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1. GERIATRIC CONSIDERATIONS IN THE MANAGEMENT
OF EDENTULOUS PATIENTS
INTRODUCTION
Perfect health is a prize that has been the goal of mankind
throughout all ages. It must be understood that there can be no
separation between good bodily health and good dental health. A
diseased body often produces a diseased mouth inturn, a diseased
mouth may often lead to a diseased body.
While the great majority of people have a heritage of good
health, many destroy this priceless possession by failure to properly
care for their bodies. Much of this neglect is due to a lack of knowledge
of the best way to care for this complicated and wonderful machine.
This is more so amongst the older age group of individuals.
The care of dental problems of the senior citizens assumes an
increasing propotion of the time of health care-takers. Dentistry for
elderly must be practiced with increased awareness of the biologic
factors, since the adaptive mechanism and tissue regenerative potentials
f the elderly patients are usually significantly lowered. The elderly are
not merely older ordinary patients because they require a different
approach, modified treatment planning and a knowledge of how the
tissue changes associated with senescence affect oral health services.
The subject of geriatrics is increasing in its importance because
of great age shift in the living population of the world. Statistical data
1

2. from United States, published in 1964, indicated that approximately
50% of the American population over 45 years of age was edentulous.
This percentage was estimated to be 75% for those over 70 years of age.
In spite of the profound changes, which can be anticipated in these
statistics in future, owing to the remarkable advancements in the
scientific disciplines of pedodontia, periodontia and restorative dental
procedure, the potential number of geriatric patients seeking
prosthodontic services in the immediate and predictable future stagger
the imagination.
Geriatrics refers to the study of aged. Dr. S. Silverman views age
as a three dimensional phenomenon; wherein, there is a constant
interaction between chronologic age, physiologic age and psychologic
age. The average life expectancy in 1789 was 35 ½ years. Today, it is
one hundred years. The man has altered his average life span, but not
his maximum potential. It seems obvious that whatever the troubles
man’s mass longevity may cause, they make him no less eager to
survive as an individual. His dream of continuing life and vigor and his
corresponding terror of impotent old age are obsessive themes I his
literature and now-a-days in his psychiatry.
The process of aging begins at birth. Thereafter, two phases of
aging must be considered. The chronologic age and the physiologic
age. The former denotes the time of existance of the individual and the
later, the resultant effect of the passage of time on the functional
elements of the body. Much of the life span is controlled by heredity,
but a degree of modification may be made by environment, diet,
emotional status and medical care. A person at the age of 60 years may
2

3. have a gastrointestinal tract comparable to that of a 40 year old, a
nervous system of a 30 year old, a cardiovascular system comparable to
that of a 50 year old person and the dental apparatus of an 80 years old,
biologically.
From this we come to understand that the degree of a person i.e.
chronologic, physiologic and psychologic, if plotted on a graph, may
invariably stand at different levels in terms of years. This is a matter of
increasing concern in the practice of dentistry, because of the number
of elderly people who require denture service. The validity of this
statement can be understood. If one maintains the records of problems
posed by aged denture patients as against the youngers. The dental
practitioner, who follows a stereo-typed treatment plan, without giving
any consideration to the age and the problem, which are specific of
each individual, certainly faces more number of failures in case of
elderly patients. This can be attributed to different oral and general
disorders of the aging persons, which, most of the practitioners fail to
realize. These patients need to be treated by nutrotherapy as well as
psychotherapy. Also the treatment procedures need to be altered
according to the requirements of individual patient.
The effectiveness of execution and application of nutrotherapy,
psychotherapy and modified clinical procedures in the success of the
treatment, greatly depends upon the thorough understanding of
changes that may take place in different systems of the body as well as
in different organs, tissues and cells.
3

4. The prosthodontist can play a key role in reducing the number of
prosthetic failures by a careful understanding of the physical, mental
and metabolic changes that occur during senescence. The oral changes
that occur during aging should be recognized, understood and treated
before prosthetic restorations are prescribed for these individuals.
This study has been aimed at reviewing the available literature
pertaining to “The problems and management of geriatric patients” and
suggest methodology which will help the prosthodontists as well as
general practitioners of dentistry, to considerably reduce the number of
prosthetic failures through a proper understanding of the pitfalls and
suggest ways and means to overcome these difficulties.
REVIEW OF LITERATURE
A search through literature provides a good amount of
information regarding the problems of geriatric patients and their
management. It is of great significance to use as prosthodontists, to get
well versed with the several physiologic, as well as mental changes
which are associated with the process of aging and must be considered
normal. We are aware of the fact that the general configuration
meaning extensions and contours of various parts of the prosthesis as
well as positioning of teeth, is determined by patient’s anatomy and
functional requirements of the stomatognathic system. Nevertheless,
the functions of speech, respiration and deglutition also play a
significant role. However, the final success of the prosthesis is
interpreted in terms of the ability of the patient to utilize if effectively.
The act of swallowing is performed as an average two times per minute
4

