PROSTHODONTIC MANAGEMENT

OF GERIATRIC PATIENTS
Guided by – Dr. Ajaykumar Nayak
Presented by – Dr. Shilpa soman
(III PG)
 CONTENTS
•Introduction
•Changes in old age
•Classification of geriatric patients
• Determining the mental attitude of elderly patients
•Geriatric psychology
•Management of gag reflex
•Management of medically compromised patients.
•Geriatric nutrition
•Treatment planning
 Introduction

• Life expectancy has increased international with many countries falling into the
category of ‘‘Greying Country’’.
• Individual’s ability to adapt to new things and integrate new ideas may be deteriorated
by physical, mental and social wellbeing of a person which are related with the aging
process.
• Many diseases and disabilities tend to develop to people with advancing age, as well as
the dental diseases in geriatric patients which considered as one of the most
predominant chronic conditions.
• Multiple social, physiologic , pathologic factors lead to partial and complete edentulism
All these factors should be identify by the clinician before initiating any rehabilitative
and therapeutic treatment
 Age changes

• 1-. Oral physiological changes.

• 2- Debilitating Diseases.
• 3-.Neurophysiological changes.
• 4-Mental changes
Classification of Geriatrics
I. According to the psychologic reactions to aging process. (Heartwell)
• A. Realistic group
• B. Resentment group
• C. Resigned group

II. According to functional criteria (Ettinger and Beck 1984)

• A. Functionally independent elderly
• B. Frail elderly
• C. Functionally dependent elderly
III - Classification according to Winkler
• A. The hardy elderly
• B. The senile aged syndromes
• C. In between groups

IV - Suzanne Riechard classification.

• Mature group.
• Rocking chair group:
• Armored:
• Angry men:
• Self haters:
Determining The Mental Attitude Of Elderly Patients

• Jamieson stated that “fitting the personality of the aged patient is often more difficult
than fitting the denture to the mouth”.

• M.M House classification :-

• 1-Philosophical patient
• 2-Exacting:
• 3-Hysterical
• 4-Indifferent
Prosthetic treatment plan considering the
geriatric psychology

• 1-“Let’s Talk” in which effective communication, good rapport, referral, counselling

and peer influence.
• 2-If the patient approaching is Anxious then –
• Pre operative –
• Effective communication, Explanation of procedures, Making patient relax and oral
sedation helps
• operative –
• Reassurance
• local anaesthesia
• oral sedation
• Post- operatively –
• Explaining complications.
• analgesics and adjunctive medications.

• 3- If the patient approaching is Depressed then –

• Pre Operative:
• Consultation with physician.
• Examination of any signs.
• Operative:-use of local anaesthesia.
• Post operative –Avoiding usage of sedatives or narcotics
Any schizophrenic patient-
• Accompanied by family member.
• Appointment should be schedule for morning session.
• Confrontation and authoritative attitude should be avoided.
• Visits should be short with maximum amount of work completed during scheduled time.
Gag reflex and its management in elderly
• Gag reflex – a normal, defensive, physiological mechanism that happens so as to forestall foreign
bodies or toxic materials from getting entry to pharynx, larynx or trachea.

• Somatogenic gagging
• Psychogenic gagging.

Techniques to tackle gagging include –

Dentist based techniques

Patient based techniques .

• Dentist based techniques –

Krols distraction method

Seong’s modified distraction method

• Prosthodontic techniques :-
• High viscosity impression materials
• Farmer et al and Anoop Jain et al - Palateless dentures.

• Pharmacological measures :-
• Topical anesthetics used include topical benzocaine 14% and tetracaine hydrochloride 2%.
• Centrally acting drugs - tranquilizers, para-sympatholytic, central nervous system depressants and
sedatives.
• Accupressure -
• Horizontal mento-labial groove app-roximately present in the middle of lower lip and prominence of the
chin. (chengjang REN 24 )

• Patient based methods –

• Systematic Desensitization
• Singer’s Marble Technique
• Behavioural approaches.
MANAGEMENT OF MEDICALLY COMPROMISED
PROSTHODONTIC PATIENTS
• Osteoarthritis - progressive pathological change of the hyaline cartilage along with bony joints that
subsequently leads to degradation of cartilage or bone.

• Prosthodontic Implications in Osteoarthritis of TMJ :-

 special impression trays to make impression are often necessary.
 During tooth preparation for fixed dental prosthesis (FDP), appointments should be kept short.
 In the active phase of the disease, full mouth rehabilitation and fixed dental prosthesis should be avoided.
• Rheumatoid arthritis –

Rheumatoid arthritis (RA) is a chronic inflammatory disease in which synovial

inflammation results in destruction of joint tissue.

• prophylactic antibiotics before surgical procedures like dental implant placement.

• Since disease occurs as transient between acute and chronic phase, definitive treatment
should be delayed until the disease is cured.
• fixed denture therapy may be suitable.
Cardiovascular diseases :-

STRESS REDUCTION PROTOCOL

 Shorter morning appointment.
 Preoperative sedation
 Intraoperative sedation (N2O-O2) may also be considered.
 Profound local anesthesia
 Adequate postoperative pain analgesia.

