Geriatric and prosthetic dentistry

Geriatric and Prosthetic Dentistry

Definitions

Geriatrics: The branch of medicine that deals with the diagnosis and treatment of diseases and problems specific to the aged.
Gerodontics: the treatment of dental problems of aging persons; also spelled geriodontics
Gerodontology : the study of the dentition and dental problems in aged or aging persons

Classification of geriatric patients

I-According to changes:

(1) physiologic

(2) psychology

(3) pathologic

II-According to functional status:

1-Functionally independent old adults

2-Frail old adults

3-Functionally dependent old adults

Classification of geriatric patients

Physical manifestations

Hair shade-off, skin rankled, and the face has different changes in expressions.

Hair, skin & face

Hearing, smelling and vision senses
May be Impaired …

Secretory glands

Respiration

Gonads and genitourinary tract

All my be functionally interrupted

Also changes may occurs obviously to:

Mental condition

Blood and vascular system

GIT

Oral manifestations

Oral manifestations
• Dental tissues
• A-enamel may be abraded
• B-dentin, calcified
• C-pulp has recession
D-hyper cementosis
2. Periodontal tissues
Decrease fibroblasts, more coarse fibers
•

3. Oral mucosa

decrease in thickness, increase permeability and so decrease tissue tolerance to appliances. presence of hyperkeratosis flabby tissues in denture wearers.
4. Gingiva
loss of stippling and
hypertrophy.

Tongue

Enlarged by loss of teeth and decrease in taste buds, it become lobulated, coarse or flat, and red.

Geographic tongue may appear as an emotional episode.

Saliva

Viscous in consistency and decrease in amount.

Lip and Facial Muscles

Angular cheilitis is very common. Falling in of lips due to the loss of adequate support and muscle tone. The facial musculature loses elasticity and resiliency with advancing.

Tempromandibular joint

By aging flattening of the articular fossa and condyle, the disk become thinner and so the joint becomes smaller.

Also joint dysfunction may occur as a result of change in occlusion or muscle hyperactivity caused by emotional stress.

Over closure for many years may damage the articular disc causing pain and limitation of range of movement of the jaws. Old patient may suffer from osteoarthritis or rheumatoid arthritis also T.M.J. can be affected

Tempromandibular joint

Residual bone and maxillomandibular relationship:
Osteoporosis has a direct relation to the ridge resorption.


Pattern of bone loss in mandible differs from that of the maxilla and so the mandible become larger and the maxilla become smaller.

Progression of resorption

Pathophysiology of Edentulous bone loss

Factors influencing edentulous bone loss

• 1) metabolic Factor: Vit. D deficiency,malnutrition…
• 2) Osteoporosis : normal with aging
• 3) osteomalacia: un mineralized & impaired bone healing is present
• 4) drug therapy : drugs associated with decreased bone density
5) mechanical factors: such as:
ill-fitting dentures
Parafunctional activity


6) anatomic factor:

(a) long face (dolichocephalic)

 tend to have longer ant. alveolar ridge in the vertical plane. than those with short face (brachycephalic)

(b) short face (brachycephalic)

 are capable of higher biting forces in both the molar and ant. regions..
After loss of teeth, higher biting forces enhance edentulous bone loss.

Xerostomia

Etiology

Aging
Foods & drugs
Systemic factors
Radiotherapy (>4000rad)
Sjogren’s syndrome
Other salivary gland diseases
irreversible change
reversible change


Clinical picture

Dry mouth

difficulty in normal oral and oropharyngeal functions

Increase susceptibility to infection

Caries

Halitosis

Medications that cause xerostomia
Anti(anxiety,depressants,seizures,diarrheal,his-taminics,nausea,parkinsonian).