5. throughout the day whereas, total mastication time per day is less than
three hours. Hence, the prosthesis should be such that it is well
tolerated during swallowing even at the expense of efficient
mastication. This means that in the management of geriatric patients,
mastication is of secondary importance as against speech, respiration
and deglutition. Any prosthesis, when impairs these latter functions,
ultimately results in failure.
The fact that the good general health and good dental health
cannot be separated, has its validity in the following statement made by
Bills; who states, that, “Sore teeth and ill fitting dental appliances make
eating less pleasurable among the aged. When the satisfaction and
gratification of eating is decreased, the desire decreases and in turn, a
vicious cycle sets in, which leads to malnutrition and its accompanying
ill-physical and mental deterioration”.
A. EFFECT OF AGING ON ORGAN SYSTEMS
No organ and tissue of the body is spared from physio-anatomic
changes, which can be called, senescent degenerations. These changes
occur to a variable extent in different organs. To make a generalized
statement, the essential changes is dehydration and waste of tissue.
This wasted tissue is either not replaced at all or is replaced by a tissue
of a different variety. Those changes in cellular function and growth are
manifested by different organs, in differeny ways.
5

6. a) Gastrointestinal system
There are dilatations of the intestine and stomach accompanied
by progressive atrophy of the glands. This probably causes irregularities
of absorption and bowel. There is a diminished secretion of
hydrochloric acid resulting in impaired absorption of dietary elements
such as calcium, iron and vitamin C. Secretion of proteolytuic
enzymes, pepsin, trypsin chymotrypsin, is markedly reduced,
consequently causing incomplete protein digestion.
b) Glandular system
There may be progressive atrophy, fibrosis, sclerosis and fatty
degeneration in different glands of the body. As a result, there is
marked degree of reduction in function which adversely affects
metabolism, nutrition, enzymatic and hormonal relationships. This will
be evident from the fact that the patient may suffer from moderate to
severe deficiency diseases, inspite of consuming a balanced diet.
Diminution of sexual power, diabetes, kidney dysfunction due to
altered acid-base balance, are some of the manifestations of diminished
glandular activity.
c) Cardiovascular system
Blood volume and haemoglobin content of blood, are reduced,
cardiac insufficiency along with vascular changes – which reduce the
optimal blood supply to tissues are common findings. The result is less
oxygen supply to the tissues. According to many Geriatricians, this fact
6

7. is the basis of senescence. Hypochromic anaemia is commonly seen in
aged patients, which can probably be attributed to achlorhydria and
deficiency of ascorbic acid, which affects absorption of iron. Sastry et al
are of the opinion that 60% of the patients seeking complete denture
treatment are anaemic.
d) Respiratory system
Lungs show gradual fibrosis, which decreases respiratory
efficiency leading to problem of oxygen exchange. This may be
manifested as breathlessness after a little physical strain.
e) Musculo-skeletal systems
Generalized dehydration results in loss of elasticity and
resiliency of the muscles. Notable skeletal changes also take place.
Organic matrix of the bone is reduced which makes the bones brittle
and prone to easy fractures, which heal with difficulty. This impaired
healing tendencies can probably be attributed to the deficiency states of
vitamin C, calcium, which are important in healing of wounds. Bone
marrow becomes gelations and contains relatively more fat that
younger bones. There is also reduced osteoclastic activity. As a result,
osteoclastic activity is apparently increased. This causes continuous
resorption of the bones. This fact also, can probably be attributed to
impaired healing of the fractures bones.
These muscular and skeletal, so called disorders, are manifested
by loss of weight and wasting of the body substance. 58% of the
subjects examined by Sastry et al present these emaciating tendencies.
7

8. f) Skin
Thin, dry, and inelastic skin is characteristic of an aged. There
may be atrophy of sebaceous and sweat glands. This makes the skin
prone to injuries. The subcutaneous fat disappears and hyperkeratotic
areas become apparent. There may be sparse and discoloured hair.
g) Nervous system
These cells reach the highest degree of specialization, undergo
senescence and die without being able to divide and produce new cells.
They lose the capacity to reproduce about the end of first year of life.
Aging changes are most evident in such tissues and cells.
A. PHYSIOLOGIC CHANGES RELATED TO COMPLETE
DENTURE PROSTHODONTICS
The above review, summarizes in brief the degenerative changes
contributing to the senescence. We as care-takers of the human
masticatory apparatus and associated structures, need to be familiar
with the physiologic changes, that take place due to aging in the
structure and functions of the stomatognathic system. This does not
imply that, one should concentrate only on the oral and dental aspects
of aging. On the contrary we should examine and treat the patient as a
whole and not his isolated oral and dental problems. This wholesome
approach should necessarily include the nutritional and psychiatric
analysis of the patient, followed by necessary nutritional and
psychotherapy.
8

9. Of the primary importance to the prosthodontists are the effects
of systemic aging changes on the oro-dental and associated structures.
a) Bone
This is the most important tissue to the prosthodontist. If we can
somehow maintain the equilibrium between osteoblastic and
osteoclastic activities in old age, the problem of maintaining dentures in
function would be greatly diminished. But unfortunately osteoblastic
activity comes almost to a standstill in elders, which results in apparent
acceleration of osteoclastic activities. Moreover, in old age, anabolism
decreases and there is a slight increase in catabolic processes.
Production of matrix is further impaired by lack of proteins which are
not either present in the diet in sufficient amount or are not completely
utilized. Calcium deficiencies and negative calcium balance are
common in the older person. Even if sufficient calcium intake is
observed, the bones may lack the ability to retain the absorbed calcium.
Amount of phosphorous intake also plays as important role, as calcium
can be retained in the body only if there is enough phosphorous.
According to Cheraskin and Ringsdorf decreased vitamin C intake
and / or protein utilization causes alveolar bone loss.
Nizel is of the opinion that poor calcium absorption is caused by
achlorydria excess calcium loss via kidneys due to diuresis and
deficiency of Vitamin D intake. Page and Abrnms have said that, the
health of oral tissues depends upon proper endocrine balance, and
proper calcium phosphorous blood vessels. Moreover, uncontrolled
diabetes hastens alveolar bone loss. In case, the patient has received
9

