Untitled 1

Geriatric Prosthodontics

Summary | About the Author | Case Study | View Presentation | Assessment

Summary

Prosthodontics for the Aging Population: Special Considerations

In 1984, Ettinger and Beck1, proposed a broad classification of the aging population into three functional groups from a perspective of treatment; these were:

  1. Functionally independent older adults who live in the community unassisted and make up about 70% of the population aged 65 years and older.
  2. Frail older adults who have lost some of their independence but still live in the community with the help of support services and make up about 20% of the older population.
  3. Functionally dependent older adults who are unable to live in the community independently and so are either homebound or institutionalized. It is postulated that about 5% of the older population are homebound and about 5% are institutionalized.

This discussion will deal with each of the groups separately with regard to prosthodontic treatment.

The Functionally Independents

The majority of the younger elderly fit this category of persons. Edentulousness increases with age, at 85+ slightly more than 50% are edentulous. Persons with family earning less than $10,000 were 6 times more likely to be edentulous than persons earning $35,000+.2 Several state or national studies3-11 have shown the emergence of new older dental consumers who are utilizing services similarly or greater than younger cohorts because they are dentate. As a group, these persons have more discretionary income than any other age group and are prepared to pay to maintain their dentitions. Many of these persons may be suffering from some age-related vision and hearing changes and some chronic diseases such as hypertension, arthritis, etc. They will also be taking a variety of medications which many influence salivary flow rates and thus put them at a higher risk for caries and periodontal disease.

To plan restorative/prosthodontic treatment for these patients will require the dentist to understand how these patients function in their environment and how dentistry fits into that environment. This requires the dentist to make assessments of the patients:

  • Socio-demographic environment
  • Medical history
  • Drug history
  • Financial history

and how these may influence treatment. This needs to be followed by a careful intraoral examination with appropriate radiographs and mounted study casts. This will allow the dentist to answer the following questions:

  • At what level is the restoration of esthetics required in their patient?
  • How many tooth pairs are required to restore function?
  • What is required to maintain the existing dentition and prevent its deterioration?
  • Is the patient motivated and able to maintain an adequate level of daily hygiene?
  • Is the patient able to withstand the level of care planned for their treatment?
  • Can the patient afford the treatment plan and are they motivated to pay for it?

Once these decisions are made, more specific decisions will be required, such as the cost/risk/benefit of saving a tooth or even crowning it.12-16 For instance, before a tooth is 2 crowned, a series of assessments need to be made and certain qualifications need to be fulfilled, such as:

  1.  There should be an adequate amount of coronal structure to support a crown otherwise it may either need crown lengthening or elective endodontics and some sort of post.
  2. The tooth should have extensive restorations and the tooth should be required as an abutment for an RPD.
  3. It should be a heavily restored tooth and opposed by a natural tooth with no other vertical stops on that side of the arch.
  4. If crowning is the only way to improve esthetics.
  5. Where a crown is required to correct the integrity of the occlusal plane.
  6. If it is an endodontically treated multi-rooted tooth which is under extensive occlusal load from a natural dentition.
  7. Is it more cost effective to extract this tooth and replace it with a fixed partial denture or an implant?

In summary, the majority of this population can tolerate the most sophisticated prosthodontic care dentistry has to offer, providing they are motivated to seek that care, can afford to pay for it, and have access to it.

The Frail Older Adult

Persons who are medically compromised, physically disabled, or mentally impaired are frail and treatment planning for them becomes much more complex. There may be problems with communication and informed consent, there may be problems with ability to maintain oral hygiene and other medical problems and daily drug regimen may impact dental care. The cost/risk/benefit equation for these patients needs to be evaluated carefully. Philosophically, complete dentures on the mandibular arch should be avoided as much as possible, especially for persons who are cognitively impaired or neurologically impaired. Thus, one needs to understand the value of “key teeth.” A key tooth can be defined as one that, if lost, dramatically changes the treatment plan, for example:

  • Changing the ability to replace a tooth with a fixed partial denture to a distal extension removable partial denture (RPD).
  • Changing no need for an RPD to needing one.
  • Changing a tooth supported RPD to a distal extension RPD.

Thus, a key tooth is one that is required to maintain an adequate chewing pair.