Hypertension :-
 Abrupt changes in body position should be discouraged.
 afternoon appointments are considered safer
 Local anesthesia with vasoconstrictor should either be avoided
 To reduce gingival bleeding, supragingival margins are advised
 Use of epinephrine for gingival retraction should be carefully administered.
 Artificial salivary lubricants can be advised

Angina pectoris :-

mild angina nonsurgical dental procedures with normal protocol.

only up to 0.004–0.005 mg of adrenaline is used

moderate angina - sublingual dose of nitroglycerine prior to extensive treatment.

anxiolytic treatment with oxygen supplementation

• Patients with unstable angina :- absolute contraindication for elective dental surgery.

• MYOCARDIAL INFARCTION :-
• If on anticoagulants ,INR to be determined and treatment.

• INFECTIVE ENDOCARDITIS :-
• prophylaxis is recommended in dental implants or subgingival cord placements in many cases.
• CONGESTIVE HEART FAILURE :-

ANTICOAGULANT THERAPY:-

INR value of 2-3 recommended.

Physician consultation

No adjustments in oral anticoagulant are indicated for minor oral surgery

Use of oxidized cellulose or collagen sponges

• use of mouthwash with 5% tranexamic acid four times a day for two days.
• NSAIDs and COX-2 inhibitors should not be prescribed in patients taking warfarin.

• Endocrine disorders

Diabetes mellitus -
• In case of hypoglycemia , if conscious - 15 gram of carbohydrate.
• If unconscious - IV 50 ml of 50% dextrose solution or 1 mg of glucagon IV/IM is given.

Diabetic ketoacidosis –
• Adequate hydration
• Insulin
• Electrolyte replacement
• Establish levels of glycemic control early in the treatment process.
• Schedule morning appointments.
• Oral hygiene instructions.
• avoid NSAIDs if the patient is on sulfonylureas.

• Implant procedures :-
Neurological disorders.

• Parkinson’s Disease :-
• Semireclined position in controlling salivation.
• Implant supported overdenture is recommended.
• Neutral zone technique.
• Selective grinding should be done to eliminate any interferences.
• Monoplane teeth can be used to establish stable occlusion.

• Implant surgery
• Epinephrine <0.05mg is considered safe.
GERIATRIC NUTRTION
 Nutritional objectives
1. To establish a balanced diet which is consistent with the physical, social, psychological and economic
background of the patient

2. To provide temporary dietary supportive treatment, directed towards specific goals such as carries control,
postoperative healing, or soft tissue conditioning.

3. To interpret factors peculiar to the denture age group of patients, which may relate to or complicate
nutritional therapy.

• Factors affecting nutrition -

• Physiological factors
• Psychosocial factors
• Functional factors
• Pharmacological factors.
Nutrient RDA
Energy 1600 Kcal -women
2400 Kcal for men
Carbohydrates 50 to 60 per cent of total calories.

Proteins 0.8-g protein/kg body

Vitamin A 800-1000 micrograms

Vitamin B1 0.5 per 1000 calories, or at least 1 mg

daily
Vitamin B6 1.2-1.4 mg

Vitamin B12 3.0 microgram

Vitamin C 60 microgram

Vitamin D 5 microgram

Vitamin k 8-10 mg alpha-TE

Folic acid s 500 microgram
Calcium 800 mg/day
Iron 10 mg
Zinc 15 mg
Post denture insertion diet plan
 Treatment planning for partially dentate patients with good prognosis.

• ‘Minimally invasive dentistry (MID).

• Design prosthesis to use all of a reduced but healthy periodontium

• minimize gingival coverage and do not encroach on root surfaces
• Delete rests from compromised abutments to avoid overload.
• Design prosthesis to allow for easy addition of teeth with poor prognosis.
• Retain questionable teeth as nonvital roots to support prosthesis and preserve alveolar bone.
• Design transitional prosthesis when remaining teeth have a poor prognosis

• use of resin-bonded or cement-retained bridges to maintain shortened dental arches where anterior teeth are
missing.
Treatment planning for partially edentulous with poor prognosis

• Immediate Denture –The goal of Immediate Denture therapy is to maintain

satisfactory appearance function during the post-extraction phase.

• Transitional partial denture to a complete immediate replacement denture.

• Overdentures – hypodontia, cleft lip, surgical defect cases.

The biomechanical goals of fixed prosthodontics for older adults are :-

1.Enhance the physical integrity of the tooth structure.

2. Eliminate the discontinuities at dentino-enamel junction

3. Develop straight peridental emergence profile

4. Reestablish proximal contact morphology

5. Stabilize tooth positions and occlusal relationship.

6. Create aesthetic harmony between restoration and surrounding structures

Treatment planning in completely edentulous patients

• . Successful provision of complete dentures, even for patients with experience of

wearing previous prostheses, can be challenging as many have resorbed alveolar ridges
and postural jaw relationships. However, many patients can be successfully managed
using conventional complete replacement dentures when fundamental prosthodontics
principles are applied
REFERENCES
 Fisher WT. Prosthetics and geriatric nutrition. J Prosthet Dent 1955;5:481-5
 Winkler S. House mental classification of Denture patients: The contribution of Milus
M House. J Oral Implant. 2005;31(6):301–3.
 Heartwell CM, Grieder A, Giddon D, Collett H, Jankelson B. Syllabus of complete
dentures. 4th ed, editor. Pennsylvania: Lea and Febiger; 1992.
 Ali S, george B, kirmani U, al-saiari AK, almasabi FR, iqbal Z. Gagging and it s
management in prosthodontic patients–a review of literature. Biomedica. 2018
jul;34(3):179.
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