Geriatrics/ dental continuing education courses


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implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic

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Geriatrics/ dental continuing education courses

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. INTRODUCTION : DEFINITIONS : GERIATRICS : The branch of medicine or dentistry that treats the problems peculiar to the aging patient, including the clinical problems of senescence and senility. GERODONTICS : The treatment of dental problems of aging persons or problems peculiar to advanced age. GERODONTOLOGY : The study of the dentition and dental problems in aged or aging persons. People who are above the age of 65 years are termed as geriatric persons.
  3. 3. AGING : The aging process may be defined as the sum of all morphologic and functional alterations that occur in an organism, and lead to functional impairment, which decreases the ability to survive stress. • Aging is manifested at all levels. • The changes seen are not dramatic, but with time leads to exponentially increasing mortality rate at the population levels. • The origin of this complex aging phenomenon is at the biological level. THE BIOLOGY OF AGING : It is difficult to delineate where the normal aging process ends and the disease process
  4. 4. FACTORS INFLUENCING AGING : Genetic factors :  Mutations  Species specific life spans  Hybrid vigor  Sex  Parental age  Twin studies  Premature aging syndrome  Cells in culture
  5. 5. ENVIRONMENTAL FACTORS :  Physical and chemical components – radiation  Biologic factors – nutrition  Pathogens and parasites  Tropical countries  Socio-economic factors  Low income groups  Bad housing  Poor working condition  Stresses of life
  6. 6. BIOLOGIC THEORIES OF AGING : Genetic theories Non genetic theories Error theories Immunologic theories Somatic mutations Free-radical theory Reduncies Cross linking theory Genetically programmed senescence Metabolic rate or wear and tear theory Disposable soma theory PHYSIOLOGY OF AGING : Physiological deterioration – increases with age It reduces physiological capacity and the ability to meet challenges. It is progressive. Major contributing factor to death of the extremely old.
  7. 7. CENTRAL NERVOUS SYSTEM :  Impairment of learning and memory after 70 yrs.  Slowing of central processing  Decrease in the brain size and weight  Deterioration of the motor systems  Decrease function of the extrapyramidal system  Cerebellar function  Muscular strength  Increase in the  Movement time 
  8. 8.  Sensory systems Loss of  Vibratory perceptions in lower extremities  Touch  Taste  Smell  Hearing  Vision  Sleep  Shortening of sleep time  Increased multiple brief awakening Special senses
  9. 9.  Neuro-muscular system  Loss of muscle mass  Loss of muscle strength  Loss of muscle performance CARDIO-VASCULAR SYSTEM : Decrease in  Intrinsic heart rate  Mean maximum HR during exercise  Cardiac output  Oxygen consumption
  10. 10. Increase in  Peripheral resistance  Muscle stiffness  Contraction period  Thickness of walls of aorta RESPIRATORY SYSTEM :  Increase in residual volume  Decrease in expiratory reserve volume  No change in total lung capacity  Marked changes in
  11. 11. KIDNEY AND BODY FLUIDS : Loss of  Weight of kidney  Glomeruli Deterioration of function  Progressive declination in renal blood flow  GFR (glomerular filtration rate) GASTROINTESTINAL SYSTEM :  Disordered contractions  Spontaneous gastro-oesophageal reflex  Slow gastric emptying  Loss fat absorption  Very slight impairment of protein
  12. 12.  Reduction in calcium absorption  Decreased secretion by gastric glands – less volume and conc. of  HCl  Intrinsic factor  Pepsin ENDOCRINES :  Adenohypophysis – secretion of thyrotropin is blunted  Neurohypophysis – greater release of antidiuretic hormone  Thyroid - Slight decrease in T4 (thyroxine) - Cortisol secretion is decreased Aldosterone – decreased  Insulin – decreased sensitivity of the target tissues to the action of insulin – glucose intolerance.
  13. 13. REPRODUCTION : Men  Decline in sexual interest, drive and vigor  Increase in plasma conc. of LH (leutenizing hormone) and FSH (follicle stimulating hormone) Women  Marked decline in estrogen concentration after menopause MISCELLANEOUS :  Loss of lean body mass  Body fat increase with age  Decrease in BMR  Reduced ability to maintain body temperature  Immune system.
  14. 14. ORAL CHANGES IN AGING : Oral mucosa : The clinical picture is one that of atrophy • Thin, smooth, dry – satin like • Loss of elasticity and stippling • More susceptible to injury • Decreased repair potential • Frequent application of soft liners. Skin changes : • Wrinkled, dry, patchy pigmentation • Loss of elasticity and fine pattern. • Diminished bulk of muscles, fat and connective tissue –
  15. 15. Gingiva : • Loss of stippling • Oedematous appearance • Thin keratinized layer • Tissue is easily injured Lips : • Angular cheilitis  Vit B deficiency  Dehydration Teeth : Enamel  Attrition  Erosion  Abrasion
  16. 16.  Fluoride content is increases  Enamel cracks – increases  Enamel lamellae – increases  Cementum – increase in thickness  Dentin - Secondary dentin formation Obturation of dentinal tubules Pulp : Fibre - Increased - Blood supply – reduces - Pulpstones – increases SALIVARY CHANGES : Salivary flow reduces Medication - Depression - Insomnia Salivary gland atrophy
  17. 17. CONSEQUENCES :  Diminished functions like mastication  Digestive problems  Poor retention of dentures  Susceptibility of mucosa to frictional irritation from denture movement.  Interference with patients ability to wear dentures. EXCESSIVE SALVIA : Transient – on insertion of denture. No reduction in salivary output from the parotid gland whereas that of submandibular gland is reduced. Submandibular gland : 45% of total output
  18. 18. CHANGES IN COMPOSITION : • Ptyalin → decreases • Mucin → increase PHYSICAL CHANGES : Viscous ropy • Plaque formation and growth of cariogenic bacteria TREATMENT OF XEROSTOMIA : Increase intake of water • Frequent mouth rinses • Lubricating jelly • Silicone fluid • Semisolid denture adhesives – decrease irritation of the tissues. • Temporarily increases denture retention • Use of silogogues – pylocarpine hydrochloride or nitrate,
