MANAGEMENT OF GERIATRIC

DENTAL PATIENT

Dr. N. Kulashekar Reddy MDS

Asst prof, Dept of Prosthodontics
College of Dentistry, Jazan.
• Old age refers to ages nearing or surpassing the life
expectancy of human beings, and is thus the end of the
human life cycle.

• But we know now that tooth loss is the sequelae of oral

pathology – largely dental caries and periodontal
diseases. But do we have any greater understanding of
what it is to be „old‟?
• Sometimes it can be difficult to relate to the generations
that have come before us. Growing up in different
circumstances can make us feel as if we have nothing in
common with them.

• But older people have plenty of wisdom and knowledge to

share with younger generations, and treating them with
respect should be second nature for all of us.
But old age is not an illness…..
• One definition states that ageing is „the gradual
development of changes in structure and function that are
not due to preventable disease or trauma, and that are
associated with decreased functional capacity and an
increased probability of death‟.
 GERIATRICS :
The branch of medicine or dentistry that treats the problems
peculiar to the aging patient, including the clinical problems of
senescence and senility.

GERODONTICS :
The treatment of dental problems of aging persons or problems
peculiar to advanced age.

GERODONTOLOGY :
The study of the dentition and dental problems in aged or aging
persons.

5/44
Glossary of prosthodontic terms 8
Interacting with Older People

Treat elderly parents with dignity

Call people sir or ma'am

Offer your help.

Be patient.

Don‟t assume they have disabilities.

Show interest in their lives.

Don‟t try to take control of their lives.

Ask for advice when needed

Value their opinions……

• You shouldn‟t be so quick to assume that older people are

out of touch with what‟s going on in the world. In fact,
because of their experience, they might have a different
perspective that helps you think about an issue or topic in
a new way.

• If your opinion differs from an older person‟s, try not to

argue over it. Instead, have a polite conversation where
you‟re both able to express your points of view, so you
can really listen to each other.
SEQUALAE OF AGING

• Human orofacial growth and development has been fairly

well defined.

• Not so well understood is orofacial aging, which is

obviously a component of general aging process.

• Evidence exists that the elderly are at a special risk for

developing malnutrition and that vulnerability to nutrient
deficiencies increases in the age.
Assessment of older adult:
• The process of assessment of the older adult has been the
keystone to operative practice.
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 evaluation.
 10

AGEING
 11/44

AGING :
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.

THE BIOLOGY OF AGING :

It is difficult to delineate where the normal aging process ends and

the disease process begins
 Factors Affecting Aging

ENVIRONMENTAL
GENETIC

 Mutations  Physical & Chemical

 Species – Specific life span  Biologic factors
 Vigor  Pathogens & Parasites
 Sex  Socioeconomic factors
 Parental age
 Premature aging synd
 13/44

PHYSIOLOGY OF AGING :
Physiological deterioration

Reduces physiological capacity and the ability to meet

challenges

Progressive.
Classification of Age Changes

I.Physiologic.
II.Psychologic.
III.Pathologic.

Aging person usually fit into one of the 3 groups

• Those who are well preserved physically and
emotionally.
• Those who are really aged and chronically ill
(senile).
• Those who fall between the two extremes
PHYSIOLOGIC AGE CHANGES
The senses:
• Diminishing vision .

• Impaired hearing.

• Decrease in perception of
taste.

• Loss or greying of hair

 16

SENSES
• Vision : Average person at
age of 60 needs twice the
illumination for reading as
one of 25 years old
• Changes in lens and iris
lead to presbyopia
• Light dark adaptation
diminishes
• Accumulation of insoluble
protein in center of lens
fibers develop into clinical
cataracts
 17

Hearing : 55 out of 1000 person 65 to 74 years of age are

functionally deaf, said to be irreversible
 18

Presbycusis :
• It‟s a sensorineural hearing loss due to cochlear
pathology
• Results in gradual , progressive bilateral hearing loss
• Communication is enhanced by slow distinct vocalisation
at a low pitch
 19

