 INTRODUCTION  DEFINITIONS CLASSIFICATIONS  COMMUNICATION WITH GERIATRIC PATIENT Dr.MM HOUSE CLASSIFICATION AGE & NUTRITION FACTORS AFFECTING NUTRITION

1. Dr. Ashitha Dominic

2. ▫ INTRODUCTION
▫ DEFINITIONS
▫ CLASSIFICATIONS
▫ COMMUNICATION WITH GERIATRIC PATIENT
▫ Dr.MM HOUSE CLASSIFICATION
▫ AGE & NUTRITION
▫ FACTORS AFFECTING NUTRITION
2

3. ▫ PROSTHODONTIC IMPLICATIONS
▫ TREATMENT PLANNING
▫ CHALLENGES OF PROSTHODONTIC TREATMENT FOR THE OLDER
PATIENTS
▫ CONCLUSION
▫ REFERENCES
3

4. Geriatric dentistry deals with delivery of dental care to the
elderly citizen. It is concerned with diagnosis, prevention
and treatment of dental problems associated with normal
aging.
The elderly require a different approach, modified
treatment planning, and knowledge of how the tissue
changes associated with senescence affect oral health
service.
4

5. As stated by GPT -9,
• GERIATRICS : The branch of medicine that treats all problems peculiar to the aging
patients ,including the clinical problems of senescence and senility.
• DENTAL GERIATRICS : The branch of dental care involving problems peculiar to
advanced age and aging or Dentistry for the aged patient.
• GERIODONTICS : The treatment of dental problem in aged or aging persons
5

6. ▫ The young old (65-74 years) –Can live life independently.
▫ The middle old (75-84 years)/ frail elderly –Live in community
with support.
▫ The old old (85 & above) -Dependent on community completely
for survival.
(Krogman WN:Geriatric research and prosthodontics JPD 1962;12:493-515)
6

7. According to Heartwell –
▫ Those who are well preserved emotionally and physiologically.
▫ Those who are really aged and chronically ill.
▫ Those who fall between these two extremes.
7

8. According to psychologic reactions to aging process -
– They are philosophical and exacting, enjoy their old
age.
- Indifferent and hysterical types, will not listen to the
advice, neglect oral hygiene & rarely seek dental care.
– In between group. Vary in emotional and systemic
status.
8

9. Winkler classified elderly as –
: well preserved, physically and psychologically
active in their professional and social lives, quickly adapt to age
changes
: Disadvantaged emotionally &
physically. Described as handicapped, chronically ill disabled
infirm and truly aged. cannot handle stress and susceptible to
disease
9

10. : Satisfied with old dentures inspite
of severe problem.
: Elderly person
edentulous for many years .No desire for complete dentures and
lacks motivation
10

11. According to DCNA -
: One or two minor chronic medical conditions,
independent living . Eg : osteoarthritis, Hiatus Hernia
: Co existing minor chronic debilitating medical
condition - with drugs Eg: Rheumatoid arthritis.
11

12. -Same as category II - but
patient debilitated –home bound or institutionalized.
Eg:- patients confined to wheel chairs
: Health
status deteriorated .Skilled nursing facility. Eg:- Patients with
Alzheimer's disease,Patient with end stage renal failure
12

13. For prosthodontic ventures to be successful, minds as well as mouths must
be individually understood and treated.
Communication is essential because it is an act of sharing. It is participation
in a relationship involving a deep understanding of the patient. Dentists are
considered to be masters of technical skills, able to provide quick solutions
to problems best solved through patiently and effectively communicating
with patients.
Patient-Dentist Communication: An Adjunct to Successful Complete Denture Treatment Journal of
Prosthodontics 19 (2010) 491–493 c 2010
13

14. ▫ Patient may disclose more information
▫ Enhances patient satisfaction
▫ Builds rapport between patient & professional involved in
decision making
▫ Leads to more accurate diagnosis
▫ Better patient adherence to treatment
▫ Patient more open to seeking further care

15. The successful prosthodontic treatment depends on both Technical skills and
Patient management, according to mental attitude.
MENTAL ATTITUDE of a patient was classified by HOUSE in 1950 as
PHILOSOPHICAL :
• This is the ideal Patient Type.
• Patient is optimistic,cooperative,rational and sensible.
• Desires dentures for maintenance of health and
appearance.
• The prognosis is good in such patients.