  19. 19. • Sucking on sour candy • Nicotinamide 250 to 400mg tid for 2 weeks. BONE TISSUE : • Compact or cortical bone • Spongy or trabecular or cancellous bone EFFECTS OF AGING : • Thinning of cortical bone • Increase in porosity • Loss of trabecular • Cellular atrophy • Sclerosis Maxilla – narrower Mandible – wider posteriorly
  20. 20. TONGUE AND TASTE : • Smooth, glossy or red and inflamed in appearance • Disturbed sensation – taste • Soreness, burning (post menopausal women) • Varicose veins on the ventral surface TONGUE SIZE : Does not vary with age but over development of intrinsic muscles, hence larger tongue (loss of teeth mastication and to keep the loose denture). IMPACT OF ENVIRONMENTAL AND SOCIAL FORCES ON AGING : An older person’s life is basically roleless, unstructured by the society, and conspicuously lacking in norms. Rosow (1974)
  21. 21. GENERAL MEDICAL ASPECTS OF AGING • CARDIOPULMONARY DISORDERS :  Valvular heart disease  Cardiac arrhythmias  Coronary artery disease / ischemic heart disease.  Hypertension  Congestive heart failure  Chronic bronchitis/emphysema. • NERVOUS SYSTEM DISORDERS :  CVA (cerebrovascular accidents) or strokes  Parkinson’s disease  Tardive dyskinesia
  22. 22. • RHEUMATOLOGIC DISORDERS :  Temporal arthritis  Osteoporosis  Osteoarthritis • MISCELLANEOUS DISORDERS :  Leukaemia  Iron deficiency anaemia  Diabetes mellitus  Thyroid disorders  Urinary incontinence
  23. 23. GEROPSYCHIATRIC DISORDERS : • Situational disorders : Associated with emotional crisis or prolonged situational stress. • Improper oral hygiene • Sustained muscular tension.  Bruxism  Atypical facial pain • Burning mouth and/or tongue. Such patients should be treated with compassion, respect and willingness to comfort them.
  24. 24. AFFECTIVE DISORDERS : Depression : Usually co-operative  Appear to forget clear instructions.  Fatigue easily and require several short appointments  Side effects of anti-depressants :  Burning mouth  Postural dizziness  Excitement  Tachycardia  Overactivity  Rapid speech  Confusion.
  25. 25. ANXIETY DISORDERS : • Apprehensiveness • Worry • Agitation • Tachycardia • Dizziness • Weakness • Visual and gastro intestinal disturbance • Fatigue and headache • Insomnia •
  26. 26. TREATMENT : • Benzodiazepines • Tricyclic antidepressants. • Disorders of cognitive function : • Dementia, deliria and toxic confusional states. PREMEDICATION : • Aggressive, confused or frightened patients. • Haloperidol 1-2 mg • Thiothixine 2-5 mg. one hour before the treatment. • Thioridazine 25-50 mg the night before the procedure. PARANOID STATES : Paranoid is a group of symptoms involving irrational suspiciousness on
  27. 27. CHRONIC MENTAL DISORDER PERSISTING INTO LATE LIFE : Chronic schizophrenics who survive into their 60’s or 70’s often display no florid psychotic symptoms, showing only passivity, impoverishment of social, intellectual and emotional life, social and financial dependency and occasional odd habits. They neglect even an extensive oral disease. AGING AND NUTRITION : The diagnosis of a nutritional deficiency-stomatitis must always be consistent with a background of nutritional impairment and substantiated by a conservative interpretation of the data derived from a careful and complete diet survey, a probing medical history and physical examination, and appropriate laboratory and roentogenographic determination.
  28. 28. ETIOLOGY OF DIETARY DEFICIENCY : • Lack of proper food intake  Low income and lack of knowledge on how to spend the money available for food to the best advantage.  Physical handicaps, debility, lack of mobility which makes preparation of food difficult  Poor facility.  Poor dentitions, or improper dentures  Depression boredom, anxiety and loneliness. • Disease which interfere with  Digestion  Absorption  Utilization of foods.
  29. 29. Eg: Oral cancers • Chronic ulcerative lesions • Diverticulosis  presented by constipation • Atrophic gastritis • Liver dysfunction ORAL SYMPTOMS OF NUTRITIONAL DEFICIENCIES : The symptoms may antidate, coincide, with, or follow the appearance of deficiency induced signs. They are represented by • Burning • Soreness • Tenderness • Dryness • Sialorrhea Loss of diminution of taste (Ageusia or dysgausia)
  30. 30. SORENESS AND BURNING OF TONGUE : • Iron deficiency anemia • Vit B12 responsive pernicious anemia. STOMATODYNIA : • Pellagra • Sprue • Kwashiorkor • Scurvy • Nutritional microcytic anemia XEROSTOMIA : • Vit A deficiency • Ariboflavinosis • Pellagra pernicious anemia
  31. 31. • Iron – deficiency anemia • Sprue • Dehydration • Sialorrhea  Acute nutritional deficiency stomatitis  Acute pellagra • Impairment of taste sense :  Pellagra  Pernicious anemia ORAL SIGNS OF NUTRITIONAL DEFICIENCY :  Cheilosis  Gingivitis  Glossitis.
  32. 32. LIP LESIONS : Deficiencies of riboflavin, niacin, protein, vitamin B12 , folic acid, iron, pyridoxine, pantothenic acid and vitamin C. ORIGINATE AS : Gingivitis : Deficiencies of niacin, tryptophan, and vitamin C. Glossitis : Niacin, folic acid, vit B12 , pyridoxine, protein and iron deficiency. TREATMENT OF NUTRITIONAL DEFICIENCIES : General principles : 1. A well-balanced high protein (120 to 150 gm) diet should be administered with adequate calories, vitamins, and minerals. 2. Therapeutic amounts of specific nutrients should be added as
  33. 33. DAILY THERAPEUTIC DOSE : • Folic acid 5 to 10mg • Niacin amide 150 to 250 mg • Riboflavin 10 – 15 mg • Ascorbic acid 150-300 mg • Vit- A 25,000 – 50,000 units. • Vit-D 3,000 – 5,000 units • Medicinal iron 200 – 400 mg (1.2 gm of ferrous sulfate) • Vit B12 10-15 µg (micrograms) 3. Coexisting diseases which cause secondary nutritional deficiencies or increase the nutritional requirements must be controlled or eliminated whenever possible. 4. Symptomatic and supportive treatment should be given to rid and comfort the patient in the presence of pain, infection, vomiting, diarrhbea and dehydration.