• Taste : young
adults have 245
taste buds on
each papilla of
tongue which is
said to diminish by
64% by the age of
70 to 80 years
 20

MEMORY
• Decrease in mental capacity to remember recent events,
new names and new places
 21

LOSS OF TEETH
• 60% of men and 70%of women over 65
years of age are edentulous
• In old age chroma and hue of teeth will
change as enamel is abraded, exposing
the underlying dentin to extrinsic stains.
chroma also deepens due to medication
containing heavy metals
• Natural teeth take on a jagged brownish
appearance of an aging dentition when
the incisal edges break and the exposed
denture gather extrinsic stains
 22

• Some patient in conflict with the

esthetic sense of the dentist
prefer to have complete
dentures with teeth that are
smaller, straighter and whiter
than natural teeth.

• The loss of teeth and also loss

of taste sensation often leads to
malnutrition.
 23

SKIN
• Skin becomes thin, wrinkled, dry and
freckled
• Aging skin is thinner with increased
susceptibility to pressure ulcers and to
abrasions from minor trauma .
• Loss of subcutaneous fat decrease in
elastic fibers renders the skin
susceptible to tear type of injuries.
• Atrophy at subcutaneous and buccal
pads of fat hollows the cheeks
• Due to loss of fat support the upper lip
droops over maxillary teeth
( chelioptosis)
 24

Factors accelerating aging:-

• Photoaging /UV light
• Cigarette smoking
• Decrease in rate of production of vitamin D3

Young skin smooth

Old age : Loss of elasticity

results in network of wrinkles

Natural folds and creases are

exaggerated
 25

Significance of this?
• Skin changes cant be compensated by
prosthodontists
• To eliminate wrinkles the patient frequently
requests the dentist to place the artificial teeth in
undesirable relation to the support, to over extend
or over contour the borders,or to decrease the
interocclusal distance
• Hence these skin changes should be brought
to patients attention before denture treatment
is started.
 26

ORAL MUCOSA
• Becomes thin, easily abraded, and frequently

reacts unfavorably to the pressure of dentures.

• Oral mucosa of geriatric patient is

characterized by a reduction of the total no of
component cells with a resultant decrease in
the thickness of both the mucosa and sub
mucosa.

• Stomatitis and other mild inflammations are the

mucosal lesions encountered most frequently in

older edentulous mouths, especially of older
men who wear dentures, smoke tobacco and
drink alcohol excessively
LIPS
• Angular cheilosis is very common and probably related
to concurrent vitamin B deficiency and close bite.

• Cheilitis and “purse string” mouth occurs due to

dehydration.
GINGIVA
• There is a loss of elasticity with dryness and atrophy.
• There is a tendency to hyperkeratosis.
• Loss of stippling.
Peridontal condition
• Collagen fibres become more coarse.
• The width of periodental ligament decreases, and
principal fibres become irregular.

PERIODONTITIS
Tongue
• Tongue seems to increase in size specially in edentulous
mouth.

• This may be possibly due to transference of some of the

masticatory and phonetic function of the tongue.

• This enlargement has a negative effect on the denture

retention.
•With ageing there is depapillation of tongue,
which usually begins at the apex and the lateral
borders.

•Fissuring is common.

•Sensitivity to taste declines with age, and

specially in older patient’s with Alzimer’s disease
(murphy, 1993)
 32

Significance of this?
• Patients mucosal tissue in elderly need extra care
• Frequent application of soft liners as well as counseling in
tissue handling and cleansing maybe needed
  TEETH :
Abfraction Erosion

Abrasion Attrition

33/4
4 Oral Diagnostics for the Geriatric Populations: Yolanda Ann Dent Clin N Am 49 (2005) 445–4
  Cementum thickness increases

 Dentin :
 Secondary dentin formation
 Obturation of dentinal tubules

 Pulp:
 Fibers - Increased
• Blood supply – reduces
• Pulpstones – increases

34/4
4 Oral Diagnostics for the Geriatric Populations: Yolanda Ann Dent Clin N Am 49 (2005) 445–4
 SALIVARY CHANGES :

 Salivary flow reduces

 Medication
 Salivary gland atrophy

 Physical changes :
 Viscous ropy
 Plaque formation and growth of cariogenic bacteria

35/4
4 Oral Diagnostics for the Geriatric Populations: Yolanda Ann Dent Clin N Am 49 (2005) 445–4
 CONSEQUENCES :

 Diminished functions like mastication

 Digestive problems

 Poor retention of dentures

 Susceptibility of mucosa to frictional irritation from denture movement.