16. EXACTING :
• This patient are far less than ideal.
• They are precise and can make unreasonable demands to the
dentist.
• Likes explanation for each step in detail.
• The prognosis varies fair/poor.
HYSTERICAL:
• This type of patient are often excitable,nervous,excessively
hypertensive and often very pessimistic.
• They may require professional psychological counselling in before
treatment.
• The prognosis often remains unfavourable.

17. INDIFFERENT :
• They lack motivation and might be unwilling to follow instructions
regarding his/her oral health.
• Most diificult category of patient to be treated..
• The prognosis is poor.
Heartwell CM, Rahn AO. Diagnosis. Syllabus of complete dentures. 4th
edn.pp:106-42

18. This expanded classification system is based on empiricism and awaits
scientific validation or clinical application to determine its ultimate validity,
reliability, and effectiveness.
The proposed classification is based on two factors:
1) the level and quality of the engagement or involvement of the patient
towards the dentist.
2) the level of willingness to submit(trust) to the dentist.
M. M. House mental classification revisited: Intersection of particular patient types and
particular dentist's needs: Simon Gamer,Richard Tuch and T.Garcia.( J Prosthet Dent
2003,89:297-302)

19. IDEAL
• Corresponds to House’s philosophical mind, is reasonably engaged
and reasonably willing to submit (trust) to the dentist.
• They recognize their responsibility,along with the dentist’s, as an
active partner in the treatment.
• They possess best treatment outcomes.
19

20. SUBMITTER
• These patients tend to idealize the dentist, which results in a high
degree of engagement and surrender.
• Cannot be an active partner in the treatment.
RELUCTANT
• Such patients are low on engagement and on willingness to submit
(trust).
Poor prognosis
20

21. INDIFFERENT
• Corresponds to House’s indifferent mind, rates very low on
engagement and on willingness to submit (trust).
• They seek treatment because of certain family members, relatives ,
friends.
RESISTANT
• This patient corresponds to House’s exacting mind .
• And, like the indifferent patient, there is no trust.
21

22. 1. To establish a balanced diet which is consistent with the physical,
social, psychological and economic background of the patient.
2. To provide temporary dietary supportive treatment, directed
towards specific goals such as caries control, postoperative healing,
or soft tissue conditioning.
3. To interpret factors peculiar to the denture age group of patients,
which may relate to or complicate nutritional therapy.
22

23. Factors contributing to nutritional problems in the elderly
are
I. Oral
▫ 1. Changes in ability to chew food
▫ 2. Changes in taste and smell
▫ 3. Drug induced xerostomia
II. Physical
▫ 1. Changes in ability to absorb and utilize nutrients
▫ 2. Changes in ability to metabolize nutrients
▫ 3. Changes in energy requirements and activity
▫ 4. Effects of medication on appetite and nutrient absorption and
utilization
23

24. ▫ Phyisological factors
▫ Psychosocial factors
▫ Functional factors
▫ Pharmacological factors
▫ Oral factors
International Journal of Oral Health Dentistry; July-September 2017;3(3):127-132
24

25. Physiological factors: With a decline in lean body mass in the elderly,
caloric needs decrease and risk of falling increases.
▫ Vitamin D deficiency
▫ Declines in gastric acidity often occur with age and can cause
malabsorption of food-bound vitamin B12.
▫ Zinc and vitamin B6 deficiency
▫ Dehydration
▫ Overt deficiency of several vitamins is associated with neurological
and/or behavioral impairment B1 (thiamin), B2, niacin, B6 [pyridoxine],
B12, foliate, pantothenic acid, vitamin C and vitaminE).
25

26. Psychosocial factors: A host of life-situational factors increase
nutritional risk in elders.
Elders, particularly at risk, include those living alone, the physically
handicapped with insufficient care, the isolated, those with chronic
disease and/or restrictive diets, reduced economic status and the
oldest old.
Functional factors: Functional disabilities such as arthritis, stroke,
vision, or hearing impairment, can affect nutrition.
26

27. Pharmacological factors: Most elders take several prescription
and over-the counter medications daily.
Prescription drugs are the primary cause of anorexia, nausea,
vomiting, gastrointestinal disturbances, xerostomia, taste loss and
interference with nutrient absorption and utilization. These conditions
can lead to nutrient deficiencies, weight loss and ultimate
malnutrition.
27