10. radiation therapy. His bone regeneration power is reduced remarkably
because of osteoradionecrosis. Blood dyscrasias, if present, prevent
proper nutrition from reaching the tissues thus reducing bone formation
and increasing tissue fragility.
Jowsey in 1960 has shown by microradiographic studies that
young persons have a high degree of both bone formation and
resorption. In young adults, there is little of both, while in persons over
70 years of age, as much as 25 percent of bone may be engaged in
resorptive processes.
Reifenstein in 1950 stated that osteoporosis in some degree may
be normal after menopause. Ortman (1962) believes that, it is not
improbable that the ridge, which appears so liable, may show
resorption in connection with a generalized osteoporosis.
By observing the axial inclination of the natural teeth, one can
predict the direction of residual ridge reduction subsequent to the loss
of teeth. Maxillary teeth generally flare downward and outwards, so
that bone reduction is generally upwards and inwards. Since the outer
cortical plate is thinner than the inner cortical plate, resorption from the
outer cortex would be greater and faster. The mandibular anterior teeth
generally incline upward and forward to the occlusal plane, whereas
the posterior teeth are either vertical or lingually inclined. The outer
cortex is generally thicker than the inner, except in the molar region.
Also the width of the mandible increases towards its inferior border. As
a result, the mandibular residual ridge appears to migrate lingually and
inferiorly in the anterior region and to migrate buccally in the posterior
10

11. region. Consequential to the resorptive patterns of maxilla and
mandible, the residual maxillary ridge becomes smaller in all
dimensions and the denture bearing surface decreases. Whereas the
residual mandibular ridge either appears to remain static or to become
wider posteriorly. This discrepancy in relative jaw sizes, can pose
several technical problems.
b) Oral mucous membrane
Oral tissues like others, change as an individual grows older. The
oral mucosa of the aged is friable and easily injured. According to
Massler, tissue friability arises from three sources : i) a shift in water
balance from the intracellular to the extracellular compartment and
diminished kidney function results in dehydration of the oral mucosa,
ii) progressive thinning of the epithelial layers which increase the tissue
vulnerability to mild stresses and iii) nutritionally deficient cells.
Even under the best circumstances, the cells of the aged do not
enjoy the optimal nourishment and vitality of youthful cells. The results
are: 1) reduced cohesiveness and integrity of the epithelial layer due to
vitamin A deficiency, 2) reduced metabolism of the cells due to a
vitamin B deficiency and 3) poorly differentiated connective tissue cells
and fibres due to vitamin C deficiency. The clinical result is the mucosa
susceptible to even minor irritating stress and connective tissue that
heals slowly. Traumatic ulcers and angular cheilosis may be produced.
The atrophic mucosa of elders is frequently thin and tightly
stretched and it blanches easily. Lammie (1960) believes that a mucosa
11

12. of reduced thickness is associated with reduced residual ridge height.
He postulated that epithelial atrophy, which results in a reduction in
the number of epithelial cells layers, and the thickness of the underlying
connective tissue, also manifests itself in a reduction of surface area of
the oral mucosa. This in turn applies pressure to the underlying ridge.
The externally applied molding force meets more or less resistance
from the bone itself and this is the action involved in the resorption
process.
Newton in 1964 studied age changes in the collagen fibres of the
oral mucosa. He has shown that these shorten to a degree compatible
with the concept of a contracting mucosa acting as a moulding force on
alveolar bone.
An atrophying denture-bearing mucosa is frequently
encountered during menopause. The reduction in the estrogen output is
known to have an atrophic effect on epithelial surface. Hormonal
replacement therapy can be beneficial in such patients to create a more
favourable oral environment for the dentures.
Aging produces changes in the blood vessels, particularly
athersosclerotic changes. Oral varicosities are often noted on the under
surface of the tongue, and in the floor of the mouth and are related to
varicosities found elsewhere. The accumulation of lipids in walls of
these medium sized sublingual arteries are result of the dietary risk
factors such as high intake of saturated fats, cholesterol and sucrose.
12

13. The degree of keratinization of the mucosa is of marked
significance and must always be carefully examined and critically
evaluated. When the mucosa lacks adequate keratinization, the
protecting capacity provided by the keratinized layer is reduced and the
patient is prone to suffer from chemical, bacterial and mechanical
irritations. The capacity of the prosthesis to initiate mechanical
irritations in these patients is therefore a significant problem in patient
management.
Frequently, the mucosa presents with heavy layers of thick
keratin. It may be distributed throughout the oral cavity or it may be
localized. Such excessive keratinization is not necessarily a problem in
patient management. Yet, it is extremely important that it be closely
and continuously examined. Its potential for leukoplakia and for
neoplastic activity is well known. Because of these changes the denture
adjustment period can be prlonged, and a continuous problem in
management. These patients should be educated to accept long-term
adjustments as routine and inevitable.
The most dangerous problem associated with epithelial changes
in the aging patients arises with the increasing incidence of oral cancer
which accounts for approximately 4 percent of all cancers. Over 75
percent of these cancers lie in the age group of persons 50 years and
over, indicating that this is a disease of the aging population and
geriatric problem. the high coincidence of these lesions around denture
borders always bring forward the speculation of irritation as an
etiologic factor.
13