 Interference with patients ability to wear dentures.

36/4
4 Oral Diagnostics for the Geriatric Populations: Yolanda Ann Dent Clin N Am 49 (2005) 445–4
TREATMENT OF XEROSTOMIA :

 Increase intake of water

 Frequent mouth rinses

 Lubricating sprays

 Use of sialogogues – pilocarpine

hydrochloride or nitrate, 5mg
before meals.

 Sucking on sour candy

37/4
4 Oral Diagnostics for the Geriatric Populations: Yolanda Ann Dent Clin N Am 49 (2005) 445–4
38
 39

OSTEOPOROSIS
• The most common systemic bone condition
occurring in both sexes
• It is likely to appear earlier in women than
in men
• Accelerated loss of trabecular bone

• Back pain, loss of bodyweight, facial height

and some types of deformity are some of
the symptoms
• Spontaneous fracture in advanced cases

• Atrophy of bone is particularly noted in

residual alveolar ridge more so when ridge
is subjected to continuous pressure of
denture
 EFFECTS OF AGING ON BONE:
 Thinning of cortical bone
 Increase in porosity
 Loss of trabecular
 Cellular atrophy
 Sclerosis

40/4
4 Oral Diagnostics for the Geriatric Populations: Yolanda Ann Dent Clin N Am 49 (2005) 445–4
 ALVEOLAR RIDGE ATROPHY :

“The diminishing quantity and quality of the residual ridge after teeth are
removed”

 Best way of preventing alveolar ridge atrophy is to maintain some teeth or

roots in the jaws for support of a removable denture.

41/4
4 Oral Diagnostics for the Geriatric Populations: Yolanda Ann Dent Clin N Am 49 (2005) 445–4
 42

PSYCHOLOGICAL CHANGES
“An older person‟s life is basically role less, unstructured by the society,
and conspicuously lacking in norms.” .

PSYCHOLOGICAL CHANGES

Reaction to Social &

Reaction to Physiological Environmental Changes:
Changes: Loss of self-esteem
Changes in appearance Retirement
Isolation
 43

PHARMOCOLOGICAL FACTORS :
Most elders take several prescription and over the counter mediations
daily.
These drugs primarily cause
Anorexia
Nausea
Vomiting
GIT disturbances
Xerostomia
Taste loss
Interference in absorption
These leads to
Nutritional deficiencies
Weight loss
Malnutrition
 44

GERIATRIC NUTRITION AND AGEING

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
 46

NUTRITION

Diagnosis of a nutritional deficiency

Careful and complete diet survey
Medical history and physical examination
 ETIOLOGY OF DIETARY DEFICIENCY :
 Lack of proper food intake
 Low income
 Physical handicaps, debility, lack of mobility which makes preparation
of food difficult
 Poor dentitions, or improper dentures
 Depression boredom, anxiety and loneliness.
 Diseases which interfere with :
 Digestion
 Absorption
 Utilization of foods.

47/4
4
 ORAL SYMPTOMS OF NUTRITIONAL DEFICIENCIES :

 Burning

 Soreness

 Tenderness

 Dryness

 Loss or diminution of taste

48/4
4 Nutrition in geriactrics:JIPS 2006;vol6,issue 1
 SORENESS AND BURNING OF TONGUE :

 Iron deficiency anemia

 Pernicious anemia.