28. Oral factors that affect diet and nutritional status
Xerostomia affects almost one in five older adults. Xerostomia is
associated with difficulties in chewing and swallowing, all of which can
adversely affect food selection and contribute to poor nutritional status.
The use of drugs with hypo salivary side effects may have deleterious
influence on denture bearing tissues.
Age-related changes in taste and smell may alter food choice and decrease
diet quality in some people. Factors contributing to this reported decreased
function may include health disorders,medications, oral hygiene, denture
use and smoking.
28

29. The presence of natural teeth and well-fitting dentures were
associated with higher and more varied nutrition intakes and
greater dietary quality.
Effects of dentures on chewing ability as adult’s age, they
tend to use more strokes and chew longer, to prepare food
for swallowing. Masticatory efficiency in complete denture
wearers is approximately 80% lower than in people with
intact natural dentition.
29

30. 30

31. Teeth
Enamel : Changes in both physical appearance and composition
Incisal and occlusal wear
Less permeable more brittle, contribute to cracks and micro fracture
Eg: attrtion, abrasion, erosin
31

32. Dentin - Pathologic effect of dental caries, abrasion,attrition or other operative
procedures cause variable changes in dentin .
Increased number of dead tracts & sclerotic dentin
Cementum - Thickness of cementum is one of the criteria to assess age of an
individual. Increase in thickness at the root by 5 to 10 times with age.
Permeability decreases with age.
Pulp - Reduction in pulpal area in coronal pulp because of continual apposition
of dentin occlusally and in furcation area
32

33. PERIODONTIUM
▫ Decrease in number of fibroblasts.
▫ Decrease in collagen and elastic fiber content.
▫ Decrease in organic matrix production.
▫ Width of periodontal space increases with occlusal loading.
33

34. Epithelial Atrophy :
▫ Epithelial layers are less in number.
▫ Mucosa, submucosa, connective tissue decrease in
thickness.
▫ Decrease in surface area of the oral mucosa.
▫ Reduction in number of elastic fibers.
▫ Decreased repair potential
▫ Denture bearing mucosa of basal seat becomes more
friable
▫ and easily traumatized.
34

35. Tongue and Taste sensation
▫ Number of taste buds decline with age.
▫ At 70yrs, taste buds decrease to 1/6th of
those present at the age of 20yrs.
▫ Acuity of taste sensation is decreased because
of depapillisation.
35

36. Salivary flow changes
Xerostomia : Due to medication for gastric complaints, depression,insomnia,
hypertension, allergies, heart problems and many other geriatric problems,
Sjogren’s syndrome, radiotherapy.
Decreased flow of saliva
Poor retention of denture
Poor taste sensitivity
Irritation of mucosa
Difficulty for bolus formation and deglutition
36

37. Mastication and deglutition
Masticatory ability is decreased in partially or fully edentulous persons. Biting
force is decreased by 16% of its original value in older patient.
Swallowing time is increased by 25 to 50% in subjects over 55years of age
37

38. Changes in Residual Ridge
▫ RRR is chronic, progressive, irreversible and cumulative process.
▫ Reduction in the size of bony ridge under mucoperiosteum
▫ Generally maxillary and mandibular residual ridge resorption is 1:4 by ratio in
edentulous person
▫ Annual rate of reduction in height is 0.1 to 0.2mm and in general four times
less in edentulous maxilla.
38

39. Changes in Maxilla
▫ Maxillary teeth are directed downward and outward thus
bone reduction is upward and inward.
▫ Resorption on outer cortex is greater and more rapid
because outer cortical plate is thinner than the inner
cortical plate
▫ Maxilla becomes smaller in all dimensions and the
denture bearing area decreases.
39

40. Changes in Mandible
▫ Resorption primarily on the crest of the ridge.
▫ Posterior aspect mandible is wider at its inferior border
than at the residual alveolar ridge
▫ As resorption continues mandible becomes wider
▫ Maxilla get confined within the mandible
40

41. ▫ Wrinkles, puffiness and pigmentation.
▫ Epidermal growths with large melanocytes (solar lentigines)
that thicken the epidermis.
▫ Gradually, dermis thins, enzymes dissolve collagen and
elastin.
▫ Layers of fat is lost, support for presymphyseal pad of fat
disappears.
41