  34. 34. PHARMACOLOGY AND AGING : General consideration : • In general, elderly people use 30% of all prescribed medications (Nielsen et al 1981). Thus, it is important to know if drug dosage has to be changed when older persons are considered. • Significant changes in pharmacokinetics and pharmacodynamics do occur with increasing age. Compliance : 1) The number of different drugs prescribed, and 2) The number of doses given per day of each drug. • More than three different drugs and more than two doses for day of each drug decrease compliance significantly. • Elderly patients are not necessarily more prone to non- compliance than younger
  35. 35. ABSORPTION : A series of physiologic functions in the gastrointestinal tract change with age. There is decrease in  Gastric emptying rate  Secretion of hydrochloric acid  Gastrointestinal mobility  Intestinal blood flow  Efficiency of many active transport systems. As a result, a higher plasma drug levels is found in elderly. VOLUME OF DISTRIBUTION : The total body weight declines steadily after the age of 50 years, because of loss of intracellular water and of lean body mass, while adipose tissue mass is increased.
  36. 36. CLINICAL SIGNIFICANCE : The volume distribution of lipid soluble drugs is higher, whereas that of water soluble drugs is decreased. PROTEIN BINDING : The concentration of serum albumin decreased with advancing age. In aged  3.5 g/dl. Young adults  4-4.5 g/dl. This causes on increased unbound fraction of drugs and influence the distribution of drugs. METABOLISM : The hepatic blood flow decreases with age and the rate of metabolism of high clearance drugs such as propranolol and lidocain whose elimination are highly flow dependent, is reduced in the elderly.
  37. 37. The elimination of low clearance drugs depends primarily on the activity of the hepatic microsomal drug metabolizing enzymes. The enzyme activity per unit liver also decreased with advancing age. RENAL EXCRETION : Renal function evaluated an the basis of insulin clearance or by endogenous creatinine decreases considerably with age. Young  20-22 mg/kg/24hr Old  10 mg/kg/24hr. Dosage modifications are necessary primarily to drugs for which the renal excretion of the parent compound or the active metabolites is the major mechanism of
  38. 38. PHARMACODYNAMICS : • Reduced hepatic synthesis of blood clotting factors with a resulting greater sensitivity to the action of oral anticoagulants. • Diazepam and nitrazepam (10mg) appear to result in greater depression of the central nervous system. ADVERSE REACTIONS : Frequency of adverse drug reactions is greater in the elderly. However, older persons take more medications and this must be taken into consideration.
  39. 39. DRUGS IN DENTAL PRACTICE ANTIBIOTICS : • Water soluble antibiotics like penicillins, cephalosporins, aminoglycosides, tetracycline will be affected by the age – dependent decrease in renal function. • In contrast, lipid-soluble antibiotics like erythromycin, chlorampheniol are primarily metabolized in liver resulting in more hydrophilic metabolites which are subsequently excreted by the kidneys. PENICILLINS : • Excretion of these drugs is much reduced in the elderly compared to younger subjects. • Because of high therapeutic index the modification of dosage to compensate for reduced renal clearance is not
  40. 40. In general, normal doses of all penicillins can be safely prescribed to all elderly patients regardless of age. ERYTHROMYCIN : • High therapeutic index. • Therefore, normal dosages should be prescribed to all patients irrespective of age. METRONIDAZOLE AND TINIDAZOLE : • It is advisable to use lower dosages of metronidazole in this age group to avoid accumulation of active water soluble metabolites when kidneys function is reduced. • The excretion of tinidazole is unchanged in renal
  41. 41. SULFAMETHIZOLE : The half life of sulfamethizole is significantly prolonged in the elderly (181±13min) as compared to younger subjects (105 ±5 min). • Absorption and distribution is age-independent. • This drug is normally used for a short period of time and the toxicity is low. • Both young and old patients can be treated with upto 4gm daily of this drug. ANALGESICS : Paracetamol (acetominophen) : upto 3 gm/day may be prescribed to patients of all
  42. 42. Aspirin (acetylsalicylic acid) : Clinically, normal dosages upto 3gm/day can be prescribed, but they should be monitored for chronic salicylate toxicity which causes mental confusion and hyperventilation, which can be mistaken for a result of age itself or a disease. BENZODIAZEPINES : Diazepam : • The clearance of diazepam is unaffected by increasing age, but the elimination of desmythyldiazepam is reduced in elderly. • Short acting benzodiazepines like temazepam and triazolam have decreased tendency to hang over symptoms and used in elderly. • In general, moderation of doses should be exercised considering how easily elderly patients develop mental confusion and loss of memory.
  43. 43. LOCAL ANALGESICS : • The clearance of lidocaine is reduced in elderly males, while females donot exhibit significant difference from younger subjects. • Concentrations greater than 5% are rarely required for infiltration analgesics. • It is important to consider the interactions which may take place between the pressor amines in the analgesics and many antihypertensives and antidepressants. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) : • No significant age-dependent differences in the kinetics is found. • Despite few and small alterations with advancing age, it seems prudent to administer smaller dosage to the elderly, because they are prone to adverse reactions such as gastric and intestinal hemorrhages, and edemas than younger subjects. • Many NSAIDs decrease the action of diuretics, probably due to interaction with the mechanisms of renal excretion.
