Geriatric Dentistry

Presented by:
Dr. Jehan Dordi
3rd Yr. MDS
GERIATRIC DENTISTRY
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CONTENTS
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• Terminologies
• Introduction to ageing
• Classification of ageing
• Mechanism and Theory of ageing
• Factors affecting ageing
• Bodily changes associated with ageing
• Orofacial ageing
• Most common diseases or medical conditions encountered in geriatric
patients
• Pharmacology and ageing
• Considerations of treatment planning in geriatric patient

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• Diet and nutrition in geriatric patients
• Prosthodontic considerations for completely edentulous prosthesis in geriatric
patients
• Prosthodontic considerations for partially edentulous prosthesis in geriatric
patients
• Prosthodontic considerations for fixed prosthesis in geriatric patients
• Prosthodontic considerations for implant prosthesis in geriatric patients
• Prosthodontic considerations for maxillofacial prosthesis in geriatric patients
• Domiciliary care
• Conclusion
• References

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• Gerontology: Branch of knowledge which is concerned with situations and
changes inherent in increments of time with particular reference to post
maturation stages. (Gerodontological society, 1959)
• Gerodontology or Gerodontics: The branch of dentistry that deals with the
oral health problems of the older people.
• Geriatric Dentistry: The provision of dental care for adult persons with one or
more chronic debilitating, physical or mental illness with associated
psychosocial problems. (D.C.N.A. 1989, Jan)
• Geriatrics: The branch of medicine or dentistry that treats the problems
peculiar to the aging patient, including the clinical problems of senescence and
senility. (D.C.N.A. 1989, Jan)

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• 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.” (D.C.N.A. 1989,
Jan)
• Ageing is manifested at all levels of life.
• 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.

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• Ageing occurs at different rates in different individuals.
• It is not a disease and does not generally cause symptoms.
• It causes cellular and physiologic deterioration.
• It decreases ability to adapt to stress.
• It causes impaired homeostasis.

According to DCNA
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Well, Elderly
• One or two minor
chronic medical
conditions:
Independent living
• E.g.- Osteoarthritis,
Hiatus Hernia
Frail, Elderly
• Co-existing minor
chronic, debilitated
medical conditions
with drugs:
• Independent living
support:
• E.G: Rheumatoid
arthritis,
constipation, ASVD,
Might use cane or
walker.
Functionally dependent
elderly
• Same as category II
but patient debilitated
to the extent that
independence is not
possible.
• Home bound or
institutionalized
• Eg: Patients are
Confined to
wheelchairs..
Severely disabled,
medically compromised
elderly
• Health status
deteriorated to the
degree it requires
constant maintenance,
skilled nursing facility
• Eg: Patient with end
stages Alzheimer’s
disease
• Patient with recent
brain stem trauma
• Patient with end stage
renal failure.

According to Sheldon Winkler
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• Hardy elder
• The Senile elder (The senile aged syndrome)
• Between these two extremes are millions of elderly.

The Hardy Elderly
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• Are those who are in excellent physical and psychological condition.
Characteristics:
• Active in business and community life.
• They quickly adapt to aging changes, they even are able to anticipate the
changes and accept them as a challenge.

The Senile Elder: (Senile Aged Syndrome)
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• They are disadvantaged physically and emotionally and may be described as
handicapped, chronically ill, disabled, infirm and truly aged.
• It is most common for them to become withdrawn, depressed, insecure and
dependent.
Characteristics:
• They have poor resistance to disease and cannot withstand the every day
stresses of life.
• They resist change, whether it is in their abode, clothing, and food or in any of
the amenities of routine life.
• They suffer from a host of disabling and crippling conditions.

According to W.H.O
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• Classifying geriatric people within certain age group allows for a more detailed
and accurate analysis of the diversity and makes diagnosis and treatment
planning more personalized.
• The following is a common classification of the elderly according to age group
• 60-65 years onset of the old age
• Initial (65- 74 years)
• Intermediate (75-89 years)
• Late (≥90 years).

According to Ettinger and Beck (1984)
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• Classified population into three broad functional categories to reflect their
ability to seek dental services
• Functionally independent older adults
• Frail older adults
• Functionally dependent older adults

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Functionally independent older adults:
• These adults live in the community unassisted and comprise about 70% of the
population over age 65 years.
• Many of these persons may have some chronic medical problems such as,
hypertension, type II diabetes, or osteoarthritis for which they are taking a
variety of medications.
• These older adults can access dental care independently using their own
vehicles or public transportation, if it exists.

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Frail older adults:
• These are those persons who have lost some of their independence, but still live
in the community with the help of family and friends who are using
professional support services.
• They make up about 20% of the population overage 65 years. These older
adults can no longer access dental services without the help of others.
• Their oral health needs require a greater understanding of medicine and
pharmacology and a careful evaluation of their ability to maintain daily oral
hygiene.

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Functionally dependent older adults:
• These are those persons who are no longer able to live in the community
independently and are either homebound(about 5% of population over 65) or
living in institutions (another 5% of population over 65).
• These older adults can only access dental services if they are transported to a
dentist’s office and many may use wheelchairs so the offices should be
wheelchair accessible.
• If they cannot be transported, then the services need to be brought to them
through mobile programs. (Domiciliary care)

Age changes in geriatric patient can be classified as
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PHYSIOLOGIC
• Loss of teeth
• Diminished senses of sight, hearing & taste
• Reactions to physiologic changes
• Reactions to social changes
PATHOLOGIC
• Metabolic
• Skeletal
• Muscular

MECHANISM & THEORIES OF
AGEING
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• Various theories are put forward, none adequately explains the various
manifestations
• Programmed ageing
• Error accumulation & mutation
• Reactive oxygen & free radicals
• Immunological theory
• Neuro-endocrine system theories

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Programmed ageing
• This theory contends that the life span of a cell or tissue is programmed into the
genome. It is supported by the fact that fibroblasts, grown in culture can only
undergo mitosis a finite number of times.
• This theory assumes that initially well ordered genetic programs becomes
progressively disordered resulting in those changes recognized as aging.
Error accumulation & mutation :
• Mutation is a result of faulty transcription of DNA during cell division.
• Results from irradiation, exposure to chemicals or other factors.
• Result in production of faulty enzymes or proteins, such error accumulation is
basis for ageing

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Reactive oxygen & free radicals
• During metabolism of normal & foreign compounds, reactive oxygen species
(peroxides & super peroxides) & free radicals (highly reactive molecular
fragments) may form.
• Damage nucleic acids, proteins, membranes & other critical cellular structures.