Diuretics, heart medications, muscles relaxants &NSAIDs

Managements
Of
Xerostomia

Dietary & environmental considerations

• Avoid drugs that may produce xerostomia
• Avoid dry & bulky foods
• High fluid intake & rinsing with water
• Avoid alcohol and smoking
• Take protein and vitamin supplements


Preventive Dental Care Measures
Smooth (sharp cusps, occlusal grooves or fissures, and irregular fillings).
Check and adjust the denture.
OHI.
Topical fluoride .
Fluoride rinses & chlorhexidine rinses.
Antifungal medications:
Denture: Miconazole gel,amphotericin or nystatin ointment
Topical: Nystatin, amphotercin suspension or fluconazole

Salivary Stimulants &Substitutes

Chewing gums

Diabetic sweets

Sialagogues (Pilocarpine)

Prosthetic options for management of Xerostomia

• Split- reservoir complete dentures containing salivary substitutes.
• 2. Complete dentures with metal palatal portion.

Psychological Manifestations

High incidence of depression and feelings of insecurity and may experience vague and pain and fear from unknown.

Also nervous habits may develop, manifested by parafunctional habits exerting extra stress on the supporting structures.
Psychological Manifestations

Medical conditions that reflected on the dental management

Arthritis





Dental considerations
• Difficulty in denture care procedure.
• TMJ may show difficulty in performing different movements during steps of denture construction.

Avoid prolonged procedure to avoid patient fatigue.

Cardiac problems:

Neurological disorders: Parkinson's disease

The movements and spasmodic head positioning associated with the disease may compromise the dentist’s ability to carry out restorative care. These patients’ involuntary movements can make the use of sharp and rotating instruments hazardous.

Osteoporosis.

May be caused by hormones or drugs as
steroids and anticonvulsants
Antiepileptic drugs

This is not a disease entity but may be a manifestation of a diverse group of diseases ,it is characterized by a reduction in the mass of bone / unit volume.

Osteoporosis can be caused by certain hormonal disturbances as:

Hyperparathyroidism
Hypothyroidism
DM
Adrenal insufficiency
Menopause in females

Dental considerations for Osteoporosis

Fragility Fractures resulting from minimal trauma can result in significant morbidity and mortality in older adults who are functionally independent.

Diabetes Mellitus (DM)

Hypoglycemia
Dental Considerations for DM
Short appointments at morning.
Treatments sh. be with minimum trauma & stress .
Maintains good oral hygiene regarding using topical agents , such: chlorhexidine.
Using Prophylactics & fluoride gel found to be effective
Management of related xerostomia & other endocrines signs.
Dentist sh. Learn about diagnosis & treatment of Hypoglycemia shock.


Nutritional deficiency

a) 1ry: which is due to lack of nutrients in diet

b) 2ry: due to failure to absorb ,utilize or increase nutrients due to illness or excessive exertion.

Vit.B12  angular chelitis

Vit.B2 pellagra

Vit.C 

General weakness, retarded wound healing, petechial patches due fragility of capillary walls, gingival bleeding and marked bone resorption.

The geriatric prosthetic patient

Geriatric patients (as well as all dental patients) should not be promised too much. Patients tend to remember every claim the dentist has made and will hold him to it.
Esthetics is important in fabricating dentures for the aged. An esthetic denture may be the turning point in patient acceptance.

Replacement options

Conventional options

Temporary RPD

Complete dentures
Permanent RPD

RPD for Geriatrics

The design should be as simple as possible

So as to decrease the trapping areas predisposing to increase the caries susceptibility

• Design should consider future addition of questionable teeth.
• The design should consider deleting rests from compromised teeth to avoid overloading.


