Geriatrics/ dental continuing education courses

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

INTRODUCTION :
DEFINITIONS :
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.
People who are above the age of 65 years are termed as
geriatric persons.

AGING :
The aging process may be defined as 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.
• Aging is manifested at all levels.
• The changes seen are not dramatic, but with time leads to
exponentially increasing mortality rate at the population
levels.
• The origin of this complex aging phenomenon is at the
biological level.
THE BIOLOGY OF AGING :
It is difficult to delineate where the normal aging process
ends and the disease process begins.www.indiandentalacademy.com

FACTORS INFLUENCING AGING :
Genetic factors :
 Mutations
 Species specific life spans
 Hybrid vigor
 Sex
 Parental age
 Twin studies
 Premature aging syndrome
 Cells in culture www.indiandentalacademy.com

ENVIRONMENTAL FACTORS :
 Physical and chemical components – radiation
 Biologic factors – nutrition
 Pathogens and parasites
 Tropical countries
 Socio-economic factors
 Low income groups
 Bad housing
 Poor working condition
 Stresses of life

BIOLOGIC THEORIES OF AGING :
Genetic theories Non genetic theories
Error theories Immunologic theories
Somatic mutations Free-radical theory
Reduncies Cross linking theory
Genetically programmed
senescence
Metabolic rate or wear and tear
theory
Disposable soma theory
PHYSIOLOGY OF AGING :
Physiological deterioration – increases with age
It reduces physiological capacity and the ability to meet
challenges. It is progressive. Major contributing factor to death
of the extremely old.

CENTRAL NERVOUS SYSTEM :
 Impairment of learning and memory after 70 yrs.
 Slowing of central processing
 Decrease in the brain size and weight
 Deterioration of the motor systems
 Decrease function of the extrapyramidal system
 Cerebellar function
 Muscular strength
 Increase in the
 Movement time


 Sensory systems
Loss of
 Vibratory perceptions in lower extremities
 Touch
 Taste
 Smell
 Hearing
 Vision
 Sleep
 Shortening of sleep time
 Increased multiple brief awakening
Special senses

 Neuro-muscular system
 Loss of muscle mass
 Loss of muscle strength
 Loss of muscle performance
CARDIO-VASCULAR SYSTEM :
Decrease in
 Intrinsic heart rate
 Mean maximum HR during exercise
 Cardiac output
 Oxygen consumption

Increase in
 Peripheral resistance
 Muscle stiffness
 Contraction period
 Thickness of walls of aorta
RESPIRATORY SYSTEM :
 Increase in residual volume
 Decrease in expiratory reserve volume
 No change in total lung capacity
 Marked changes in airflowwww.indiandentalacademy.com

KIDNEY AND BODY FLUIDS :
Loss of
 Weight of kidney
 Glomeruli
Deterioration of function
 Progressive declination in renal blood flow
 GFR (glomerular filtration rate)
GASTROINTESTINAL SYSTEM :
 Disordered contractions
 Spontaneous gastro-oesophageal reflex
 Slow gastric emptying
 Loss fat absorption
 Very slight impairment of protein digestionwww.indiandentalacademy.com

 Reduction in calcium absorption
 Decreased secretion by gastric glands – less volume and
conc. of
 HCl
 Intrinsic factor
 Pepsin
ENDOCRINES :
 Adenohypophysis – secretion of thyrotropin is blunted
 Neurohypophysis – greater release of antidiuretic hormone
 Thyroid - Slight decrease in T4 (thyroxine)
- Cortisol secretion is decreased
Aldosterone – decreased
 Insulin – decreased sensitivity of the target tissues to the action
of insulin – glucose intolerance.

REPRODUCTION :
Men
 Decline in sexual interest, drive and vigor
 Increase in plasma conc. of LH (leutenizing hormone) and FSH
(follicle stimulating hormone)
Women
 Marked decline in estrogen concentration after menopause
MISCELLANEOUS :
 Loss of lean body mass
 Body fat increase with age
 Decrease in BMR
 Reduced ability to maintain body temperature
 Immune system. www.indiandentalacademy.com

ORAL CHANGES IN AGING :
Oral mucosa : The clinical picture is one that of atrophy
• Thin, smooth, dry – satin like
• Loss of elasticity and stippling
• More susceptible to injury
• Decreased repair potential
• Frequent application of soft liners.
Skin changes :
• Wrinkled, dry, patchy pigmentation
• Loss of elasticity and fine pattern.
• Diminished bulk of muscles, fat and connective tissue –www.indiandentalacademy.com

Gingiva :
• Loss of stippling
• Oedematous appearance
• Thin keratinized layer
• Tissue is easily injured
Lips :
• Angular cheilitis
 Vit B deficiency
 Dehydration
Teeth :
Enamel
 Attrition
 Erosion
 Abrasion

