Prosthetic Treatment of the Elderly

MUDr. Emília Janská, PhD

LF UK Bratislava

“…..Last scene of all,

That ends this strange eventful history,

Is second childishness, and mere oblivion,

Sans teeth, sans eyes, sans taste, sans everything.”

William ShakespeareQuickTime™ and a

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Introduction

recent decades - decline in edentulism among elderly people (however, still rather large population of older with few or no teeth)

Prosthetic therapy and the choice of treatment modality

patient’s demand

professional consideration

socio-economic situation

Assesment of

- the patient’s general physical and cognitive state

- the realistic needsprofessional assessment perceived needexpressed demand for treatmentgeneral mental and physical state

- socio- economical factors often limits the possibilities to very simple treatments

Study in Sweeden (2007) 70-year-old patients:- prevalence of edentulism - 51% in 1971 declined to 7% in

2001- prevalence of FPD (fixed partial dentures) increased form

26% to 68%- 20 remaining teeth from 13% to 65%

Study in Germany (2004)- tooth loss and the risk of wearing complete dentures

associated with low incomelow education levelsmoking

Prosthetic therapy for the Elderly

1. Indication

2. Treatment planning - partially edentulous patients

- edentulous patients

3. Risk factors - partially edentulous patients

- edentulous patients

4. Restoration of the partially edentulous mouth

5. Restoration of the edentulous mouth with conventional complete dentures

6. Implants for older people

When considering prosthetic therapy for older patients - important to identify major risk factors:

- progression of periodontal disease

- caries activity (high incidence of secondary caries and root caries)

- residual ridge resorption

- functional problems

- to restore - masticatory function - aesthetics (pleasant appearance) - unimpaired speech

Eight occluding pair of teeth in the anterior and the premolar region seem to be sufficient to satisfy elderly patient’s aesthetic and functional demand.

(in the future, older individuals might be more demanding in this respect, …..not existing any true subjective or objective need)

1. Indication for the prosthetic therapy

2.1. Treatment planning

Partially edentulous patients

- reduced masticatory ability (related linearly with the number of teeth present)

- overt symptoms in the masticatory system (adaptive capacity is reduced if occlusal instability develops suddenly - tooth extraction or poorly disigned prothesis)

- reduced occlusal face height (it is unrealistic to anticipate that the anterior pattern will change markedly even after replacement of missing posterior teeth)

2.2. Treatment planning Edentulous patients

Assesment of the patient’s - existing dentures (broken or poor fitting)- anatomical situation (resorption of the residual underlying ridge)- condition of of the oral mucosa - stomatitis, lesions, candidosis….

(predisposition for candida spreading - medication, frequent carbohydrate intake, reduced salivary flow, poor oral hygiene…)

No treatment if - discrepancy between the patient’s demands patient’s treatment abilityobjective treatment needs

and - existing dentures do not have a major faults - patient do not accept the diagnostically modified treatment- there is underlying mental disorder…..

Quality of life and prosthodontics

Assessment of oral health related quality of life (OHRQoL) in 2004 study (Mike at al.):

- 107 patients, before treatment considerably impaired level of OHRQoL

- 1 month after treatment rapid improvement continued following 6-12 months

- largest improvement - fixed partial dentures- smallest improvement - complete dentures (difficulty do adapt)- osseo-integrated implants - secure retention and stability of a

complete denture

3.1. Risk factors

Partially edentulous patients

Main risk factors:- caries activity - increased risk of root caries (gingival retraction

cause exposure of the root surface)additional risk factors - poor oral hygiene, xerostomia, frequent carbohydrate intake, wearing of removable dentures, high level of mutans streptococci in saliva)

- periodontal disease - the elderly partially edentulous patient is

expected to have reasonable periodontal prognosis

- needed strict hygiene measures

3.2. Risk factors

Edentulous patients

- poor adaptation - the adaptive capacity to new dentures tends to decrease with age

- poor treatment outcomechewing problem - frequentlocalized pain reactionsburning mouth syndrome, itching - often due to

psychiatric disorders (anxiety, depression, obsession), patients should be referred to a psychiatrist before the treatment

The gold standard - treatment with implant-retained complete dentures in patients poor anatomic conditions or difficulties in adapting

4. Restoration of the partially edentulous mouth

Fixed Partial Dentures Cross-Arch FDPs Small Cantilever FDPs

Removable Partial Dentures

Overdentures Simple Overdentures Attachment-Retained Overdentures

Fixed Partial Dentures (FDP)

Cross-Arch FDPs - limited indication in elderly (oral hygiene,

caries, complications)