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Immunology:
• The immune theory hinges on two main findings:
1. The functioning of immune system declines qualitatively and quantitatively
with age.
2. With the declining of normal immune system, it becomes less able to
discriminate between self and non-self, resulting in an increase in
autoimmune disease. (This results in an increase in incidence of chronic
autoimmune diseases that is characteristically associated with aging.)

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Neuro endocrine system theory:
• The neurological and endocrine systems influence all the tissues of the body.
• For instances, a disturbance in hypothalamic function may result in pituitary
malfunctioning, the ramification of which would effect all the major endocrine
glands e.g.: menopausal steroid loss may lead to conditions necessary for
osteoporosis.

Various factors are as follow
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• Genetic factors
• Mutation
• Species specific life spans
• Sex, parental age
• Pre mature ageing syndrome
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

BODILY CHANGES ASSOCIATED
WITH AGEING
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Body Composition
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• Advancing age, with or without illness, results in significant changes in body
composition.
• As age advances, there is a steady decrease in lean body mass (muscle mass)
of about 6.3% for each decade of life. This loss in lean tissue, however, is
accompanied by an increase in body fat and decrease in total body water.

Skin & Appendages
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• Skin wrinkles & sags due to subcutaneous fat reduction, increased collagen &
fragmented inelastic elastin.
• To eliminate these wrinkles, the patient frequently request the dentist to place
the artificial teeth in undesirable positions to the support, to overextend/over-
contour the borders or to decrease the interocclusal distance.
• Blood capillaries become more fragile & rupture lead to purpura.
• Hair greys because of decreased pigment production by follicle & nail growth
reduces to one-half.

Heart & Blood Vessels
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• Collagen in vessel wall increases & elastin becomes less elastic.
• Arteries become stiffer & systolic BP & pulse pressure rises.
• Arteriosclerosis is commonly seen.
• Hypertrophy of heart may be seen & fibrosis develop.
• Heart valves become stiffer.
• If coronary disease is absent, cardiac output is well maintained.

Lungs
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• Changes in pulmonary physiology seen in non-smokers also
• Vital capacity falls, with increase in residual volume
• Thoracic compliance is decreased & lead to fall in maximal respiratory
capacity.
• Coughing not efficient & ciliary function in bronchial epithelium decreases,
may lead to lower respiratory tract infections.

Gut & Liver
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• Decreased acid output.
• Absorption of iron, calcium & sugar decrease
• Esophageal motility may be disorganized & lead to swallowing problems, &
hiatus hernias seen
• Large bowel motility decline & constipation & diverticulosis are frequent
• Liver tends to shrink and decreases blood flow

Kidneys
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• Renal function decreases, with a fall in nephron numbers of between 30% &
40% from 25-85 years.
• Renal blood flow, GFR & tubular function decline.
• Renal drug excretion decreases.

Blood
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• Blood volume & RBC survival do not alter.
• Anemia due to iron or vitamin deficiency or disease.
• WBC & differential count is unaltered.
• Decreased T-cell count.

Muscles
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• Muscle mass & power decline.
• Arthritis, especially osteoarthritis is common.
• Muscle activity lacks coordination & mandible appears to drop slightly more in
protruded position.
• Fibrous tissue replace some of the muscle fibers.
• Decrease in nerve conduction, loss of muscle tonus; slowing down of muscle
activity; lack of moisture in skin; & lack of muscle coordination all influence
the recording of maxilla-mandibular relations

Changes in function of mastication and deglutition
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• Most frequent oral motor disturbance in older persons is related to mastication.
• Masticatory ability is further decreased in those who are partially or fully
edentulous.
• Biting force is said to be decreased by 16% of its original value in older
patient.
• Ultrasound imaging has estimated the oral and pharyngeal phases of
swallowing to be longer in older than younger adults.
• The biting force reduces from 300lb/in2 to 50lb/in2 with age.
• Lip seal is less efficient in older subject.
• Swallowing time is increased by 25 to 50% in subjects over age of 55years.

Bones
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• Bone density declines with age. After peak bone age is achieved, usually
between 30 and 40 years of age, bone loss begins to occur, as bone resorption
exceeds bone formation. Bone adapts to meet the functional demands.
• Blood capillary walls supplying the bone thicken because in old age, bone
derives its nutrition mainly from periosteal blood supply.
• Histologically there is decrease in bone forming cells.
• Imbalance between resorption & replacement of bone in Haversian systems.

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• Gradual increase in diameter of bones & similar changes in skull and internal
architecture of bone.
• Increase in the porosity of bone.
• Bones become less dense, more brittle, and there is increase in micro fractures.
• Osteoblasts deprived in number & activity.
• Imbalance between osteoclastic & osteoblastic activity exacerbated by
withdrawal of estrogen during menopause.
• Decrease in circulatory level of hydroxylated Vitamin-D3, impairs Ca
absorption.

Endocrine Glands & Metabolism
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• In women, the menopause results in decreased estrogen levels, may lead to
osteoporosis & high level of pituitary gonadotrophins.
• Glucose tolerance is impaired
• Response to glucose load is impaired, non –insulin dependent diabetes occurs
commonly.

Nervous system & senses
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• Loss of neurons in cortical areas & cellular inter connections.
• Cerebral blood flow decrease significantly.
• Decrease in mental capacity to remember recent events, new names & new
places; but recall of the past events & places seem less impaired.
• During conversation geriatric patients may distress/bore their listeners by
repeating the same incidents many times & there’s no correction for the same
• Eye, lens become thicker & less pliable.
• Hearing is impaired, high tones in men over 60
• Smell, taste, touch sensations all decline

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• In general, visual and hearing activity declines with age.
• These changes can indirectly affect nutritional intake through altered food
purchasing and preparation behaviors.
• Loss of hearing can result in a self-imposed restriction on social activities such
as eating out or asking questions in grocery stores.
• In addition to visual and hearing activity, smell and possibly taste declines with
age.

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• Olfaction is the act of perceiving odors and Gustation is the taste perception.
• In contrast with gustation, olfaction can be stimulated by extremely low
chemical concentrations.
• Denture wearers, do exhibit a significant decrease in their ability to decipher
differences in sweetness of certain foods, along with hardness and texture.
• This decrease in the sensory aspect of the food can result in a decrease in food
consumption because tasteless, odorless food most likely will not be eaten.

Alveolar bone
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• The supporting bony tissues will undergo resorption to a greater or lesser
degree, with the potential for excessive atrophy constantly present.
• The crest of the residual alveolar ridge is usually found to be concave or flat
and can terminate in a “ knife edge.”
• In some geriatric patients extensive resorption of the mandibular alveolar ridge
may place the mental foramen at or near the crest.
• The geriatric mandible, as a result of senile atrophy, will exhibit a decrease in
surface area with a corresponding reduction of the denture bearing area.

