Sri Guru Ram Das Institute of Dental Sciences & Research

Sri Amritsar

Department of Prosthodontics and Crown &

Bridge

A seminar on
Geriatrics

Date: 26.2.2021 Presented By :

Dr. Jashandeep singh dhillon

Batch - 2020
 CONTENTS

 DEFINITION
 CLASSIFICATION
 THEORIES OF AGEING
 NEED FOR GERIATRIC EDUCATION
 PYSIOLOGICAL CHANGES IN THE ELDERLY
 NUTRITION FOR GERIATRICS PATIENTS
 PROSTHODONTIC CONSIDERATIONS FOR GERIATRIC
PATIENTS
 CONCLUSION
 DEFINITIONS:

• Geriatrics : The branch of medicine that treats all problems, peculiar

to the ageing patient, including the clinical problem of senescence and
senility.
• Gerodontics : Treatment of dental problems of ageing persons.
• Dental Geriatrics : The branch of dental care involving problems
peculiar to advanced age and ageing.
 CLASSIFICATIONS

ACCORDING TO D.C.N.A
 Well Elderly:
 One or two minor chronic medical conditions
 Independent living

 Frail, Elderly:
 Co-existing minor chronic, debilitating medical conditions with
drugs.
 Independent living support.

 Functionally dependent elderly:

 Same as category II but patient debilitated to the extent that
independence is not possible.
 Home bound or institutionalized.
 Severely disabled, medically compromised elderly:
Health status deteriorated to the degree it requires constant
maintenance or skilled nursing facility.

Thus, we can define “Geriatric Dentistry” as the provision of dental

care for adult persons with one or more chronic debilitating,
physical or mental illness with associated medication and
psychosocial problems.
• Classification by Sheldon Winkler:
 The Hardy Elderly: Are those who are in excellent physical and
psychological condition.
 The Senile Elderly: Senile Aged Syndrome
They are disabled physically and emotionally and may be
described as handicapped, chronically ill, disabled, infirm and truly
aged.
 Between these two categories there are millions of elderly:
They may have been hardy at one time or their impeding illness
is predictable. As a group they exhibit every shade of health or
illness .
• THEORIES OF AGEING

Multifactorial in nature.
Age changes are generally considered to reflect one or more of the
following:
• Decline in efficiency of the defense system.
• Malfunctioning of the neuro-endocrine system.
• Genetic determination of life span of both cell and tissues.
• Metabolic error.
• Effects of free radicals, and / or molecular instability.
• Cell loss exceeding cell renewal.
Organ theory- functioning of organs with age decreases.

Immunological theory- : The immune system is programmed to

decline over time, which leads to an increased vulnerability to
infectious disease and thus aging and death. The functioning of
immune system qualitatively & quantitatively decreases with
age.

Neuroendocrine System theory-Biological clocks act through

hormones to control the pace of aging. Recent studies confirm
that aging is hormonally regulated and that the evolutionarily
conserved insulin/IGF-1 signaling (IIS) pathway plays a key role
in the hormonal regulation of aging. neurological and endocrine
systems declines with age.
 GENOME BASED THEORIES
Somatic Mutation theory- mutation in somatic cells bring changes
characteristic of ageing.

Error theory- error in DNA replication results in ageing.

Programme theory-The programmed theories imply that aging

follows a biological timetable, perhaps a continuation of the one
that regulates childhood growth and development. This regulation
would depend on changes in gene expression that affect the
systems responsible for maintenance, repair and defense response.
 ORAL ASPECTS OF AGEING

ORAL MUCOUS MEMBRANE

 The oral mucosa of the aged is friable and easily injured.
This is due to-
 A shift in water balance from the intracellular to the extra cellular
compartment and diminished kidney function results in dehydration of
the oral mucosa.
• Progressive thinning of the epithelial layers which increase the
tissue vulnerability to mild stresses .
• Even under the best circumstances, the cells of the aged do not
enjoy the optimal nourishment and vitality of youthful cells.
• The atrophic mucosa of elders is frequently thin and tightly
stretched and it blanches easily.
• Mucosa of reduced thickness is associated with reduced residual
ridge height.
• Epithelial atrophy, 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.
BLOOD VESSELS
 ageing produces changes in the blood vessels, particularly
atherosclerotic changes.
 Oral varicosities are often noted on the under surface of the
tongue, and in the floor of the mouth and are related to
varicosities found elsewhere.
 KERATINIZATION