42. ▫ Upper lip droops
▫ Reduction in concavity and pout of the upper lip.
▫ Flattened philtrum, deepened nasolabial grooves
▫ Sagging look in middle 3rd of face.
▫ Atrophy of subcutaneous and buccal pads of fat
hollowing of cheek
42

43. Because of loss of teeth and resultant pattern of loss of alveolar
bone support (in maxilla & mandible) following morphological
changes are seen
1. Deepening of nasolabial groove
2. Loss of labiodental angle
3. Decrease in horizontal labial angle
4. Narrowing of lips
5. Increase in columella-philtrum angle
6. Prognathic appearance
7. Reduced concavity & pout of upper lip
8. Flattening of philtrum

44. ▫ Assessment of provisional treatment plan
▫ Primary care
▫ Definitive treatment plan
▫ Secondary care
▫ Tertiary care
44

45. ASSESSMENT OF OLDER ADULT
Steps involved are:
▫ 1. Identification data.
▫ 2. Information source.
▫ 3. Medical history and physical evaluation.
▫ 4. Patient questionnaire.
▫ 5. Patient interview and summary.
▫ 6. Dental history and evaluation.
▫ 7. Chief complaint.
▫ 8. Extra and intra oral examination.
▫ 9. Diagnostic aids.
▫ 10.Prosthesis.
45

46. Primary objective of treatment plan
▫ Secure stable occlusal contact
▫ Maintain or restore a functional vertical dimension of occlusion
▫ Financially acceptable treatment plan
▫ Simple treatment procedures that result in comfort and esthetics
46

47. Completely edentulous
▫ Restoration of
Esthetics
Mastication
Comfort
 Primary care
Instant relief of pain
Management of periodontal diseases
Identify and treat the causative factor for deterioration of oral health
Treatment of active caries and basic restoration
Examination of TMJ
47

48.  Secondary care
Includes reconstruction phase
 Tertiary care
▫ Prevention: Oral hygiene instructions
Flouride mouth washes
▫ Monitoring : Regular recall
Check stability of restoration
Minor occlusal adjustments
▫ Maintenance
48

49. ▫ If prosthodontic replacement of teeth is required, the majority
receive removable partial dentures (RPDs) to meet functional and
aesthetic demands. Acrylic RPDs often gain retention through
extending over the soft tissues or engaging with the embrasure
spaces of remaining teeth.
49

50. ▫ RPDs constructed with a cobalt-chromium
framework can be used to minimize gingival
coverage & ensure that components do not
encroach on root surfaces.
50

51. ▫ In addition to caries prevention strategies and conservative
management of cavities, this strategy also includes the use of
resin-bonded or cement-retained bridges to maintain shortened
dental arches where anterior teeth are missing. Resin-bonded
bridges offer a good treatment alternative to RPDs
51

52. Glass fibre-reinforced composite bridgework can also
be used to restore patients with a shortened dental
arch. These functionally-oriented treatment
strategies aim to reduce the burden of maintenance
for older adults.
52

53. Shortened dental arch concept (SDA) -Kayser in1981
▫ Relevant for patient aged 50 – 80years
▫ Provides sub optimal but acceptable functionality
▫ Anteriors and premolars are strategic parts
▫ Sufficient adaptive capacity – with 4 occluding units
▫ One unit corresponds to a pair of occluding premolars
The shortened dental arch concept: A treatment modality for the partially dentate
patient,Vernie A. Fernandes, Vidya Chitrej-ips.org on Monday, May 4, 2020, IP: 137.97.132.1
53

54. Advantages of SDA
▫ Simplification of extensive restorative management
▫ Easier maintenance
▫ Good prognosis for remaining teeth
SDA is applicable to
▫ Caries and periodontal disease confined to molars
▫ Good long term prognosis for anteriors and premolars
▫ Financial and other limitations to dental care
54

55. ▫ Immediate dentures - for appearance and
function
▫ Over dentures – retaining some roots
prevent RRR improves retention, comfort
and biting force
▫ Retention highly compromised – Precision
attachments
55

56. Immediate Denture
The goal of Immediate Denture therapy is to maintain satisfactory appearance
& function during the post-extraction phase of treatment.
Removable partial dentures can be used to replace mainly posterior teeth in the
first instance. After a suitable transitional period, six months is usually
sufficient, the clinician may convert the transitional partial denture to a
complete immediate replacement denture.
Occasionally, it is possible to rebase the immediate replacement dentures but,in
most cases, new replacement complete dentures would be required after 6–12
months.
56