XEROSTOMIA :

 Vit A deficiency
 Pellagra & pernicious anemia

49/4
4 Nutrition in geriactrics:JIPS 2006;vol6,issue 1
 C.
TREATMENT OF NUTRITIONAL DEFICIENCIES :

1. A well-balanced high protein (120 to 150 gm) diet should be administered

with adequate calories, vitamins, and minerals.

2. Therapeutic amounts of specific nutrients should be added as a supplement

to the daily diet.

50/4
4 Nutrition in geriactrics:JIPS 2006;vol6,issue 1
 DAILY REQUIREMENTS:

Food Group Quantity Sources

Cereals 300 g Wheat, Rice, Millets
Pulses 60g (Veg), 30g(Non- Sprouts/dal
Veg)
Meat 30 g Egg / Chicken / Fish
Vegetables 300 g (minimum) Peas, Carrot, Pumpkin,
Beans, Green Leaf
Vegetables etc.
Fruits 100 g (minimum) Orange, Apple, Papaya,
Guava, Mango etc
Milk & Milk products 300 g Cheese, Curd etc
Sugar 20 g Confectionary
Fats 20 g Oil/ Butter/ Ghee
51/4
4 Nutrition in geriactrics:JIPS 2006;vol6,issue 1
 52

In 1992, the U.S. Department of Agriculture developed the Food

Guide Pyramid. This replaces the former basic four model of
milk, fruits and vegetables, and grains. The pyramid now
contains six categories:
1. Bread, cereal, rice, and pasta.
2. Vegetables.
3. Fruits.
4. Milk, yogurt, cheese.
5. Meat, poultry, fish, dry beans, eggs, and nuts.
6. Fats, oils and sweets.
 54

Prosthodontic considerations in
geriatric patient
 FACTORS TO BE CONSIDERED DURING THE
CLINICAL EXAMINATION

 Function of temporomandibular joint

 Size and tone of musculature
 Quantity and quality of saliva
 Health of the oral mucosa
 Dental and periodontal health
 Oral and denture hygiene
 Size and shape of alveolar ridges
 Inter-ridge space and ridge relations
 Fit and extension of existing denture
55/4
4
Fundamentals of complete denture. Boucher.Ed 11
Challenges of prosthodontic treatment for
the older patient:
• 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 in turn, pave the way for prosthodontic challenges

such as hygiene difficulties, periodontal problems,
nonparallel abutments, long preparations and potential
food traps.

• So the design and execution of prosthesis must take

these factors into account.
Certain points should be taken into
consideration for clinical management of
elderly .
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. 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.
Certain points should be taken into
consideration for clinical management of
elderly .
4. 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.

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.
 GUIDELINES FOR REHABILITATION WITH REMOVABLE PARTIAL DENTURES

To restore function of the masticatory system by providing adequate occlusal

support and mastication.

To prevent development of occlusal disturbances.

TMJ-dysfunction.

59/4
4
Fundamentals of complete denture. Boucher.Ed 11
 GUIDELINES FOR REHABILITATION WITH COMPLETE DENTURES :

Restore the lost function

Esthetically acceptable

Economical

60/4
4
Fundamentals of complete denture. Boucher.Ed 11
 OVERLAY DENTURE :

The advantages of treatment with overdentures in elderly patients are :

 Provide support for the denture

 Minimize future loss of the alveolar ridge
 Proprioceptive response
 Retention to the removable denture
enhanced

61/4
4
 62

Denture Irritation Hyperplasia

A common sequela of wearing ill-fitting dentures is the

occurrence of tissue hyperplasia of the mucosa in contact with
the denture border. The lesions are the result of chronic injury
by unstable dentures or by thin, overextended denture
flanges.
 63

Traumatic Ulcers

• Traumatic ulcers or sore spots most commonly develop within

1 to 2 days after placement of new dentures.
• The direct cause is usually overextended denture flanges or
unbalanced occlusion.
 64

Oral Cancer in Denture Wearers

An association between oral carcinoma and chronic irritation of
the mucosa by the dentures has often been claimed.

• Case reports have detailed the development of oral

carcinomas in patients who wear ill- fitting dentures.

• Most oral cancers do develop in partially or totally

edentulous patients.