14. The level of the pain threshold of soft tissue changes markedly
after the menopausal period and the male climacteric. Commonly,
there is an increase in sensitivity. Denture tolerance, as a consequence
is markedly reduced. The capacity of the tissues for repair through cell
division is impaired. As a consequence these patients present a
foundation for the prosthesis which has reduced capacity to adapt to
the demands of appliance.
As a result of reduced pain threshold and the reduction in
muscular adaptability. There is a considerable reduction in the
masticatory force value from an average of over 150psi in the young
adult to an average of 25 psi or less in the elderly.
Patient management requires that we educate our patients to
understand and accept this reduced masticatory capacity.
c) Changes in inter alveolar space and relation
With the loss of teeth, the patient may develop a protruding
chin, wrinkling, which extends downward from the oral commissures
and an obtuse angle of the mandible. There is also loss of inter-arch
space especially in the posterior segment. Patient develops a habitual
mandibular prognathism, failure to restore and maintain the proper
inter-arch space places undue stress on the temporomandibular joints.
Fore-shortening of the inter-arch distance results in the establishment of
a state of hypotonicity of all the muscles of mastication except the
external pterygoid, which becomes hypertonic, as it is one of the
mandibular depressants. The resultant tension produced upon the
14

15. capsular ligament of temporomandibular joint produce pain in this
region. These changes in the muscles, coupled with the residual ridge
reduction, bring about a change in the relation of mandible to the
maxillae. This may also result in catarrhal deafness and neuralgias of
the tongue and of the pharyngeal and cephalic regions. Management of
the geriatric patients experiencing temporomandibular joint pain
requires further evaluation of the validity of vertical dimension of
occlusion of the prosthesis.
d) Tongue and taste sensation
Probably the most common manifestation of aging of the tongue
is depapillization, which usually begins at the apex and lateral borders.
Tongue frequently becomes smooth and glossy or red and inflamed in
appearance. The tongue seems to increase in size in the edentulous
mouth. The tongue loses its usual muscle tone and offers less
resistance when palpated bidigitally. Glossodynia and glossopyrosis are
common complaints in senescence. These symptoms are usually
attributed to the nutritional deficiencies of folic acid, vitamin B12 and /
or iron.
Vitamin B12 deficiency, particularly in menopausal women is
characterized by a triad of symptoms, generalized weakness, sore,
painful tongue and numbness or tingling of the extremities.
Achlorhydria, sensory disturbances, difficulty in walking are some of
the characteristic features of pernicious anaemia. The major treatment
consists of intramuscular administration of vitamin B12.
15

16. The elderly patient who lives on a “tea and toast” diet is a prime
candidate for iron deficiency anemia. On the other hand, and
adequately nourished older man or post menopausal woman would
probably not have this problem unless there is hemorrhage. The oral
manifestations of iron deficiency anemia are glossitis and fissures at the
corners of the mouth.
Tongue thrusting associated with nervous tension or with
attempts to control a lower denture can lead to a sore tongue.
Lingual tissue changes are commonly associated with alterations
in the taste sensation. This diminished acuity of taste can be because of
some gradual nerve degeneration and / or hyperkeratinization of the
epithelium which may occlude the taste bud ducts and pores. Vitamin
A deficiency may be associated with such epithelial
hyperkeratinization. If there are not systemic contraindications,
increased use of condiments might provide more flavour to the food.
e) Xerostomia
Salivary secretion is usually a reflex response to movements of
the jaw during chewing or speaking. Salivary flow can be increased by
aromas of food and by stimulation of other special senses. On the other
hand, a variety of conditions can tend to reduce the salivary flow, such
as menopause, fear, anxiety, diabetes, and vitamin B complex
deficiency particularly in alcoholics.
As a result of regressive changes in the salivary glands,
particularly atrophy of the cells lining the inter-mediate ducts, there is a
16

17. decrease in salivary flow in the aged. This diminished function of the
glands also results in physiochemical changes in the saliva, which
shows a decrease in ptyalin content and an increase in mucus content.
Saliva becomes more viscous and ropy. Further when salivary flow is
reduced, the oral mucosa becomes dry and inelastic. There may be
cracking of the lips and fissuring of the tongue. Oral mucosal sore spots
are seen under a denture because of the lack of lubrication by the saliva.
Denture retention is adversely affected. Chewing and swallowing
become difficult. As a result food selection becomes limited to soft or
liquid type. Because of lowered ptyalin contents of saliva, digestion of
cooked starch is remarkably reduced. Xerostomia also affects oral
hygiene as in absence of lubricant action of saliva, food particles adhere
to the tissues. This makes the oral cavity prone to infection. Xerostomia
is frequently accompanied by achlorhydria, which causes gastritis.
Statistics indicate that primary gastritis is most prevalent in the
edentulous aged.
f) Motor-nervous control
Prosthodontists face severe problems because of altered capacity
of motor learning in elderly patients. As a result of aging there is
diminution in the brain substance. The ventricular spaces also increase
in size, causing further reduction in the brain substance. In the age
period from 60-85 years this capacity declines from an approximate 50
percent reduction at 60 years of age to over 85 percent reduction in
motor learning in the age group above 65 years. This fact gives an
indication of the motor learning capacity one should expect the patient
to possess.
17

