescence. A range of tinted conventional and flowable
materials may be applied using suitable instruments or brushes
labial enamel layer
The final layer generally comprises an enamel or incisal material with smaller
average filler particle size with translucent (and often opalescent) optical
properties that modify those of the underlying layers.
B. Shape reproduction: (third year notes)
1- Matrix technique using interdental wedges:
This matrix technique with interdental wedges fails When a change in outline,
i.e: change shape of peg shaped laterals. If the cervical morphology of one or
both teeth is defective, there will not be sufficient contact surface to anchor the
wedge. The wedge might slip in the coronal direction or towards the side of the
defect leading to what is known by “cervical contour problem”
9
2-Approximal matrix technique-constructing an individual approximal
framework
This facilitates the cervical shaping of the matrix and its adujstment to the
contours of the gingiva, as well as providing an extensive area of contact. As a
stable negative shape, the matrix should reflect the outer contours of the
restoration as accurately as possible.
The approximal shaping and fixing of the transparent matrix should be carried
out against a provisional, photopolymerzing plastic. When in its non
polymerized state, the material has a tough, plastic consistency and adheres to
both tooth surfaces and the gingiva. Once the partial matrix is put in place, this
plastic is inserted between the rear side of the matrix and the neighboring tooth.
A fine double-ended spatula is then used to shape the matrix against the tough
plastic mass, starting from incisal end
The desired proximal contour are achieved by systematic displacment of the
interdental plastic mass, taking into account the cervical contours of the tooth
and the contact area with the neighboring tooth . Photopolymerization of the
plastic mass is then done
3- Palatal matrix technique (palatel index)
If more extensive class IV lesions are present, in cases of correct positioning
and thickness of the whole restoration will be made much easier by the use of
shaping aids or negative forms. “back wall technique”. It is silicone template
made from a prototype restoration (or wax-up) that simplifies placement of the
palatal composite increment.
Finishing protocol:
Steps for reproduction of surface texture:
10
Following shape, restoration surface texture is the next most important factor
influencing successful intergration and requires a detailed understanding of the
equivalent anatomical features in natural teeth.
The labial surface texture of young, unworn teeth is highly reflective and
results in an attractive bright appearance. Surface texture features may be
divided into three groups.
Primary surface texture
When incident light strikes the labial surface of an anterior tooth the majority is
reflected back to the observer.
This reflective area, which has various names (reflective face/zone; apparent
face; silhouette form), is bordered by curved surfaces which deflect light giving
a darker outline. The junctions of these zones, widely referred to as transition
lines, are key features in restorative dentistry. Accurate positioning of transition
lines in direct (and indirect) restorations is critical if restorations are to blend
seamlessly with the residual dentition.
Secondary surface texture
This is referred to as macrotexture and includes:
• Developmental
lobes
(usually
three)
on
the
labial
surface;
Developmental grooves of varying length dividing the lobes longitudinally;
• A cervical bulge in the gingival third;
• Mamelons (often present on the tips of unworn incisors in young patients);
Tertiary surface texture
This is referred to as microtexture and includes:
• Accessory ridges/grooves
• Perikymata - very small surface striations caused by the formation of enamel
prisms
11
• Imbrication lines - subtle, broken, crescent- shaped ridges on the cervical
bulge, running parallel to the amelo-cemental junction.
Polishing protocol: A final surface polish can be obtained by using a a silicon carbide impregnated
disk. Aluminum oxide or diamond polishing pastes can be used to obtain a high
polish
Reference:
Hilton T, Ferrancane JL, Broome JC. Summitt’s Fundamentals of operative
Dentistry; Acontemporary Approach. Fourth Edition, Quintessence publishing
2013, Chapter 10; 249-279
Mackenzie L. Direct Anterior Composites: A Practical Guide , Dental Update,
2013
12
Dental Esthetics and Smile Analysis
ILOs:
•
Preferences and judgment over aesthetics
•
Growing concerns of esthetics (Why?)
•
Value of the smile (the main issue of esthetics in the face is the smile)
•
Components of the smile
•
Smile design
‘Beauty is in the eye of the beholder’, it is said, and we have been hearing this
old comment for many years. One person can love Renaissance art, for instance,
while another favours post-modernism, and neither would be wrong. However,
while the perception of ‘beauty’ is a subjective experience. Each environment
develops its own culture, which then develops and embraces a sense of beauty
related to its environment. The sense of beauty spreads by imitation and
develops by creation and vice versa. So when lack of creation occurs, it changes
the culture and leads to a loss of standards and ruins the environment.
Preferences and judgment over aesthetics may vary according to:
1- Sense
2- Emotions
3- Intellectual opinions
4- Will
5- Desires
6- Culture
7- Preferences
8- Values
9- Subconscious behavior
10- Conscious decisions
13
11- Training
12- Instinct
13- Some complex combination of previous factors based on which theory the
person believes in.
Some authors used psychological techniques for studying aesthetic reactions. It
was proved that even the highly educated people’s opinion regarding beauty is
affected by:
1- Education
2- Other people’s opinion
3- Social and circumstantial factors
Others believe that some other conditions have great effect such as:
1- Fashion
2- Traditions
3- Resistance to change, and other social factors.
Some authors believe that the average face is the most beautiful and it can be
even more attractive if some facial details are slightly exaggerated such as
slightly wide eyes, or thinner chin of a woman.
All of these factors have to be considered when planning for Esthetic Dental
treatment. Today – due in part to a convergence of trends in tooth-whitening,
‘Extreme Makeover’ style television shows and oral care companies spending
millions on advertising – the smile has been solidified in our culture as a
centrepiece of a trip to the dentist meant either a cleaning or the resolution of
pain. Patients today, in addition to wanting clean, pain-free mouths, commonly
seek rejuvenated, improved or completely transformed smiles. The esthetic
demands and expectations of patients have risen with the impact of social
media, which has made it easy to access information about new technologies
and a lot of different esthetic cases.
Why do people seek esthetics and attractiveness
1- Please the beholder
14
2- Improve Self- Esteem
3- Perceived as intelligence, kinder, happier
4- self-fulfillment
5- Self-confidence and serenity
6-Perceived friendliness, social class, and popularity
7- Different sex appeal
8- Professional and career needs
9- Jalousie, Imitation
First Step you have to understand why your patient is seeking esthetic
treatment
This could be done via interview with your patient, The dentist must strive to
create a safe environment, one in which the patient's fears of self-expression are
minimized. A non-judgmental and empathic stance, conveyed through tone and
posture, is critical to the dentist gaining a clear understanding of the patient's
motivation for esthetic treatment and their expectations of outcome.
We begin by asking our patient the open-ended question, ‘If there was anything
you could change about your smile, what would it be?’ This question is
designed to elicit as much information as possible, as opposed to a closedended right from the beginning, ‘Do you like your smile?’ which only gives the
clinician a yes or no answer. We want the patient involved in the process and,
by creating effective communication right from the beginning, the team
(comprised of the patient, dentist and technician) can then begin to build a
strong relationship that is focused on effective communication and, by default,
success. We are guided by the 80 : 20 rule of listening, where we ask our
effective questions and we listen 80% of the time.
15
Once the patient is able to tell the esthetic dentist what the degree of naturalness
the patient desires. Because ‘beautiful’ means different things to different
people, it is crucial to establish the patient's preference at this early stage.
Therefore, we ask, ‘Do you like the visual image of “straight, white and
perfect”, “clean, healthy and natural” or “white and natural”?' ‘Straight, white
and perfect’ is defined as a symmetrical smile where the right and left sides are
mirror images and all teeth are a very light shade and in perfect alignment. We
like to offer a picture of the actress Halle Berry, someone everybody knows
whose smile is a great example of this. The ‘clean, healthy and natural’ category
is defined as having the perfect imperfections of nature: slight rotations and/or
setbacks of the lateral incisors, slightly irregular incisal edges and a more
natural shade. The actress we refer to for this description is Sarah Jessica Parker.
The final category, a middle ground mentioned only after the first two have
been described, is ‘white and natural’. This implies natural tooth forms but in a
light shade, exemplified by the smile of Julia Roberts.
Properly designed questionnaire is mandatory.
The Questionnaire should include:
1. Why did you come to visit the dentist?
2. What do you think is deranging your smile? (lips, teeth, gums, all)
a. If lips:
i.
Is it narrow (will need filler)
ii.
Wide (surgery)
iii.
Hides your teeth (curtain lips) (surgery)
iv.
Show
your
teeth
more
(hyperactivity/hypermobility of the lips)
16
than
they
should
b. If Gums: (red, swollen or receding): usually patients with receding gums will
come to you complaining that their teeth are elongating
c. If teeth: is it too long, too short, too wide, too small, too square, too rounded,
wrong shaped, wrong position or spaced. (the patient will check or select
what he sees)
N.B: The patient now starts to understand his problem before you propose the
treatment plan.
3. What do you expect? (the patient can choose one or more)
a. Hollywood smile: it is the worst out of all the smiles (about 20 smiles),
because it is artificial, but its name is attractive giving it its popularity
b. Natural smile: The patient complains of his bad smile but do not want a fake
artifical smile (i.e. seeks a natural smile)
c. Improved smile: The patient smile is good but wants to improve it
d. Improved colour or position
4. If we are going to do only ONE thing what would you want it to be? This
question will help you know his PRIORITY as he will never be satisfied if it
was not done even if all the other work is good.
Now, this questionnaire brought the patient’s mind figure and yours closer, as
the patient knew what’s exactly is wrong with his smile and you too.
• Tools required for proper smile analysis
1. Models and casts
2. Photographs: Frontal and lateral views
3. Videos
4. Computerized video-imaging: a very good tool that shows the case live on a
screen and helps in smile analysis.
17
•
Those Tools are used for:
o Documentation of the preoperative condition
o Patient education through diagram and graphics
o Simulation and treatment alternatives ( you should simulate the case on
photoshop by drawing it and showing it to the patient, and always give him
alternatives for the treatment plan so if at any time he wants to modify
anything it won't ruin the treatmet), it should be:
Ø Discussed
Ø Documented for legal conflicts
Ø Accepted and modified
Ø Approved and printed for the patient to sign on it
o Proper communication with the lab
o Recording post-operative results: together with the preoperative results you
can compare between the before and after
o Follow up your case through the following years to know if any changes
happened and know the fate of the treatment
o compare to:
Ø Judge on the material you use and know which is better for you to
us
Ø Know which lab is better if you deal with several labs
Ø Know which technique is prefered
Know the effect of the environmental condition (e.g case has bruxism, other has
xerostomia, so know the effect of each condition on the treatment
But again, beauty is extremely subjective and so the patient's desires need to be
determined early on.
Roadmap for esthetic restoration
18
•
How to obtain an esthetic restoration or How to be a good
esthetician?
o You need to have a good sight (not meant by it to have a sharp vision as this
can be dealed with by using magnifying loops, but to be able to differentiate
normal from abnormal)
o Vision (To have imagination; imagine the future result before starting the
case)
o Training (train yourself for these esthetic techniques)
o Armamentarium (Materials, tools, trays, etc.)
o Artistic and creative sense (which could be improved by watching beautiful
natural scenes like seas, forests, sky, etc.. and hearing beautiful music , etc.)
o To identify and value, manage and apply an interdisciplinary team work.
o Esthetics (which is a new discipline or a speciality) is obtained not only by
restorative dentistry ,but also there are other disciplines involved
(interdisciplinary/ multidisciplinary team) who will related in preparing the
case to receive the restoration like:
Ø Maxillofacial Orthopedic
Ø Plastic Surgery
Ø Orthodontics (position of teeth)
Ø Implantology (missing teeth)
Ø Modern Endodontology
Ø Periodontology
Ø Esthetic Microsurgery
Ø FINALLY, Restorative Dentistry
Esthetic parameters:
19
Since Esthetic is a subjective issue. there are certain universal guidelines that
transcend this subjectivity and provide us with factual, objective criteria as to
what pleases the human eye. These fundamental esthetic standards can help us
as clinicians to design and create ‘beauty’ in a quantitative, scientific and
predictable manner
Facial view: (Macro-elements, macro-esthetics) :
The critical elements we look for in the facial view are balance and harmony, or
a lack of tension in the composition of the face. We start by observing a frontal
view with a full smile and then take two orthodontic measurements from the
profile view with the patient in repose. The macro-esthetic elements are as
follows:
I. Symmetry
1- Symmetry of the face: Most people are Asymmetric
If the face is divided into two halves vertically and we flipped one side and and
attached it to the unflipped version of it the person will look different not
normal.