• The degree of keratinization of the mucosa is of marked significance

and must always be carefully examined and critically evaluated.
 When the mucosa lacks adequate keratinization, the protecting
capacity provided by the keratinized layer is reduced and the patient is
prone to suffer from irritations.
• The capacity of the prosthesis to initiate mechanical irritations in
these patients is therefore a significant problem in patient
management.
• The most dangerous problem associated with epithelial changes in the
ageing patients arises with the increasing incidence of oral cancer
which accounts for approximately 4 percent of all cancers.
 Over 75 percent of these cancers lie in the age group of persons 50
years and over, indicating that this is a disease of the ageing
population and geriatric problem.
 The high coincidence of these lesions around denture borders always
bring forward the speculation of irritation as an etiologic factor.
 PAIN THRESHOLD
 The level of the pain threshold of soft tissue decreases markedly in
elderly patients.
 Denture tolerance, as a consequence is markedly reduced.
 The capacity of the tissues for repair through cell division is impaired.
 As a consequence these patients present a foundation for the
prosthesis which has reduced capacity to adapt to the demands of
appliance.
 MASTICATION AND MASTICATORY FORCE
 Reduced chewing effectiveness with increasing age.
 As a result of reduced pain threshold and the reduction in muscular
adaptability there is a considerable reduction in the masticatory
force value from an average of over 150psi in the young adult to an
average of 25 psi or less in the elderly.
 SWALLOWING
 It has been reported that sequence and timing of oropharyngeal
swallowing events may change with age.
 Studies have found that healthy elderly persons open their mouth less
widely and chew with less power due to the loss of muscle bulk with
age.
 Decreased ability to prepare food for swallowing and decreased
tongue strength coupled with increased swallowing times, probably
reflect an adaptive process.
 CHANGES IN THE SIZE OF THE BASAL SEAT
 ageing is frequently accompanied by the osteoporotic changes in the
human skeleton.
 As the maxillary residual ridges are reduced it migrates in upward
direction. Mandibular residual ridge appears to migrate lingually and
inferiorly in the anterior region and buccally in the posterior region.
Therefore, the mandibular arch appears to become wider posteriorly.
 Both the jaws become smaller in all dimension and the denture
bearing surface decreases.
CHANGES IN THE INTERALVEOLAR SPACE AND
MAXILLOMANDIBULAR RELATION

• With the loss of teeth, the patient may develop a protruding chin, wrinkling, which
extends downward from the oral commissures and an obtuse angle of the mandible.
• There is also loss of inter-arch space especially in the posterior segment.
• Patient develops a habitual mandibular prognathism.
• Failure to restore and maintain the proper inter-arch space places undue stress on the
temporomandibular joints
• Fore-shortening of the inter-arch distance results in the establishment of a state of
hypotonicity of all the muscles of mastication except the external pterygoid, which
becomes hypertonic, as it is one of the mandibular depressants.
• The resultant tension produced upon the capsular ligament of temporomandibular
joint produce pain.
 Management of the geriatric patients experiencing
temporomandibular joint pain requires further evaluation of
the validity of vertical dimension of occlusion of the
prosthesis.
 Certain amount of reduction of vertical dimension or
increased freeway space is permanent and any attempt to
restore the so called normal vertical dimension may cause
patient discomfort.
 TONGUE AND TASTE SENSATION
 Probably the most common manifestation of ageing 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.
• This diminished acuity of taste can be because of gradual nerve
degeneration or hyperkeratinisation of the epithelium which may
occlude the taste bud ducts and pores.
 It loses its usual muscle tone and offers less resistance when palpated
bidigitally.
 Glossodynia and glossopyrosis are common complaints in senescence.
 Tongue thrusting associated with nervous tension or with attempts to
control a lower denture can lead to a sore tongue.
 SALIVA AND SALIVARY GLANDS
Regressive changes in the salivary glands, particularly atrophy of the
cells lining the inter-mediate ducts, result in
 decrease in salivary flow
 physiochemical changes in the saliva - decrease in ptyalin content
and an increase in mucus content
 Saliva becomes more viscous and ropy.
Further when salivary flow is reduced
 oral mucosa becomes dry and inelastic.
 cracking of the lips and fissuring of the tongue.
 Oral mucosal sore spots are seen under a denture because of the lack
of lubrication by the saliva.
 Denture retention is adversely affected.
 Chewing and swallowing become difficult. As a result food selection
becomes limited to soft or liquid type.
 Xerostomia also affects oral hygiene as in absence of lubricant action
of saliva, food particles adhere to the tissues. This makes the oral
cavity prone to infection.
 AGE CHANGES IN THE BONE TISSUE