18. Prosthodontic management of the geriatric patients having an
earlier prosthetic restoration in use, presents different problems than the
patient, who is going to receive his first ever prosthesis. These problems
are in terms of differences in the concepts of earlier days and those
followed by prosthodontist. In this connection, Paul W. Vinton has a
suggestion to make to the professionally. He advises construction of an
appliance, which would resemble the old appliance in terms of its
extensions, tissue coverage and interarch relationships. He further says
that the patient has already made the necessary adaptive motor learning
responses to this appliances. Deviations at this time may in his opinion,
pose handicaps in its utilization.
However, this suggestion of Vinton, does not seem to be
recommendable in the opinion of the author, because the clinical and
technical procedures at present are modified according to the patient’s
requirements, which are beneficial to the patient’s oral health in long-
run. This can probably be attributed to the better understanding on the
part of the operator, or oral anatomy, histology and physiology and
response of oral tissues to different materials, used in the fabrication of
the prosthesis as well as availability of a wide range of new dental
mateials.
B. NUTRITIONAL PROBLEMS
The terms diet and nutrition are often confused. Diet refers to
the amount of food being ingested. While nutrition results in the
building and repair of body tissues through the assimilation of food
substances into living tissue.
18

19. Diet is one of the important factors, in the management of
geriatric patients, particularly those, who are edentulous. These
edentulous individuals belonging to the retired age category often
present a challenge to prosthodontist. This is in the form of numerous
deficiency states these individuals are predisposed to. In the
management of such patients, it is imperative that an additional load be
placed on the denture foundation tissues. These patients need an
approach at improving the nutritional status of the individual and
health of foundation tissues. Thus, an adequate nutrition plays a large
part in health and contributes to the successful wearing of complete
dentures. However, there may be some individuals, who may be able to
masticate food properly, but whose digestive systems prevent proper
absorption. An adequate nutrition should be ensured to: 1) establish a
proper diet, which provides the needed substances for body building, 2)
supplement the diet with vitamins and minerals, and 3) emphasize the
importance of proper exercise, rest and when necessary medical
assistance.
If these, so called rules, are followed, particularly for older
denture patients, the equilibrium between bone resorption and bone
formation of the residual ridges will be maintained optimally.
In geriatrics, two important factors influence the health of senior
citizens. They are nutrition and exhaustion. There is a definite
relationship between impaired masticatory function and general
nutritive disorders. There is a definite correlation between what and
how a man eats and how long he lives. Stieglitz, who once, was
19

20. President of the Academy of Geriatrics said, “We are what we are
today because of our yesterdays”.
Poor nutrition in older group is one of the most common causes
of boredom and loss of interest in daily living. Obesity is frequently the
result of poor nutrition and a prime factor affecting longevity. A sound
nutritional program will do much to maintain the physical vitality and
nervous stability of the older patient.
Studies in geriatric nutrition have organized the existing
knowledge concerning the nutritional needs of older persons. As yet
specific nutritional requirements for older people have not been
established, nor is there any sound basis for assuming that the
nutritional requirements of the aged are different from the nutritional
requirements of any other age groups. In fact the primary objective of
research studies in geriatric nutrition is to establish specific
requirements.
According to Paul W. Vinton, the caloric requirements do
diminish as the age increases. This, he has explained in two ways. In
the first place, there is a decline in activity with advancing age.
Secondly, the actual quantity of tissue undergoing metabolic activity is
reduced. The ability to maintain body weight is still the best yardstick
available to measure the sufficiency of caloric intake.
The patient must be informed that, he/she may be well
nourished without natural teeth and that dentures will not affect their
general health. In fact, dentures may contribute to better utilization of
20

21. food substances even though new dentures and tender gums may
necessitate a change from fibrous to semisolid and softer food
substances. Fortunately, semisolid or even liquid foods can supply all
the essential elements necessary for good nutrition. Patients should
further be made aware of the fact that aging need not lead to sad, tired,
inactive existence. With the aid of synthetic vitamins, this period may
be active, productive and enjoyable.
Spies and associates in 1955 screened 5000 chronically ill
persons of who 893 were so feeble, they had not worked for years. All
the patients were subjected to complete clinical and laboratory
diagnosis to rule out tuberculosis, heart disease or any of the easily
recognized chronic illnesses. Patient’s complaints were related to
digestive, nervous and mental ailments. These patient’s were fed diets
rich in proteins, natural vitamins and minerals, supplemented with
large doses of synthetic vitamins.
The result of this study was the rehabilitation of many persons
through supplementation of the diet with essential materials.
This shows that the adequate nutrition plays an important role in
the maintenance of general health and mental well being of the patient.
a) Nutrition
Nutritional authorities have classified food substances into the
following components:
1. Proteins
21

22. 2. Carbohydrates
3. Fats
4. Vitamins
5. Minerals.
A brief discussion of these food elements would furnish us the
information, the dentist should have, if he is to attain success in the
management of geriatric denture patients.
PROTEINS
Proteins are necessary for building, repairing and maintaining
body tissue, as well as supplying energy. Meat, fish, dairy products, and
eggs are best sources of animal protein, whereas peas and beans are the
best source of vegetable proteins. Milk and cheese are good protein
foods.
Protein is a ‘MUST’ for denture wearer. The average patient will
have more comfortable gums and the dentures will continue to fit
longer if the amount of carbohydrates in the diet is reduced and
proteins are increased.
According to Jamiesan (1958), old people require less fat and
more proteins. The older the individual, the more protein per kilogram
of body weight is required. For optimum nutrition. 1.4 grams of protein
per kilogram of body weight is necessary. There is nerve any damage to
the health of older persons from too much protein, but if there is
inadequate protein, excessive nitrogen loss occur. Loss of weight
22

