Cardiovascular Disease

 Cardiovascular disease is the number one cause of mortality in the older adult population. Physiologic cellular and tissue changes during aging such as decreased cardiac muscle strength, increased amounts of fat, and a reduction in the number of normal functioning cells require the heart to work harder to adequately oxygenate the blood. The heart muscle may become stiff due to an increase in connective tissue and ventricular hypertrophy.17 Conditions such as hypertension, valvular disease, and anemia are further complicated by these changes. Ventricular arrhythmias are relatively common in older adults and often require a pacemaker. The prevalence of atrial fibrillation also increases with age and raises the older adult’s risk of developing congestive heart failure (CHF) and stroke.18

CHF usually begins with a weakening of the left ventricle. If the left ventricle fails, blood cannot be forced out into the systemic circulation. An accumulation of blood in the pulmonary vessels results. This condition is referred to as pulmonary edema. Consequently, the right ventricle becomes overworked to compensate for the back flow of blood from the lungs. The right stasis of blood often leads to systemic edema manifested as pitting edema of the extremities such as swollen ankles, for example. Medical management of CHF includes weight control and a reduction in sodium intake; limited exertion; and drugs such as ACE inhibitors, diuretics, glycosides, vasodilators, and long-acting nitrates.9

When a patient exhibits atherosclerosis (the deposition of fatty plaques in the coronary vessels), the lumen of the vessel is narrowed, further impeding blood flow. Both angina pectoris and myocardial infarction can manifest as a result of the heart being deprived of oxygen. The treatment of angina typically involves a low-fat, cholesterol and sodium diet; exercise; smoking cessation, if applicable; and drugs such as nitrates, calcium channel blockers, platelet aggregation inhibitors, and ß-adrenergic blocking agents.9,19

Stroke or cerebrovascular accident (CVA) also may result from impaired oxygenation. The risk factors for stroke include previous stroke or transient ischemic attack (TIA), hypertension, atherosclerosis, cardiac abnormalities, erythrocytosis, diabetes mellitus, periodontal disease, elevated blood lipids, tobacco, alcohol or drug abuse, stress, or inactivity.20-27 Hypertension is managed with antihypertensive drugs such as ACE inhibitors; calcium channel blockers; loop diuretics; and a reduction in weight, sodium, stress, and smoking, if applicable.28 The medical management of stroke may involve surgery (particularly if carotid vessel calcifications are present); physical and occupational therapy; and drugs such as anticoagulants, antihypertensives, thrombolytics, vasodilators, and steroids. The major cause of death among stroke survivors is myocardial infarction.29

Dental patients with cardiovascular complications such as a history of hypertension, stroke, congestive heart failure, angina, or myocardial infarction require discretion when administering a local anesthetic. Strong vasopressors should be avoided and dosages should be adjusted for such patients. These conditions do not require antibiotic prophylaxis prior to dental procedures. The blood pressure should be monitored at each visit and long-term administration of nonsteroidal anti-inflammatory drugs (NSAIDs) by the dentist should be avoided, because they are known to decrease the activity of many antihypertensive drugs. Aspirin, NSAIDs, and certain herbs potentiate the effects of anticoagulants. Drugs used in the treatment of cardiovascular disease should be assessed and managed for druginduced oral side effects, particularly xerostomia that places the patient at a higher risk for caries and periodontal disease.9,30

Prothrombin levels and the international normalized ratio (INR) should also be monitored for all patients taking anticoagulants; a patient should not be treated if the INR exceeds 3.0 or the prothrombin time (PT) is greater than 1.5 times the normal control value.9 Additional factors to consider when caring for these patients should include chair positioning (semi-supine); length of appointments (brief, midmorning); physical limitations (paralysis, mobility needs, poor manual dexterity, fatigue with limited exertion, dysphagia, sensory deficits); impaired mental functioning (slow, poor memory, speech and vision difficulties, loss of initiative, increased sensitivity to pain and touch); and the existence of anxiety or depression.30

Dementia
Although dementia normally occurs later in life, it is not a normal consequence of aging. Less than 10% of persons aged 65 and older are affected, while 25 to 50% of those aged 85 and older acquire this condition.31 The most common form of dementia is Alzheimer’s disease. Other disorders that may exhibit dementia because they destroy brain cells include Parkinson’s and Huntington’s Huntington’s diseases. Vascular dementia results from a disruption of blood flow to the brain caused by stroke. Dementia caused by depression, alcoholism, drug interactions, head injuries, infections (AIDS, meningitis, syphilis), brain tumors, nutritional deficiencies and thyroid problems can be reversed if treated early. Dementia attributed to dental restorations or aluminum is unfounded.6,31

All forms of dementia exhibit major impairments in recent memory, comprehension, judgment, orientation to time, people and places, attention span, and an inability to think abstractly. Agitation, anxiety, delusions, paranoia, and hallucinations are also common signs of dementia.32

Presently there is no cure for Alzheimer’s disease. Four cholinesterase inhibitor drugs are used in the treatment of this condition. They are Cognex®, Aricept®, Exelon®, and Reminyl®. The mechanism of action of these drugs is to prevent the breakdown of acetylcholine in the brain.