57. OVERDENTURES
One possible alternative to complete tooth loss is the retention of a number of
strategically important teeth and the utilization of overdentures.
Overdentures have proven to be very successful, especially in the mandible
where bone resorption can severely compromise denture stability and retention.
57

58. Advantages of overdentures
Retaining some portion of their natural dentition will be of great benefit.
They can be useful if partial denture construction is proving difficult, for example
in cases with unsuitable abutment teeth or where saddles have conflicting paths
of insertion.
Overdentures can prove successful in hypodontia cases as well as cleft palate or
surgical defect cases.
With non-carious tooth surface loss, an increasing problem amongst older
patients, overdentures can be used as diagnostic or definitive prostheses to
restore teeth.
58

59. Planning for overdentures requires the careful assessment of potential abutment
teeth. The prognosis for the retained teeth should be good, and they should be
considered restorable.
Saving some of the remaining natural teeth can convey huge psychological
benefits to the patient.
International Journal of Oral Health Dentistry; July-September 2017;3(3):127-132
59

60. Complete Denture
Examine denture bearing area
Abused tissue – Tissue conditioners (preprosthetic care)
Old denture wearer – no gross changes, duplicate the old denture and
modify
Finished denture has to be extended within functional limits
60

61. Preprosthetic Care- Tissue conditioning therapy
Preprosthetic surgery- alveoloplasty
vestibuloplasty
61

62. 62
Implant supported denture
▫ Used to stabilize complete removable prosthesis
▫ Helps to over come functional, psychological and physiological
consequences of edentulousness
▫ Helps to preserve alveolar bone and ↑biting force

63. In an older individual, teeth lost earlier in the life have often brought
about disruption in the dental arch over times as a result of drifting,
tipping and supraeruption
These inturn, pave the way for prosthodontic challenges such as
hygiene difficulties, periodontal problems, nonparallel abutments,
long preparations and potential food traps.
Prosthodontic treatment protocol for a geriatric dental patient R. Ravichandran.j-
ips.org on Friday, March 24, 2017, IP: 49.206.1.43]
63

64. Regarding the clinical management of older individuals, certain points
should be taken into consideration.
1. The elderly have both greatest level of need of prosthodontic
service and the greatest degree of complicating dental, medical and
behavioral factors.
2. Age is not a contraindication to complex prosthodontic treatment.
So patients with advanced age will appreciate the aesthetic and
functional advantages.
3. Successful execution to prosthodontic treatment needs to include
attention to altered pulpal size, changes in dentinal properties and
any periodontal changes to prior history of periodontal disease.
64

65. 4. The dental aspects of planning prosthodontic treatment for the
older should focus on the integrity of individual tooth on the potential
contribution of each tooth to the masticatory system. Hence we
should anticipate a restorative, occlusal and functional challenges
likely to arise on the course of the treatment.
5. Removable prosthodontics, whether with complete or partial
dentures require attention to procedures that provide greater
precision for occlusal, dental, mucosal and esthetic relationship that
can develop over a lifetime.
65

66. ▫ The treatment options for geriatric patients is determined by
several factors such as the general health, nutritional status,
oral health status of the patient, the patient’s degree of
cooperation, economic resources, knowledge of the
prosthodontist’s judgment and technical skills.
66

67. ▫ Prosthodontic treatment for ednentulous patients, Boucher, Eleventh edition.
▫ Syllabus of complete denture prosthesis , Charles M. HeartWell
▫ Essentials of complete denture prosthesis prosthodontics ,Sheldon Winkler
▫ Zarb - Bolender, Prosthodontic treatment for edentulous patient, 12th edition
▫ Vernie Ann Fernandes et al, The shortened dental arch concept: A treatment
modality for the partially dentate patient, JIPS 2008, Vol 8, Issue 3
67

68. ▫ Patient-Dentist Communication: An Adjunct to Successful Complete
Denture Treatment Journal of Prosthodontics 19 (2010) 491–493 c 201z
▫ Dr.Meena Aras.Nutrition for geriatric denture patients, JIPS 2006; Vol 6:
22-28
▫ The shortened dental arch concept: A treatment modality for the partially
dentate patient,Vernie A. Fernandes, Vidya Chitrej-ips.org on Monday,
May 4, 2020, IP: 137.97.132.1
68

69. 69