23. follows with mental depression and fatigue accompanied by a
decreased resistance to infection and functional disorders. Hypo-
proteinosis causes poor calcium absorption.
CARBOHYDRATES
Carbohydrates include sugars and starches and are obtained
mainly from plants, they are primarily a source of energy. In today’s
diet, many of the carbohydrates are in refined form, as in sugar, white
bread, refined cereals. These refined carbohydrates are the “empty
calories” and contain little or none of the essentials required for
building and maintaining a healthy body and mouth.
Carbohydrates are the best and the least expensive source of
needed calories. According to Vinton, at least 50-55 percent of the total
caloric requirement has to be provided in the form of carbohydrates.
Otherwise, part of the valuable dietary proteins are utilized for caloric
purposes. Such proteins are required for specific purposes such as the
maintenance of nitrogen balance.
FATS
The primary function of fats is to produce heat and energy. Only
secondarily do they build and repair tissue. Chief sources of fats are
meat, vegetable oils, butter, cream, eggyolk etc. Fats are an essential
part of the diet. A suitable diet for the elderly should contain enough fat
to provide about 25-30 percent of the caloric intake.
23

24. High quantities of fat in the diet are not desirable. Statistics of
over last 60 years show that the average daily intake of animal fats has
increased from 83 to 87 grams. On the other hand, the intake of
vegetable fats has increased from 5 to 41 grams per day. Undesirability
of consuming fats in excess, is seen in considerable increase in the
incidence of atherosclerosis and heart disease, over last 60 years.
Most of the vegetable fats are ingested subsequent to
hydrogenation, which converts them from the unsaturated to the
saturated state. It has been found that the degree of saturation of fatty
acids rather than the cholesterol content of the diet, is responsible for
the increased blood cholesterol levels, observed in the cases of
atherosclerosis. Populations consuming mainly unsaturated vegetable
oils have lower blood cholesterol levels than populations consuming
the saturated fats. It is therefore, suggested that it is not the source or
quantity of the fat that matters, but rather its degree of saturation. The
increased incidence of degenerative diseases in western civilization
have been shown to be directly related to increased consumption of
hydrogenated vegetable oils.
VITAMINS AND MINERALS
Vitamins are chemical substances which promote growth and
assist in the maintenance of healthy body tissues. There are times when
the body may be unable to provide a sufficient amount of vitamins.
Under such circumstances, they must be obtained from outside sources,
as they are dietary essentials. One who eats the proper variety of food is
relatively sure of getting of required assortment of vitamins needed.
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25. Denture patients, however, frequently are on a deficiency diet and may
need additional vitamins.
Vitamin A helps to keep the skin and mucous linings of the
mouth, nose and inner organs in healthy condition and thus aids in
making them more resistant to infection, good sources of vitamin A are
egg yolks, butter, whole milk, cream and fish liver oils.
Vitamin D is essential as it works with minerals, particularly
calcium, to form straight, strong bones and sound teeth. Foods such as
egg yolk, cream, butter, contain vitamin D. Fish liver oils are the
richest natural sources of vitamin D.
Thiamine, riboflavin, niacin, folic acid and vitamin B12 are
important members of the vitamin B complex group. They are
necessary for a healthy state of the blood. Their deficiency is
manifested as burning tongue and / or cracking at the corners of the
mouth.
Vitamin C deficiency causes scurvy. There are tendencies to
bruise easily and bleeding from gums. All of the citrous fruits are
excellent sources of vitamin C. Other sources are tomatoes, green
vegetables, potatoes etc.
Certain minerals are essential nutritional elements. Most
important of these are calcium, phosphorous and iron. In women 40-60
years of age, an appreciable amount of calcium is lost from the body,
unless their average intake of calcium is 1gm per day. Body can adapt
to the low calcium intake, but as safeguard against the osteoporosis,
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26. easy fractures of bone, sufficient calcium and phosphorous intake
should be assured. Iron is important for the developing red blood cells.
b) Nutritional Recommendations for the Aged
Nutrition is more than just diet. Nutrition includes not only the
ingestion of an adequate and balanced diet, but also the digestion,
absorption and transportation to the tissues, of essential food elements
and utilization of these elements by the body cells. Nutrition may be
seriously impaired at any one or more points in the complex chain of
metabolic activity.
For a satisfactory diet, the older persons require more attention
to the preparation of the food. The acuteness of our senses decreases as
we get older, so that our continued loss of sense of taste and smell leads
use to seek more spirited, highly seasoned or sweeter foods to
compensate for the diminishing sense of taste. Thus the older denture
patient is led into undesirable nutritional habits. More attention to food
preparation and serving will tend to correct these undesirable habits.
Regardless of its palatability, food is chewed poorly, when the teeth are
faulty. This leaves the stomach more work to do, with discomfort and
indigestion, the inevitable results of this added burden.
With the slowing down of general metabolism in the aging
process, there is a decrease in glandular function. The salivary glands
secrete less, so that there are less mucin and other digestive enzymes
present during the initial stages of digestion. thus, a great deal of food
reaches the stomach partly lubricated and digested, which again
26