2. Symmetry of the lip: This is viewed in terms of symmetry to the face and
fullness of the upper and lower lips. We also assess how prominent or retruded
20
the lips are, from a profile view. The degree of lip support helps determine if
the case should be ‘built out’ facially or not.
II-Proportions:
Proportions of the face:
It should be divided horizontally into
3 equal parts:
• From
forehead
to
Nasion
or
Glabella (ophriac line)
• From Glabella (ophriac line) to
base of the nose (interalar line)
• From Base of the Nose (interalar
line) to the tip of the Chin.
The face can also be horizontally
divided into thirds
• Interpupillary distance should be
equal to the distance between the
corners
of the mouth.
Vertical lines can be drawn from the
pupil of the eye to the corner of the
mouth
21
• The face can be divided into 5 equal
parts each part equal to the width of
the eye (Greek Criteria of perfect
width)
The Greek criteria of perfect width. 5X
the width: width of the eye
• Lower third of the face can be
divided by which the distance from
the base of the nose to the lip line
(meeting of the lips) is 1/3 the
distance from the base of the nose to
the chin OR in other words, the
distance from the base of the nose to
the chin is half the distance from the
lip line to the chin.
The lower third of the face can be
further divided into 1/3: base of the
nose to where the lips meet
III-Reference Lines
1.
The parallelism between the interpupillary line and the line
corresponding to the occlusal plane (drawn between the cusp tips of the
maxillary canines). Here we are looking to determine any canting of the
maxilla. Clinically, a length of floss can be used to visualize this
22
2.
Nasolabial angle. This is an orthodontic measurement assessed from a
profile view of the patient with the lips in repose. Typically, we strive
for a nasolabial angle of 90°, and thus an angle of less than 90°
(prominent maxilla) means the maxillary anterior restorations should be
smaller and less dominant, while an angle of greater than 90° (retruded
maxilla) means the patient can afford to have their maxillary anterior
restorations ‘built out’.
3.
Ricketts' E-plane. A second orthodontic measurement, also assessed
from a profile view, describes the imaginary line drawn from the tip of
patient's nose to the chin. Clinically, we can utilize a length of floss held
against these two facial landmarks and measure with a periodontal
probe. Ideally, the upper lip is 4 mm from the E-plane and the lower lip
is 2 mm away. If the upper lip is greater than 6 mm from the plane then
we consider this a concave profile. If the lips are on the plane then there
is more of a convex profile. In nature, a maxillary central incisor can be
90o
4
2m
m
Rickett’s E- Plane
Nasolabial Angle
23
Rickett’s
E-Plane
anywhere from 10 mm to 12.5 mm long, and it is appropriate to design
maxillary centrals towards the larger end of this range for the concave
patient and towards the smaller end of this range for those who are more
convex. As a rule of thumb, for the convex patient with a high smile
line, the length of the maxillary central should not exceed 10.5 mm
Chart for facial analysis
Dentofacial view (mini Esthetic elements):
1.
The position of the facial midline in relation to the maxillary dental
midline is noted. From Kokich's study that the midline can be ‘off’ up to 4 mm
in either direction and will still be inoffensive to the layperson's eye. According
to that same study, however, a midline cant is extremely noticeable to most
people and thus a higher priority to correct.
2.
Tooth exposure at rest. This is one of the most critical elements of facially
directed treatment planning. As known from Vig and Brundo's study , a woman
24
at age 30 shows 3.4 mm of her maxillary central incisors with the lip at rest; at
60 years of age the maxillary centrals are no longer displayed and she shows
approximately the same 3.4 mm of her lower incisors. A man shows 1.7 mm of
the maxillary centrals at 30 years of age and that same amount on the lower arch
at 60 years of age. This decrease in maxillary central display is due to the loss
of muscle tone over time, gravity and wear of the incisal edges. Lengthening the
incisal edges of the patients' teeth will thus result in a more youthful appearance.
To assess the amount of tooth display at rest, we ask our patients to relax their
lips, say the word ‘Emma’ and then freeze . In the Esthetic Evaluation Form this
is the step towards determining the existing incisal edge position of the tooth to
the lips and face.
1.
Smile analysis; it is to analyze the smile frame work boarded by lips
on smile animation
•
We have 4 dimensions:
o
A: Length of teeth shown (Exhibition of teeth)
o
B: Distance between the inner commissures of the lip
o
C: Distance between the outer commissure of the lip
o
D: The width or breadth of the face at the level of the commissures
25
These dimensions gave us 5 criteria: (study definition & formula)
1-Smile Fullness: (Its maximum is 1 or
100%)Teeth should fill all the mouth. It is
the visible width if maxillary anterior
teeth divided by inner commissure width
Smile fullness = A/B
So, Maximum fullness means A=B so,
A/B= 1 this means that there is no buccal
corridor (Zero).
2-Buccal Corridor:
It is the difference between the inner
commissures width and the visible width
of maxillary anterior teeth.
B-A/B to give a percentage
Small buccal
corridor
Large buccal
corridor
26
3-Smile Breadth: It is defined as the ratio
between the width of outer commissures (c
) to the breath of the face at the same level
of the commissures
(D ). C/D = Smile breath
4.Smile Arc: The incisal plane line or
curve which passes from the upper canine
to canine passing through the incisal edges
and passing by the central incisors should
be coinsiding with the lower lip curve (this
is the best) and there could be difference but
still parallel (acceptable) In
an inverted
smile the lower teeth will show instead of
the upper during smiling
5. Gingival Display:
A study showed that more than 2mm of
gingival display tremendously reduces the
smile attractiveness. Therefore, more than
2mm of gingival display is known as a
gummy smile
27
Microesthetics: (Dental Esthetics):
The dental esthetics consists of the teeth (size and shape), and their intra- and
inter-arch relationships.
• Tooth size is determined by measuring the inciso-gingival length and dividing
by the mesio-distal width to obtain the width/length ratio:
• Width/ length (w/ l )ratio of a tooth = width /length
• The w/l ratio of the central incisor should range from 0.75–0.8, less than this
value creates a long narrow tooth, while a larger w/l ratio results in a short
wide tooth
• The central incisor is dominant in the anterior dental composition
• The shape of the upper anterior teeth is also widely debated. The two
prominent studies are by Williams and Frush and Fisher. Williams
established a relationship between the shape of the central incisor and the
face, while Frush and Fisher related sex, age and personality (SAP) to the
contour of the anterior dental segment. The Williams theory was invalidated
by subsequent studies.
Interteeth relations:
Golden proportions:
• Ancient Greeks endeavoured to formulate beauty as an exact mathematical
principle. They believed that beauty could be quantified and represented in a
mathematical formula. This lead Pythagoras to conceive the Golden proportion
(1/1.618 = 0.618)
• The most widely used concept in dentistry is the Golden proportion, whose
formula is as follows:
28
• where S is the smaller and L the larger part. The uniqueness of this ratio is
that when applied by three different methods of calculations, linear,
geometric and arithmetic, the proportional progression from the smaller to the
larger to the whole part always produces the same results. This concept has
been described by Lombardi and Levin.
• The ratios between the widths of the incisors should be 1.618 for the central,
to 1 for the lateral, and 0.618 for the canine.
Golden
Proportion
It must be kept in mind that the golden proportion rule is not the actual width
measurement of the maxillary anterior teeth and only perceived when observed
from the frontal aspect.
Conflicting reports indicate that the majority of beautiful smiles did not have
proportions coinciding with the golden proportion formula. Recently, the
“recurring esthetic dental proportion” “RED” concept was introduced, stating
29
that clinicians may use a proportion of their own choice, as long as it remains
consistent, proceeding distally in the arch
Red Proportion
The incisal edge position of the lateral is placed 0.5 to 1 mm apically compared
to central and canine in young dentitions.
30
Contacts and embrasures:
The broad zone in which two adjacent teeth appear to touch is called the
interdental contact area (ICA). Observation suggests that the 50-40- 30 rule,
indicating the relationship between the anterior teeth, applies to 50% of the length
of the maxillary central incisors and is defined as the ideal connector zone. This
means that 40% of the length of the central incisor is the ideal con nector zone
between a maxillary lateral and central incisors. When viewed from the lateral
aspect, the prime connector zone between a maxillary canine and a lateral incisor
is about 30% of the length of the central incisor
In cases where the teeth are too long, it may be best to increase the vertical
contact area and thereby keep the embrasures (both gingival and incisal) as
narrow as possible. This will enhance the perception of a relatively wider and,
therefore, a relatively shorter incisor. The contact area can also be lengthened
apically to close the interdental embrasure, if enough papilla cannot be obtained
The incisal Embrasures
o Between 2 centrals 20%
o Central and lateral 30%
o Lateral and canine 40%
o Canine and Premolar 50%
31
Contacts
Embrasures
Axial inclinations:
A line extending from the height of the tooth from the free gingival margin to
the center of the incisal edge implies the alignment of the axis of each tooth.
The maxillary anterior teeth ideally display mesial axial inclination, with the
central incisors appearing to be the almost vertical and the lateral incisors and
canines each tipping more toward the midline.
The arrangement of the teeth throughout the arch follows tangents that subtlety
converges toward the midline. This convergence creates a soſt look throughout
the smile. If teeth are distally inclined or extremely inclined toward the
midline, more times than not there is crowding in the arch and one or several
teeth may be out of the arch form. Correcting the inclinations will allow for the
fabrication of restorations that orientate well in the arch and begin to establish
a golden proportion. It becomes easy to see that many of the criteria that will
produce a good smile are interrelated and rectification of one flawed
component will lead to the correction of another.
32
The maxillary anterior
teeth ideally display
mesial axial inclination,
with the central incisors
appearing to be the
almost vertical and the
lateral incisors and
canines each tipping
more
toward
the
midline.
Gingival Zenith:
The gingival zenith is defined as the most apical point of the buccal marginal
gingiva. The location of zenith of the central incisors is located approximately 1
mm distal to the midline of the anatomical crown). Zenith of the lateral incisors
is usually concurrent with the midline, whereas in canines, zenith points are
reported to be either at the midline or distal to it.
Usually, the zenith points of the lateral incisors are 0.5 to 1 mm below those of
the central incisors and canines, while the zenith points of the canines and
central incisors remain on the same horizontally drawn imaginary line. This
relationship of the zenith points actual- ly forms a type of an imaginary
triangle.