  44. 44. ANTICOAGULANTS : Age itself is not a contraindication for the use of anticoagulants. It is difficult to treat on an outpatient basis. The patients should be monitored carefully and closely watched for the risk of potential drug interactions. ORAL DISEASES CAUSED BY DRUGS : Ulcerations of mucosa • Salicylates • Potassium • Corticosteroids • Pancreatic enzymes • Emepronium • Tetracycline • Clindamycin • Phenylbutazone
  45. 45. Stevens-Johnson syndrome • Sulfonamides • Penicillins Herpes • Immunosuppressive therapy Candida infection • Corticosteroids • Antibiotics Xerostomia • Anticholinergics • Antihistamines • Cyclic antidepressants • High doses of neuroleptics • Opioids and • Disopyramide
  46. 46. GERIATRICS
  47. 47. PROSTHETIC CONSIDERATIONS IN GERIATRIC DENTISTRY : Oral status and treatment needs : In elderly populations the pattern of use of dental services and the need and demand for dental treatment are clearly different from that of younger populations. Diagnosis and treatment planning : A careful history and clinical examination of the elderly patient are essential in attempting to clarify the patients demand and need for prosthetic treatment. Also, it is important to consider systemic and local factors as well as the patients previous experience with dentures before deciding treatment and establishing prognosis.
  48. 48. SYSTEMIC FACTORS NUTRITION : • The elderly patients are very often deficient in one or several nutrient or minerals. • A decreased plasma concentration of thiamine, riboflavin, or folic acid in elderly patients may be associated with reduced tolerance to removable dentures. • Dietary supplements of proteins and minerals will increase tolerance to dentures. DEBILITATING DISEASES : • Systemic diseases, such as gastrointestinal disorders, diabetes mellitus, or arteriosclerosis, may enhance the symptoms and signs of debility.
  49. 49. • As a consequence patients will often totally neglect oral and prosthetic care. Any treatment should be postponed until the patients general health is restored. • For chronically ill patients, a professional oral hygiene care must be scheduled to control caries and periodontal disease. NEUROPHYSIOLOGICAL CHANGES : • With advancing age there is degeneration of functional elements in the central nervous system. • Adaptation and learning becomes slow. The patients existing dentures can be used as a template for the design of new dentures, to make adaptation to new dentures more
  50. 50. PSYCHIC CHANGES : • Progressive cerebral involution in the elderly patient may result in psychic changes which complicate the outcome of prosthetic treatment. • Elderly patients often feel neglected and rejected. • To receive some attention some mentally ill patients may complain of soreness produced by the dentures where no evident symptoms exist and may try to damage the dentures. • When mental diseases are suspected, the patients physician should be consulted regarding an appropriate time for prosthetic treatment. LOCAL FACTORS : • Some diseases such as nutritional disorders, skin diseases or blood dyscrasias, may manifest themselves initially in the oral cavity and dentist may be the first person to evaluate the signs and symptoms.
  51. 51. FACTORS TO BE CONSIDERED DURING THE CLINICAL EXAMINATION • Function of temporomandibular joint • Size and tone of musculature • Quantity and quality of saliva • Tissue tone • Health of the oral mucosa • Dental and periodontal health • Oral and denture hygiene • Size and shape of alveolar ridges • Interridge space and ridge relations • Occlusal conditions • Fit and extension of existing
  52. 52. ORAL PHYSIOLOGIC CHANGES : • Progressive atrophy of the masticatory, the buccal, and the labial musculature is a sign of aging. This may cause severe reduction of chewing efficiency. Patient should be advised to take adequate diet, which is easy to chew. • Atrophy of buccal musculature may result in accumulation of food especially on buccal denture flanges. The placement of denture teeth buccal to the alveolar ridges may help establish contact between the denture flanges and cheeks. However, this may compromise the stability of the dentures. • Reduced salivary secretion or xerostomia. Frequently, a complication debilitating diseases e.g. diabetes, or treatment with psychopharmacologic
  53. 53. This will result in • Rampant caries • Loss of denture retention • Traumatic lesions • Infections of oral mcuosa Meticulous oral hygiene supplemented by mouth washes with chlorhexidine and daily use of artificial saliva substitutes are important means to reduce complications. The regular use of removable dentures should be restricted in patients with
  54. 54. ALVEOLAR RIDGE ATROPHY : • Alveolar ridge atrophy is a continuing process of reduction of the edentulous alveolar ridge which takes place at varying rates in different individuals. • Various anatomic, metabolic or mechanical factors are involved in this process (Atwood 1979). • There is no reliable way of reducing alveolar ridge atrophy but the correction of metabolic alterations and meticulous denture care may have a positive effect. • The best way of preventing alveolar ridge atrophy is to maintain some teeth or roots in the jaws for support of a removable denture.
  55. 55. ORAL MUCOSAL LESIONS : Lesions of the oral mucosa associated with wearing of removable dentures may represent (1) acute or chronic reactions to microbial denture plaque, 2) reactions to constituents of the denture base material, or 3) a mechanical injury caused by the denture. The lesions constitute a heterogeneous group with regard to pathogenesis, and include denture-induced stomatitis, angular cheilitis, traumatic ulcers, denture irritation hyperplasia, flabby ridge and oral carcinomas (Budtz-Jorgensen 1981). Most of the lesions are caused by a chronic infection (Candida albicans) or mechanical injury. Denture-induced stomatitis may also represent an allergic reaction to constituents of the denture base material.