27. increases the budern on the stomach and intestines. Older people must
masticate their food more thoroughly, so that it is more easily digested.
Furthermore, in the geriatric individuals, the tonus of the muscles of
mastication and deglutition is markedly reduced. As with all other
body joints, the temporomandibular articulation also shows the
degenerative changes. The prosthodontist who gives some thought to
the importance of nutrition can help the older patient make use of most
of his limited functional resources and can spare the patient many of
the consequences of nutritive and masticatory deficiencies.
Foods have been grouped into four groups on the basis of their
similarly in composition and nutritive value. The variety of food within
each group is usually enough to allow for a wide selection of favourite,
economical and seasonably available foods. In 1958, the United States
Department of Agriculture published a food guide based on four food
groups which are:
1. Milk, cheese, ice-cream.
2. Meat, fish, eggs or alternately dried peas and beans.
3. Vegetable fruit group, includes leafy green and yellow
vegetables, potatoes, citrous fruits, tomatoes and cabbage.
4. bread, cereal group.
No one of the above food groups provides all the required
nutrients, but when all the food groups are included in the diet, a
27

28. person may be reasonably assured of getting the necessary dietary
requirements.
A.E. Nizel suggested following procedure for nutritional
evaluation of the patient and necessary advice regarding diet
modifications if required. The procedure comprises of following steps:
- Evaluation of food habits through diet history.
- Evaluation of adequacy of the diet by comparison of the
actual intake with the recommended requirements.
- Prescribing an individualized diet with due considerations to
above two factors and to the chewing limitations of the
masticatory mechanism of the patient.
a) Evaluation of food habits
Food habits of most of the individuals, irrespective of their age,
are not easily altered. It is particularly more true of the elderly people,
because they are longstanding.
Some of the following factors may govern patient’s dietary habits
like social, psychological, financial aspects of the patients as well as his
general systemic health may force him to follow particular food habits.
Patient’s likes and dislikes should not be overlooked.
28

29. b) Evaluation of adequacy of the diet
Patient may be asked to keep a food dietary for five consecutive
days including a week-end day. The points in the food diary, that
should be noted are number of eating periods, whether each of the meal
consists of foods from each of the food groups. This food intake can be
then compared with the recommended amounts of respective food
groups. This forms a useful guide in the patient education regarding his
nutritional requirements and dietary habits.
c) The diet prescription
On the basis of the information gained from the history of food
habits and the actual food intake, the prosthodontist should now be
able to suggest required modifications. Improvements should be
advised in the food groups in which he is inadequate. It is advisable to
make gradual than sudden changes. The dietary improvements should
be based on the patient’s present food habits, social and financial status
and status of patient’s general systemic health i.e. presence of any
disease which may govern the food selection.
c) Diet suggestions following denture insertion
In case of the patient, who is a new denture wearer, the ability to
manage the physical consistency of the food is an important
consideration. The process of eating food actually involves three steps,
incising, chewing and swallowing.
29

30. Incising is a grasping and tearing action and involves opening
the mouth wide, which might cause a dislodgement of the denture by
the action of overtensed muscle attachments. This makes the first step
of eating food, most difficult of all three masticating actions.
The chewing of the bolus of food is less difficult than incising or
biting, but co-ordination of the many muscles of mastication which
control the movements of mandible, requires some experience.
The easiest and the least complex steps in the eating process is
swallowing. With the exception of the initial propelling of the bolus
into the pharynx, the process of deglutition is an involuntary action.
In the light of the complexities of these different steps, it is
advisable for the patient to master these processes in the sequence,
swallowing first, chewing next and incising, last although the sequence
of eating food is just reverse of this.
This means, food of the consistency that will require only
swallowing, such as liquids, should be prescribed for the first day or
two after insertion of the denture. These use of soft foods can be
recommended for the next few days and a regular diet by the end of the
week, depending upon patients motor learning capacity and response of
the denture foundation tissues, to the stresses added by the dentures.
Regardless of the consistency, the diet can be made balanced and
adequate by including foods from all the four food groups.
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31. C. PSYCHOLOGIC ASPECTS OF AGING
In addition to the physiologic and nutritional evaluation of the
geriatric patient who is to undergo prosthodontic treatment, a
psychologic preparation is most important, which plays an important
role in the success of the treatment. It is important to have some
understanding of the psychology of human aging, to be able to
appreciate the difference between behavioral disorders associated with
organic brain disease and those which are not. According to Dr.
Donald B. Giddon, this differentiation is necessary, as it would decide
the need of measures to be followed in psychological conditioning of
the patients.
Among the psychologic disorders which are associated with any
organic brain damage, hypochondriasis (morbid anxiety about one’s
own health, with complaint of imaginary disorders) is the common
behavioral disturbance). In the older people this is basically withdrawal
phenomenon where the individual substitutes his body for his previous
concern for the world about him.
Organic brain damage presents difficult problems in the dental
treatment. For example, in senile dementia, an irreversible
deterioration of intellectual faculties develops and the patient is
frequently withdrawn and incapable of adjusting to any prosthesis.
Such patients are probably best treated by the eradication of oral
disease and dietary changes to accommodate to their modified
dentition or their non-existent prosthesis.
31