33
Gingival Zenith and Zenith Triangle
Digitization of the smile
• Applying the smile design on the computer gives the digital smile. This was
started by the Ackerman brothers in 1998. They created a program known as
the smile mesh. It is composed of 3 horizontal and 4 vertical lines. A
photograph of a smile is taken and entered on the program. The
measurements are then done using the lines. The lines and proportion are
fixed, so most of the cases did not suit the program. Therefore, the program
was not reliable enough. In addition, the program do not accept videos
• However, Ackerman brothers developed the program in 2004 to accept
videos, but it takes a long time to upload so was time consuming. The
program at that time was very expensive nowadays it is available for free
download on the smart phones, known as softonic. The program also had
limitations in using dynamic records and needed more facilities to benefit it
in:
• Diagnosis
• Treatment planning
• Evaluation of treatment results
34
• Research fields around smile
• Gholami introduced the software “smile analysis” in 2010, which is
practically very useful, but it was not well marketed. This program allowed
for
o Depiction of lines and points, meaning to choose and mark the point, so you
can control the results according to your choices. This provided:
o Increased precision of finding locations
o Determines the direction of lines accurately
o Perform calculations
o Scale determination: can determine the mistakes or abnormality in
photographing and adjust it automatically. This is performed either by using
the real distances or a scaled instrument
o Using dynamic records easily
o Easy and rapid use of videos: importance of videos is to capture the favourite
image. However, this is not a big benefit as the most probably the capture is
not correct as the patient is not stable. To obtain a right capture the patient
must be positioned in a cephalometric (by adjusting 2 axis lines)
o Relates between miniesthetics, macroesthetics and microesthetics
• In 2012 the DSD (Digital Smile Design) was invented by a professor in
Brazil. It is a very good system but 80% more to the technicians than the
dentist.
• DSD is a conception but do not perform any treatment protocols (e.g. crown,
cavities, inlay, etc). The DSD:
• correlates between the intraoral and extraoral esthetics giving a good
diagnosis
• perform structural evaluation
35
• standardize the tools and language between all clinicians and technicians
• The DSD allows the clinicians to: (other benefits of the DSD are for the
technicians)
• Educate and motivate their patients
• Enhances the patients’ visual perception (i.e. something to see)
• Ultimately increases case acceptance (i.e. more convinced to buy the product
by 30-40%)
• DSD interface/connects with different platforms such as:
• CAD/CAM: main drawback of the CAD/CAM is that it is a closed system
(i.e. do not accept from any other system, or give any other system (e.g.
cannot be connected by a scanner from another system)
• 3D orthodontics
• 3D surgical plannings
• This interface is done through “DSD connect” that bridges the project to any
other software
• 4 main goals/advantages of the DSD concept:
• Become a better smile designer. This is an advantage but abusing as it
benefits from your ignorance
• Team communication
• Increase case acceptance (30-40% increased acceptance)
• Link to other software’s
• The DSD provided the patient picture for the technician giving more details
for the patient, facilitating the choice of the color complex
• The DSD is available on the Iphone for free as an introduction for the project
before buying it
36
• The DSD drawing sequence allowed for:
• Better understanding of the esthetic issue
• better insight into the various possible interdisciplinary solutions
• enhances the interdisciplinary interactions
• connect the treatment planning to the 3D software systems
• DSD allows for waxing up. Take an impression of the case without any
preparation and pour the cast. Take a photograph of the cast. The DSD will
draw the design on the software. You apply the design on the wax-up, and
take an impression for the wax up or by vaccum tray. Fill the tray or
impression with the temporary material and insert it in the patient’s mouth
(i.e. mock up), but the DSD recommend to take a picture for the mock up and
not to allow the patient to see it directly in a mirror, as it won’t be perfect as
the final design
References:
a.
Stephen C, Devigus A, Paravina R, Mieleszko A, Fundamentals of color
matching and communication in esthetic dentistry. Second eidition,
Quintessence publishing, 2010.
b.
Hugo B, Esthetics with resin composite, basics and techniques, , Quint
essence publishing, 2009
c.
Douglas A, Geller W, Esthetic and restorative dentistry, material
selection and techniques, second eidition, Quintessence publishing,
2013.
d.
Freedem, G, Contemporary esthetic dentistry, Quintessence publishing
2011
e.
Levine J, Smile Design Integrating Esthetics and Function Essentials of
Esthetic Dentistry, second eidition, Elsevier, 2016
37
38
Gerontology:
ILOS:
1- Describe the different changes associated with aging procedure and its
implication on restorative dentistry.
2-­‐ Integrate and link the information gained across the course program with
the problem solving in different clinical situations.
3- Correlate between the data collected regarding age changes and restorative
treatment planning for elderly.
Introduction to Geriatric Dentistry
It is defined as the study of physiological age-related changes, whereas the
specialty of medicine dealing with the study of diagnosis and treatment of
diseases associated with advanced age is called geriatrics. Gerodontology in
general refers to "the dentistry for the elderly" and may be defined as the
investigation and management of age-related diseases and changes in the oral
region. The elderly is anyone over 65-75 years of age due to the consideration of
the biological age.
Why are we so concerned recently with geriatric dentistry?
The emphasis of the profession is shifting towards the care for the senior adult
segment of population, as a rising geriatric population remains dentate and
requires more dental care to maintain dental health and function. This
population will require significant dental care due not only to replacement needs
for existing restorations but also to the development of new patterns of caries.
Two factors are mainly responsible for the increasing relevance of dentistry for
39
the elderly, an increase in the proportion of the elderly in the population and the
improvements in dental health, which resulted that more people keeping their
teeth for longer. In 2001 the proportion aged more than 75 years was 22%, as
well as only 10% of adults were edentulous, compared with 25% edentulous
adults in 1983.
Age changes:
It may be defined as the gradual alteration in the form or function of a tissue or
organ as a result of biological activity associated with minor disturbance of
normal cellular turnover. Age changes could be physiological or pathological. It
is often difficult or even impossible to differentiate between physiological and
pathological age changes that affects teeth.
Most tissues have a physiological turnover of their components. The rate of
turnover varies from tissue to tissue and depends on a number of local and
systemic factors, including age. The growth factors that regulate cell
proliferation have been characterized as peptides and proteins. Inhibitory or
controlling substances, referred to as chalones, are normally present and are
specific to the various cell lines. The tooth enamel is a tissue in which
essentially no biological activity takes place after being formed. Its reactivity is
limited to physicochemical processes. A limited turnover based on cellular
activity is believed to occur in dentin and cementum. The pulp and especially
the periodontal ligament are examples of tissues in which turnover is high.
Two major damaging influences are associated with aging:
1. Increasing brittleness that predisposes to cracks, fractures and shearing of
tooth substance.
40
2. Progressive apical migration of soft tissue attachment leading to root
exposure and diminished bony support.
a) Macroscopic changes:
Teeth change in form and color with age. Wear and attrition affects the tooth
form. Loss of structural details on enamel surface is noted over time, this gives
the teeth a different pattern of light reflection. This feature causes a change in
the observed color. Yellowing and loss of translucency are common.
Pigmentation of anatomical defects, corrosion products and inadequate oral
hygiene may also change teeth color.
b) Enamel:
All changes in enamel are based on ion exchange mechanisms. Enamel becomes
less permeable and more brittle with age, due to changes in enamel matrix. The
decrease in permeability is referred to as enamel maturation. Bhussiy & Hess
reported no significant differences in the density of enamel as a function of age.
However, the nitrogen content showed an increase with age. Some of the
acquired
properties of surface enamel are slowly built up during life, such as the fluoride
content. These changes in surface contents may therefore be considered as age
changes. However, they are not due to aging per se, and they are not permanent
because they are affected by attrition, abrasion and erosion. Caries also alters
the chemistry of the surface enamel.
c) Dentin:
Two independent changes take place in dentin. Physiological secondary dentin
41
formation and gradual obturation of dentinal tubules, referred to as physiologic
dentin sclerosis. Odontoblasts continue matrix formation at a slow rate to form
the physiological secondary dentin, which is more irregular, probably due to
crowding of odontoblasts. The number of dentinal tubules is reduced, and their
course is somewhat more irregular. The predentin width increases with age,
possibly due to a slow rate of mineralization of secondary dentin. The mineral
content and hardness of dentin increase with age. Obturation of the tubules by
gradual growth of the peritubular dentin is a typical age change. It results in a
change in the refractive index of the dentin, making it more translucent, hence
the term transparent dentin. The obturation of tubules leads to reduction of
sensitivity of the tissues. Furthermore, the "adhesive properties" of aged cervical
dentin are different from those of young dentin.
d) Pulp:
Formation of secondary dentin reduces the size of pulp chamber. This reduction
in size does not affect the pulp chamber evenly and varies between teeth. With
age pulp tends to have more fibers and fewer cells. The blood supply apparently
decreases with age. Bennet et al indicated that the number of branches of blood
vessels was markedly decreased with age, including the branching in the
subodontoblastic region. These changes are clinically important because the
pulp in the older individuals cannot be expected to have the same reparative
capabilities as that in young teeth. Thus the pulp capping procedures must be
expected to have
less success rate in old individuals; that is repair by dentin bridge formation
should not be expected. The cross-linking between collagen fibers in the pulp
decreases with age and the calcium content increases.
42
Electron microscopy of old pulps in cats has shown loss and degeneration in
length, diameter and degree of myelination of myelinated and unmyelinated
nerves. Marked decrease in pulpal calcitonin-gene related peptide and substance
p-like immunoreactivity was also demonstrated. These findings may explain the
reduced sensitivity in teeth from older individuals. It is also likely that these
changes in nerves affect hemoregulation of the pulp and thus decreasing the
healing capacity of the pulp in old individuals. The presence of pulp stones has
been attributed to pathological changes, but they have also been considered as
age changes.
e) Cementum:
Cementum may be resorbed and new cementum may form both locally in
resorption defects or more generally over the root especially in the apical half to
compensate for tooth wear during function. The susceptibility to resorption and
number of resorption areas increase with age. The composition of cementum has
also been reported to change with age, i.e., increased fluoride and magnesium
contents. Cervical acellular cementum becomes exposed to oral environment
when gingival recession occurs. The exposed cementum becomes lost or
influenced by environmental factors. This is not considered to be age changes
per se, but the clinical implications of such changes must not be over looked in
geriatric dentistry. Cementum deposition occurs throughout life. The total width
of cementum almost triples between the ages 10 and 75 years. Hypercementosis
may affect one or more teeth. It is a pathological condition that may be caused
by local factors or certain systemic conditions as Paget's disease.
f) Bone:
43
Bone is a labile tissue. Resorption and deposition occur synchronously in the
process of growth and remodeling. Once growth is complete, bone is notably
less labile. As physical activity diminishes, as does the demand for new bone
formation and, by the time old age is reached, atrophy has resulted from slow,
uncompensated resorption. Increasing fragility of elderly bone is not a
consequence of atrophy. Bone composition gradually alters, resulting in reduced
resilience and increased brittleness. It is estimated that the mineral content is
reduced by 50% in women and 40% in men by age 75.
g) Oral soft tissues:
A decrease in the thickness of epithelium, mucosa and submucosa is seen. Loss
of the alveolar bone that normally surrounds roots and affords anchorage for the
fibers of the periodontal ligament is hastened by extraction of teeth. Epithelial
rests of Malassez decrease in number with age. Taste bud function is
diminished. With age an increase occurs in the number and size of Fordyce's
spots (sebaceous glands), lingual varices and foliate papillae. Elderly patients
suffer a loss of tissue and oral fluids associated with reduced vascularity and
salivary secretion. This depletion is attributable to an age-related decrease in
acinar tissue, compared with ductal and connective tissues, resulting in
increasing vulnerability to minor injury. Recent evidence showed that
stimulated salivary flow rate does not fell purely as a result of age. However,
medications or systemic diseases can affect salivary output.
Wound becomes progressively less rapid with advancing age because of
decreased vascularity and locally impaired hemodynamics, which arise from
damage and thickening of vessel walls. Decreased, immune response introduces
another obstacle to healing and the capacity of cells to undergo division can
44
decline until the proliferative response essential for repair is deficient.
h) Masticatory musculature and TMJ:
Muscle fibers decrease in size and number and are replaced by fat and fibrous
connective tissue. Atrophy of masticatory muscles is due in part to disuse, as
less muscular effort is required due to softer food intake and failing dentition.