  56. 56. Injurious stimulus Defence mechanisms Denture plaque In oral cavity Mechanical irritation In oral mucosa Intolerance to materials Mucosal inflammatory response
  57. 57. Saliva plays an important role as a defense mechanism acting in the oral cavity. Use of sedatives may cause xerostomia, which in turn may reduce the resistance of the oral mucosa to trauma and infection. Nutritional deficiencies and treatment with immunosuppressive drugs may lower mucosal resistance to infections and may also predispose to the establishment of a Candida infection in the angles of the mouth, the soft palate, or the fauces. In order to prevent or minimize the extent of the lesions denture wearers should be recalled regularly for check-ups on the oral mucosa and the dentures. ORAL HYGIENE : In denture wearers, meticulous oral hygiene is important to prevent dental caries and periodontal diseases in the remaining teeth and inflammation of denture-bearing oral mucosa. The presence of removable partial dentures will usually increase accumulation of microbial plaque on tooth surfaces adjacent to denture saddles, clasps and rests. If the patient’s cooperation is absent, careful consideration should be given to the long-term
  58. 58. EXISTING DENTURES : The design of existing dentures should be carefully evaluated and related to the patient’s complaints. Obviously, the new dentures must correct faults of the existing dentures. However, in order to facilitate neuromuscular adaptation the new dentures should be designed with careful consideration to the design of existing dentures. GUIDELINES FOR REHABILITATION WITH REMOVABLE PARTIAL DENTURES : Functional aspects : Removable partial dentures may be indicated in elderly patients in order 1) to restore function of the masticatory system by providing adequate occlusal support and mastication, 2) to prevent development of occlusal disturbances and TMJ-dysfunction. Furthermore, the patient’s demand for improved esthetics and phonetics may be achieved by placement of a removable partial denture.
  59. 59. The masticatory system of elderly patients may function satisfactorily the only a few natural teeth, if functional adaptation has been achieved during a period of gradual loss of the teeth. However, the loss of additional teeth there is an increased susceptibility for developing TMJ-dysfunction in elderly patients. This indicates that treatment with removable partial dentures should be considered in patients with less than 3-4 premolars or molars in occlusion (3-4 occlusal units). A tooth-supported removable partial denture will increase occlusal support by distributing the occlusal forces from denture saddles to the abutment teeth. A distal-extending removable partial denture is exclusively supported by the mucosa and the alveolar ridge in the posterior part of the saddle. This situation is not likely to create the same degree of support for the mandible as is provided by an entirely tooth-born
  60. 60. In elderly patients distal extension removable partial dentures may be indicated. 1. To restore esthetics or phonetics 2. To improve mastication 3. In Patients with significant signs and symptoms of TMJ- disturbances and extensive loss of teeth. 4. In a jaw opposing a complete denture to increase functional stability of the complete denture DESIGN OF REMOVABLE PARTIAL DENTURES IN ELDERLY PATIENTS : In geriatric dentistry the prosthodontist should use the same guidelines for the design of removable partial dentures as used in the treatment of younger age groups.
  61. 61. THESE GUIDELINES COULD BE SUMMARIZED AS FOLLOWS : • The design should be as simple as possible with saddles, major connectors and minor connectors avoiding contact with the free gingiva and contacting the alveolar ridge or the palate approximately 3 mm from the teeth surfaces in order to reduce the negative effect on oral hygiene. • Saddles should be tooth supported, if possible; in distal extension removable partial dentures occlusal rests should be placed in such a way that tilting of abutment teeth will not take place. • Major connectors, minor connectors, reciprocating clasp arms, and occlusal rests should be rigid in order to withstand and distribute occlusal forces.
  62. 62. • The denture should be designed in such a way that appropriate retention is achieved by two retentive clasps. In distal extension removable partial dentures retention is improved by placement of indirect retainers opposite to the fulcrum line. • The dentures should provide bilateral and simultaneous occlusal contact between natural and prosthetic teeth in centric occlusion at an acceptable vertical dimension. Centric occlusion is recorded for setting of prosthetic teeth when there is stable maximal occlusal contact in this position, no sign of TMJ-dysfunction, and major anterior or mediolateral deflections from centric relation have been adjusted. Centric relation is recorded for setting of prosthetic teeth when there is insufficient occlusal contact to relate the mandible and there is no consistent centric occlusion. Furthermore, this relationship is used when it is essential to make eccentric contacts or when a complete denture opposes the removable partial denture. However, it is important to secure a balanced centric occlusion by adjustment of the occlusal
  63. 63. In elderly patients excessive occlusal wear of the natural teeth may be seen frequently which makes restoration of the occlusion mandatory. This is both clinically and technically a complicated treatment. Placement of removable partial dentures with onlays on the abutments teeth to obtain a harmonious occlusion is a solution to the problem that is relatively inexpensive but which requires excellent oral hygiene. GUIDELINES FOR REHABILITATION WITH COMPLETE DENTURES : Complete denture prosthodontics involves the replacement of the lost natural dentition and associated structures of the maxilla and the mandible in patients who have lost their remaining teeth or are soon to loose them. OVERLAY DENTURE : Today, with the stress on preventive measures in prosthodontics, this type of treatment is a realistic alternative to conventional complete dentures in most patients with some remaining teeth.
  64. 64. The advantages of treatment with overdentures in elderly patients are the following: • The natural roots provide support for the denture. They stabilize the dentures during occlusion and mastication and reduce trauma of the denture-supporting oral mucosa. • The roots and periodontal ligament membrane will aid in minimizing future loss of the alveolar ridge. • The existence of the periodontal membrane may preserve the pro-prioceptive response and give the patient a sense of discrimination not possible with conventional complete dentures. • The roots can be provided with various types of retentive devices to give added retention to the removable denture. • If the periodontal ligament membrane is significantly reduced a complete overlay denture may be more favorable than a removable partial denture. With an overdenture the reduction in the crown-root ratio has a favorable effect on tooth ratio has a favorable effect on tooth mobility and on the stability of the tooth in the jaw.
  65. 65. There are no serious disadvantages of treatment with overlay dentures in elderly patients compared with treatment with conventional complete dentures. However, the need for endodontic treatment and subsequent care to prevent caries and periodontal disease will cause added expense. Occasionally, an overlay denture may be bulkier than a conventional complete denture, particularly because of bony undercuts adjacent to the overlaid teeth. This may result in improper fullness of the lips. In geriatric dentistry treatment with overlay dentures is particularly relevant in the following situations: • In patients with clinical signs of muscular hyperfunction of the masticatory apparatus, e.g. severe attrition, bruxism. • In patients where there are no overt signs of a decreased vertical dimension of occlusion but where an increase of the vertical dimension of occlusion is indicated to create sufficient space for a denture.