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• The origins of the mentalis and buccinator muscles will migrate inward toward
the receding crest of the ridge.
• The origins of the mylohyoid and buccinator muscles can actually be above the
crest of the ridge when marked senile atrophy has occurred.
• The presence of a denture on an exposed mental nerve emerging from the
mental foramen can cause pain and paresthesia of the lower lip and chin.

TMJ
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• Old-age changes can result in:
• Partial or complete forward displacement of the disc
• Disc perforation
• Ankylosis
• Cyst formation in the disc
• Disc delamination in the horizontal plane
• Decrease in the joint size
• Demineralization
• Chondrocyte accumulation
• Reduction in the mandibular head
Katarzyna Romanczuk Prosthodontic rehabilitation of the elderly – a literature review . Clin Exp Med Lett 2008; 49(4):
203-206

Saliva & Salivary Glands
48
• Elderly secrete lower quantity of saliva both at rest & in response to stimuli of
talking & eating.
• Due to loss of salivary flow, difficulties in speech & swallowing, caries,
mechanical trauma to mucosa & microbial infection occurs.
• Salivary epithelial degeneration, atrophy, loss of acini & fibroblasts occur with
increasing frequency & severity as age increases.
• Total amount of secretory tissue in parotid is gradually replaced by fibro-fatty
tissue.
• Minor salivary glands show degenerative structural changes & losses of
glandular epithelium.

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• Since saliva lubricates the oral mucosa, the lack of saliva creates a dry and
often painful mucosa. Without significant salivary flow, food debris will
remain in the mouth, where it is fermented by dental plaque bacteria to organic
acids that initiate the dental caries process.
• In addition, lack of saliva can affect the nutritional status in a number of ways;
1. It hinders the chewing of food because it prevents the formation of a bolus.
2. It makes the mouth sore and chewing painful.
3. It makes swallowing difficult due to the loss of saliva’s lubricating effect.
4. It can cause changes in taste perception that decreases adequate food intake.

Oral mucosa
50
• Surface of oral cavity is made of mucous membrane and its structure varies in
apparent adaptation to function.
• According to Massler- tissue friability arises from three sources:
1. A shift in water balance from the intracellular to the extracellular
compartment and diminished kidney function results in dehydration of the
oral mucosa.
2. Progressive thinning of the epithelial layers which increases tissue
vulnerability to mild stress.
3. Nutritionally deficient cell.

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• Even under the best circumstances, the cells of the aged do not enjoy the
optimal nourishment and vitality of youthful cells. The results are
• Reduced cohesiveness and integrity of the epithelial layer due to vitamin A deficiency.
• Reduced metabolism of the cells due to a Vitamin B deficiency.
• Poorly differentiated connective tissue cells and fibers due to Vitamin C deficiency.
• The clinical result is that the mucosa is susceptible to even minor irritating
stress and connective tissue that heals slowly.
• The atrophic mucosa of elders is frequently thin and tightly stretched and it
blanches easily.
• Lammie (1960) believes that a mucosa of reduced thickness is associated with
reduced residual ridge height.

52
• 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 and the contracting
mucosa acts as a molding 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 favorable oral environment for the dentures.

Tongue
53
• Probably the most common manifestation of aging of the tongue is
depapillation, which usually begins at the apex and lateral borders.
• Tongue frequently becomes smooth and glossy or red and inflamed in
appearance.
• The size of the tongue probably does not vary with age. However tooth loss can
lead to a wider tongue by virtue of its overdevelopment of some parts of the
tongues intrinsic musculature.

54
• It loses its usual muscle tone and offers less resistance when palpated bi-
digitally.
• Glossodynia and glossopyrosis are common complaints in geriatric patients.
• The elderly patient who lives on a “tea and toast” diet is a prime candidate for
iron deficiency anemia. 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.

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• Lingual tissue changes are commonly associated with alterations in the taste
sensation.
• This diminished activity of taste can be because of gradual nerve degeneration
and / or hyperkeratinisation of the epithelium which may occlude the taste bud
ducts and pores.
• Vitamin-A deficiency may be associated with such epithelial
hyperkeratinisation.

Teeth
56
Teeth
Enamel
Cementum
Dentin
Pulp
PDL

Enamel Changes
57
• Attrition
• Change in permeability
• Discoloration

Attrition
58
• Attrition may be defined as the physiologic wearing away of a tooth as a result
of tooth-to-tooth contact, as in mastication.
• This occurs only on the occlusal, incisal, and proximal surfaces of teeth, not on
other surfaces unless a very unusual occlusal relation or malocclusion exists.
• This phenomenon is physiologic rather than pathologic, and it is associated with
the aging process.
• The older a person becomes, the more attrition is exhibited.

Change in Permeability
59
• Young enamel acts as a semi-permeable membrane and permits slow passage
of water and molecular substances through the pores between the crystals.
• With age the enamel crystals grow in size and the pores between them is
obliterated resulting in reduced permeability of the enamel.

Discoloration
60
• Normal colour: white to yellowish white.
• With age darkening is observed.
• Thought to be because of:
1. Loss of enamel rods alters the light reflection of enamel and results in tooth color
change.
2. Deepening of dentin color seen through progressively thinning layer of enamel.

Dentinal Changes
61
• The main changes in dentin associated with aging are
• Increase in sclerotic dentin.
• Increase in the number of dead tracts.
• Increase in formation of reparative and reactive dentin.

Dead Tracts
62
• In normal dentin the odontoblastic processes may disintegrate and the empty
tubules get filled with air. These are called dead tracts.
• They appear black in transmitted light and white in reflected light.
• In narrow pulpal horns degeneration of odontoblast is seen due to crowding of
odontoblasts.
• It is thought to be the initial step in the formation of sclerotic dentin.

Sclerotic Dentin
63
• Refers to the dentinal tubules that have become occluded with calcified
materials.
• It may be result of the aging process and called physiologic dentin sclerosis or
may occur due to some irritation like caries, attrition, abrasion and called
reactive dentin sclerosis
• When this occurs in several tubules in the same area , the dentin assumes a
glassy appearance and become transparent.
• Most common in apical 3rd of the root.
• It appears transparent or light in transmitted light and dark
in reflected light.

Reparative –Reactive Dentin
64
• If the provoking stimulus cause destruction of the original odontoblasts, the
new, less tubular dentin formed by newly differentiated odontoblast like cells is
called reparative dentin.
• However if the odontoblast survive the provoking stimuli the dentin produced
by them is called reactionary dentin.

Cementum Changes
65
• Hypercementosis .
• Cementicles.