Evidence of age related disease in the TMJ is sufficient to warrant its
consideration when masticatory problems arise in older people. Thirty percent
of patients older than seventy years exhibit TMJ dysfunction, tenderness of the
masticatory muscles and abnormal joint sounds. The mean age of patients with
osteoarthrosis of the TMJ is 62 years.
Clinical assessment of the elderly patient
A) Principles of evaluation:
a. Patient behavior:
When illness occurs, the behavior of the patient is influenced by social, ethnic,
physiological and biological phenomena, including:
· Perceived severity of illness
· Disruption of daily life
· Denying or minimizing symptoms
· Previous experience of care and availability of care Since aging
additionally influences health and illness, behavior, it is helpful to
consider the impact of aging on illness behavior and learn its clinical
45
implications. B) Patient examination: Evaluation of older person
requires some modification and supplementation of the usual clinical
examination administered to younger patients. Communication concepts
and environment: It is important to build good communication ties
between the patient and the health care provider and to establish a trusting
relationship. The patient should be encouraged to discuss the chief
complaint and any other possible symptoms,
feelings and fears. Begin the interview with reassurance and introduce yourself
to establish a friendly relationship, older people can often be comforted by a
gentle touch on hand or arm during conversation. The location of interview
should be free of noise to allow communication and prevent distraction.
Words should be spoken clearly, directly facing and leveled with the patient to
allow lip reading and other visual clues. Speaking louder, in lower frequency
range, is often helpful for communication with a hearing-impaired elderly. A
reminder about bringing a hearing aid before visit is most useful. Since visual
impairment is also common in older people, adequate lighting is important for
safety, perception of instruction and emotional comfort for patient. Also, chairs
of adequate height to allow easy sitting and rising are essential in dental clinics.
a. The medical assessment:
The practitioner should note the first impression of the patient. The patient's
physical appearance, nutritional status, gait, posture, attitude and behavior may
provide important clues during the assessment and diagnosis process. Gathering
an adequate history from older people is more complex and time consuming
46
because they have had more time to accumulate disease and disease is more
common in aged people. Family members can make important contributions to
the history. The patient should be seen alone first unless mere is outright refusal.
Only after the patient is interviewed should family join or be seen separately.
Before any procedure is performed, essential medical data should be gathered:
1. under the present care of a physician
2. previous hospitalizations
3. current medications
4. allergies, heart disease, heart murmur, high blood pressure or history of
rheumatic fever 5. diabetes
6. tuberculosis or other lung disease 7. hepatitis or other liver disease 8. kidney
diseases 9. bleeding disorders or blood disorders b. Physical examination
It requires special attention in older patients, some components do require
special attention and certain findings mean something different in older people.
Vital signs: It is important to record a baseline blood pressure for all patients.
Together
with pulse and respiratory rates that should be noted. Temperature recordings
should be verified with appropriate low- reading thermometers.
c. Mental status:
Affective and organic mental disorders occur frequently in older adults. Nearly
47
20% of those older than 75 years of age have some degree of clinically
detectable impairment of cognitive function, and mental status is therefore
another important component of the assessment. Depression and cognitive
impairment (especially memory deficits) should be differentiated from
dementia.
d. Oral health assessment: Careful attention should be paid to understand the
patient's perceived needs
and priorities for care. Questions should be directed toward the specific reason
for dental visit, the previous history of dental utilization, and the reason for the
last visit. Patients should be queried on their regularity with preventive oral
health behavior (brushing, flossing, use of fluoridated mouth rinse and
toothpaste).
I. Extraoral clinical examination:
When the dental history interview is completed, the next general step in the
assessment is a detailed extraoral examination of the head and neck.
II. Intraoral and perioral soft and hard tissue examination:
1. Soft tissue and dry mouth evaluation:
Lips, corner of the mouth and the vermilion border of the lips are examined for
ulcers, areas of swelling and enlargements. Areas of tenderness and induration
should be identified by palpation of the buccal mucosa and mucobuccal folds.
The dorsal, ventral and lateral surfaces of the tongue should be inspected for
atypical size, color, papillae, coating, lesions, and tremors or movements. Older
48
people frequently present with acute or chronic salivary flow reduction.
Generalized dryness, red, pale, or atrophic tissues may signal a dry mouth as
well as fissured or inflamed tongue. Both soft and hard palate should be
palpated and examined for lesions and symmetry.
2. Tooth structure loss, caries and restorations: Attrition, abrasion and erosion
are very common findings in elderly patients.
Both coronal and root caries are prevailing problems in older adults. Evidence
of softness obtained with an explorer on pit and fissures or smooth surfaces
should be recorded. Visual inspection of demineralization must be done.
Anterior proximal lesions can be detected by transillumination. Root caries is
usually found on virgin root surfaces exposed by gingival recession but may
also appear adjacent to previous restorations.
3. The peridontium:
Severe periodontal disease in dentate elderly people is probably less common
than might presume. Several parameters should be considered. These include
the location and degree of gingival bleeding and inflammation, and associated
soft plaque and hard calculus build-up. The relative positioning of adjacent and
opposing teeth as well as inadequate proximal contact and marginal ridge
relationships should be examined and charted.
4. Alveolar ridge:
Extensive alveolar bone changes are common in partially or fully edentulous
elderly people. The dentist should record alveolar ridge snaps, size,
alveolar mucosa integrity, tuberosities, interarch distance and degree of bony
49
resorption.
5. Occlusion:
During opening and closing of the mouth, deviations and deflections associated
with maxillary and mandibular midlines should be checked.
6. Diagnostic aids:
Radiographic evaluation is one of the most important diagnostic tools in the oral
assessment. For dentate patients, the initial examination usually requires
posterior bitewing and selected periapical radiographs, however, a full mouth
intraoral radiograph or a panoramic radiograph is usually indicated for the
edentate patient. Pulp assessment is necessary when patients complain of pain.
Laboratory testing
Is an additional method of assessing older patients. These include
microbiological testing: caries activity tests, antibiotic sensitivity tests, root
canal and root apex cultures.
Medical issues in the dental care of older adults:
Indications for medical consultation:
Dentists should consider consulting with physicians for three basic reasons.
First, dentists may have questions about the accuracy of the medical history or
medication regimen provided by the patient. Second, dentists may have specific
concerns regarding the ability of a patient to tolerate a proposed course of
treatment. Finally, dentists can provide physicians with significant information
regarding the potential relationship between oral health problems or
50
interventions and systemic health
Selected geriatric problems relevant to dentistry
1. Influenza:
Influenza A is a major cause of morbidity and mortality among elderly people.
Members of the dental team with substantial exposure to elderly patients,
particularly in long-term care settings, should receive the influenza vaccine
yearly to reduce the risk of transmission of the virus from health care workers to
susceptible persons.
2. Tuberculosis: People over 65 years of age are more susceptible to
tuberculosis than any other age group. People who live in nursing homes are
nearly twice as likely to have tuberculosis as elderly people living in the
community. Although the risk of tuberculosis transmission in dental settings is
generally relatively low, practitioners caring for immune-compromised or
institutionalized older adults may be of higher risk if there have been
documented tuberculosis cases in the community or facility in the preceding 12
months.
3. Infective endocarditis:
Dentists should pay special attention to eliciting potential risk factors for
infective endocarditis in their older patients. If doubt exists about the presence
of an underlying risk factor, the dentist should initiate consultation with the
patient physician to clarify the patient's status.
4. Arthritis:
51
When arthritis causes hand deformities, the patient's ability to carry out an oral
hygiene program may be compromised. Many patients are treated with aspirin
or nonsteroidal anti-inflammatory drugs and clinician needs to be alert to
potential bleeding tendency due to anti-platelet effect of drugs.
5. Diabetes mellitus:
When the dentist anticipates that the patient must fast for a procedure, the
physician should be consulted and consideration given to increasing monitoring
of blood sugar level and reducing the dosage of the patient's anti-diabetic drug.
Oral infections are more likely to occur in diabetic patients, especially those
with poor diabetic control.
6. Osteoporosis:
Research now suggests an association between bone loss at other anatomic sites
and alveolar bone loss in dentate and edentulous individuals, and studies have
also detected a relationship between osteoporosis and edentulous ridge
resorption. Clinicians may find that extra effort may be needed to position
osteoporotic patients comfortably in the dental chair due to skeletal, especially
spinal deformity.
7. Parkinsonism:
Parkinsonism is a condition with a variety of important oral manifestations and
oral health effects. Tremors may affect the head and tongue and excessive saliva
is common due to swallowing difficulty. Most of the drugs used to treat this
condition are xerogenic in nature. Parkinsonism compromises patient dexterity
and mobility, potentially limiting the ability to perform personal hygiene
52
independently as well as access to professional dental care.
8. Depression:
Depressive disorders are common in elderly people, although exact prevalence
rates are difficult to determine. One study found that over 28% of nursing home
residents had either major depression or depressive symptoms at admission.
Oral symptoms may be included in the array of functional complaints voiced by
a depressed individual. Problems with appearance, chewing, altered taste,
denture problems or unpleasant breath may be reported. When the patient
presents with vague or multiple oral complaints without obvious pathology, the
dentist should consider the possibility of depression.
Preventive dental care for elderly people
The development of oral health care services has followed a specific pattern.
Most attempts begin with relief of pain followed by conservative treatment. The
result of this order is usually reflected in a sophisticated treatment oriented
service. In 1980s, prevention, particularly health care promotion, came into
focus. Numerous programs have been initiated and evaluated. In dental field
these efforts have resulted in large proportions of child-populations being free of
oral and dental diseases.
The development of oral health service or care for elderly people is still in its
infancy. Dental attendance among elderly people is still less than any other age
group and usually problem-oriented rather than preventive. One of the major
challenges in providing restorative as well as preventive care for elderly people
is to develop an appreciation of the need for regular care.
53
Factors that influence older people utilization of dental services can be
divided into 4 main categories:
1. Illness and health related Factors:
General ill health, discomfort, mobility and functional limitations. 2. Sociodemographic factors:
2. Education, income, age, sex, culture, ethnicity, place of residence.
3. Service-related factors: Dentist behavior and attitude, cost-insurance
coverage, satisfaction with
service, transport
4. Attitudinal or subjective factors:
Personal beliefs, perceived importance, fear and anxiety, resistance to change,
perceived financial strain, satisfaction with dental visits.
Provision of dental care for adult special needs patients with some degree of
mental disability can present the dentist with a variety of complex medical
problems. The most difficult question concerns their ability to participate in
treatment decisions. Gillion identifies the possible conflict between the
principles of helping those in need of help and recognizing their right to make
their own decisions. Patients who are clearly incompetent to make decisions
ought to have that decision made for them.
Methods of preventing plaque induced- infections in elderly patients:
Periodontal disease and dental caries are plaque-induced diseases; inhibiting
54
plaque formation is effective in preventing these diseases so prevention is
related to the ability of the patient to accomplish adequate oral hygiene. Plaque
retention if elderly is a problem exacerbated by exciting restorations, missing
teeth, gingival recession, wearing removable prostheses and inadequate oral
hygiene due to lower digital dexterity, impaired vision, physical limitations
associated with diseases like Parkinson's and decreased motivation. To help the
elderly people to perform oral hygiene, several ideas were introduced.
Increasing the size of a toothbrush handle and using an electric toothbrush is
usually easier that manual toothbrush.
A toothpick may be an excellent substitute to dental floss for inter proximal
cleaning, it is simpler and safer. In wider interdental spaces, interproximal
brushes may be useful. The use of antimicrobial rinses to reduce supragingival
plaque is recommended. An oral irrigator is an effective device for application
of antimicrobial agents for chemical plaque control. The dramatic increase in
the number of dependent elderly in developed countries has created a great need
for their improved oral care. However, optimal oral care by caregivers is not
possible because of time constraints, difficulty involved in brushing other
individual’s teeth, lack of cooperation and the lack of perceived need.