  66. 66. • In patients where severe difficulties of adaptation to complete dentures can be anticipated, e.g. pronounced gagging reflexes, previous problems of wearing a removable partial denture, severe resorption of the edentulous alveolar ridge, hyperfunction of the facial musculature. In the latter instance the roots can preferably be provided with copings fitted with special retentive attachments. In order to prevent problems in treatment with overlay dentures it is important to carry out a proper examination and treatment planning with regard to the selection of abutment teeth. Thus, the following criteria might be employed: • The abutment teeth should have ≥ 5 mm periodontal support and at least 2-3 mm attached
  67. 67. • Canines and second molar teeth are both ideally located and numerous enough to provide optimal dental support for the denture. In most cases two abutments will give sufficient stability; however, two diagonally located abutments may give a very unstable denture. • The abutments should have a height of 2-3 mm with a dome- shaped contour. If this is not possible copings should be cemented or the roots should be restored with resin to give the abutment an acceptable dimension and contour. • Generally, it is sufficient to place an amalgam restoration in the exposed root canal. The restoration and the remaining dentin are smoothed and polished leaving a surface that will accumulate a minimum of plaque and that can be easily cleaned. The root may be fitted with a cast coping if caries has developed shortly after placement of the
  68. 68. When a significant improvement of retention is desired and the abutment teeth have sufficient root length the cast coping can be fitted with a precision attachment. Because of the added costs and the risk of technical failures this procedures should be reserved for patients with a favorable dental prognosis. It is advisable not to construct the attachment denture initially, but rather a simple overlay denture, to await healing after extraction of neighbouring teeth and the patient’s degree of cooperation. There are several types of precision attachments available which have the advantage of being simple in design, e.g. the Rothermann attachment, the Dalbo attachment, the Ceka attachment and the Zest anchor. Bar attachments are more complicated but provide splinting of the abutment teeth as well as retention and support and the denture.
  69. 69. IMMEDIATE COMPLETE DENTURE : A conventional immediate complete denture is a dental prosthesis constructed to replace the lost teeth and associated structures immediately after the last tooth is removed. In elderly patients this treatment is indicated if no teeth can be retained. This treatment procedure is advantageous compared with treatment with a conventional complete denture, the later starting 2-3 months after tooth extraction when healing of the edentulous ridge is completed. Thus, after treatment with immediate dentures, adaptation to the dentures will be more easy, the patient will suffer less from the psychologic distress of becoming edentulous and the denture will act as bandage to help control bleeding and to protect against injury from food and direct mechanical
  70. 70. There are no definite contraindications to treatment with maxillary immediate dentures in elderly patients who are otherwise fit as complete denture patients. However, treatment with immediate mandibular dentures may give complications such as pain and progressive resorption of the alveolar ridge. In elderly patients it is often advisable to plan a sequential approach to the treatment to achieve uncomplicated adaptation to the dentures. Such treatment procedures may include step-wise extraction of teeth with adjustment of an existing partial denture accordingly, or initial treatment of the patient with a partial immediate denture, which after 6-12 months is altered to a complete denture; at that time a complete overlay denture will often turn into a realistic alternative. This approach is particularly relevant when providing prosthetic treatment to the mandibular
  71. 71. THE CLINICAL TREATMENT PLAN INCLUDES : 1. Removal of posterior teeth 3-4 weeks prior to denture construction. It is important to maintain one or two occlusal contacts in the premolar region to maintain the vertical dimension of occlusion. 2. Primary impression 3. Functional secondary impression in an individual tray 4. Recording of the jaw relationship in centric relation and at an acceptable vertical dimension of occlusion. 5. Arrangement of posterior teeth 6. Arrangement of anterior teeth which are usually placed in the same position as the natural teeth to support neuromuscular and psychologic adaptation to the
  72. 72. 6. Alteration of the cast to compensate for soft tissue changes. Alterations for soft tissue changes. Alterations to compensate for bone changes are only indicated for esthetic reasons and when there are severe bony undercuts. 7. After extraction and adjustment of the alveolar ridge the denture is inserted, the occlusion correction and the patient instructed to return the following morning. Postoperative care includes instruction in oral and denture hygiene and regular control of occlusion and fit of the dentures. Soft relining materials, and tissue conditioning material may be used as an effort to keep the occlusion of the teeth, the fit of the denture and the tissue changes in harmony. Gross tissue changes are usually completed 3-6 months after extraction. At that time a permanent denture is constructed or the immediate denture is relined or rebased.
  73. 73. COMPLETE DENTURE WEARERS : In elderly patients treatment with complete dentures most frequently involves replacement of existing complete dentures. Thus, patients may require prosthetic treatment because the existing dentures have broken, because of excessive wear of teeth or for esthetic reasons. Most frequently the patients are satisfied with their old dentures in spite of severe resorption of the alveolar ridges, poor retention and stability of the dentures and loss of vertical dimension and occlusal stability. For this group of denture patients the treatment procedures should aim at restoring prosthetic conditions which may – if not corrected – become invalidating. This should be done with much delicacy as it will be difficult for most elderly patients to adapt to significant changes of existing dentures.
  74. 74. WELL-ADAPTED DENTURE WEARERS : In well-adapted elderly denture wearers with relatively well- fitting dentures, i.e. an acceptable vertical dimension of occlusion and relatively stable occlusal relationship but poor adaptation between the denture base and the underlying mucosa, relining or rebasing of the existing dentures is the treatment of choice. The extension of the denture flanges are corrected and the dentures are used as individual trays for functional impressions. The impression of the maxillary jaw is made first – without occlusal contact – using a suitable impression material with low viscosity. Thereafter a functional impression of the mandibular jaw is obtained with the upper denture in situ and during slight occlusal contact in centric relation. After processing of the dentures it may be necessary to remount the dentures in an adjustable articulator to perform occlusal grinding.