Small Cantilever FDPs - several smaller - more safe solution, or placement of implants

Prognosis depends on:

- abutment selection

- control of occlusal forces

- provision of connector rigidity

Removable Partial Dentures (RPD)

- non-invasive treatment- low cost solution- might be impaired aesthetic and oral control - increased risk of caries and periodontal disease (high salivary levels of mutans streptococci and yeast)

Compulsory - to design RPD according to simple and logical principles - to secure the stability and the best possible comfort

Complications- mechanical failures (fracture of major or minor connectors,

oclusal rests……deformation or fracture of retentive clasps…)- coverage of the gingival tissue by minor connectors -

detrimental effect on periodontal health

Prosthetic rehabilitation of shortened dental arches and tooth wear with reduction of the occlusal face height:

- extensive FDPs, crowns and RPDs

or- less complicated: RPD with

occlusal overlay rests and restoration of anterior teeth with composite resin (less expensive, reversible, not involving extensive preparation of tooth structure

Overdentures

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- in patients with few remaining teeth inadequate to serve as abutments

Advantages: - better preservation of neuromuscular function

- perceptive ability and proprioception

- improved masticatory performance

- stability of the denture

- stable occlusion,

- psychological benefits

Simple Overdentures

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Attachment-Retained Overdentures

(f.e. telescopic crowns…..)

Prevention and maintainance

Plaque control of teeth Plaque control of overdenture Dietary advice (avoid cariogenic foods)

Fluoride treatment (beneficial effect)

Maintainance of abutment teeth (carious attack treated

with glass-ionomer cement) Maintainance of overdentures (regular control)

“important : selection of suitable patients”

5. Restoration of the edentulous mouth with conventional complete dentures

3 groups of patients:

- well adapted to existing dentures

- poorly adapted denture wearers

- no experience in wearing dentures

Guidelines for constructing complete dentures : Minimum acceptable protocols (2006)

1. Preparatoty phase - patient’s specific goals,insurance of healthy oral mucosa

u Treatment phase - impressions, centric relation, vertical dimension of occlusion, tooth arrangement, aesthetics, final adjustment of occlusion, instruction of the patient)

u Post-treatment phase - control of hygiene, occlusion, function

Existing denture wearers

Well adapted denture wearers -

- if reduced vertical dimension, poor fit, unstable occlusal conditions…existing dentures are used diagnostically (as individual tray for a functional impression, determination of vertical dimension….)

Non-adaptive denture wearers- careful interview and examination (not to be carried out if there

is no major disorder of existing dentures, if evidence of mental disorder…..)

Edentulous patients without existing dentures

- first maxillary dentures….

- implant-retained complete dentures is an excellent alternative

Implants for older people

Indication

Patient evaluation - general examination - local examination

Treatment plan, treatment sequence, informed consent

Maintenance

Indication for dental implants in the older patients and types of implant-supported

prostheses

- chronological age is not a contraindication- 1998 (Bryant) - comparison of osseointegration in older and

younger adults - follow-up times 4-16 years: success rate in the older 92%, in the younger 86,5%

- main factor - quality and quantity of jawbone, risk of systemic condition

- influences: social, cultural, socio-economical, individual adaptive capacity

Patient evaluation

General examination

Medical history including medication Chief complaint and expectation Social and family history Dental history Motivation Habits

Local examination

Extraoral examination

Intraoral examination and radiographs

Implant specific diagnostics

Patient evaluation

Treatment sequence for implant assisted prosthodontics

Examination, diagnosis and treatment planning (one or more visits) Presentation of treatment plan, patient’s informed consent Treatment of active disease including extractions (caries, periodontal..) Re-evaluation Orthodontic pre-treatment (if indicated) Surgical pre-treatment (if indicated…bone or soft tissue augmentation) Implant surgery (single stage to multiple stages) and healing Prosthodontic phase:

a/ provisional restoration (especially in complex cases and implants in the aesthetic zone)

b/ permanent restoration Maintenance (long-term)

“Age is something that doesn’t matter, unless you are a cheese”

Billie Burke

References:

1. Lamster I.B., Northridge M.E.: Improving Oral Health for the Elderly. Springer Verlag NY 2008

2. Weber T. Memorix Zahnmedizin. Thieme, Stuttgart; 2009.

3. Rahn A., Ivanhoe J., Plummer K.: Textbook of Complete Dentures. People’s Medical Publishing House Shelton, Connecticut 2009, 446pp

4. Barnes I.E., Walls A.: Gerodontology. George Warman Publication UK 1994