Therefore, the development of an effective instrument simplifying and
supporting oral care to relieve the strain on caregivers is a matter of some
urgency.
Sumi et al, have developed a new oral care support instrument (an electric
toothbrush in combination with an antibacterial-agent supply and suction
system), they performed a study on 10 subjects who were dependent elderly.
They received oral care using the new oral care support instrument for two
55
weeks. Plaque and gingival indices were used for clinical evaluation. They
found that, the new oral care support instrument allows a more effective
removal of dental plaque and shows a significant improvement in the gingival
indices for dependent elderly. In a study by Simon et al, they suggested a way of
improving oral health for an elderly population. The use of chewing gum as an
adjunct to oral health because of the buffering action of saliva has long been
recognized and chewing gum manufacturers have responded by encouraging the
use of sugar free gums. This study showed that the elderly are able and willing
to chew gum. The use of antimicrobial agents in gum would assist oral health.
Other pharmaceutical agents might also have a place for example anticandidal
agents could be incorporated to aid resistance in patients with the difficult to
resolve conditions associated with long- term oral steroid inhalers.
Xylitol gums may also be advised. It is usually recommended that a patient
chew a piece of xylitol gum after eating or snacking for 5-30 minutes. Chewing
any sugar-free gum after meals reduces acidogenicity of plaque because
chewing stimulates salivary flow which improves the buffering of the pH drop
that occurs after eating. Xylitol is a natural five- carbon sugar obtained from
birch trees. It keeps the sucrose molecule from binding with mutans streptococci
and so keeping mutans streptococci from fermenting xylitol. Oral health
promoting services should address the factors that prevent or hinder older
people’s use of services. Oral health services should be organized and
developed to secure adequate early, detection, prevention and treatment of
dental problems for all elderly patients whether livings at home or in hospitals
or institutions. The achievement of such service goes beyond what the dental
profession can do alone. It requires the help and willingness of other health
professionals and carriers for elderly people. Elderly patients who are unable to
56
perform effective oral hygiene for themselves need assistance from professional
staff or a family member. Oral health education is a useful mean to increase the
awareness of elderly people and care providers.
Problems affecting elderly patients:
Dental
caries,
Dentin
hypersensitivity
Tooth
surface
loss Tooth
fracture Occlusion Management of missing teeth
1. Dental Caries:
In elderly patients, the number and type of restorations as well as areas of wear
will give an indication of the patient's previous caries experience and may be
useful in predicting the risk factors of further problem areas. New carious
lesions in enamel are uncommon unless the patient suffers from changes in
medical status (radiation therapy) or adopts a diet conductive to caries. Dental
caries in the elderly most commonly involves root surfaces or appears as
secondary caries around previous restorations.
1) Root caries:
a. Prevalence:
Communities with easy access to dental health care exhibit a prevalence of root
caries in their elderly population range from 80-100%. A striking feature is the
high treatment frequency and the accompanying recurrent caries, in an eightyear longitudinal study on periodontally treated patients, a total of 157 new root
surface caries lesions in 31 patients, and 80 along the margin of restoration.
b. Location and appearance:
57
Root caries occurs typically at CEJ, as this is the first area exposed to the oral
environment, but with further exposure of root surfaces via periodontal
breakdown, lesions may be found at sites apical to this point The root surface
lesion whether develop in exposed cementum or in exposed dentinal root
surface, due to scaling and polishing, comprise a subsurface mineral loss deep to
a surface zone of higher mineral content.
Initially root caries appears yellow to light brown; the cementum and dentin
become softened and there is no sharply demarcated cavitation. It is a
superficially spreading lesion, with a depth of 0.5- to 1 mm. and is found most
commonly on the proximal and facial surfaces of the mandibular anterior and
premolar teeth. The superficial nature of root caries produces a lateral spread of
the lesion toward the proximo-buccal or proximo-lingual line angles of teeth.
The dentin between the root surface and the pulp is very thin in these areas; thus
restorative procedures should be undertaken early.
The lesion development may be rapid because these areas have no enamel
protection and the dentin is less mineralized. However, the lesion may undergo
a maturation phenomenon, resulting in a remineralized area. This is probably
due to the fact that this area of the tooth is exposed to the oral environment and
constantly bathed in salivary ions.
Active root surface lesions appear well defined and show yellowish, brownish
or black discoloration. The lesion is most likely covered by visible plaque
and/or J presents a softened leathery consistency on probing with moderate
pressure. While inactive root surface lesions appear well-defined brownish or
black discoloration (brown spots). The surface of the lesion is smooth and shiny
and appears hard on probing with moderate pressure. Cavities may be present in
58
both active and inactive lesions. In inactive lesions the margins appear to be
smoothed off.
c. Microbiology:
Actinomyces viscous is the most likely organism to initiate root caries. After
caries initiation, lactobacilli then become important residents of the carious
lesion, once their niche is available. In contrast to enamel lesions, microbial
invasion into carious tissue occurs at a very early stage in root surface caries.
d. Diagnosis:
Root surfaces exposed to oral environment are at risk for caries and should be
examined visually and tactilely. Active progressing root caries shows little
discoloration and is detected by softness and cavitation.
Discoloration of root surface caries indicates mineralization. Although root
surface caries may be detected on radiographic examination is critical. One of
the more difficult diagnostic challenges is a patient who has attachment loss
with no gingival recession, thereby limiting accessibility for clinical inspection.
These rapidly progressing lesions are best diagnosed using vertical bitewings.
However, differentiation of a carious lesion from cervical burnout radiolucency
is essential.
e. Histopathological features of root surface caries:
Microradiographically, early root surface lesions appear as radiolucent zones in
the outer part of the root surface. Even in early stages the lesion may extend into
dentin, although a relatively higher mineralized surface zone may be present.
These observations indicate that the progressive loss of mineral from both
59
enamel and root surfaces appears to follow similar physico-chemical rules. They
also indicate that dissolved minerals may precipitate in the surface beneath the
microbial plaque. Thus exchange of minerals may be quite extensive at the
cementum plaque fluid interface.
At an early stage of root caries, at the ultrastructural level, changes have been
described in hydroxyapatite crystals, and exposed collagen fibers appear split.
Bacterial invasion takes place along the exposed collagen fibers, and may be
responsible for the splitting of fibers.
At slightly more advanced stages of destruction, the demineralization spreads
into the underlying dentin, frequently extending several hundred microns below
the surface. Even exposed dentinal surfaces may exhibit a relatively wellmineralized surface below which the demineralization occurs, cementum splits
in thin parallel layers along its incremental lines as microorganisms invade the
tissue.
f. Prevention and maintenance:
Diet and plaque control are essential elements of root caries prevention. Studies
suggest that fluoride can be effective in the management of root surface lesions.
Good home care, regular professional prophylaxis and dietary control can affect
60
remineralizatipn of early root carious lesions and may arrest more extensive and
active lesions. In a study by Nyvad & Fejesko, they tried to convert active into
inactive root caries by instructions to remove plaque and the use of fluoridated
toothpaste. In another study by Emilson, Ravald & Birkhed, over a 12-month
period they were able to convert 54% of 46 buccal active root surfaces lesions
into inactive caries. The results were remarkable, as patients had received only
6- 10 sessions in 12 month.
If fluoride is to be used, it should not be in the form of acidified gels whose low
pH is likely to decalcify the root surface. A more suitable choice would be a
fluoride-containing varnish or an aqueous solution of sodium fluoride. Patients
should be encouraged to use a fluoride-containing mouth rinse on regular basis.
Silver diamine fluoride (SDF) is an alkaline topical solution containing fluoride
and silver that clinicians mainly have used for caries treatment in young children.
1. reducing the growth of cariogenic bacteria
2. promoting the remineralization of the inorganic content of enamel and dentin,
3.prevents collagen degradation in dentin by inhibiting the activity of collagenases
and cysteine cathepsins.
4. Is known for its ability to desensitize hypersensitive teeth.
Clinicians have used SDF for decades in some countries such as Australia,
Brazil, China, and Japan. The Food and Drug Administration of the United States
61
approved it in 2016 as a dentine desensitizing agent, but clinicians also use it
off- label for caries treatment. The application of SDF is simple, painless,
noninvasive, and inexpensive.
Recently, the use of calcium phosphate compounds was suggested to help the
remineralization.
Synthetic hydroxyapatite:
It has been used to block opened dentinal tubules apertures. When
hydroxyapatite was used with iontophoresis, it was shown that precipitation of
insoluble salts is possible.
Casein phosphopeptides:
It can stabilize and localize amorphous calcium phosphate at the tooth surface
and prevent dental decay. It was shown too that it can repair early lesions by
promoting enamel subsurface remineralization. Recaldent, derived from casein
(protein of cow milk), has been added to toothpaste and chewing gum to
promote remineralization. It also provides a topical coating for patients suffering
from erosion, caries and conditions arising from xerostomia.
Bioactive glass:
It has the ability to act as a biomimetic mineralizer-matching the body's own
mineralizing traits while also affecting all signals in a way that benefits the
restoration of tissue structure and function.
NovaMin, remineralizing technology:
62
It is a break through advance in remineraliation. The present treatment for
remineralization and prevention of dental caries is slow acting and is dependent
on adequate saliva and frequent use for efficacy. It has several advantages:
1. Remineralizes faster and more substantially than fluoride. The mineral layer
provides noticeable tooth whitening.
2. Non-toxic.
3. Does not require saliva as a source of calcium and phosphorus (this is of
major importance for geriatric patients and other patients who suffers from
diminished salivary flow).
4.
Use of Ozone delivery system for remineralization and treatment of root caries:
Ozone kills microorganisms on tooth surface, sterile and penetrates decayed
tissues, allowing the tooth to remineralize. HealOzone delivers a 10 seconds
burst of Ozone gas at a concentration of 2,100 ppm, through a hose and hand
piece into a removable silicone cup that is placed around the tooth surface to be
treated. The tightly fitting cup includes a resilient edge for sealing the edge of
the cup against the selected area on the tooth to prevent escape of ozone. The
unit vacuums any residual Ozone back at 615 cc/min into second HealOzone,
unit then pumps a reductant fluid/mineral wash onto the treatment site, to start
the mineralization which takes 5 seconds. The patient takes a house care kit,
consisting of dentifrice and convenient full-size mouth rinse. In a study by
Lynch&. Baysanl, they tested
the use of HealOzone in treatment of primary root caries, they concluded that
63
the use of Ozone in treatment of caries is safe and effective.
Factors promoting caries occurrence in elderly patients:
1. Missing teeth, which can enhance caries due to:
a. Reduced chewing efficiency, leading to high carbohydrate diet of softer and
more cariogenic foods.
b. Depending on the side that still has more teeth in chewing, leading to plaque
accumulation on the nonfunctional side.
c. Wearing removable partial dentures, leading to plaque accumulation on
abutment teeth and around clasps.
d. Misaligned and shifted teeth.
2. Increased sugar intake to compensate for loss of taste.
3. Xerostomia, which may be due to some medications or systemic diseases.
4. Gingival recession that exposes cementum and dentin which are less resistant
to decay.
Restoration: The nature and site of root caries make restoration difficult. On
the root surface, the margins of cavities will exist in either cementum or dentin.
Compared with enamel, these tissues are relatively soft and ill defined; thus
smooth margins are difficult to create. There is usually little dentin available in
which to prepare retentive features. For a restoration to be successful, it must
64
not only replace missing tooth structure and provide a good marginal seal, but
also conform to the anatomy of the tooth. In the root area, this is especially
critical for periodontal health and response. The complicated anatomy of the
root surface around furcation and interproximal areas presents a special
challenge. The problem is further complicated by inaccessibility of lesions in
these areas.