 Cortical thinning
The cortex thins and porosity increases from about 4% to 10% from
age of 40-80. Bone loss is about 3% per decade after the age of 40;
but increases to 9% per decade in postmenopausal women.

 Loss of trabeculae
Loss of trabecular bone is often a more severe deficit than cortical
thinning.
 Cellular atrophy
• Osteoclasts are derived from circulating monocytes. Since they are
not dependent on atrophic bone cell populations, resorption is not
usually affected by bone ageing.

• Osteoblasts are derived from bone lining cells, which unfortunately

are severely depleted in number and activity by ageing.

• Failure in osteoblastic function and their production itself is thought

to be key factor in the long term skeletal involution.
 SCLEROSIS
 With age perilacunar bone around osteocytes converts to a
hypomineralized amorphous structure which abruptly mineralizes
after osteocytes death. Mineral eventually fills the lacunae with
age and are usually not remodeled because of low turnover rate.

 Resulting hypermineralized non-vital bone in aged individuals is

associated with increased brittleness which is predisposed to
fracture.
 AGE CHANGES IN THE MAXILLARY AND MANDIBULAR
BONES:
 The crest of the residual alveolar ridge is usually found to be concave or flat
and can terminate in a knife edge.
 Extensive resorption of mandibular alveolar ridge may place the mental
foramen at or near the crest of the ridge.
 In extreme cases, a thin layer of oral epithelium as the only protection for
the contents of the exposed canals.
 The origin of mentalis and buccinator muscles will migrate towards the
receding crest of the ridge.
 A potential source of discomfort in marked senile atrophy is the
compression of nerve endings between sharp vertical bony projections and
the thin mucosal covering by a hard denture base, particularly in the anterior
mandibular region.
 Treatment plan should include
Careful relief
Soft denture liners
 AGE CHANGES IN THE TEETH:
Macroscopic Changes:

 Teeth changes in form and color with age.

 Tooth form is affected by wear and attrition.

 The altered surface structures gives the teeth in older individuals

different patterns of light reflection than that of young teeth.
Changes in dentin result in a gradual alteration of color with age.
Other causes for changes in color

1. General loss of translucency

2. Pigmentation of anatomical defects.
3. Corrosion products
4. Inadequate oral hygiene
 Enamel

 Less permeable and possibly more brittle with age.

 Some of the acquired properties of surface enamel are slowly built up
during life e.g. the fluoride content.
 Caries will also alter the chemistry of surface enamel.
 CEMENTUM

 Cementum may be resorbed and new cementum may form both

locally in resorption defects or more generally over the roots,
especially at the apical half; to compensate for the wear during
function.

 The most significant age change in cementum is gradual increase

thickness.

 Width of the cementum almost triples between the age of 10 years to

75 years.
 DENTIN
 Two age-related changes take place in dentin.
 Physiologic secondary dentin formation
 Gradual obturation of dentinal tubules or dentin sclerosis.