• The reasons appear to include an association with more

heavy alcohol and tobacco use, less education, and lower
socioeconomic status, which predispose to oral cancer as
well as to poor dental health, including tooth extraction and
denture wearing.
 65

• This underlines the necessity of strict and regular recall visits

at 6-month to 1-year intervals for comprehensive oral
examinations.
• The opinion is still valid that if a sore spot does not heal after
correction of the denture, malignancy should be suspected.
Patients with such cases and clinically aberrant
manifestations of denture irritation hyperplasia should be
referred immediately to a pathologist.
 66

BURNING MOUTH SYNDROME

BMS could be a sequela of denture wearing and is characterized by a

burning sensation in one or several oral structures in contact with the
dentures.
• In patients with BMS, the oral mucosa usually appears clinically healthy.
• The vast majority of patients affected by BMS are older than 50 years of
age, female, and wear complete dentures.
• In the edentulous patient wearing complete dentures, burning sensations
from the supporting tissues or the tongue are common complaints,
particularly in post- menopausal women.
 67

• Usually, there are no overt clinical signs, but the symptoms often
appear for the first time in association with the placement of new
dentures.

Symptoms:
• Burning sensation in mouth, throat, lips and tongue.
• Scalding feeling
• Dry mouth,
• Bitter or metallic taste
• Taste alterations
• Changes in eating habits
• Pain which can be gradual and spontaneous, intensifying as the day
goes on
• Interferes with sleep
• Restlessness that may cause mood changes, irritability, anxiety and
depression
 TEMPROMANDIBULAR JOINT
• With increasing age the joint tends to lose its ability to

withstand degenerative changes and shows progressive

change comparable to those seen in osteoarthritis.

• These changes are more severe with advancing age and

more intense when there is loss of the posterior teeth.

• These changes vary from slight fraying of the articular

surfaces to cleft formation between the fibrous tissue

IMMEDIATE COMPLETE DENTURE :

• A conventional immediate complete denture is a dental prosthesis

constructed to replace the lost teeth and associated structures
immediately after the last tooth is removed.

• This treatment procedure is advantageous compared with treatment

with a conventional complete denture, the later starting 2-3 months
after tooth extraction when healing of the edentulous ridge is
completed.

• Thus, after treatment with immediate dentures, adaptation to the

dentures will be more easy, the patient will suffer less from the
psychologic distress of becoming edentulous and the denture will act
as bandage to help control bleeding and to protect against injury from
food and direct mechanical injury.
ORAL IMPLANTS IN THE AGED
 ORAL IMPLANTS IN THE AGED :
• INDICATIONS
• For treatment with implants in the aged are as follows :
• Insufficient retention of prosthetic devices
• Extensive resorption of the alveolar bone.
• Hypersensitive and highly vulnerable mucosal conditions.
• Defects of the jaw after trauma or tumour resection.
• Age related adaptation difficulties to dentures.
• Severe nausea and vomiting reflexes
 CONTRA INDICATIONS :
• Oral rehabilitation with conventional prosthetic devices which has

already been accepted.

• Insufficient residual bone volume with poor quality.

• Lack of motivation for treatment with implants.

• Lack of motivation for sufficient oral hygiene measures

• General medical conditions. Eg: diabetes and severe

osteoporosis.
 CONTRA INDICATIONS :
• 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.

• One of the main reasons for the failure of dental implants
is poor oral hygiene, and in particular, the accumulation of
plaque on the implants.
• Plaque precipitates inflammation of gingiva (peri-
implantitis) that surrounds the implants, which can lead to
subsequent bone loss
Conclusion…
• Fast paced society is failing to respond to the needs of
older people with care and compassion and to provide
even the most basic standards of care.‟

• Few practicing dentists have received any formal

education on the significance of age and ageing for their
patients.

• Dentist should to cater for the increasing numbers of

motivated, dentate older people to come.
• By encouraging greater collaboration and contact
between dentists, geriatricians, and nurses, the care of
the older patient will become more holistic.