Materials:
Three materials can be used to restore teeth affected by root caries: amalgam,
composite resin and glass-ionomer restorations.
1. Amalgam:
It is an excellent restorative material, but it has two main disadvantages for root
restorations. First, it requires mechanical undercuts for retention, and second,
adequate condensation is essential for a restoration of good quality.
Condensation is difficult if the interproximal or furcation area is involved.
2. Composite resin:
Composite resin became an excellent material too after recent developments in
bonding agents. Modern microfilled composites provide a smooth and highly
polishable surface, this inhibits plaque accumulation, which is favorable to
decrease tendency of recurrent caries formation. Mechanical retention poses the
same problems that occur with amalgam; also the high coefficient of thermal
expansion of composite compared to that of tooth represents a disadvantage as it
allows for microleakage.
3. Glass-ionomer restorative: This is the material of choice for restorations of
65
the root surface lesion.
Several advantages of glass-ionomer led to this conclusion. The set material is
capable of producing a degree of true adhesion to tooth structure via ionic and
polar bonds. The material is also capable of producing a good marginal seal, so
mechanical undercuts are not essential. Fluoride release from the material is
taken up by the tooth tissues around restoration and provides protection against
recurrent caries. Little preparation of teeth is required beyond caries removal
and establishment of minimal resistance form to promote adhesion to tooth
structure. Pulpal reaction is mild. An initial acute inflammatory response
resolves quickly and pulpal vitality is not compromised.
This material also suffers from disadvantages, as its handling. The
powder/liquid ratio is critical, strict adherence to manufacture's instruction is
important if optimal physical properties are to be achieved. Also, the final
setting of the cement does not take place for at least 1 hour, during this time the
cement is vulnerable to moisture contamination. This problem is now overcame
by incorporation of unfilled composite resin that showed to be effective in
preventing water sorption. Carious lesions involving root surface are generally
close to the free gingival margin. The use of a rubber dam or proper isolation to
gain control of the operating field provides great advantages. Carious tissue
should be removed carefully. It is recommended that, where vital dentin has
been cut or where the lesion is in close proximity to pulp (which, on anatomic
grounds, applies to virtually all root caries lesions), a protective base be applied.
In addition to pulpal protection, the base will prevent exudation of fluid from
the cut dentinal tubules; this fluid may interfere with both the setting reaction
and adhesion of glass- ionomer.
66
To provide a clean surface for adhesion of glass- ionomer, conditioning of the
remaining exposed tooth tissue is done. Glass-ionomer is then mixed and
applied into the cavity with a syringe. This allows placement under a positive
pressure, which permits easier handling, reduces voids and contamination, and
facilitates incremental application and condensation. It is important that a matrix
be used to allow improved adaptation and permit the cement to set without
being disturbed. Suitable matrices are the commercially available cervical foils,
which may be readily burnished to conform to the contours of the tooth. The
cement is trimmed parallel to the margins of the cavity to prevent the cement
from pulling away from the cavity walls. After the second stage of setting
reaction, the restoration is finished with a lubricated white stone used at a very
low speed.
2) Secondary caries: The diagnosis of secondary caries is easy when a new
lesion is obviously associated with an existing restoration. Discoloration of
tooth structure adjacent to a restoration is not an absolute diagnostic criterion.
Proper diagnosis requires a through clinical examination of dry teeth under good
illumination. Radiographs are essential; bitewing views are more informative
than periapical radiographs. Loss of marginal integrity of the restoration
provides a ground for removal and assessment. However, when amalgam is
involved, it may be prudent to leave the restoration in place and reevaluate at a
later visit. Loss of marginal integrity and ditching of amalgam is very common.
Despite small marginal fractures and loss of integrity, the restoration tends to
maintain its overall marginal seal and prevent microleakage through the
deposition of corrosion products at the tooth-restoration interface. Thus, if no
signs of secondary caries are present, the dentist may choose to do nothing and
to reevaluate at a later date. If posterior teeth with amalgam restorations exhibit
67
recurrent caries in the root area, it may be reasonable to remove the existing
restoration via an occlusal approach to gain access to the carious lesion. Such,
cavities are suitable for restoration with amalgam, because mechanical retention
is easily produced and straight-line access for condensation is possible. If an
occlusal approach is deemed too destructive, an approach can be made from the
facial or lingual aspect via a slot preparation. This slot preparation is then best
restored with glass-ionomer.
B) Dentin hypersensitivity: Dentin hypersensitivity is described clinically as
an exaggerated response to non-noxious stimuli and satisfies all the criteria to be
classified as a true pain syndrome. The hypersensitivity can develop as a result
of pulp inflammation, but the symptoms are more severe and persistent than the
typical short sharp pain of dentin hypersensitivity. Management is completely
different where it is directed at pulp pathology. To date there is no information
concerning the state of the pulp in dentin hypersensitivity. Dentin
hypersensitivity is characterized by short sharp pain arising from exposed dentin
in response to stimuli, typically thermal, evaporative, tactile, osmotic or
chemical and which cannot be ascribed to any other dental defect or pathology.
The prevalence and clinical features of dentine hypersensitivity are well
documented. However, the prevalence is likely to increase in the future as more
adults retain their teeth into later life, the available prevalence data ranges from
8- 57% of elderly suffering from this problem. Recent work has provided further
support for the hydrodynamic mechanism of dentine sensitivity. Evidence that
the tubules in hypersensitive dentine are wider and more numerous compared
with non-sensitive dentine lends weight to tubule occlusion as the principal
means of treating dentine hypersensitivity. There are potentially numerous and
68
varied etiological and predisposing factors to dentin hypersensitivity. By
definition, dentin hypersensitivity may arise from loss of enamel and root
surface denudation with exposure of underlying dentin. Enamel loss can result
from attrition, abrasion, abfraction and erosion (non-carious lesions).
Two phases are identified in the development of dentine hypersensitivity. First,
dentine has to be exposed (lesion localization) and then the dentinal tubules
must be opened (lesion initiation). Dentine hypersensitivity is most common in
cervical dentine. Here, gingival recession caused by brushing trauma is thought
to be a more important factor in lesion localization than loss of cervical enamel.
Lesion initiation involves removal of cementum and dentinal smear layers. This
is mainly caused by erosive agents but these can be potentiated by abrasion.
Management of dentine hypersensitivity should therefore include instruction in
correct oral hygiene techniques and avoidance of erosive factors. In this respect,
dietary logs may prove helpful. This preventive approach should accompany
treatment with either home care products or professionally applied desensitizing
therapy. These strategies will not make the treatment of dentine hypersensitivity
any easier, but they may well improve efficacy.
Topical desensitizing agents
Are classified on the basis of their chemical and physical properties into:
1. Chemical agents:
Corticosteroids, silver nitrate, strontium chloride, formaldehyde, calcium
hydroxide, potassium nitrate, fluorides, sodium citrate, potassium oxalate,
ionophoresis with 2% sodium fluoride.
69
2. Physical agents:
Composites, resins, varnishes, sealants, soft tissue grafts, glass ionomer
cements. Treatments can be categorized and summarized according to delivery
and therapeutic aims into professional (in office) and home use treatments.
Professional treatments usually include application of a material to the tooth
surface with the aim of occluding tubules. The home care treatments usually
include mouth rinses or toothpaste. The therapeutic aims of both methods are
either to interrupt the pulp neural response or block the sensitivity mechanism
through tubules occlusion.
C) Tooth surface loss:
The loss of enamel and dentin caused by means other than caries and trauma has
become more significant as teeth are retained for longer and people's dietary
habits change. The etiology is often complex, as can be the treatment Prevention
of the condition by education and intervention by the dentist is important. Tooth
surface loss, also called tooth wear, refers to interrelated effects of:
a. Attrition:
Loss of enamel and dentin resulting from tooth to tooth contact, interproximal
attrition on contacting proximal surfaces of adjacent teeth occurs during
occlusal loading.
b. Abrasion:
Involves an abrasive agent between or against tooth surface.
c. Erosion:
70
Involves a chemical agent, which may be an extrinsic factor (industrial acids,
acidic food and drinks and certain medications) or an intrinsic factor (gastric
acid, excessive vomiting, bulimia and anorexia).
d. Abfraction:
Is currently regarded as theoretical but helps to explain the occurrence of tooth
surface loss in the cervical region. Excessive occlusal load may contribute to
erosive process through either compression or tension in the cervical region of
the tooth, just above its bony support.
The principal causes or predisposing factors are:
1. Developmental anomalies 2. Malocclusion 3. Posterior tooth loss 4.
Parafunctions and habits 5. Restorative material
6. Diet and life style 7. Oral hygiene techniques 8. Systemic disease 9. Natural
wear and tear I. Etiology and clinical features: 1. Developmental anomalies:
Localized enamel hypoplasia is never a serious problem, since isolated zones of
surface loss will not usually disturb occlusal stability. However, the more
difficult conditions are those of amelogenesis imperfecta and dentinogenesis
imperfecta. These are part of a range of pathology, including osteogenesis
imperfecta that is manifestation of disturbances in the formation of calcified
tissues. These disturbances are genetic in origin and are often seen as familial
traits. In amelogenesis imperfecta, the enamel matrix formation is disturbed but
with normal calcification. The extent of the disorder varies from localized areas
of
pitting, to a very thin shell of enamel. The enamel is hard but may be deposited
71
in fine lamellations as well as in normal prismatic structure in other areas. Teeth
are poor esthetically and vulnerable to caries and attrition in affected areas.
Dentingenesis imperfecta is uncommon and is due to defective dontoblastic
activity. The dentin is soft, with the deeper layer having few tubules and
incomplete calcification. Also the pulp chamber becomes obliterated. Clinically
the weak bond of enamel to dentin results in enamel loss, even though the
enamel itself is usually normal. The color of teeth is abnormal, being brownish,
and roots are stunted and apical infection may occur due to obliteration of root
canals.
2. Malocclusion:
Certain malocclusions, particularly involving the anterior teeth, may bring teeth
into abnormal functional contacts. Those that create the most problems are edge
to edge incisor relationship and unfavorable Angle's class II division 2 incisor
relationship. The latter case may involve close apposition of the palatal surfaces
and tips of the upper incisors with the labial surfaces of the lower incisors. Also
gingival trauma may result from the deep overbite. Surface loss may be
dramatic if the malocclusion remains untreated.
3. Posterior tooth loss:
If several posterior teeth are lost, mastication is likely to be effected on the
remaining anterior teeth. These teeth are not well suited for grinding movements
and rapid surface loss result This type of problem is more common in
geographic areas where the level of dental care and awareness has been
inadequate, and is usually coupled with non-provision o£ or refusal to wear,
dentures.
72
Even with partial dentures present, there is a great tendency to use the natural
teeth, and part of the education of the patient at the fitting stage of dentures
should be to stress the need to use them effectively. Cases exhibit progressive
loss of incisors and canine crown length and when this becomes unsightly the
patient is prompted to seek treatment.
4. Parafunctions and habits:
Bruxism is the most dangerous Para function, with enamel and dentin loss.
Again, the incisor length loss is what prompts, the request for treatment, but
prevention, in the form of an occlusal splint, should be applied as soon as the
surface loss is noted. The exposed dentin may be sensitive, but since the attrition
is usually coupled with secondary dentin formation and the retreat of pulp, it is
more often symptomless. The obliteration of the root canals by secondary dentin
can lead to apical infection, and the routine use of apical radiographs in the
diagnostic phase is important. Root canal therapy would be indicated before the
canals become obstructed.
Habits like nail biting, pipe smoking and hair grip opening can cause abnormal
wear patterns, particularly of ah isolated nature. Toothbrush abrasion may be
caused by incorrect brushing technique, seen particularly at the cervical margin
of the buccal surfaces of the left in a right-handed person (or vice versa). It is
accompanied by gingival recession and loss of exposed cementum. There has
been a suggestion that the occlusion may cause cervical stresses leading to
dentin fatigue and breakdown rather than brushing.