The philosophy of treatment for any frail adult is to:

  1. Reduce the risk of morbidity.
  2. Restore the dentition to functional health within the constraints of their frailty.
  3. Build in a contingency plan for failure of key teeth.
  4. Try to predict a plan that has a good prognosis.

Therefore, when designing a Removable Partial Denture, the following basic principles should be kept in mind:

  1. Do the least possible harm by preserving the existing dentition.
  2. The RPD must be easy to insert and remove.
  3. The design of the RPD should be simple.
  4. The RPD should be designed for potential failure of its weakest units.

The Functionally Dependent

These functionally dependent older adults can no longer survive in the community independently and so they are homebound or institutionalized. We know very little about the homebound because they selectively remove themselves from all epidemiological studies. However, there is a great deal of knowledge about those who are institutionalized. Philosophically, we can divide these patients into three groups:

A. Patients with an acute medical problem. For these patients, one should only do palliative and comfort care and delay all other treatment.

B. Patients with chronic unstable medical problems. These patients have chronic medical problems that require the dentist to use stress reduction techniques during treatment. Nevertheless, if treatment is phased in over time, comprehensive care is possible. The rate of deterioration for these persons is slow and phasing in treatment over time is not a problem.

C. Patients with progressive medical problems. These patients require the dentist to act decisively. The patients’ medical problems will become progressively worse with time so there may be a small window in which restorative work can be done. The philosophy with these patients is:

  • Maintain and preserve key teeth.
  • Remove questionable teeth now.
  • If necessary, crown teeth now.
  • Try to preserve the mandibular dentition and avoid a complete denture on the mandibular arch.

Conclusions

The aging population is increasing in size and remarkably heterogeneous. There is great variation in health and function and financial ability in this population. A treatment plan requires the dentist to assess how that patient is functioning in his/her environment and then develop a treatment plan that fits into the patient’s lifestyle/philosophy and is in their best interest.

References

  1. Ettinger RL, Beck JD. Geriatric dental curriculum and the needs of the elderly. Spec Care Dent 4:207-213, 1984.
  2. White BA, Caplan DJ, Weintraub JA. A quarter century of changes in oral health in the United States. J Dent Edu 59:19-59, 1995.
  3. Ettinger RL, Beck JD. The new elderly: What can the dental profession expect? Spec Care Dent 2:62-69, 1982.
  4. Thomas-Weintraub A. Dental needs and dental service use patterns of an elderly edentulous population. J Prosthet Dent 54:526-532, 1985.
  5.  Hand JS, Hunt RJ, Beck JD. Coronal and root caries in older Iowans: 36-month incidence. Gerodontics 4:136-139, 1988.
  6. Hunt RJ, Eldridge JB, Beck JD. Effect of residence in a fluoridated community on the incidence of coronal and root caries in an older adult population. J Public Health Dent 49:138-141, 1989.
  7.  Burt BA, Ismail AI, Morrison EC, Beltrah ED. Risk factors for tooth loss over a 28-year period. J Dent Res 69:1126-1130, 1990.
  8.  Hand JS, Hunt RJ, Kohout FJ. Five-year incidence of tooth loss in Iowans aged 65 and over. Comm Dent Oral Epidemiol 19:48-51, 1991.
  9. Graves RC, Beck JD, Disney JA, et al. Root caries prevalence in black and white North Carolina adults over age 65. J Public Health Dent 52:94-101, 1992.
  10. Douglass CS, Jette AM, Fox CH. Oral health status of the elderly in New England. Gerontology 48:M39-M46, 1993.
  11. Brown LJ, Winn DM, White RA. Dental caries restoration and tooth conditions in U. S. adults, 1988-1991: Selected findings from the Third National Health and Nutrition Examination Survey. J Am Dent Assoc 127:1315-1325, 1996.
  12.  MjÖr IA. Placement and replacement of restorations. Oper Dent 6:49-54, 1981.
  13. Braun RJ, Marcus M. Comparing treatment decisions for elderly and young dental patients. Gerodontics 1:138-142, 1985.
  14. Maryniuk GA, Brunson ND. When to replace faulty-margin amalgam restorations. A pilot study. Gen Dent 37:463-467, 1989.
  15. Ettinger RL. Restoring the aging dentition: Repair or replacement? Int Dent J 40:275-282, 1990.
  16. Bader JD, Shugars DA. Variation, treatment outcomes and practice guidelines in dental practice. J Dent Edu 59:61-95, 1995.

[ return to top ]