Hypercementosis
66
• It is a non-neoplastic condition in which excessive cementum is deposited in
continuation with the normal radicular cementum.
• Hypercementosis may be regarded as a regressive change of teeth characterized
by the deposition of excessive amounts of secondary cementum on root
surfaces.
• This most commonly involves nearly the entire root area, although in some
instances the cementum formation is focal, usually occurring only at the apex of
a tooth.

Cementicles
67
• Cementicles are small foci of calcified tissue, not necessarily true cementum,
which lie free in the periodontal ligament of the lateral and apical root areas.
• The exact cause for their formation is unknown, but it is generally agreed that
in most instances they represent areas of dystrophic calcification and thus are
an example of a regressive or degenerative change.

Pulp
68
• The dental pulp in teeth of old individuals differs from that in young teeth by
having:
1. More fibers
2. Less cells
• The blood supply apparently decreases with age, at least, the number of
arteries entering the apical foramen does.
• Presence of pulp stones has been attributed to pathological changes, but they
have also been considered as age changes.

PDL
69
• Periodontal connective tissue becomes denser and coarsely textured upon
aging. A decrease in the number of fibroblasts occurs.
• Calcification occurs on and between the collagen fibers in old individuals.
• With aging collagen fibers becomes more stable showing increased thermal
stability, insolubility and mechanical strength.
• The width of periodontal ligament increases with age due to excessive occlusal
loading and that a decrease in the width of PDL is observed with advancing
age due to continuous deposition of cementum on root surface or if the tooth
is unopposed (Hypofunction)

MOST COMMON DISEASES OR MEDICAL
CONDITIONS ENCOUNTERED IN GERIATRIC
PATIENTS
70

Diabetes Mellitus
71
• In case of patients with diabetes mellitus, loss of teeth due to mobility or
periodontitis is the most commonly seen condition.
• Schedule and plan short appointments preferably in the morning hours and
ensure patient is not fasting to avoid hypoglycaemic syncope's.

Hypertension
72
• Hypertension is a long term medical condition in which blood pressure in the
arteries is persistently elevated.
• The history of hypertension and drugs used should be enquired if extraction is
planned followed by denture fabrication or implant treatment.
• Avoid any invasive procedure without obtaining fitness from the physician.

Depression
73
• For the aged themselves, these are frustrating years. They realize that they are
beyond their productive peak and many of their goals, ideals, ambitions, and
hopes can never be attained.
• As certain physical attributes decline, others becomes stronger.
• Memory may decline, but judgment may improve with age. Experience, being
dependent on time, inevitably increase with age.
• Retirees should be encouraged to participate in creative activities as long as
they are able, especially in the social, economic and political life of their
community.

74
• Lonely patients can turn to the dentist for aid in their never ending struggle
against illness and old age.
• Weekly and monthly appointments can become the most significant aspects of
their live.
• It gives them a reason for having to do something or go somewhere and they
look forward to it.
• A sympathetic word when inserting dentures into the mouth often does
wonders.

Osteoporosis
75
• It is a disorder that adversely affects the collagen metabolism with concomitant
decrease in bone mass.
• It is due to negative calcium balance.
• Common in females.
• Reduces the bone mineral content of jaws and associated with periodontal
attachment loss and tooth loss.
• One of the reason for increased residual ridge resorption.

Residual ridge resorption
76
• With age, number of teeth present in the oral cavity decreases, so the force
acting on the remaining teeth is more.
• The changes in the alveolar processes of edentulous persons are more marked.
• In the first year after tooth extraction reduction of height in the mid sagittal
plane is about 2 to 3 mm for maxilla and 4 to 5 mm for mandible.
• Decrease in vertical dimension at occlusion occurs.

77
• Decrease in lower facial height. Annual rate of reduction in height is 0.1 to
0.2mm and in general four times less in edentulous maxilla.
• Etiology:
• Anatomic factors
• Short square face related to elevated masticatory forces
• Alveoloplasty
• Intensive denture wearing
• Unstable occlusal conditions metabolic and systemic factors
• Osteoporosis
• Calcium and vitamin D supplements

78
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
• Thus the maxilla becomes smaller in all dimensions and the denture bearing
area (basal seat) decreases.
• Maxillary bone resorbs on the crest and labial and buccal cortices.
• Thus, maxillary ridge loses height and becomes narrower in transverse and
antero-posterior direction. Resorption towards the center.

79
Changes in Mandible
• The mandibular ridge resorbs primarily on the crest of the ridge.
• Because the mandible is wider at its inferior border than at the residual alveolar
ridge in the posterior part of the mouth, resorption, in effect, moves the
opposite sides of the ridges farther apart.
• Mental foramen with the resorption of the alveolar process lies at or near the
level of the upper border of ridge.

80
• Genial tubercles project above the upper border of the mandible in the
symphyseal region.
• The residual alveolar ridge becomes wider with resorption.
• Resorption away from center.

Xerostomia
81
• Xerostomia is the subjective feeling of dry mouth, is a symptom most
frequently associated with alterations in the quality and quantity of saliva
resulting from poor health, certain drugs, and radiation therapy.
• The normal saliva secretion is
• 0.3 mL/min at rest
• ≥3 mL/min when salivation is stimulated
• total daily salivary production is 500– 600 mL

Etiology
82
• Salivary gland agenesis
• Injury to the salivary glands
• Radiotherapy (RT) of the head and neck
• Autoimmune Diseases (i.e. Sjogren’s syndrome, systemic lupus erythematosus,
rheumatoid arthritis, scleroderma,etc)
• Viral infections (i.e. cytomegalovirus, HIV, hepatotropic viruses)
• Sialolithiasis
• Diabetes mellitus
• Aging
• Bacterial infections (i.e. Staph. aureus, Strep pyogens, E. coli)
• Mechanical peripheral nerve injuries
• Autonomic system dysfunctions (e.g. neuropathy of the trigeminal ganglion)

83
• Oral sensory impairment, disorders causing difficulties in chewing and
swallowing (e.g. glossopharyngeal nerve palsy)
• Psychogenic factors or mental illness (e.g. anorexia, depression, schizophrenia)
• Side-effect of medications (e.g. tricyclic antidepressants, antihypertensive
medications, antispasmodic drugs)
• Mouth breathing ,dehydration
• Decreased fluid intake
• Loss of water through the skin (i.e. fever, excessive sweating)
• Loss of water through the alimentary tract (i.e. vomiting, diarrhea)
• Excessive diuresis
• Nutritional deficiencies and/or eating disorders anorexia/bulimia
• Idiopathic xerostomia

84
• The most common medications causing hyposalivation are those with
anticholinergic activity, sympathomimetics, and benzodiazepines. Medications
that can cause xerostomia include:
• Cytotoxic Drugs;
• Anti-cholinergic Agents (i.e. atropine, atropinics, hyoscine)
• Anti-reflux Agents (i.e. proton pump inhibitors e.g. omeprazole)
• Sympatho-mimetics (Ephedrine)
• Anti-hypertensives α1 antagonists (e.g. terazosin and prazosin), α2 agonists (e.g.
clonidine), and β-blockers (e.g. atenolol and propranolol)
• Diuretics.