 Fluoride content is increases
 Enamel cracks – increases
 Enamel lamellae – increases
 Cementum – increase in thickness
 Dentin - Secondary dentin formation
Obturation of dentinal tubules
Pulp : Fibre - Increased
- Blood supply – reduces
- Pulpstones – increases
SALIVARY CHANGES :
Salivary flow reduces
Medication - Depression
- Insomnia
Salivary gland atrophy

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.
EXCESSIVE SALVIA :
Transient – on insertion of denture. No reduction in salivary
output from the parotid gland whereas that of submandibular
gland is reduced.
Submandibular gland : 45% of total output

CHANGES IN COMPOSITION :
• Ptyalin → decreases
• Mucin → increase
PHYSICAL CHANGES :
Viscous ropy
• Plaque formation and growth of cariogenic bacteria
TREATMENT OF XEROSTOMIA :
Increase intake of water
• Frequent mouth rinses
• Lubricating jelly
• Silicone fluid
• Semisolid denture adhesives – decrease irritation of the tissues.
• Temporarily increases denture retention
• Use of silogogues – pylocarpine hydrochloride or nitrate, 5mgwww.indiandentalacademy.com

• Sucking on sour candy
• Nicotinamide 250 to 400mg tid for 2 weeks.
BONE TISSUE :
• Compact or cortical bone
• Spongy or trabecular or cancellous bone
EFFECTS OF AGING :
• Thinning of cortical bone
• Increase in porosity
• Loss of trabecular
• Cellular atrophy
• Sclerosis
Maxilla – narrower
Mandible – wider posteriorly

TONGUE AND TASTE :
• Smooth, glossy or red and inflamed in appearance
• Disturbed sensation – taste
• Soreness, burning (post menopausal women)
• Varicose veins on the ventral surface
TONGUE SIZE :
Does not vary with age but over development of intrinsic
muscles, hence larger tongue (loss of teeth mastication and to
keep the loose denture).
IMPACT OF ENVIRONMENTAL AND SOCIAL FORCES
ON AGING :
An older person’s life is basically roleless, unstructured by
the society, and conspicuously lacking in norms. Rosow (1974).www.indiandentalacademy.com

GENERAL MEDICAL ASPECTS OF AGING
• CARDIOPULMONARY DISORDERS :
 Valvular heart disease
 Cardiac arrhythmias
 Coronary artery disease / ischemic heart disease.
 Hypertension
 Congestive heart failure
 Chronic bronchitis/emphysema.
• NERVOUS SYSTEM DISORDERS :
 CVA (cerebrovascular accidents) or strokes
 Parkinson’s disease
 Tardive dyskinesia

• RHEUMATOLOGIC DISORDERS :
 Temporal arthritis
 Osteoporosis
 Osteoarthritis
• MISCELLANEOUS DISORDERS :
 Leukaemia
 Iron deficiency anaemia
 Diabetes mellitus
 Thyroid disorders
 Urinary incontinence

GEROPSYCHIATRIC DISORDERS :
• Situational disorders :
Associated with emotional crisis or prolonged situational stress.
• Improper oral hygiene
• Sustained muscular tension.
 Bruxism
 Atypical facial pain
• Burning mouth and/or tongue.
Such patients should be treated with compassion, respect and
willingness to comfort them.

AFFECTIVE DISORDERS :
Depression :
Usually co-operative
 Appear to forget clear instructions.
 Fatigue easily and require several short appointments
 Side effects of anti-depressants :
 Burning mouth
 Postural dizziness
 Excitement
 Tachycardia
 Overactivity
 Rapid speech
 Confusion.

ANXIETY DISORDERS :
• Apprehensiveness
• Worry
• Agitation
• Tachycardia
• Dizziness
• Weakness
• Visual and gastro intestinal disturbance
• Fatigue and headache
• Insomnia
•

TREATMENT :
• Benzodiazepines
• Tricyclic antidepressants.
• Disorders of cognitive function :
• Dementia, deliria and toxic confusional states.
PREMEDICATION :
• Aggressive, confused or frightened patients.
• Haloperidol 1-2 mg
• Thiothixine 2-5 mg. one hour before the treatment.
• Thioridazine 25-50 mg the night before the procedure.
PARANOID STATES :
Paranoid is a group of symptoms involving irrational
suspiciousness on others.www.indiandentalacademy.com

CHRONIC MENTAL DISORDER PERSISTING INTO
LATE LIFE :
Chronic schizophrenics who survive into their 60’s or 70’s
often display no florid psychotic symptoms, showing only passivity,
impoverishment of social, intellectual and emotional life, social and
financial dependency and occasional odd habits.
They neglect even an extensive oral disease.
AGING AND NUTRITION :
The diagnosis of a nutritional deficiency-stomatitis must
always be consistent with a background of nutritional impairment
and substantiated by a conservative interpretation of the data
derived from a careful and complete diet survey, a probing medical
history and physical examination, and appropriate laboratory and
roentogenographic determination.