  75. 75. In well-adapted elderly denture wearers with severe tissue deterioration or poorly fitting existing dentures, i.e. significant decrease of the vertical dimension of occlusion, unstable occlusal conditions and poor adaptation of the denture base to the denture bearing mucosa, it is realistic to consider restoring the inadequate esthetic and occlusal conditions. In this situation it is important to use the patient’s existing dentures diagnostically to determine which changes the patient will be able to accept. This could be done by temporary relining of the dentures using a tissue conditioning material. A temporary relining technique could be used which restores the vertical dimension of occlusion, secures a balanced occlusion in centric relation and centric occlusion as well as esthetics, the extension and fit of the dentures to the alveolar mucosa and the surrounding
  76. 76. The patient is allowed to use the temporarily relined dentures for 1-2 weeks. If denture function and esthetics are acceptable the altered dentures could be rebased after a final functional impression through the use of a closed mouth impression technique. If the esthetics are poor new dentures should be constructed. However, existing dentures could be used as individual trays for a functional impression and a guide to determining the vertical dimension of occlusion for the new dentures. POORLY ADAPTED DENTURES WEARERS : In elderly patients who have no existing denture or who do not accept the diagnostic dentures, prognosis for prosthetic treatment is questionable. Treatment with a complete lower denture may be especially hazardous. It may be advantageous to use an impression technique for the mandibular jaw which records supporting mucosa as well as the shape of the polished denture surfaces and which also allows determination of the horizontal and vertical dimension of occlusion in the same treatment period.
  77. 77. An occlusion rim could preferably be used as an individual tray after having been adjusted to the correct vertical dimension of occlusion. A functional impression is made using a closed mouth technique. With the impression in situ the patient may be able to determine whether placement and orientation of the occlusal plane, vertical dimension of occlusion and extension, outline and fit of the final denture will be suitable. In elderly patients who have had a number of recent unsuccessful prosthetic treatments, a careful interview and examination of the patient are very important. Prosthetic treatment should not be considered if there is evidence of an underlying psychiatric disease, if there are no major prosthetic faults of existing dentures, or if the patient does not accept the diagnostically altered
  78. 78. PROGNOSIS: DENTAL AND PROSTHETIC CARE : Regular recall of denture wearers should take place for the following reasons : • In order to control development of microbial plaque on tooth surfaces and on dentures. A denture is a predisposing condition to caries, periodontal disease and denture-induced stomatitis . • In order to control development of functional disorders of the masticatory system resulting from changes of occlusal relationships. Such changes may occur due to breakage of clasps and rests, wear of denture teeth and atrophy of the alveolar ridge. • In order prevent mechanical injury to periodontal and denture- supporting tissues.
  79. 79. PLAQUE CONTROL : Plaque control is planned by proper motivation and instruction of the patients and secured by employing an individual recall system for the professional care of the oral hygiene. Most elderly denture wearers will respond favorably to motivation and instruction in oral hygiene. It is, therefore, usually sufficient to arrange appointments for check-ups of oral and denture hygiene at 6-month intervals. Special brushing techniques are essential to control plaque on tooth surfaces adjacent to denture saddles and of the abutment teeth supporting overlay dentures. Chemical agents may be important adjuncts in oral hygiene care of elderly patients who cannot be motivated or who are physically unable to maintain sufficient oral and denture hygiene. Thus, daily mouthrinsing with chlorhexidine solutions or the application of chlorhexidine gel as well as the immersion of dentures in chlorhexidine are effective means in chemical plaque control.
  80. 80. Topical treatment with fluoride is an important means of reducing caries activity, especially on tooth surfaces particularly exposed to caries. A wide range of commercial products of chemical denture cleansers are available but they are not a substitute for mechanical cleansing. Peroxide cleansers have only limited effect on denture plaque; hypochlorite cleansers are effective but may cause bleaching and tarnish and have a bad taste, acid cleansers that are based on hydrochloric acid are hazardous to use and should not be recommended. Recently, enzyme-based denture cleansers have been introduced. These are efficient adjuncts to mechanical cleansing, and have no negative
  81. 81. FIXED PROSTHODONTICS IN GERIATRIC DENTISTRY : Patients with advanced oral diseases and multiple missing teeth jeopardizing an optimal masticatory function can now be treated successfully irrespective of age. Furthermore, treatment success can be maintained for many years provided an adequate maintenance care program is established. CAUSE-RELATED THERAPY : Besides improving chewing comfort fixed reconstructions generally offer better accessibility for oral hygiene than do removable prosthetic
  82. 82. A detailed medical and dental history and a thorough clinical examination are prerequisites for a comprehensive treatment planning in the elderly patient. The following documentation is generally needed for successful treatment planning, especially in a patient with multiple problem: • A set of full mouth intraoral radiographs. • A complete chart of the periodontal status including pocket probing depths and levels of probing attachment. • An assessment of the caries activity, prevalence, incidence and history. Special emphasis should be given to root surface caries. • An evaluation of pulp vitality of all teeth. • An analysis of the occlusion and function of the masticatory system.
  83. 83. It is important to gain a clear perception of the patient’s motivation for dental treatment and desire to maintain teeth, as well as his/her ideas of chewing comfort and the need for improved esthetics. Also, information about the willingness to maintain a healthy dentition is of utmost importance. Every single tooth should be diagnosed for caries, periodontal and pulp disease as well as for masticatory function. A comprehensive treatment plan for the elderly patient encompasses four distinct phases: 1. SYSTEMIC PHASE : Due consideration is given to the medically compromised patient. The risks for the patient and for the operator are identified. If necessary , the patient’s physician is consulted and possible medication
  84. 84. 2. HYGIENIC PHASE : The goal of this treatment phase is the establishment of optimal oral hygiene. Instruction of oral hygiene is accompanied by motivation of the patient and by thorough scaling and root planing. “Hopeless” teeth are extracted. 3. CORRECTIVE PHASE : This includes further periodontal treatment, endodontic therapy, restoration of teeth with alloplastic material and the incorporation of fixed or removable partial restorations. Occasionally, occlusal therapy, such as the application of a bite splint followed by occlusal adjustment, or orthodontic therapy may also be performed during this phase. Prior to reconstructing the partially edentulous patient retained and/or impacted teeth/roots should be removed, if indicated. During the entire corrective phase oral hygiene is monitored.