Management
85
• Sialagogues -Pilocarpine, Neostigmine
• Mucolytic Drugs - Ambroxol, Bromhexine
• Saliva Secretory Agents
• Dietary Supplements
• Fruits; Plums, Apples, Lemons, Olives, Lozenges With Lemon Juice
• Salivary Substitutes
• Carboxymethylcellulose, Mucin, Glycerin, Sodium, Potassium, Calcium,
Magnesium, Chloride and some enzymes

86
• Acupuncture Neuro-electro Stimulation
• Para sympathomimetic agent – Pilocarpine, Cevimeline
• Dietary modification steps include avoiding dry or acidic foods, accompanying
dry foods with frequent sips of water, and limiting caffeinated or alcoholic
beverages that cause dehydration and oral dryness

88
General consideration:
• In general, elderly people use 30% of all prescribed medications. 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.

89
Compliance :
• The number of different drugs prescribed, and
• 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
patients.

90
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.

91
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.
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 decreases with advancing
age. This causes an increase in unbound fraction of drugs and influence the
distribution of drugs.
• In aged  3.5 g/dl.
• Young adults  4-4.5 g/dl.

92
Metabolism:
• The hepatic blood flow decreases with age and the rate of metabolism of high
clearance drugs such as propranolol and lidocaine whose elimination are highly
flow dependent, is reduced in the elderly.
• The elimination of low clearance drugs depends primarily on the activity of the
hepatic microsomal drug metabolizing enzymes. The enzyme activity per unit
of liver also decreases with advancing age.

93
Renal excretion:
• Renal function evaluated on 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 elimination.

CONSIDERATIONS OF TREATMENT
PLANNING IN GERIATRIC PATIENT
94

95
Provision of dental care for the old patient may be made in following
sequence ;
• Assessment & provisional treatment plan
• Primary care
• Definitive treatment plan
• Secondary care
• Tertiary care

96
Assessment
• Basis of sound treatment planning is the recording of high clinical records at
initial assessment visit.
• Comprises results of a detailed clinical dental examination, including a
periodontal & occlusal assessment, impressions of study casts & radiographic
investigations.
• After this 3 factors are taken into consideration:
• What patient wants
• What patient can tolerate
• What can be achieved

97
Provisional treatment plan:
• For many old patients, treatment consists of continuation of routine care, with
likely increasing problems of management.
• 4 possibilities of treatments are taken into consideration:
• Fixed crown & bridge work
• Limited use of crowns in association with a partial denture to restore edentulous spaces
• Construction of overdentures
• Clearance & provision of complete dentures

98
Principles of provisional treatment planning:
• Teeth reduced to gingival level as a result of wear, or caries, are often used as
overdenture abutments.
• In cases where anterior teeth are extensively worn & there is a loss of posterior
support, increase in vertical dimension upon edentulous spaces alone should not
be done, in order to create space for anterior reconstruction.
• It is difficult to achieve a good standard of colour match & aesthetics if length
of worn front teeth is increased by partial overlay denture.
• Severely periodontally involved tooth should not be used to support or retain a
partial denture.
• Decision should be taken carefully before extracting teeth as it is irreversible.

99
Primary care
• Includes initial relief of pain, management of periodontal disease & oral
hygiene instructions, the identification & treatment of factors causing
deteriorations in dentition.
• Treatment of caries & restoration.
• TMJ & musculature examination, signs & symptoms of dysfunction identified
& treated.

100
Definitive treatment plan
• After primary care clinician is able to assess the patient’s oral status.
• Initial treatment plan is reassessed & a definitive treatment plan is formulated.
• Clinician assesses the type of restoration appropriate for any tooth &
determines the crown lengthening procedures
Secondary care
• Considerations taken while planning restorative care are 2 types :
• Those which relate to whole mouth, particularly occlusion
• Those related to individual tooth

101
Tertiary care
• Is a fundamental & often highly problematical stage in long term management
of the ageing patient.
• Comprises of 3 parts ;
• Prevention
• Monitoring
• Maintenance

DIET AND NUTRITION IN
GERIATRIC PATIENTS
102

103
• Enjoyment of food is regarded as an important determinant of an adult’s
quality of life. Mobile teeth, ill-fitting complete denture prosthesis or
edentulism may preclude eating favorite foods, as well as limit the intake of
essential nutrients.
• Decreased chewing ability, fear of choking while eating, and irritation of the
oral mucosa when food particles get under the dentures may influence food
choices of the denture wearers.
• Conversely, a complete denture prosthesis depends ultimately on the health &
the integrity of the denture bearing tissues for successful function and the
comfort of the patient.

104
• If the denture bearing tissues are nutritionally deficient, the prosthesis will be
uncomfortable with the complaints of the wearer, no matter how well
constructed.
• Malnourished denture bearing tissues probably accounts for as many denture
failures, as do the imperfect designs to resist for forces of occlusion.
• This is especially true in the later middle years and the elderly, the major
recipients for all the types of complete denture prosthesis.

5
Factors affecting nutrition
Physiological
Psychosocial
Functional
Pharmacological
Age related change
in taste and smell
Yogeshwari Krishnan et al. Nutritional and prosthodontic care for geriatric patients International Journal of Oral Health Dentistry; July-

Physiological factors
106
• With a decline in lean body mass in the elderly, caloric needs decrease and risk
of falling increases.
• Vitamin D deficiency in turn, is a major cause of metabolic bone disease in the
elderly.
• Decline in gastric acidity often occur with age and can cause malabsorption of
food-bound Vitamin B12.
• Many nutrient deficiencies common in the elderly, including zinc and Vitamin
B6, seem to result in decreased or modified immune responses.
• Dehydration, caused by declines in kidney function and total body water
metabolism, is a major concern in the older population.

Psychosocial factors
107
• 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 nutritional status of geriatric patient .

Pharmacological factors
108
• 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..

Food Guide Pyramid
109
• Russell et al. in 1999 suggested Food Guide Pyramid and the modified Food
Guide Pyramid for adults more than 70 years of age. This was recommended
for dietary needs of older adults.