ETIOLOGY OF DIETARY DEFICIENCY :
• Lack of proper food intake
 Low income and lack of knowledge on how to spend the
money available for food to the best advantage.
 Physical handicaps, debility, lack of mobility which makes
preparation of food difficult
 Poor facility.
 Poor dentitions, or improper dentures
 Depression boredom, anxiety and loneliness.
• Disease which interfere with
 Digestion
 Absorption
 Utilization of foods.

Eg: Oral cancers
• Chronic ulcerative lesions
• Diverticulosis  presented by constipation
• Atrophic gastritis
• Liver dysfunction
ORAL SYMPTOMS OF NUTRITIONAL DEFICIENCIES :
The symptoms may antidate, coincide, with, or follow the
appearance of deficiency induced signs.
They are represented by
• Burning
• Soreness
• Tenderness
• Dryness
• Sialorrhea
Loss of diminution of taste (Ageusia or dysgausia)

SORENESS AND BURNING OF TONGUE :
• Iron deficiency anemia
• Vit B12
responsive pernicious anemia.
STOMATODYNIA :
• Pellagra
• Sprue
• Kwashiorkor
• Scurvy
• Nutritional microcytic anemia
XEROSTOMIA :
• Vit A deficiency
• Ariboflavinosis
• Pellagra pernicious anemia

• Iron – deficiency anemia
• Sprue
• Dehydration
• Sialorrhea
 Acute nutritional deficiency stomatitis
 Acute pellagra
• Impairment of taste sense :
 Pellagra
 Pernicious anemia
ORAL SIGNS OF NUTRITIONAL DEFICIENCY :
 Cheilosis
 Gingivitis
 Glossitis.

LIP LESIONS :
Deficiencies of riboflavin, niacin, protein, vitamin B12
, folic
acid, iron, pyridoxine, pantothenic acid and vitamin C.
ORIGINATE AS :
Gingivitis :
Deficiencies of niacin, tryptophan, and vitamin C.
Glossitis :
Niacin, folic acid, vit B12
, pyridoxine, protein and iron
deficiency.
TREATMENT OF NUTRITIONAL DEFICIENCIES :
General principles :
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 awww.indiandentalacademy.com

DAILY THERAPEUTIC DOSE :
• Folic acid 5 to 10mg
• Niacin amide 150 to 250 mg
• Riboflavin 10 – 15 mg
• Ascorbic acid 150-300 mg
• Vit- A 25,000 – 50,000 units.
• Vit-D 3,000 – 5,000 units
• Medicinal iron 200 – 400 mg (1.2 gm of ferrous sulfate)
• Vit B12
10-15 µg (micrograms)
3. Coexisting diseases which cause secondary nutritional
deficiencies or increase the nutritional requirements must be
controlled or eliminated whenever possible.
4. Symptomatic and supportive treatment should be given to rid
and comfort the patient in the presence of pain, infection,
vomiting, diarrhbea and dehydration.

PHARMACOLOGY AND AGING :
General consideration :
• In general, elderly people use 30% of all prescribed medications
(Nielsen et al 1981). Thus, it is important to know if drug dosage
has to be changed when older persons are considered.
• Significant changes in pharmacokinetics and pharmacodynamics
do occur with increasing age.
Compliance :
1) The number of different drugs prescribed, and
2) The number of doses given per day of each drug.
• More than three different drugs and more than two doses for
day of each drug decrease compliance significantly.
• Elderly patients are not necessarily more prone to non-
compliance than younger patients.www.indiandentalacademy.com

ABSORPTION :
A series of physiologic functions in the gastrointestinal tract
change with age.
There is decrease in
 Gastric emptying rate
 Secretion of hydrochloric acid
 Gastrointestinal mobility
 Intestinal blood flow
 Efficiency of many active transport systems.
As a result, a higher plasma drug levels is found in elderly.
VOLUME OF DISTRIBUTION :
The total body weight declines steadily after the age of 50 years,
because of loss of intracellular water and of lean body mass,
while adipose tissue mass is increased.

CLINICAL SIGNIFICANCE :
The volume distribution of lipid soluble drugs is higher,
whereas that of water soluble drugs is decreased.
PROTEIN BINDING :
The concentration of serum albumin decreased with
advancing age.
In aged  3.5 g/dl.
Young adults  4-4.5 g/dl.
This causes on increased unbound fraction of drugs and
influence the distribution of drugs.
METABOLISM :
The hepatic blood flow decreases with age and the rate of
metabolism of high clearance drugs such as propranolol and
lidocain whose elimination are highly flow dependent, is reduced in
the elderly.