Complete dentures

considerations

benefits
Contributes further bone loss

Tissue support sore spots

Nerve exposure pain
On going expenses to maintain by relining, denture adhesives &cleansers.
Loose fitting diff. in eating and speaking.
Palatal coverage interferes with normal sensation of food.
Least costly approach

fast

Implant as a prosthetic option

Over denture supported with implants

Benefits:


Next least costly approach
Better fixation of denture
Improve chewing ability




Benefits: Best fit mostly like natural teethNo dietary limitationsMaximize nutritional intakeNo interference with taste due to minimal coveragePreserve bone

Implant retained fixed bridge

• Considerations:
• Cost
• Longer treatment time
• Multiple visits

Masticatory Performance

All Natural teeth 100%
Implant retained bridge 90%
Implant with over denture 60%
Conventional complete denture 10%
No teeth or denture 0%


What is the best choice?
Several factors are considered to choose the best treatment modality:
Amount of bone available
Quality of bone
Patient systemic conditions
Amount of force applied
Patient financial conditions

Implants for irradiated patients

Problems of irradiated bone:

Decrease number of osteoblasts and osteocytes

Fatty degeneration in marrow spaces
Blood vessels undergo progressive degeneration, hyalinization and fibrosis, resulting in regional ischemia.

Recommendations for using irradiated bone for implant insertion

Minimal one year elapsing before implant insertion.

Using hyperbaric oxygen

Complete denture construction

Prior to making edentulous impressions for geriatric patients, the denture-bearing tissues must be carefully examined.

If ill-fitting dentures have abused them, the use of tissue conditioner is a necessity until their return to normal physiologic color and tone.

The final steps of impressions are made according to the condition of residual alveolar ridge
Impressions:

Flat ridge

• Muco-compressive impression technique

• Called closed mouth technique, it requires;
• A well fitting record base.
• An accurate occluding rims
• An acceptable vertical dimension
• Final impression made using zinc oxide impression paste or viscous elastomeric material while the patient closing on the occlusal rims

• Selective pressure impression techniques

Dynamic impression technique (Functional impressions)

• These techniques may be used where problems of stability exist :
• Three materials are commonly used for functional impressions.
• Alginate materials
• Elastomeric materials
• Tissue conditioning materials
• Used to record the range of muscle action, spaces into which the dentures can extend without displacement.


Final impression making

Butterfly impression technique

Indicated with advanced ridge resorption with projecting sublingual gland and with presence large mandibular tori
Projecting sublingual gland
Mandibular tori

Flabby Tissue

A selective pressure impression technique

Sufficient relief and escape hole drilled in special tray opposite to flabby tissue to ensure relief of pressure over this area and proper load distribution.

A sectional impression technique (Two part impression technique)

Vertical dimension:

Certain acts must be taken into consideration during determining the vertical dimension.

The interocclusal distance increases with age. Excessive restoration of the vertical dimension to achieve a more youthful appearance is contraindicated.


Properly constructed bite blocks support the lips and improve the facial appearance are necessary.

In severe cases of over closure of patient’s old dentures it must be done over a period of time gradual elevations.
The vertical dimension should be opened no more than 5 mm at any one time. After a period of a few years, the dentures can be remade and the interocclusal distance increases another 3 to 4 mm.

• An interocclusal distance of 5 to 10 mm may be indicated because of physiologic changes in the facial musculature, alveolar bone, skin, and sensory perception.

Centric relation:

The determination of centric relation must be precise and accurate and not left to chance

• Posterior tooth selection:

• The arrangement of posterior teeth plays a significant part in the retention and stability of the dentures.
• Many Prosthodontist recommend zero degree posterior teeth according to zones be as follows:
• More adaptable for class II and III
• More easily for width variation of jaws
• Eliminate the horizontal forces
• Less time consuming technique and offer greater comfort and efficiency for a longer period.
• If anatomic teeth are used for an aged person, balanced occlusion is necessary to ensure no interference with jaw movements.


Selection and setting up of teeth:
Cross-linked cusp-less acrylic teeth to decrease lateral force to increase stability
Set up the teeth in neutral zone to increase denture stability.
Non anatomic or cross linked zero degree teeth with curves or ramps.
Zero degree teeth with reverse lateral curve (curve of Pleasure)

Adjustment

The insertion usually followed by irritation and trauma in varying degrees. The geriatric patient should be seen the day after insertion or at least the second day, depending upon the condition the patient can remove one or both dentures during the day if their mouth feels tired after adjustment period.
Home care of complete denture should be stressed throughout the adjustment period.