5. Restorative materials:
Conventional composites and unglazed dental ceramics can remove enamel
73
quite successfully during normal function, with their effect greatly accelerated
.by parafunction. Again, correct treatment planning, or early intervention, is the
best course. Coarse particled composites should be avoided for large
restorations. If a ceramic occlusal surface has been prescribed, it should be
reglazed following adjustments rather than polished.
The creep of amalgam represents a loss of occlusal stability due to surface
deformation, and the upshot of this may be to put an extensively restored case
into the same treatment-planning group as surface loss cases.
6. Diet and life style:
Abrasion is intricately related to diet and culture. For example, non- industrial
populations living in a harsh environment, masticating hard, fibrous foods show
more extensive abrasion than those in industrial urban societies consuming soil
processed food High consumption of acidic food and drinks such as citrus fruits,
cola and lemonade removes surface enamel. Cola is a particular hazard as it
contains phosphoric acid, citric acid and carbonic acid.
The labial surfaces are usually affected unless drinking is via a straw, in which
case the palatal aspects of the upper incisors, may dissolve. The worst cases are
diet freaks who eat large amounts of citrus fruits and brush their teeth
immediately afterwards. The acid removes the mineral and brushing removes
whatever matrix is left-thus accelerating the process. The logical alternative is to
advice the patient to brush teeth before ingestion of acidic food or drink. After
acid intake, it will be sufficient to merely wash the mouth vigorously with water
to remove the acid residue. Delaying brushing for up to 3 hours will give time
for sufficient remineralization from calcium and phosphate ions in the saliva,
74
and no permanent loss of tooth structure will occur. There are no problems
likely to arise from this advice in relation to caries activity because, in the
absence of mature plaque, there can be no caries generation, and whether the
plaque is removed before or after eating, is not relevant. Another modern habit
is to sip cans of fruit drinks throughout the day; this simply drips acid
continuously on the tooth surface. As with carbohydrate intake and caries, it is
the frequency of exposure rather than the volume.
Prevention via dietary advice is the best approach, and patients could be advised
to rinse with fresh water after eating fruit, rather than brushing. A reduction in
intake of fruit and acidic drinks should also be advised. The surface enamel will
lose its lamellated appearance and will have a high amorphous gloss. Eventually
dentin will be exposed in eroded areas, particularly bucco-cervical and
occlusally. Because the erosion causes a more rapid enamel loss than that
caused by attrition alone, secondary dentin does not form quickly enough to
prevent sensitivity.
7. Oral hygiene techniques:
Although routine tooth cleaning is desirable to reduce the risk of periodontal
disease and caries, the cleaning process itself may result in the loss of tooth
structure through abrasion. The use of an abrasive dentifrice, combined with
vigorous brushing with a hard toothbrush, can result in abrasive defects
particularly near the gingival margin on the facial surfaces. Such loss of tooth
structure can pose a significant problem. When dentin is exposed by abrasion
alone the tubules may remain closed by the smear layer. In the presence of acid,
the dentinal tubules may be opened through loss of this layer and the pulp may
become inflamed and respond to changes in temperature, osmolality and tooth
75
drying. Loss of tooth structure from abrasion may become so severe that the
strength of the tooth is threatened.
8. Systemic diseases:
Childhood diseases may interfere with enamel mineralization of developing
teeth and these may erupt with bands or localized zones of hypomineralization.
These areas are weak and if they are in functional relationship with opposing
teeth, will be lost rapidly. In the adult the most common systemic disease
affecting the tooth surface is gastric reflux. Due to cardiac sphincter problems,
gastric secretions are forced up the esophagus and into the mouth. These
secretions are highly demoralizing and the areas most commonly affected are
the palatal surfaces of upper teeth. Occlusal surface loss also occurs, leading to
existing restorations being left above the level of the surrounding teeth. This is a
classic feature of erosion in the absence of occlusal forces, where the affected
tooth surface has no occlusal contact Prolonged vomiting may also create the
same picture, and is one hazard of pregnancy. In addition, the disorders of
bulimia and anorexia nervosa may be accompanied by vomiting.
Certain medications are also acidic in nature and the potential for
demineralization must be recognized and the patient counseled. A lack of gastric
acid may be compensated for by the oral administration of concentrated
hydrochloric acid with advice that it should be taken through straw or glass
tube. However, there is still a tendency to force some of the acid into oral cavity
by the act of swallowing. Erosion of lingual surfaces of the upper teeth is
evidence of this problem and such drugs should preferably be administrated in
an alternative form.
76
9. Natural wear and tear:
Elderly population keeps teeth longer; it is therefore inevitable that teeth simply
wear out.
II. Indications for treatment:
Wear that is slight in proportion to the patient's age and is not causing any
symptoms requires no active treatment. However, the patient should be
examined at recall appointments to determine whether any significant change
has taken place. It is helpful to make impressions for study casts, which can be
retained for comparisons at subsequent visits.
Cases with tooth surface loss will require restorative treatment if there is: ·
Associated pathology like caries or apical infection. · Sensitivity
• Loss of occlusal stability and function
• Deterioration in esthetics
III. Principles of treatment: When there is a clear etiological factor, it should
be eliminated prior to restorative work. Elimination of habits, dietary advice,
and medical referral for gastric reflux and occlusal splints for bruxism fall under
this heading. Provision of partial dentures to provide posterior support prior to
consideration of advanced restorations for worn anterior teeth is essential. The
severe malocclusions mentioned previously will require orthodontic correction
or extractions. The correction of unfavorable relationships by crowns has
limitations due to root position. Patients with progressing anterior surface loss
particularly male may be only concerned that the condition does not worsen.
Timely provision of partial dentures coupled with glass-ionomer cement
77
restoration of incisal edge saucers may be sufficient in many cases.
Worn teeth are not particularly difficult to restore when the materials are used in
non-occluding areas. Where a functional surface has become worn and requires
restoration, the main problem is one of a lack of space for the restorative
material without preparing an already worn tooth. The traditional prosthodontic
approach has often been to restore all the teeth in one or both arches to increase
the occlusal vertical dimension. This can require the unnecessary treatment of
teeth, which have not been greatly affected by wear but require restoration to
bring them into contact with antagonists at the new vertical dimension of
occlusion. One of the most significant advances in treatment has been the ability
to re-create the space lost by the teeth as they wear. It is based on the use of a
bite-plane appliance localized to the worn teeth. This intrudes them and their
antagonists while encouraging the eruption of those taken out of contact by the
appliance. Used in combination with adhesive restorative techniques this
method has provided an extremely conservative approach to the restorative
management of worn teeth.
Treatment of abrasive/erosive lesions is dependent on the location and the
degree of erosion. It ranges from contouring with composites, to composite or
compomere or glass-ionomer restorations, to even porcelain veneer or full
crown. Abfraction could be treated with occlusal adjustment together with
restorative treatment, or a night guard. Application of desensitizing agents for
patients with dentin sensitivity of occlusal surfaces may not be successful There
seem to be a difference between response of a relatively localized zone of
cervical dentin and the larger area of occlusal exposed dentin. This is
particularly true for acid erosion cases where the dentinal tubules will be opened
78
by demineralization.
Localized hypomineralized areas of enamel can be successfully restored with
acid-etch retained composite. Larger areas with esthetic problems will require
onlays or crowns. Treatment planning of more extensive cases is influenced by
the age of the patient and the number of missing teeth. In generalized tooth wear
where there are indications to consider a full mouth reconstruction of the
dentition, the use of adhesive onlay restorations can be of value. Restoring
posterior quadrants with adhesive onlays is a conservative method, although it is
not always possible to create sufficient inter-occlusal space by increasing the
vertical dimension alone, particularly if opposing occluding surfaces in the
molar regions need to be restored. In these circumstances some occlusal tooth
reduction may also be necessary. Where space is at a premium the selection of a
gold alloy as opposed to porcelain will be advantageous.
IV. Tooth Fracture: Elderly patients commonly suffer from tooth fracture
without trauma.
Fracture may range from chipping of the incisal edge of an anterior tooth to loss
of a cusp from a posterior tooth to complete loss of clinical crown. Factors
responsible for tooth fracture related to age changes in the dental tissues, the
effect of previous restorations and caries, and occlusal disharmonies. Clinical
observation suggests that the incidence of tooth fracture is increasing as people
retain their teeth for longer periods. The following forms of tooth loss from
fracture should be noted:
a. Enamel flaking:
Slivers of enamel of various sizes may fracture from the incisal edges of anterior
79
teeth or from the buccal or lingual edges of posterior teeth, particularly if the
occlusal table is flat. Occasionally large areas of buccal or lingual enamel plate
may split of leaving dentin exposed. It is important to distinguish between
chipping from direct trauma and that arising from habits like fingernail biting or
opening hair clips with teeth. However, enamel flaking is resulting from toothgrinding and the pattern that results reflects the direction of the mandible during
the forceful phase, of the grinding stoke.
Observation of the micro-detail of wear patterns on facets suggests that they
arise from lateral movements of the mandible. It is the labial incisal edges of the
upper incisors and the lingual incisal edges of the lower incisors that tend to
flake, indicating a grinding movement away from the normal intercuspal
position. The direction of a forceful grinding stroke may be affected by a
deflective incline on a posterior tooth, which has become a guiding factor, as a
result of a change in the distribution of the posterior teeth. Such guidance may
produce a subtle change in wear pattern that is specific for that individual.
b. Cusp fracture:
It is possible for unrestored teeth to fracture, but it is far more common for this
to happen in teeth weakened iatrogenically by placement of restorations.
Endodontically treated teeth are also at increased risk because of loss of tooth
structure related to access of root canal therapy.
As the patient ages tooth develop minor cracks in the enamel that are usually
repaired by precipitation of salivary pellicle followed by mineral deposition.
However, if the tooth is at subject to heavy occlusal load the crack can
80
propagate through to dentin. Movement of the cusp during function may then be
extremely painful because of hydraulic stimulation of odontoblast sensory nerve
receptors. Treatment involves identifying, protecting and strengthening the cusp.
The cusps most prone to split and fail are the lingual cusps of upper first and
second promoters.
c. Crown fracture:
The crowns of anterior teeth are most at risk, in older patients the presence of
caries, restorations, erosion, abrasion or attrition may have already weakened
the crown structure, and even a minor blow may lead to loss of part or the entire
crown. Both crowns and roots are at increased risk of fracture in endodontically
treated teeth.
Restoration of fractured teeth in the elderly involves some special
considerations. If the amount of tooth fracture was small and the rest of the
tooth is sound bonded restoration is recommended, to keep the preparation as
minimal as possible and to get the ability to strengthen the remaining tooth
structure. If the tooth suffers from both fracture and carious lesion on occlusal
or incisal surfaces, the outline form of the tooth preparation could be extended
to include the area of fracture. If severe loss of tooth structure occurred due to
fracture, pins should be considered. The introduction of self-threading pins has
made the use of pins relatively common. However, these pins create stresses
within tooth structure. Dentin in the elderly has increased brittleness, and pins
must be used with extreme caution and in type, quantity (maximum of one pin
per missing cusp). When teeth are brittle or weakened pins should be avoided.
Attempts should be made to produce maximum retention and resistance form
81
through boxes and grooves. In case of endodontically treated teeth the root canal
area should be used to gain retention. When pin retention is unavoidable in
brittle teeth, cemented pins, which do not create installation stresses, should be
used.
Selection of the appropriately sized pin is important Most elderly patients show
increased clinical crown length, so die most likely area in which to place pins
often lies at or apical to the cemento-enamel junction. There is only a small bulk
of dentin between the periodontal ligament and the root canal of the tooth in this
area, so pins of smaller diameter must be used to avoid periodontal or pulpal
perforation.