110
• In 2008, Lichtenstein et al. suggested MyPyramid which recommended the placement of
physical activities at the bottom of pyramid. More physical work will lead to more
consumption of food which means better intake of nutritional supplements. Physical activity
also helps maintaining muscle mass with increasing age
Singh, et al. Nutrition in edentulous geriatric patients Journal of Oral Research and Review. 2018;4(1): 5

Recommended Daily Allowance
111

Physical signs of Nutrient Deficiencies
112
Nutrients Physical Signs
Protein Edema •Dull, dry, sparse, easily plucked hair •Parotid gland enlargement, •Muscle
wasting
Iron Pallor •Pale, atrophic tongue •Spoon nails •Pale conjunctiva
Niacin Nasolabial seborrhea •Fissuring of eyelid corners ••Papillary atrophy •Pellagrous
dermatitis •Mental confusion
Riboflavin Nasolabial seborrhea •Fissuring and redness of eyelid corners and mouth •Magenta
colored tongue •Genital dermatosis
Thiamine Mental confusion, •Irritability, •Sensory losses •Loss of ankle and knee jerks, •Calf
muscle tenderness, •cardiac enlargement

113
Nutrients Physical Signs
Pyridoxine Nasolabial seborrhea, •Glossitis
Vitamin A Bitot’s spots (eyes), •Conjunctival and corneal xerosis
(dryness) •Xerosis of skin, •Follicular hyperkeratosis
Vita B 12 & Folic Acid Glossitis, •Skin hyper pigmentation
Ascorbic acid Spongy, bleeding gums, •petechiae, •painful joints
Iodine Goitre
Vitamin D Bow legs •Beading of ribs

Teaching The Patient To Masticate With The New Prosthesis
114
• The ability to manage the physical consistency of food can be easier for a new
denture wearer if an analysis of the jaw movements involved in mastication is
made. The process of eating actually involves three steps; biting or incising;
chewing or pulverizing; and, finally swallowing.
• Incision of food involves a grasping and tearing action by the incisor teeth-
requiring opening the mouth wide, an action that can cause dislodgment of the
denture by the pulling action of over-tensed muscle.
• When the leverage force of the incising action is exerted in the anterior segment
of the mouth, the only equal and opposite force to prevent dislodging the
denture is the seal created by the post-dam compressive force of the denture on
the soft palate.

115
• The counter dislodgement forces in the incising action are not effective as, for
example the balancing forces of the occlusal surfaces of the bicuspid and
molars used in the chewing process. This makes the first step, the incising
action the most difficult of all three masticating actions.
• The chewing and pulverizing of the bolus of the food by the molars and
bicuspids are less difficult than incising, but still, the coordination of the many
muscles of mastication that produce the hinge and sliding movement of the
mandible during eating requires some experience.
• The easiest and least complex step in the eating process is that of swallowing
for new denture wearers.

Diet After Insertion Of Complete Denture Prosthesis
116
• On the first post insertion day: A new denture wearer can choose from the
following foods, which are essentially liquids and are arranged according to the
four basic food groups.
• Vegetable fruit group; juices
• Bread cereal group; gruels cooked in either milk or water
• Milk group; fluid milk may be taken in any form
• Meat group; for the first day or so eggs will be the first food choice

117
• On the second and the third post insertion days: the denture patient can use
soft foods that require a minimum of chewing.
• Vegetable fruit group in addition to fruit and vegetable juices, tender cooked
fruits and vegetables (skin and seeds must be removed) cooked carrots, tender
green beans.
• Bread-cereal group: cooked cereals such as cream of wheat and softened
bread; boiled rice.
• Milk group; fluid milk
• Meat group: chopped beef, ground liver, tender chicken or fish in a cream
sauce; eggs may be scrambled or soft cooked.

118
• By the fourth day: Or as soon as all the sore spots have healed, in addition to
the soft diet, firmer foods can be eaten.
• In most instances, these foods should be cut into small pieces before eating.
• In general it has been found that raw vegetables and sandwiches are the foods
least preferred by denture wearers.
• In fact, raw vegetable requires more force during mastication to prepare them
for swallowing than most other foods.
• Therefore if the denture patient is able to manage salads, the ultimate in denture
success and patient achievement will have been realized.

PROSTHODONTIC CONSIDERATIONS FOR
COMPLETELY EDENTULOUS PROSTHESIS
IN GERIATRIC PATIENT
119

Clinical Considerations
120
• It is better to retain the natural teeth for as long as possible and eventually
accept the complete dentures with their decreased efficiency.
• The longer a patient retain some of his natural teeth, the shorter the time he
will be edentulous and better the residual ridges will be.
• The patient must realize his need for prosthetic treatment, want dentures,
accept the prosthesis and attempt to learn to use it. This is ensured by constant
counselling to the patient in every visit.

Complete Denture Construction
121
Impressions
• Prior to making edentulous impression for geriatric patients, the denture
bearing tissues must be thoroughly examined.
• Although it is true that age tolerance change badly and it is wise to avoid major
changes, this does not mean that new dentures should be under extended, no
matter how short the patients old dentures were.
• The finished dentures should be as large as possible within the functional
limitation of the patients with no impingement on functional borders, hence full
depth impressions should be made.

Vertical Dimension
122
• With the geriatric patients, much more time and efforts are required to ensure
an accurate physiologic recording. The interocclusal distance increases with
age.
• The falling-in of the lips, due to loss of adequate support and muscle tone,
complicates the difficulty of determining vertical dimension.
• Geriatric patients needs more than the average 3-mm inter occlusal distance of
the young adult with a full complement of teeth.

123
• If severe difficulty exists in the determination of vertical dimension, the
patient’s old dentures, if available, can be used as a guide.
• In some elderly patients, even though the vertical dimension is carefully and to
the best of our knowledge correctly determined, “clicking” of the dentures may
still occur because of muscular incoordination or habit.

Centric relation
124
• The correct recording and duplication of centric relation is paramount to the
success of complete denture.
• A prognathic position of the mandible with a resultant convenience eccentric
bite is often acquired by the geriatric patients, usually the result of a closed
occlusal vertical dimension.
• The patients must be seated in an upright position, if at all possible, before
centric relation can be recorded.

Posterior tooth selection
125
• The posterior teeth are responsible for the occlusion of a complete denture.
• The arrangement of the posterior teeth plays a significant part in the retention
and stability of the dentures and the condition of the supporting tissues.
• Several non anatomic modification of posterior tooth forms constructed wholly
or partially of chromium cobalt alloy are available that are claimed to be
advantageous for patients with less than average closing pressure and where it
is necessary to reduce the force of the denture on the bearing surface during
function.

126
• Many prosthodontics recommend zero degree posterior teeth for the
edentulous geriatric patients.
• Hardy has designed blocks of upper and lower acrylic posterior teeth in which
curved metal cutting blades are embedded.