Alzheimer’s disease can progress at varying rates. The duration of the disease may range from 3 to 20 years and usually progresses through stages that begin with impaired memory and cognitive skills. Eventually the individual requires complete care.32 (See Table I for a simplistic description of these stages.6,33) Subtle changes can be observed in the subdivision of these stages based on the source.

Dental intervention should begin early in the disease process. Neglect for personal hygiene is often one of the initial signs. The dental hygienist should address patients by a favorite name and should speak using simple words and short sentences in a soothing, clear voice. If the patient appears agitated, it is always best for the caregiver to redirect his or her attention to something else, rather than argue or try to reason with him or her.31 Often the agitation is associated with a change in environment or caregiver. Therefore, it may be advisable for the dental hygienist to see the patient at his or her home or living facility, if feasible. It is important for the dental hygienist to simplify oral hygiene tasks so the patient successfully incorporates these tasks into the daily routine. The dental hygienist should give the patient a toothbrush to hold on to with one or both hands. Eye contact should be maintained during instruction by the caregiver and distracting noises should be kept to a minimum.

Figure 3The health care provider must work quickly and mouth props and restraining devices (physical/chemical) may be necessary to stabilize the patient and facilitate treatment. Druginduced tardive dyskinesia (central nervous system disorder causing facial distortions) may make oral hygiene treatment a greater challenge.34 Caregivers should set a specific time of day for oral care and play the same music each time to cue the patient to enter the bathroom and sit by the sink, so the oral care regimen can begin.3 Mouth props, antimicrobial rinse, multi-surface toothbrushes, and fluoride are essential for optimal homecare (Figure 3).35

Depression
Depression can affect older adults as they try—and experience different levels of success—in adjusting to major lifestyle changes such as loss of a loved one, separation from career and children, loss of independence, loneliness, and chronic illness. Depression is characterized by a sad demeanor with a lack of interest in normal daily activities. Many older adults become obsessed with physical pain and discomfort rather than appearing sad. Loss of appetite or excessive consumption of carbohydrates and salty foods, fatigue, slowed responses, hopelessness, lack of self-worth, and preoccupation with death also are indicative of depression.36

The most effective treatment appears to be the combination of psychotherapy and medication. Common drugs administered for depression include Paxil®, Zoloft®, Elavil®, Prozac®, Effexor®, and Remeron®. Caution should be exercised when administering local anesthetics; the lowest concentration of epinephrine is advised. Demerol is contraindicated in persons taking monoamine oxidase (MAO) inhibitors. Orthostatic hypotension is a common side effect of antidepressants, and patients should remain upright in the dental chair for several minutes before rising to leave.37

The dental hygienist may be the first person to notice signs of early depression because many older adults live alone and experience very little interaction with others. Areferral for psychological consultation is recommended prior to oral health treatment. Preventive measures include the assessment and management of intraoral associated signs of depression such as hyposalivation leading to dysphagia, caries, periodontal disease, burning mouth, candida, inability to tolerate prostheses, fissuring of the tongue and lips; temporomandibular joint (TMJ) and facial pain; and drug-induced xerostomia and bruxism. Early intervention including frequent recalls, diet counseling, suggesting the use of artificial salivas and topical fluorides, offering oral lubricants and toothpastes formulated to relieve the symptoms of dry mouth, and supportive assistance are important to the overall success of the oral treatment plan.38

Osteoarthritis
Osteoarthritis is the most common form of arthritis. It is classified as a noninflammatory type of joint destruction primarily affecting the large joints. The incidence of osteoarthritis increases with age and almost all persons over the age of 70 have some form of the disease.39 Treatment may range from simple monitoring of the disease without treatment to NSAIDs (i.e., Celebrex® and Vioxx®), hot/cold compresses, periods of rest and exercise, walking aids/braces, and artificial joint replacement surgery.40

Dental considerations include monitoring the risks of gastrointestinal bleeding associated with the use of Celebrex and aspirin, or prolonged bleeding with either Celebrex or Vioxx when taken with Coumadin™. Vioxx is also given for acute oral health pain.40,41 Prosthetic joints require antibiotic premedication before oral health treatment if the replacement occurred two years or less prior to the appointment or if the patient exhibits Figure 4uncontrolled insulindependent diabetes, hemophilia, rheumatoid arthritis, lupus, or any other immune-compromising condition with a reduced capacity to resist infection. Pins, screws, and plates do not require premedication.42 Efforts should be made to keep the patient comfortable during the appointment. The waiting room and operatory should be climate-controlled to alleviate joint stiffness. Moist heat is recommended to reduce TMJ pain, and the use of a mouth prop during treatment is advised to prevent fatigue associated with trying to keep the mouth open. Short appointments, supporting affected joints, and allowing the patient to change positions frequently will enhance comfort. If manual dexterity is compromised, a power-driven toothbrush, floss holder, or a tailored toothbrush modified to meet the patient’s individual needs are suggested34 (Figure 4).