V. Occlusion:
Natural dentition should demonstrate multiple even contacts between the
posterior teeth when the patient closes. In a protrusive movement the posterior
teeth should separate. In lateral excursions of the mandible, the non-working
side contacts should not exist. Following these basic concepts reduces tooth and
restoration fracture, as the forces of mastication are sufficient to fracture even
the strongest available restorative material. In the elderly, it is common to see an
opposing cusp that is overerupted relative to the occlusal plane of the arch. Such
plunger cusps are frequent causes of non-functional side interferences and
should be aggressively reduced. This reduction not only eliminates occlusal
interferences but also allows an increased bulk of material to be incorporated
into an opposing restoration.
VI. Management of missing teeth:
82
Management of missing teeth in the elderly often requires some type of denture
service, because of compromising factors such as periodontal health, tolerance
of dental procedures, systemic health, and financial availability. In many cases
fixed prosthodontics and implants may be used, and the same principles that are
used for younger patients are employed because proper case selection has
assured a predictable response. Implants in elderly require an extra 3-4 month
for osteointegration to take place. There are unique partial denture designs that
may help to solve the special problems in elderly patients, for example:
- Two-part denture: provides comfort and stability when tilted teeth adjacent to
saddle are present.
- Locking denture: uses the locking principal to join a two-part denture on a
hinge running between abutment teeth.
- Rotational path of insertion denture: consists of a cast-metal framework with
an angle of insertion at an axis of rotation determined by a surveyor, usually in
anterior region.
- Overdenture: simple design that has no retainers but conforms to certain
principles of retention and soft tissue coverage. Overdentures rest on 2 or more
prepared root surfaces, almost always receiving endodontic therapy.
Overdentures should always be considered in the mandible, where loss of
remaining teeth can create the floating lower denture.
Complete dentures for the elderly retain the basic principles of construction, but
with special considerations. Patients should be made aware that there are real
problems in their mouth and cautioned not to be too optimistic.
83
Future in sites:
Remineralization will be done routinely in the near future, early diagnosis of
incipient carious lesions will increase the percentage of positive outcomes of
remineralization therapy. Hopefully the future will carry for us new minimally
invasive surgical methods that will decrease patient discomfort and reduce their
anxiety over dental treatment.
"The day is surely coming when we will be practicing preventive rather than
reparative dentistry", a statement by GV Black the father of operative dentistry
in 1896, which actually came true.
Conclusion:
Thorough assessment has been described as the keystone of geriatric dentistry.
The dentist must determine which factors directly influence the physical,
psychosocial and dental health outcomes associated with older adults. Dental
examination strategies should identify objective clinical signs and subjective
patient perceptions as well as other important prognostic factors affecting
potential treatment approaches.
Oral Care for the Dependent Elderly 【 Fourth Edition】
84
Department for Advanced Dental Research, Center for Development of
Advanced Medicine for Dental and Oral Diseases,
National Center for Geriatrics and Gerontology
Introduction
The aging of Japanese society is unprecedented in the world. To remain healthy
and enjoy a good quality of life (QOL), maintaining oral hygiene and healthy
eating habits are crucial, and to ensure such dietary it is important to retain oral
function.
In recent years it has come to be known that a deep relationship exists between
the oral cavity and general body systems, and this has stimulated interest in oral
care for the elderly. It has also come to be understood that aspiration pneumonia
and endocarditis are related to foreign material and microorganisms in the
mouth, and that oral function is related to nutritional status and cognitive
function. Aspiration pneumonia in particular is a leading cause of death among
the elderly in Japan, and there is growing scientific evidence that it can be
85
prevented by thorough oral care. Such oral care for the elderly not only prevents
oral disease such as caries and periodontal disease, it also helps to prevent
aspiration pneumonia, a potentially fatal disease in the elderly, and conditions
such as dehydration and malnutrition.1 Oral care is thus very important from the
perspective of QOL. It is our hope that appropriate oral care will contribute to
the prevention of disease in the dependent elderly and the maintenance of oral
and general health.
The National Center for Geriatrics and Gerontology established Japan’s first
oral care outpatient clinic in 1999. Since then we have instructed many people
in oral care methods, earning an outstanding reputation. In this clinic we teach
“standard” oral care that can be done by anyone, anytime and anywhere. For
those who have difficulty maintaining hygiene in the oral cavity because of
disabilities or disease during hospitalization, we provide “specialty” oral care by
a dentist or dental hygienist. This special oral care maintains a hygienic oral
cavity, and we provide oral care instruction that will reduce the burden on
caregivers so that a clean oral cavity can be maintained even after the patient
leaves the hospital.
Through these efforts we aim to maintain and improve the QOL of both
dependent elderly and caregivers.
86
Illustration of aspiration pneumonia
A quick overview of the oral conditions in the dependent elderly
Swollen gingiva
Bits of food remaining
Plaque on teeth
87
Gingiva is swollen as a result of plaque on the teeth.
88
In elderly people with paralysis,
remaining food accumulates on the paralyzed side of the mouth.
Plaque is died red with a staining
solution. The teeth are unclean overall.
The mouth becomes very
dry when it is constantly left open.
Unclean tongue
Unclean denture
Dryness
89
White coating on tongue.
Coated tongue is a microbial breeding ground and a cause of bad breath.
Clumps of foreign material
adhere to dentures that are not cleaned properly, and microbes proliferate.
Specific measures to deal with the above
90
Here we introduce two types of oral care. As shown below, people are separated
by whether or not they are able to gargle, swallowing function, risk of aspiration
etc.
Swallowing function
○
×
Can gargle. Risk of aspiration is low
1. Standard oral care (oral care system)
Cannot gargle. There is a risk of aspiration
2. Specialoralcare (waterless oral care)
At initial examination After six months
Remaining food and plaque are removed, redness and swelling of gingiva is
91
eliminated, and the mouth has become significantly cleaner.
2. Waterless special oral care
Special oral care by dentist or dental hygienist
In some people swallowing function has decreased because of disease or
disability so that food and drink cannot be swallowed well, or the individual
chokes on them. Water or food that should have flowed into the esophagus may
be aspirated into the airway or lungs, causing aspiration pneumonia when
inflammation occurs.
Microbes that can cause aspiration pneumonia exist in the mouth, and dependent
elderly with decreased swallowing and cough reflexes are susceptible to entry
into the airway or lungs of the dirty water from cleaning during oral care. At the
National Center for Geriatrics and Gerontology we have further developed oral
care using a moist gel as proposed by Dr. Takeo Suga of Tsurumi University.
When providing special oral care, instead of a washing solution we use an oral
care gel that does not easily drip into the throat.
Examples of waterless special oral care
At initial examination
A patient hospitalized for aspiration pneumonia. Decreased swallowing function
and uncleanliness even of the tongue and throat.
At initial examination
Mouth dryness was severe and dry sputum and peeling epithelium caked the
roof of the mouth.
92
On leaving hospital
Oral cavity became clean and the patient left the hospital with no new
occurrences of aspiration pneumonia during his stay.
On leaving hospital
The risk of aspiration was decreased and the oral cavity could be cleaner and
more hygienic without damage to the mucosa.
Special Oral Care Method used for waterless special oral care
93
Oral cavity before special oral care
This patient’s mouth was very dry, and large amounts of sputum and
desquamated epithelium adhered to the teeth and mucosa. The oral cavity was
extremely unclean.
The structure of the oral cavity is very complex, and the operator always wears a
headlight since ambient light does not easily reach inside the oral cavity because
of the teeth and lips.
94
1. Gauze is dipped in 1 % povidone- iodine and firmly wrung and used to wipe
around the lips. This is to prevent microbes from outside the mouth being
transferred into the mouth.
• Be aware of allergies.
2. Oral care gel is applied to the lips to prevent dryness. If the oral cavity is dry
there is concern about bleeding when the mouth is opened.
95
3. A cheek retractor is used to expand the visual field for careful observation to
understand the condition of theoral cavity.
4. Oral care gel is applied to the entire oral cavity to soften the contaminants
adhering to the mucosa due to dryness.
96
5. First, the contaminants that can be removed with suction are suctioned out of
the mouth to reduce the number of microbes as much as possible before
brushing or other procedures.
6. Using suction, the number of microbes can be quickly reduced without
spreading contamination in the mouth.
97
7. The teeth are brushed while the oral care gel is left to soak in. The gel is
removed in appropriate amounts with the toothbrush, while dislodged
contaminants are constantly suctioned.
8. Oral care gel is also used with an interdental brush, suctioning out dislodged
contaminants.
10. The entire mouth is wiped with foam stick and oral care gel thinly applied to
moisten the entire oral cavity.
11. Finally, with gauze from which the water has been firmly wrung out, the
area around the lips is wiped, remaining povidone-iodine is wiped off the skin,
and the lips are moistened.
9. A soft bristle mucosa brush is used to clean the tongue, suctioning out
dislodged contaminants.
Oral cavity after special oral care in this patient
98
After several weeks
Aspiration was prevented and the mouth is almost unrecognizably cleaner with
use of waterless special oral care
Saliva secretion also increased with improvement of the oral cavity.
99
Waterless special oral care is used with people who have decreased swallowing
function and a risk of aspiration pneumonia.
Special oral care reduces the risk of aspiration of microbes from the mouth
during oral care, and effectively cleans the oral cavity.
This patient was able to leave the hospital with no further occurrence of
aspiration pneumonia.
Instruments needed for waterless special oral care
Instruments suited to each task are used for safe, reliable, and efficient oral care.
Assembling the appropriate oral care items in advance reduces the burden on
both the operator and the person receiving the care, and enables efficient oral
care to be provided in a short time.
1. Suction tube
2. Oral care gel
100
3. Cheek retractor
4. Headlight
5. Pulse oximeter
6. Foam stick
7. Toothbrush
8. Soft bristle brush (for mucosa)
9. Interdental brush
10.
Electric toothbrush
In addition to instruments such as a toothbrush and foam stick, a suction unit,
headlight, and cheek retractor are also used in special oral care.
Use of the headlight and cheek retractor gives a bright visual field. In addition,
contaminants can be constantly eliminated from the mouth and the risk of
aspiration reduced by suctioning with a suction tube when using the foam stick
or toothbrush.
Conclusion
101
At the National Center for Geriatrics and Gerontology, we have established
methods of oral care for elderly people with mild to severe dependence in order
to provide effective oral care for dependent elderly and caregivers. We have also
established a method of waterless oral care that greatly reduces the risk of
aspiration for dependent elderly with decreased swallowing function. With both
types of oral care we have attempted to improve the QOL and general condition
of both dependent elderly and their caregivers.
By spreading these oral care practices we hope to improve or prevent local oral
diseases such as periodontal disease or candidiasis, improve eating and
swallowing function by maintaining or restoring oral function, and reduce
aspiration pneumonia, endocarditis and other systemic diseases that can be fatal
for the elderly, thereby improving their QOL by helping them to regain their
health and the confidence to engage socially.
Daily care for the mouth is important in order to lead a healthy life. Regular
checkups by a dentist once or twice a year are recommended to stay free of
symptoms such as pain and swelling, so that people can chew with their own
teeth throughout life.
We also accept observers for the special dental care in our department. People
who are interested are invited to contact us.
102
References
Yasunori Sumi, Director, Center for Development of Advanced Medicine for
Dental and Oral Diseases,
National Center for Geriatrics and Gerontology
1. Sumi Y, Ozawa N, Miura H, Michiwaki Y, Umemura O. Oral care help to
maintain nutritional status in frail older people. Arch Gerontol Geriatr.
51:125-128, 2010
2. Sumi Y, Nakamura Y, Michiwaki Y: Development of systematic oral care
program for frail elderly persons. Special Care Dentist. 22:151-155, 2002
103