The elimination of low clearance drugs depends primarily
on the activity of the hepatic microsomal drug metabolizing
enzymes. The enzyme activity per unit liver also decreased with
advancing age.
RENAL EXCRETION :
Renal function evaluated an the basis of insulin clearance or
by endogenous creatinine decreases considerably with age.
Young  20-22 mg/kg/24hr
Old  10 mg/kg/24hr.
Dosage modifications are necessary primarily to drugs for which
the renal excretion of the parent compound or the active
metabolites is the major mechanism of elimination.www.indiandentalacademy.com

PHARMACODYNAMICS :
• Reduced hepatic synthesis of blood clotting factors with a
resulting greater sensitivity to the action of oral anticoagulants.
• Diazepam and nitrazepam (10mg) appear to result in greater
depression of the central nervous system.
ADVERSE REACTIONS :
Frequency of adverse drug reactions is greater in the elderly.
However, older persons take more medications and this must be
taken into consideration.

DRUGS IN DENTAL PRACTICE
ANTIBIOTICS :
• Water soluble antibiotics like penicillins, cephalosporins,
aminoglycosides, tetracycline will be affected by the age –
dependent decrease in renal function.
• In contrast, lipid-soluble antibiotics like erythromycin,
chlorampheniol are primarily metabolized in liver resulting in
more hydrophilic metabolites which are subsequently excreted
by the kidneys.
PENICILLINS :
• Excretion of these drugs is much reduced in the elderly
compared to younger subjects.
• Because of high therapeutic index the modification of dosage to
compensate for reduced renal clearance is not necessary.www.indiandentalacademy.com

In general, normal doses of all penicillins can be safely
prescribed to all elderly patients regardless of age.
ERYTHROMYCIN :
• High therapeutic index.
• Therefore, normal dosages should be prescribed to all patients
irrespective of age.
METRONIDAZOLE AND TINIDAZOLE :
• It is advisable to use lower dosages of metronidazole in this age
group to avoid accumulation of active water soluble
metabolites when kidneys function is reduced.
• The excretion of tinidazole is unchanged in renal failure.www.indiandentalacademy.com

SULFAMETHIZOLE :
The half life of sulfamethizole is significantly prolonged in the
elderly (181±13min) as compared to younger subjects (105 ±5
min).
• Absorption and distribution is age-independent.
• This drug is normally used for a short period of time and the
toxicity is low.
• Both young and old patients can be treated with upto 4gm daily
of this drug.
ANALGESICS :
Paracetamol (acetominophen) : upto 3 gm/day may be
prescribed to patients of all groups.www.indiandentalacademy.com

Aspirin (acetylsalicylic acid) : Clinically, normal dosages upto
3gm/day can be prescribed, but they should be monitored for
chronic salicylate toxicity which causes mental confusion and
hyperventilation, which can be mistaken for a result of age itself
or a disease.
BENZODIAZEPINES :
Diazepam :
• The clearance of diazepam is unaffected by increasing age, but
the elimination of desmythyldiazepam is reduced in elderly.
• Short acting benzodiazepines like temazepam and triazolam have
decreased tendency to hang over symptoms and used in elderly.
• In general, moderation of doses should be exercised considering
how easily elderly patients develop mental confusion and loss of
memory.

LOCAL ANALGESICS :
• The clearance of lidocaine is reduced in elderly males, while
females donot exhibit significant difference from younger subjects.
• Concentrations greater than 5% are rarely required for infiltration
analgesics.
• It is important to consider the interactions which may take place
between the pressor amines in the analgesics and many
antihypertensives and antidepressants.
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) :
• No significant age-dependent differences in the kinetics is found.
• Despite few and small alterations with advancing age, it seems
prudent to administer smaller dosage to the elderly, because they
are prone to adverse reactions such as gastric and intestinal
hemorrhages, and edemas than younger subjects.
• Many NSAIDs decrease the action of diuretics, probably due to
interaction with the mechanisms of renal excretion.

ANTICOAGULANTS :
Age itself is not a contraindication for the use of anticoagulants.
It is difficult to treat on an outpatient basis. The patients should
be monitored carefully and closely watched for the risk of
potential drug interactions.
ORAL DISEASES CAUSED BY DRUGS :
Ulcerations of mucosa
• Salicylates
• Potassium
• Corticosteroids
• Pancreatic enzymes
• Emepronium
• Tetracycline
• Clindamycin
• Phenylbutazone

Stevens-Johnson syndrome
• Sulfonamides
• Penicillins
Herpes
• Immunosuppressive therapy
Candida infection
• Corticosteroids
• Antibiotics
Xerostomia
• Anticholinergics
• Antihistamines
• Cyclic antidepressants
• High doses of neuroleptics
• Opioids and
• Disopyramide

GERIATRICS

PROSTHETIC CONSIDERATIONS IN GERIATRIC
DENTISTRY :
Oral status and treatment needs :
In elderly populations the pattern of use of dental services
and the need and demand for dental treatment are clearly different
from that of younger populations.
Diagnosis and treatment planning :
A careful history and clinical examination of the elderly
patient are essential in attempting to clarify the patients demand and
need for prosthetic treatment.
Also, it is important to consider systemic and local factors as
well as the patients previous experience with dentures before
deciding treatment and establishing prognosis.