Insertion and post insertion visits
127
• The soft tissue pain threshold changes greatly after menopause and the male
climacteric, with an increase in the sensitivity, which according to Vinton,
frequently reaches the magnitude of 400%.
• The geriatric patients should be seen the day after insertion or, at the latest, the
second day.
• If the patients is a new complete denture wearer, mastication of firm food
should not be attempted until the denture can be worn comfortably and speech
presents no problems.

128
• During the adjustment visits, the patients should be asked for pointing out areas
of soreness. However, patients are poor judges and usually cannot locate exact
areas of discomfort.
• Geriatric patients can remove one or both dentures during the day if their
mouth feel tired after the adjustment periods.
• If the patients is unable to care for his denture or is afraid to try because of the
fear of dropping and breaking them, oral hygiene will be entirely dependent on
another person.

Overdentures
129
• In geriatric dentistry treatment with overdenture is particularly relevant in
following cases.
1. In patients with clinical signs of muscular hyper function of masticatory
apparatus e.g. severe attrition, bruxism.
2. In patients where there is no overt signs of decreased vertical dimension of
occlusion but where in increase of the vertical dimension of occlusion is
indicated to create sufficient space for a denture.
• By utilizing teeth to retain the prosthesis, alveolar bone is preserved.

130
• Through the retained roots, sensory feedback and proprioception are
maintained, helping to provide an awareness of jaw-space relationships and
improving chewing efficiency.
• Saving some of the remaining natural teeth can convey huge psychological
benefits to the patient.
• 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.

Immediate Complete Denture
131
• 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.

132
Advantages:
• It is advantageous if 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.
• 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 injury.
Contraindications:
• 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.

PARTIALLY EDENTULOUS PATIENTS IN
GERIATRIC PATIENTS
133

134
Need for rehabilitation with removable partial dentures:
• Removable partial dentures may be indicated in elderly patients in order
• To restore esthetics or phonetics
• To improve mastication
• In Patients with significant signs and symptoms of TMJ-disturbances and
extensive loss of teeth.
• In a jaw opposing a complete denture to increase functional stability of the
complete denture

135
General principles for partial denture design for elderly :
• Denture teeth should be placed as near as possible to the position of their
natural predecessors.
• Existing intercuspal position should be maintained unless there is harmful
displacement of mandible on closure from muscular contact position to
intercuspal position
• Unnecessary coverage of the marginal gingiva by the denture base, or minor
connectors should be avoided.
• Muscle adaptation to the prosthesis should be facilitated by proper contouring
of the denture base.

136
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. 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.

137
• 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.
• 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.

138
• 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.

FIXED PROSTHESIS IN GERIATRIC
PATIENTS
139

140
• 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.

141
• The following documentation is generally needed for successful treatment
planning, especially in a patient with multiple problem:
1. A set of full mouth intraoral radiographs.
2. A complete chart of the periodontal status including pocket probing depths
and levels of probing attachment.
3. An assessment of the caries activity, prevalence, incidence and history.
Special emphasis should be given to root surface caries.
4. An evaluation of pulp vitality of all teeth.
5. An analysis of the occlusion and function of the masticatory system.

142
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 is
administered.
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 planning.
“Hopeless” teeth are extracted.

143
3. Corrective Phase :
• This includes further periodontal treatment, endodontic therapy, restoration of
teeth with alloplastic material and finally fixed prosthesis is delivered
• Occasionally, occlusal therapy, such as the application of a bite splint followed
by occlusal adjustment.
• 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.

144
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.
• 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 less.

Conditions which contraindicate Fixed Prosthodontics in older adult are
145
• Pulpal stenosis
• Extensively restored tooth surfaces
• Root exposure from gingival recession
• Incisal attrition penetrating the enamel
• Cervical caries/erosion/abrasion
• Uncompensated posterior tooth loss
• Compromised oral hygiene skill

IMPLANT PROSTHESIS IN GERIATRIC
PATIENTS
146

147
• The purpose of the oral implant is to create stable retention of prosthetic appliances.
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 rehabilitation of geriatric dental patients.

148
Surgical and medical aspects for implant treatment in geriatric patients:
• 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 anesthesia. 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. Aseptic surgical
procedures should be followed to prevent postoperative complications.

149
• 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.
• 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.

150
Indications for treatment with implants in the aged are as follows:
• 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 tumor resection.
• Disturbed innervation of the oral and perioral muscles following trauma of cerebrovascular
diseases.
• Functional disturbances, preventing the patient from wearing prosthetic devices
due to,
• Age related adaptation difficulties to dentures.
• Severe nausea and vomiting reflexes
• Psycho-social inability to accept a prosthetic device in spite of adequate
morphological and functional prerequisites.

151
Contra indications:
• Insufficient residual bone volume with poor quality.
• Lack of motivation for treatment with implants and 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 programs.

152
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. Osseo integrated titanium implants ad modum Branemark especially suitable
for edentulous cases.
2. Endosseous implants of aluminum oxide ceramics ad modum Schulte for single
tooth loss.

MAXILLOFACIAL PROSTHESIS IN GERIATRIC
PATIENTS
153

154
• Since there is a significant correlation between the aging process and incidence
of head and neck oncology, emphasize on cancer of head and neck cannot be
ignored.

Defects of Maxilla
155
• Hard and soft palates rank fourth with respect to tumor occurrence.
• Generally 3 series of obturators are prescribed
1. Surgical obturator
2. Interim obturator
3. Definitive obturator

Defects of the mandible
156
• Malignant tumor's of the mandible account for 0.5% of all deaths attributable to
cancer.
• Mandibular resection prosthesis are amongst the most challenging in all of
prosthetics.
• A basic understanding of the functional movement of the resected mandible is
essential for those performing this prosthetic treatment.
• Removable partial prosthesis for the most part require conventional designs,
with emphasis on functionally registering the borders of the resected area.

157
• The segmentally resected mandible presents difficult problems requiring non-
conventional prosthetic solutions.
• Two series of prosthesis-
• Interim guiding flange
• Definitive prosthesis
• After surgery, remaining mandibular segment deviates medially and returns
laterally when jaw is opened and closed.
• Based on the amount of scarring present, the maxillofacial prosthodontist may
be able to develop a guide flange prosthesis to assist in repositioning the
mandible to permit maximal closure efficiency with maximum intercuspation.
• Following this definitive treatment is undertaken.

Defects of the Tongue
158
• Tongue ranks second only to lips as most frequently site of oral cancer. The
posterior two thirds and lateral borders of the tongue exhibit highest prevalence.
• If residual tongue is non-movable or if little or no tongue remains after
glossectomy substitute formats of speech and swallowing must be made by
special modifications of the intraoral prosthesis.