  85. 85. 4. MAINTENANCE PHASE : A maintenance care program with regular recall visits at frequent intervals (3-4 months) should be established in order to assure a favorable prognosis. During this phase attention should also be given to possible technical failures in the reconstruction. The necessity of a complete dentition with 14 antagonistic occlusal units for maintaining adequate function of the masticatory system is important as a shortened dental arch may act as an etiologic factor for functional disturbances in the masticatory system. This is necessary for providing a subjective chewing comfort. The need for replacing lost teeth beyond the second premolar might not be indicated as previously thought, and so limited and individual treatment planning should be given preference over ‘ideal’ professional concepts of optimal function.
  86. 86. The subjective masticatory function and oral well being should be the leading concept in treatment planning. Extension bridges offer a valuable alternative to removable partial dentures, especially if the dental arch is to be lengthened unilaterally or by one occlusal unit only. Success of advanced fixed bridgework depends on a competently and successfully performed endodontic and periodontal therapy of the abutment teeth and not on the amount of remaining periodontal tissues. In geriatric dentistry, the use of acid etch resin bonded restorations may have a promising future. These require much less chairside time and costs
  87. 87. POST THERAPEUTICAL MAINTENANCE : Maintenance care should include the continuous monitoring of the bridge work, assessment of pulp vitality and patients need for fluoride treatment. Recall visits will reemphasize the necessity for good home care and correct any irregularities in optimal plaque control. Topical fluorides should be applied at each recall. ORAL IMPLANTS IN THE AGED : An implant can be defined as an alloplastic device placed in the body for a specific functional purpose. The purpose of the oral implant is to create stable retention of prosthetic
  88. 88. In the aged patients, morphological pre-requisites for retention of dentures are limited. New dentures with a low retention capacity demand complicated functional patterns, the aged patient often has a limited ability to learn. This warrants the use implant dentures. Further, old age anxiety provides an additional burden. In such clinical situations the development of soundly documented implantology provides solutions and offers real progress in oral relabilitation of geriatric dental patients. The implant treatment in the aged must be performed by a specially trained team including a prosthodontist, oral surgeon, radiologist, physician and
  89. 89. SURGICAL AND MEDICAL ASPECTS : Pre operative measures for improving the prognosis of implant therapy should be undertaken, the nutritional status should be improved, anti coagulation therapy stopped and antibiotics administered for the prevention of infections. Surgical procedures can be done under local anaesthesia. Nervous patients should be sedated with an appropriate preparation, for example a benzodiazepine. Surgery must be performed as quickly and as atraumatically as possible to reduce strain on the aged patient and tissues in question. Asceptic surgical procedures should be followed to prevent postoperative complications. When the osseous implant sites are being prepared, heat due to friction has to be reduced to a minimum by continuous irrigation with sterile saline and by minimizing drill speed.
  90. 90. In aged patients susceptible to local infections, the area of surgery should be protected by antibiotics. During healing an optimal diet containing enough calories, protein, vitamins and supplementary calcium is essential. It is also important to give the patient or his next kin careful and detailed instructions to be followed during the post operative period. If all the above said principles are followed, implant surgery seems to be
  91. 91. INDICATIONS : Indications for treatment with implants in the aged are as follows : • A. Insufficient retention of prosthetic devices due to, • Extensive resorption of the alveolar bone. • Hypersensitive and highly vulnerable mucosal conditions. • Defects of the jaw after trauma or tumour resection. • Disturbed innervation of the oral and perioral muscles following trauma of cerebrovascular diseases. B. Functional disturbances, preventing the patient from wearing prosthetic devices due to, • Age related adaptation difficulties to dentures. • Severe nausea and vomiting reflexes C. Psycho-social inability to accept a prosthetic device in spite of adequate morphological and functional prerequisites.
  92. 92. CONTRA INDICATIONS : These are • Oral rehabilitation with conventional prosthetic devices which has already been accepted. • Insufficient residual bone volume with poor quality. • Lack of motivation for treatment with implants. • Lack of motivation for sufficient oral hygiene measures • General medical conditions. Eg: diabetes and severe osteoporosis. • Alcoholic and / or narcotic misuse. • Special oral conditions as seen after radiation therapy. • Certain psychological conditions and other mental conditions that might indicate negative psychological outcome. • Inability to perform meticulous postoperative care and long standing maintenance
  93. 93. IMPLANT PROCEDURES : There are at present two different, well-documented implant designs which are shown to be successful in the aged patients. They are, 1. Osseointegrated titanium implants ad modum Branemark especially suitable for edentulous cases. 2. Enosseous implants of aluminium oxide ceramics ad modum Schulte for single tooth loss.
  94. 94. IMPLANTS AD MODUM BRANEMARK : After a careful pre operative analysis regarding the patients general, physical and psychological health including an evaluation of the oral condition from a prosthodontic surgical and radiographic point of view, the treatment is performed in three stages. Stage I : titanium threaded implants are installed according to an elaborate surgical procedure. An undisturbed and relatively long period (5-6 months) of healing and osseointegration of the implants is necessary in the treatment of the aged. Stage II : after the healing period the abutment connection is surgically achieved. Stage III : about 2 weeks later, the prosthetic procedures should be finished.
  95. 95. IMPLANTS AD MODUM SCHULTE : These implants are made of aluminium oxide and produced in different sizes. The implants are inserted according to the surgical principles to achieve osseointegration. During healing the implant is not protected by covering mucosa. After a healing period of about 3 months, treatment is completed by application of a prosthetic reconstruction on the implant. The frequency of successful cases is about the same as for titanium implants and covers a period of 8 years. Both systems have their special advantages and indications.
  96. 96. CONCLUSION : The outcome of prosthetic treatment in geriatric dentistry is determined by several factors such as the general and oral health status of the patient, the patient’s degree of cooperation, economic resources, biologic and technical quality of prosthetic materials, and the prosthodontist’s knowledge, judgment and technical abilities. Thus, insight in clinical and technical aspects of prosthetic treatment is important in order to be able to successfully treat elderly patients who are partially or totally edentulous. However, the greatest challenge to the clinician is to make a choice between treating the patient, with the risk of producing iatrogenic disease, or not treating the patient, with the risk of more damage occurring to the masticatory system.
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