SYSTEMIC FACTORS
NUTRITION :
• The elderly patients are very often deficient in one or several
nutrient or minerals.
• A decreased plasma concentration of thiamine, riboflavin, or
folic acid in elderly patients may be associated with reduced
tolerance to removable dentures.
• Dietary supplements of proteins and minerals will increase
tolerance to dentures.
DEBILITATING DISEASES :
• Systemic diseases, such as gastrointestinal disorders, diabetes
mellitus, or arteriosclerosis, may enhance the symptoms and
signs of debility. www.indiandentalacademy.com

• As a consequence patients will often totally neglect oral and
prosthetic care. Any treatment should be postponed until the
patients general health is restored.
• For chronically ill patients, a professional oral hygiene care
must be scheduled to control caries and periodontal disease.
NEUROPHYSIOLOGICAL CHANGES :
• With advancing age there is degeneration of functional
elements in the central nervous system.
• Adaptation and learning becomes slow. The patients existing
dentures can be used as a template for the design of new
dentures, to make adaptation to new dentures more easy.www.indiandentalacademy.com

PSYCHIC CHANGES :
• Progressive cerebral involution in the elderly patient may result
in psychic changes which complicate the outcome of prosthetic
treatment.
• Elderly patients often feel neglected and rejected.
• To receive some attention some mentally ill patients may
complain of soreness produced by the dentures where no evident
symptoms exist and may try to damage the dentures.
• When mental diseases are suspected, the patients physician
should be consulted regarding an appropriate time for prosthetic
treatment.
LOCAL FACTORS :
• Some diseases such as nutritional disorders, skin diseases or
blood dyscrasias, may manifest themselves initially in the oral
cavity and dentist may be the first person to evaluate the signs
and symptoms. www.indiandentalacademy.com

FACTORS TO BE CONSIDERED DURING THE
CLINICAL EXAMINATION
• Function of temporomandibular joint
• Size and tone of musculature
• Quantity and quality of saliva
• Tissue tone
• Health of the oral mucosa
• Dental and periodontal health
• Oral and denture hygiene
• Size and shape of alveolar ridges
• Interridge space and ridge relations
• Occlusal conditions
• Fit and extension of existing denturewww.indiandentalacademy.com

ORAL PHYSIOLOGIC CHANGES :
• Progressive atrophy of the masticatory, the buccal, and the
labial musculature is a sign of aging. This may cause severe
reduction of chewing efficiency. Patient should be advised to
take adequate diet, which is easy to chew.
• Atrophy of buccal musculature may result in accumulation of
food especially on buccal denture flanges. The placement of
denture teeth buccal to the alveolar ridges may help establish
contact between the denture flanges and cheeks. However, this
may compromise the stability of the dentures.
• Reduced salivary secretion or xerostomia. Frequently, a
complication debilitating diseases e.g. diabetes, or treatment
with psychopharmacologic drugs.www.indiandentalacademy.com

This will result in
• Rampant caries
• Loss of denture retention
• Traumatic lesions
• Infections of oral mcuosa
Meticulous oral hygiene supplemented by mouth washes with
chlorhexidine and daily use of artificial saliva substitutes are
important means to reduce complications.
The regular use of removable dentures should be restricted in
patients with xerostomia.www.indiandentalacademy.com

ALVEOLAR RIDGE ATROPHY :
• Alveolar ridge atrophy is a continuing process of reduction of
the edentulous alveolar ridge which takes place at varying rates
in different individuals.
• Various anatomic, metabolic or mechanical factors are involved
in this process (Atwood 1979).
• There is no reliable way of reducing alveolar ridge atrophy but
the correction of metabolic alterations and meticulous denture
care may have a positive effect.
• The best way of preventing alveolar ridge atrophy is to maintain
some teeth or roots in the jaws for support of a removable
denture.

ORAL MUCOSAL LESIONS :
Lesions of the oral mucosa associated with wearing of
removable dentures may represent (1) acute or chronic reactions
to microbial denture plaque, 2) reactions to constituents of the
denture base material, or 3) a mechanical injury caused by the
denture. The lesions constitute a heterogeneous group with
regard to pathogenesis, and include denture-induced stomatitis,
angular cheilitis, traumatic ulcers, denture irritation hyperplasia,
flabby ridge and oral carcinomas (Budtz-Jorgensen 1981). Most
of the lesions are caused by a chronic infection (Candida
albicans) or mechanical injury. Denture-induced stomatitis may
also represent an allergic reaction to constituents of the denture
base material. www.indiandentalacademy.com

Injurious stimulus Defence mechanisms
Denture plaque In oral cavity
Mechanical
irritation
In oral mucosa
Intolerance
to materials
Mucosal
inflammatory
response