159
• In addition to palatal augmentation an artificial articulation of acrylic palatal to
upper anterior teeth will allow patient to make /S/Sh/Z/Zh speech sounds.
• Various other maxillofacial prosthesis such as nasal prostheses, orbital,
auricular and combination facial prosthesis are fabricated in restoring
maxillofacial defect patients.

161
• Elderly infirm people living within private homes.
• Persons who are unable to achieve movement alone.
• Caring for elderly disabled persons is a team matter and the dentist is often a
neglected member of the multi-disciplinary services that should be made
available thereby making a balanced insight into the conditions that may
influence the oral health of the elderly infirm patient.
Reasons For Domiciliary Visit
• Physical assistance required for moving the disabled person & the special
transport
• Risk during journey to distant clinic through exhaustion, emotional
disturbance or infection

162
Objectives of dental domiciliary visit
• To provide assessment, guidance and treatment to elderly infirm patients
• To provide information and health education to the client group
• To support the professional and non-professional care takers and participate in
the team approach to the concept of total health care
• To provide sensitive and effective palliative care for the infirm patient

163
Advantages of domiciliary visiting
• Patient is more rested at home with reduced liability towards disorientation
• For the frightened patient the home visit can act as a reassuring bridge between
home & clinic.
• It provides an easier way to check level of medication and prescription
compliance.
• It allows appropriate assessment of self-care levels and of manipulative skills
related to oral health.
• Patient may be more confident in accepting advice if they have the territorial
advantage.

Morais JA, Heydecke G, Pawliuk J, Lund JP, Feine JS. The effects of mandibular
two-implant overdentures on nutrition in elderly edentulous individuals. Journal
of dental research. 2013 Jan;82(1):53-8.
165
• In a randomized clinical trial, authors tested for post-treatment differences in
nutritional status between patients with mandibular two-implant retained
overdentures and those with conventional complete dentures.
• Edentulous subjects (ages 65- 75 yrs.) received two-implant mandibular
overdentures (IOD, n = 30) and conventional dentures (CD, n = 30).
• Measures of nutritional state were gathered before and 6 months after
treatment. Significant improvements in anthropometric parameters were
detected in the IOD but not in the CD group, for percent body fat and skin-fold
thickness at the biceps, subscapularis, and abdomen, with significant decreases
in waist circumference and waist-hip ratio

166
• Significant increases were seen in concentrations of serum albumin,
hemoglobin, and B12.
• Authors concluded that low-cost IOD treatment may improve the nutritional
state of edentulous people.

Oates TW, Huynh‐Ba G, Vargas A, Alexander P, Feine J. A critical review of
diabetes, glycaemic control, and dental implant therapy in Geriatric patients.
Clinical oral implants research. 2013 Feb;24(2):117-27.
167
• The aim of the study was to systematically examine the evidence guiding the
use of implant therapy in geriatric patient relative to glycemic control for
patients with diabetes and to consider the potential for both implant therapy to
support diabetes management and hyperglycemia to compromise implant
integration.
• A systematic approach was used to identify and review clinical investigations
directly assessing implant survival or failure for geriatric patients with diabetes.
A MEDLINE (PubMED) database search identified potential articles for
inclusion using the search strategy: (dental implants in geriatric patients OR
oral implants) AND (diabetes OR diabetic).

168
• Authors concluded that clinical evidence is lacking for the association of
glycemic control with implant failure while support is emerging for implant
therapy in diabetes patients with appropriate accommodations for delays in
implant integration based on glycemic control.
• The role for implants to improve oral function in diabetes management and the
effects of hyperglycemia on implant integration remain to be determined.

Mundt T, Schwahn C, Stark T, Biffar R. Clinical response of edentulous people
treated with mini dental implants in nine dental practices. Gerodontology. 2015
Sep;32(3):179-87.
169
• The aim of the study was to analyse implant survival, prosthetic aftercare and
quality of life (QoL) after stabilization of complete dentures with mini-
implants.
• A total of 133 participating patients from nine private practices were evaluated
via patient records, questionnaires and clinical examinations. Complications,
maintenance, QoL questions and the German short version of the oral health
impact profile (OHIP-G14) were analyzed.
• It was concluded that Mini-implant survival was similar to that of regular-
diameter implants. Although some prosthetic aftercare was necessary, none of
the overdentures had to be replaced. Prospective studies comparing
conventional and mini-implants are warranted.

171
• 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.

173
• Prosthodontics for the elderly, diagnosis and treatment ; by Ejvind Budtz –
Jorgensen
• Gerodontology ; Ian Barnes & Angus Walls
• Textbook of geriatric medicine & gerodontology J.C. Brockehurst, Churchil
livingstone
• Text book of complete dentures ; Charles M Heartwell 4th edition
• Essentials of complete denture prosthodontics ; Sheldon Winkler 2nd edition
• Boucher ( 2004)Prosthodontic Treatment for Edentulous Patients 12 edition .
Mosby
• Sharry J.J. – ‘Complete denture prosthodontics’ 1962
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• Ferguson D B ( 1987 )The Aging Mouth Vol 6 Karger,Basel 6. Burket (2003)
Oral Medicine 10 edition B C Decker

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• Clinical decision making in geriatric dentistry. Dent Clin North Am
1997;41:752-61.
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568.
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1994;72:487-91.
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1988;59:94-104.
• Denture status and need for Prosthodontic treatment among institutionalized
elderly. Community Dent Oral Epidemiol 1987;15:128-33.
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1994;72:492-9.
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175
• Rehabilitation with new dentures based on comfort rather than function in
elderly. Dent Clin North Am 1994;41:848.
• The dietary adequacy of edentulous older adults. J Prosthet Dent 1995;73:142-
5.
• Tongue motor skills and masticatory performance in adult dentates, elderly
dentates and complete denture wearers. J Prosthet Dent 1997;77:147-52.
• Gerodontic nutrition and dietary counseling for prosthodontic patients. Dent
Clin N Am 2003;47:355-71.
• Nutrition intake and gastrointestinal disorders related to masticatory
performance in the edentulous elderly. J Prosthet Dent 1993;70:468-73.

176
• Nutrition intake and gastrointestinal disorders related to masticatory
performance in the edentulous elderly. J Prosthet Dent 1993;70:468-73.
• Influence of impaired mastication on nutrition. J Prosthet Dent 2002;87:667-73
• The psychology of aging ,JPD 1972 : 27 569-573
• Nutrition for geriatric denture patients, JIPS 2006 vol 6, 1
• Sheldon winkler, 2nd edition essentials of complete denture prosthodontics.

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