PULP
 The dental pulp of old individuals differ from that in young teeth by
having,
 More fibers
 Less cells
 blood supply apparently decreases with age.
 Presence of pulp stones.
 MOTOR-NERVOUS CONTROL

• Prosthodontists face severe problems because of altered capacity of

motor learning in elderly patients.
• As a result of ageing there is diminution of the brain substance.
• In the age period from 60-85 years this capacity declines from an
approximate 50 percent reduction at 60 years of age to over 85
percent reduction in motor learning in the age group above 65
years.
 PSYCHOLOGICAL CHANGES

 High incidence of depression, feeling of insecurity, bizarre pains and

fears, nervous habits like clenching may develop.
 They are best treated by the eradication of oral disease and the
institution of dietary changes to accommodate their modified or
nonexistent dentition.
• A study of multi-level effects of loss of dentition among a geriatric
population revealed that residual ridge resorption is the primary
intraoral complication of complete edentulism. (Gerodontology 2010)
• Another common complication in geriatric patients is development of
temporomandibular joint disorders.
• Time of being edentulous was strongly associated with mandibular
but not maxillary RRR, as well as development of TMD among the
geriatric patients.
 NUTRITION
IN GERIATRIC PATIENTS
 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 caries 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.
 AGEING FACTORS THAT AFFECT
NUTRITIONAL
STATUS
1. Physiological factors
2. Psychosocial factors

3. Functional factors

4. Pharmacological factors
 Nutrient deficiencies common in the elderly, including
zinc and vitamin B6, seem to result in decreased or
modified immune responses.

 Dehydration caused by decline in kidney function and

total body water metabolism is of major concern .
ORAL FACTORS THAT EFFECT DIET
AND NUTRITIONAL STATUS

Xerostomia
Sense of taste and smell
Oral infectious conditions
Dentate status
 Poor oral health leads to impaired masticatory
function.
Hence impaired masticatory function leads to
inadequate food choice and therefore alter nutrition .
 Effects of dentures on taste and swallowing
 A full upper denture can have an impact on taste
and swallowing ability.
 The hard palate contains taste buds, so taste
sensitivity may be reduced when an upper denture
covers the hard palate.
Effects of dentures on chewing ability
 As aged , they tend to use more strokes and chew
longer, to prepare food for swallowing.
 Masticatory efficiency in complete denture
wearers is approximately 80% lower than in people
with intact natural dentition.
 Effect of dentures on food choices, diet
quality and general health
The effect of dentures on nutritional status varies greatly among
individuals.
Replacing ill-fitting dentures with new ones does not necessarily
result in significant improvements in dietary intake.
Similarly, exchanging optimal complete dentures for implant-
supported dentures, has not resulted in significant improvement in food
selection or nutrient intake.
 Nutrient needs of the elderly
Energy

 Energy needs decline with age due to a decrease in basal

metabolism and decreased physical activity.

 Cross-sectional surveys show that the average energy consumption

of 65-74 year old women is about 1300 kilocalories (Kcal) and 1800
Kcal for men of the same age.
Diet recommended for new denture wearer
 The logical sequence of eating food is biting, chewing and
swallowing and it is much easier for the new denture wearer
to master this complex of masticatory movements in the
reverse order
 Consequently, food of a consistency that will require only
swallowing, such as liquids, should be prescribed for the first
few days after insertion of the denture.
 The use of soft foods is advocated for the next few days
and a firm or regular diet can be eaten later on.
Nutrition counseling and dietary guidance for the
elderly
Since denture construction requires a series of appointments,
dietary analysis and counseling can be easily incorporated into
the treatment sequence.
The patient should be urged to see his physician for more
detailed diagnostic procedures and treatment, when severe
deficiency disease of any kind is present.
On the other hand, advice can be given properly by the
dentist, when there is obvious excessive use of cariogenic
foods and evidence of imbalanced diet.
PROSTHODONTIC TREATMENT PROTOCOL FOR A
GERIATRIC DENTAL PATIENT
ORAL STATUS AND TREATMENT NEEDS
Oral health and oral health care are important in order to
maintain proper