Saliva plays an important role as a defense mechanism
acting in the oral cavity. Use of sedatives may cause xerostomia,
which in turn may reduce the resistance of the oral mucosa to trauma
and infection. Nutritional deficiencies and treatment with
immunosuppressive drugs may lower mucosal resistance to
infections and may also predispose to the establishment of a Candida
infection in the angles of the mouth, the soft palate, or the fauces. In
order to prevent or minimize the extent of the lesions denture
wearers should be recalled regularly for check-ups on the oral
mucosa and the dentures.
ORAL HYGIENE :
In denture wearers, meticulous oral hygiene is important to
prevent dental caries and periodontal diseases in the remaining teeth
and inflammation of denture-bearing oral mucosa. The presence of
removable partial dentures will usually increase accumulation of
microbial plaque on tooth surfaces adjacent to denture saddles,
clasps and rests. If the patient’s cooperation is absent, careful
consideration should be given to the long-term prognosis.www.indiandentalacademy.com

EXISTING DENTURES :
The design of existing dentures should be carefully evaluated
and related to the patient’s complaints. Obviously, the new dentures
must correct faults of the existing dentures. However, in order to
facilitate neuromuscular adaptation the new dentures should be
designed with careful consideration to the design of existing
dentures.
GUIDELINES FOR REHABILITATION WITH
REMOVABLE PARTIAL DENTURES :
Functional aspects :
Removable partial dentures may be indicated in elderly
patients in order 1) to restore function of the masticatory system by
providing adequate occlusal support and mastication, 2) to prevent
development of occlusal disturbances and TMJ-dysfunction.
Furthermore, the patient’s demand for improved esthetics and
phonetics may be achieved by placement of a removable partial
denture. www.indiandentalacademy.com

The masticatory system of elderly patients may function
satisfactorily the only a few natural teeth, if functional adaptation
has been achieved during a period of gradual loss of the teeth.
However, the loss of additional teeth there is an increased
susceptibility for developing TMJ-dysfunction in elderly patients.
This indicates that treatment with removable partial dentures should
be considered in patients with less than 3-4 premolars or molars in
occlusion (3-4 occlusal units).
A tooth-supported removable partial denture will increase
occlusal support by distributing the occlusal forces from denture
saddles to the abutment teeth. A distal-extending removable partial
denture is exclusively supported by the mucosa and the alveolar
ridge in the posterior part of the saddle. This situation is not likely
to create the same degree of support for the mandible as is provided
by an entirely tooth-born saddle.www.indiandentalacademy.com

In elderly patients distal extension removable partial dentures
may be indicated.
1. To restore esthetics or phonetics
2. To improve mastication
3. In Patients with significant signs and symptoms of TMJ-
disturbances and extensive loss of teeth.
4. In a jaw opposing a complete denture to increase functional
stability of the complete denture
DESIGN OF REMOVABLE PARTIAL DENTURES IN
ELDERLY PATIENTS :
In geriatric dentistry the prosthodontist should use the same
guidelines for the design of removable partial dentures as
used in the treatment of younger age groups.

THESE GUIDELINES COULD BE SUMMARIZED AS
FOLLOWS :
• The design should be as simple as possible with saddles, major
connectors and minor connectors avoiding contact with the free
gingiva and contacting the alveolar ridge or the palate
approximately 3 mm from the teeth surfaces in order to reduce the
negative effect on oral hygiene.
• Saddles should be tooth supported, if possible; in distal extension
removable partial dentures occlusal rests should be placed in such
a way that tilting of abutment teeth will not take place.
• Major connectors, minor connectors, reciprocating clasp arms,
and occlusal rests should be rigid in order to withstand and
distribute occlusal forces.

• The denture should be designed in such a way that appropriate
retention is achieved by two retentive clasps. In distal extension
removable partial dentures retention is improved by placement of
indirect retainers opposite to the fulcrum line.
• The dentures should provide bilateral and simultaneous occlusal
contact between natural and prosthetic teeth in centric occlusion
at an acceptable vertical dimension. Centric occlusion is recorded
for setting of prosthetic teeth when there is stable maximal
occlusal contact in this position, no sign of TMJ-dysfunction, and
major anterior or mediolateral deflections from centric relation
have been adjusted. Centric relation is recorded for setting of
prosthetic teeth when there is insufficient occlusal contact to
relate the mandible and there is no consistent centric occlusion.
Furthermore, this relationship is used when it is essential to make
eccentric contacts or when a complete denture opposes the
removable partial denture. However, it is important to secure a
balanced centric occlusion by adjustment of the occlusal surfaces.www.indiandentalacademy.com

In elderly patients excessive occlusal wear of the natural
teeth may be seen frequently which makes restoration of the
occlusion mandatory. This is both clinically and technically a
complicated treatment. Placement of removable partial dentures
with onlays on the abutments teeth to obtain a harmonious
occlusion is a solution to the problem that is relatively inexpensive
but which requires excellent oral hygiene.
GUIDELINES FOR REHABILITATION WITH COMPLETE
DENTURES :
Complete denture prosthodontics involves the replacement
of the lost natural dentition and associated structures of the maxilla
and the mandible in patients who have lost their remaining teeth or
are soon to loose them.
OVERLAY DENTURE :
Today, with the stress on preventive measures in
prosthodontics, this type of treatment is a realistic alternative to
conventional complete dentures in most patients with some
remaining teeth.