Osteoporosis
Oral and systemic loss of bone mass is often associated with aging, particularly in postmenopausal women. Osteoporosis can manifest as fractures, especially of the spine and hip, curvature of the spine, and a loss of height.43

Resorption of the alveolar bone may result in tooth loss.44 A combination of local factors, such as plaque with systemic osteoporosis, may exacerbate alveolar bone loss. Treatment usually entails the administration of calcium, vitamin D supplements, supplements, hormone replacement, and/or biphosphonate therapy.45 Fosamax® and Actonel® are the only biphosphonate drugs accepted for use in the United States for the treatment of osteoporosis. Evista®, a selective estrogen receptor, also increases bone mineral density.46 Changes observed in the alveolar bone by routine evaluation utilizing radiographs and periodontal assessments of probing depth and mobility may identify early signs of osteoporosis.44

Diabetes
The majority of diabetics diagnosed in the United States have type 2 or non-insulin dependent diabetes mellitus (NIDDM). Type 2 diabetes has the highest rate of co-morbidity with coronary artery disease, hypertension, and osteoarthritis among older adults.17 It is one of the most common systemic diseases in older adults encountered by oral health practitioners. This condition has a late onset clinically and usually affects adults aged 40 and older who are obese. Oral hypoglycemic agents and diet modifications are used to manage the disease.9

It has been shown that diabetics under poor glycemic control have an increased risk and severity of periodontal disease.47-49 Conversely, periodontal infections can cause blood glucose levels to rise, making the management of diabetes difficult. Glycemic control can be determined by asking a patient how often the blood glucose level is monitored, what technique is used for monitoring, what forms of treatment have been prescribed, and how compliant the patient is with taking medications and adhering to his/her diet restrictions. The health of the oral soft tissues is also indicative of glycemic control. Uncontrolled diabetes may be characterized by dry cracked lips, xerostomia, parotid gland enlargement, burning inflamed mucosa, gingival edema and bleeding, poor wound healing, candidiasis, periodontal abscesses, significant probing depths, and neuropathy. Research findings also suggest that older adults with diabetes exhibit a higher rate of dental caries and tooth loss than non-diabetics of the same age group.50 Frequent recall examinations, periodontal debridement, meticulous home care—including the use of fluoride and oral lubricants and toothpastes formulated to reduce the total microbial flora in the mouth—and systemic control of blood glucose levels are critical to maintaining optimal oral health.

Sensory deficits
Vision and hearing changes are very common among older adults. Approximately one-third of persons aged 65 and older have hearing impairments, and 30% of those individuals are deaf in at least one ear. Most older adults experience presbycusis or a progressive bilateral inability to hear high frequency tones (above 4000 Hz) or in some cases, the loss of ability to comprehend speech (300 to 2000 Hz). Presbycusis appears to be related to external factors such as working in factories or living in large cities. Tinnitus, or ringing of the ears, also is prevalent with advancing age and is particularly acute in quiet surroundings.8,32

Visual disturbances include a decline in accommodation (ability to focus from near to far), cataracts, alterations in color and distance/depth, and limited ability to adjust from light to dark. More than half of the individuals termed legally blind are aged 60 and older and macular degeneration is the most common cause. The most common type of cataract is related to aging, and more than half of Americans age 65 and older have a cataract.32,51

The oral health care provider must be cognizant of any sensory impairments to ensure effective communication. Most forms of hearing loss occur gradually and patients often read lips to compensate. A thorough medical history is essential and aids in the development of creative ways to instruct the patient to enhance complete comprehension. The caregiver should appeal to the patient’s other senses as much as possible. If the patient is hearing impaired, the caregiver should face the patient, remove his/her face mask, speak normally, pause frequently—particularly when giving instructions—and never sit in front of a window or bright light that may cast a shadow on his/her face. Apencil and paper can also be used to communicate and send home instructions. Background noises can disturb a patient wearing a hearing aid. Therefore, it is recommended that the dental hygienist ask the patient to turn off a hearing aid when using high-pitched powered scaling and toothbrush devices. Caregivers should learn some common signs for “open,” “close,”“rinse,” and “tell, show, do” to reinforce all procedures performed and to prevent confusion.34

Certain guidelines should be followed when treating a patient with vision impairments. The caregiver should lead the patient to the operatory by standing slightly in front; the patient will grasp the caregiver’s bent arm near the elbow for guidance. The patient should always be informed about changes in floor textures, steps, and so forth. The path also should be kept free of obstacles. Loud noises should be avoided when treating a patient with a vision impairment. The caregiver also should notify the patient when approaching him/her or exiting the room to prevent startling or embarrassing the patient. Procedures should be described by the caregiver in a step-by-step fashion and the patient’s own mouth can be utilized to provide oral hygiene instructions. If a guide dog accompanies the patient, office personnel should not distract the dog. The dog should be permitted to sit in the corner of the operatory until the appointment is concluded.34