 Mastication
 Digestion
 Speech
 Appearance
 A careful history and clinical examination of the elderly patient are
essential in attempting to clarify the patients demands and need for
prosthodontic treatment.
Systemic Factors
 Nutrition
 Debilitating diseases
 Neurophysiologic changes
 Psychic changes
 Local factors

 Function of temporomandibular joint

 Size and tone of musculature
 Quantity and quality of saliva
 Tissue tone
 Dental and periodontal health
 Oral and denture hygiene
 Size and shape of alveolar ridges
 Inter ridge space and ridge relation
 Fit and extension of existing dentures
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 inturn, 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.
 ORAL REHABILITATION OF GERIATRIC
PATIENT WITH COMPLETE DENTURES
 First time denture wearers are presented with challenges that require
changes in normal patterns of speech and chewing.
 Those patients with the ability to use tongue as a denture stabilizer, to
incise with posterior teeth rather than anterior teeth, to chew
bilaterally , to tolerate episodic, mild , transient intraoral mucosal
discomfort are more likely to do well with new dentures.
 It is upto the prosthodontist to educate and coach the patient through
these challenges.
 IMMEDIATE COMPLETE DENTURE

 In elderly patients this treatment is indicated if no teeth can be

retained.
 It is advantageous, since adaptation to the dentures will be more easy,
patient will suffer from less psychological distress of becoming
edentulous and denture will help control bleeding and protect against
injury from food and direct mechanical injury.
 There is no definite contraindication to treatment with maxillary
immediate dentures in elderly patients. However treatment with
immediate mandibular dentures may give complications such as
pains and progressive resorption of alveolar ridge.
 In elder patients its often advisable to plan a sequential approach to
the treatment to achieve uncomplicated adaptation to the dentures.
 Such treatment plan may include
Step wise extraction of teeth with adjustment of the existing partial
dentures accordingly.
Initial treatment of patient with partial immediate dentures, which
after 6-12 months altered to a complete overlay denture will often
turn into a realistic alternative.
• Treatment of geriatric patient with mandibular implant supported
overdenture and maxillary conventional denture significantly increases
the comfort of chewing of edentulous patients. (Gerodontology 2011)
• But there was considerable decrease in the chewing efficiency five year
after the use of dentures. Decreased chewing efficiency should be
compensated with regular maintenance of the dentures or replacement
after 5 years of use.
• The patient may also refuse to get implant treatment either due to fear
and anxiety or due to appropriateness of the procedur in an elderly
person
 CONCLUSION
Clinical adaptability is the key to prosthodontic success with the
geriatric patient. No one procedure, material or technique is adequate
for all elderly edentulous patients treatments success. Hence, the
prosthodontist must be able to select features from different treatment
modalities that suit each patient best. Age alone is not a
contraindication to complex prosthodontic treatment. Patients of
advanced age may still have many years of life a head, during which
they will appreciate the aesthetic and functional advantages of a
restored dentition
 REFERENCES

 Zarb Bolender - Prosthodontic treatment for

edentulous patients. 12th ed.
 Sheldon winkler, 2nd edition essentials of complete denture
prosthodontics.
 Prosthodontic Treatment for the Geriatric Patient. J Prosthet Dent
1994;72:486-568. 
 Prosthodontic consideration for older patients.
DCNA Oct. 1997;41(4).
•    Gerodontic nutrition and dietary counseling for prosthodontic
patients. Dent Clin N Am 2003;47:355-71.    
• Nutrition for geriatric denture patients, JIPS 2006 vol 6, 1
• Loss of natural dentition: multi-level effects among a geriatric
population; gerodontology, march 2010
• Implant supported dentures: an estimation of chewing efficiency;
gerodontology march2010
• Refusal of implant supported mandibular overdentures by elderly
patients; gerodontology march 2011