The advantages of treatment with overdentures in elderly
patients are the following:
• The natural roots provide support for the denture. They stabilize
the dentures during occlusion and mastication and reduce trauma
of the denture-supporting oral mucosa.
• The roots and periodontal ligament membrane will aid in
minimizing future loss of the alveolar ridge.
• The existence of the periodontal membrane may preserve the
pro-prioceptive response and give the patient a sense of
discrimination not possible with conventional complete
dentures.
• The roots can be provided with various types of retentive
devices to give added retention to the removable denture.
• If the periodontal ligament membrane is significantly reduced a
complete overlay denture may be more favorable than a
removable partial denture. With an overdenture the reduction in
the crown-root ratio has a favorable effect on tooth ratio has a
favorable effect on tooth mobility and on the stability of the
tooth in the jaw.

There are no serious disadvantages of treatment with overlay
dentures in elderly patients compared with treatment with
conventional complete dentures. However, the need for
endodontic treatment and subsequent care to prevent caries and
periodontal disease will cause added expense. Occasionally, an
overlay denture may be bulkier than a conventional complete
denture, particularly because of bony undercuts adjacent to the
overlaid teeth. This may result in improper fullness of the lips.
In geriatric dentistry treatment with overlay dentures is
particularly relevant in the following situations:
• In patients with clinical signs of muscular hyperfunction of the
masticatory apparatus, e.g. severe attrition, bruxism.
• In patients where there are no overt signs of a decreased vertical
dimension of occlusion but where an increase of the vertical
dimension of occlusion is indicated to create sufficient space for a
denture.

• In patients where severe difficulties of adaptation to complete
dentures can be anticipated, e.g. pronounced gagging reflexes,
previous problems of wearing a removable partial denture, severe
resorption of the edentulous alveolar ridge, hyperfunction of the
facial musculature. In the latter instance the roots can preferably
be provided with copings fitted with special retentive
attachments.
In order to prevent problems in treatment with overlay
dentures it is important to carry out a proper examination and
treatment planning with regard to the selection of abutment teeth.
Thus, the following criteria might be employed:
• The abutment teeth should have ≥ 5 mm periodontal support and
at least 2-3 mm attached gingiva.www.indiandentalacademy.com

• Canines and second molar teeth are both ideally located and
numerous enough to provide optimal dental support for the
denture. In most cases two abutments will give sufficient
stability; however, two diagonally located abutments may give
a very unstable denture.
• The abutments should have a height of 2-3 mm with a dome-
shaped contour. If this is not possible copings should be
cemented or the roots should be restored with resin to give the
abutment an acceptable dimension and contour.
• Generally, it is sufficient to place an amalgam restoration in the
exposed root canal. The restoration and the remaining dentin
are smoothed and polished leaving a surface that will
accumulate a minimum of plaque and that can be easily
cleaned. The root may be fitted with a cast coping if caries has
developed shortly after placement of the denture.www.indiandentalacademy.com

When a significant improvement of retention is desired and
the abutment teeth have sufficient root length the cast coping can be
fitted with a precision attachment. Because of the added costs and
the risk of technical failures this procedures should be reserved for
patients with a favorable dental prognosis. It is advisable not to
construct the attachment denture initially, but rather a simple
overlay denture, to await healing after extraction of neighbouring
teeth and the patient’s degree of cooperation.
There are several types of precision attachments available
which have the advantage of being simple in design, e.g. the
Rothermann attachment, the Dalbo attachment, the Ceka attachment
and the Zest anchor. Bar attachments are more complicated but
provide splinting of the abutment teeth as well as retention and
support and the denture. www.indiandentalacademy.com

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. In elderly
patients this treatment is indicated if no teeth can be retained. 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.www.indiandentalacademy.com

There are no definite contraindications to treatment with
maxillary immediate dentures in elderly patients who are
otherwise fit as complete denture patients. However, treatment
with immediate mandibular dentures may give complications such
as pain and progressive resorption of the alveolar ridge. In elderly
patients it is often advisable to plan a sequential approach to the
treatment to achieve uncomplicated adaptation to the dentures.
Such treatment procedures may include step-wise extraction of
teeth with adjustment of an existing partial denture accordingly,
or initial treatment of the patient with a partial immediate denture,
which after 6-12 months is altered to a complete denture; at that
time a complete overlay denture will often turn into a realistic
alternative. This approach is particularly relevant when providing
prosthetic treatment to the mandibular jaw.www.indiandentalacademy.com