32. Geriatric patients show high incidence of depression and feelings
of insecurity and experience vague pains and fears. Nervous habits like
tooth clenching may develop and this places extra stress on tissues that
already have lowered load bearing capacity.
Older patients are also likely to be using drugs and care must be
taken to understand the clinical dental implications of such drug use.
Tissue distortion can result from medication taken for oedema caused
by kidney or cardiac dysfunction, from fatigue or changes in fluid
intake. Tissue distortion can seriously affect impression making and it
is recommended that morning appointments be organized to ensure
minimum tissue distortion from oedema.
Reassurance, tolerance and a patient clinical approach can
usually help the elderly obtain satisfactory prosthodontic results.
DISCUSSION
General health and oro-dental health, are interdependent. In
other words, one must have good bodily health, if he is to have a
healthy oral cavity. Similarly, an unhealthy oral cavity and
stomatognathic system adversely affect the general health of the
individual. Again, the general as well as oral health depend upon the
age of the person and his dietary habits. As for any construction to be
successful, a strong and stable foundation is the basic requirement,
similarly for the artificial dentures to function successfully, healthy
foundation tissues are necessary. No prosthesis, even if it is fabricated
by a highly skilled and well experienced clinician using latest materials
32

33. and techniques, can be and should not be expected to function
satisfactorily, if it is to rest on poor and weak foundation. Moreover,
psychological constitution of the patient also plays an important role in
the success of treatment procedures and hence this aspect of patient
evaluation cannot be overlooked.
Nutrition too, contributes to the final outcome of the efforts put
in from the examination and diagnosis till completion of the treatment
and even after that.
Human body as a whole undergoes degenerative changes during
the declining years of life. Stomatognathic system manifests these senile
changes in different ways depending upon nutritional status of the
patient. The alterations seen in the oral cavity during the old age should
be considered to be physiologic. We, as dental professionals, should be
able to appreciate these physiologic aging manifestations and should
also be in a position to treat these conditions, so as to improve the
individual’s oral health, thereby uplifting the stress bearing capacity of
the denture supporting and denture bearing elements of the orofacial
complex. The treatment procedures aimed at betterment of the oral and
dental health status, should include the recognition of the dietary
inadequacies and psychological setbacks and their treatment by proper
dietary and psychologic counseling. This make evident the necessity of
the knowledge of aging changes in different tissue of the body,
particularly, those in the province of the prosthodontist.
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34. CONCLUSIONS
1. Knowledge of the senile changes that take place in
different tissues, is important for the prosthodontists, to be
able to appreciate and treat these conditions.
2. Evaluation of the nutritional status of the patients
belonging to old age group and prescribing an
individualized diet helps to improve the health of their
denture foundation tissues, thereby improving the
prognosis.
3. Dietary recommendations after denture insertion help to
overcome the difficult learning phase.
4. Psychologic evaluation and counseling plays and
important role in the treatment success.
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35. SUMMARY
Systemic changes that take place due to aging have been
discussed in brief, followed by a detailed review of the senile changes in
the tissues of oral cavity. Nutritional problems, commonly faced by
older peoples are dealt with and necessary dietary recommendations
are suggested. A system of diet, following insertion of dentures, has
been suggested psychologic aspects of aging have been evaluated.
35

36. BIBLIOGRAPHY
1. Bills E.D. : Counsel to the aging dental patient. J. Pros. Dent., 9 :
881-885, 1959.
2. Boitel R.H. : Problems of old age in denture prosthetics and
restorative procedures. J. Pros. Dent., 26 : 350-356, 1971.
3. Detroit Mich : Nutrition for the aging patient. J. Pros. Dent., 10 :
53-60, 1960.
4. Fisher W.T. : Prosthetics and geriatric nutrition. J. Pros. Dent.,
5 : 481-485, 1955.
5. Jamiesan H.C.H. : Geriatrics and the denture patient. J. Pros.
Dent., 8 : 8-13, 1958.
6. Perry C. : Nutrition for senescent denture patients. J. Pros. Dent.,
11 : 73-78, 1961.
7. Ramsay W.D. : Role of nutrition in conditions of edentulous
patients. J. Pros. Dent., 23 : 130, 1970.
8. Sharry J.P. : Complete denture prosthodontics. 3rd
Ed. Mc Graw
Hill Book Co., 1974.
9. Silverman S.I. : Geriatrics and tissue changes problems of aging
denture patients. J. Pros. Dent., 8 : 734-739, 1958.
36

37. 10.Schweiger J.W. : Prosthetic considerations for the aging. J. Pros.
Dent., 9 : 555-558, 1959.
11.Wendt D.C. : The degenerative denture ridge care and
treatment. J. Pros. Dent., 32 : 477-491, 1974.
37

38. CONTENTS
I] INTRODUCTION
II] REVIEW OF LITERATURE
A. Effects of aging on organ systems.
B. Physiologic Changes Related to Complete Denture
Prosthodontics.
a. Bone.
b. Oral mucous membrane.
c. Changes in interalveolar space and relation.
d. Tongue and taste sensation.
e. Xerostomia.
f. Motor nervous control.
3. Nutritional problems
a. Nutrition.
b. Nutritional recommendations for the aged.
c. Diet suggestions following denture insertion.
4. Psychologic aspects of aging
III] DISCUSSION
IV] CONCLUSION
V] SUMMARY
VI] BIBLIOGRAPHY
38