THE CLINICAL TREATMENT PLAN INCLUDES :
1. Removal of posterior teeth 3-4 weeks prior to denture
construction. It is important to maintain one or two occlusal
contacts in the premolar region to maintain the vertical
dimension of occlusion.
2. Primary impression
3. Functional secondary impression in an individual tray
4. Recording of the jaw relationship in centric relation and at an
acceptable vertical dimension of occlusion.
5. Arrangement of posterior teeth
6. Arrangement of anterior teeth which are usually placed in the
same position as the natural teeth to support neuromuscular and
psychologic adaptation to the dentures.www.indiandentalacademy.com

6. Alteration of the cast to compensate for soft tissue changes.
Alterations for soft tissue changes. Alterations to compensate
for bone changes are only indicated for esthetic reasons and
when there are severe bony undercuts.
7. After extraction and adjustment of the alveolar ridge the
denture is inserted, the occlusion correction and the patient
instructed to return the following morning.
Postoperative care includes instruction in oral and denture
hygiene and regular control of occlusion and fit of the dentures.
Soft relining materials, and tissue conditioning material may be
used as an effort to keep the occlusion of the teeth, the fit of the
denture and the tissue changes in harmony. Gross tissue
changes are usually completed 3-6 months after extraction. At
that time a permanent denture is constructed or the immediate
denture is relined or rebased.

COMPLETE DENTURE WEARERS :
In elderly patients treatment with complete dentures most
frequently involves replacement of existing complete dentures.
Thus, patients may require prosthetic treatment because the
existing dentures have broken, because of excessive wear of teeth
or for esthetic reasons. Most frequently the patients are satisfied
with their old dentures in spite of severe resorption of the alveolar
ridges, poor retention and stability of the dentures and loss of
vertical dimension and occlusal stability. For this group of denture
patients the treatment procedures should aim at restoring prosthetic
conditions which may – if not corrected – become invalidating.
This should be done with much delicacy as it will be difficult for
most elderly patients to adapt to significant changes of existing
dentures. www.indiandentalacademy.com

WELL-ADAPTED DENTURE WEARERS :
In well-adapted elderly denture wearers with relatively well-
fitting dentures, i.e. an acceptable vertical dimension of occlusion
and relatively stable occlusal relationship but poor adaptation
between the denture base and the underlying mucosa, relining or
rebasing of the existing dentures is the treatment of choice. The
extension of the denture flanges are corrected and the dentures are
used as individual trays for functional impressions. The impression
of the maxillary jaw is made first – without occlusal contact – using
a suitable impression material with low viscosity. Thereafter a
functional impression of the mandibular jaw is obtained with the
upper denture in situ and during slight occlusal contact in centric
relation. After processing of the dentures it may be necessary to
remount the dentures in an adjustable articulator to perform occlusal
grinding. www.indiandentalacademy.com

In well-adapted elderly denture wearers with severe tissue
deterioration or poorly fitting existing dentures, i.e. significant
decrease of the vertical dimension of occlusion, unstable occlusal
conditions and poor adaptation of the denture base to the denture
bearing mucosa, it is realistic to consider restoring the inadequate
esthetic and occlusal conditions. In this situation it is important to
use the patient’s existing dentures diagnostically to determine
which changes the patient will be able to accept. This could be
done by temporary relining of the dentures using a tissue
conditioning material. A temporary relining technique could be
used which restores the vertical dimension of occlusion, secures a
balanced occlusion in centric relation and centric occlusion as well
as esthetics, the extension and fit of the dentures to the alveolar
mucosa and the surrounding tissues.www.indiandentalacademy.com

The patient is allowed to use the temporarily relined
dentures for 1-2 weeks. If denture function and esthetics are
acceptable the altered dentures could be rebased after a final
functional impression through the use of a closed mouth impression
technique. If the esthetics are poor new dentures should be
constructed. However, existing dentures could be used as individual
trays for a functional impression and a guide to determining the
vertical dimension of occlusion for the new dentures.
POORLY ADAPTED DENTURES WEARERS :
In elderly patients who have no existing denture or who do
not accept the diagnostic dentures, prognosis for prosthetic
treatment is questionable. Treatment with a complete lower denture
may be especially hazardous. It may be advantageous to use an
impression technique for the mandibular jaw which records
supporting mucosa as well as the shape of the polished denture
surfaces and which also allows determination of the horizontal and
vertical dimension of occlusion in the same treatment period.

An occlusion rim could preferably be used as an individual
tray after having been adjusted to the correct vertical dimension of
occlusion. A functional impression is made using a closed mouth
technique. With the impression in situ the patient may be able to
determine whether placement and orientation of the occlusal plane,
vertical dimension of occlusion and extension, outline and fit of
the final denture will be suitable.
In elderly patients who have had a number of recent
unsuccessful prosthetic treatments, a careful interview and
examination of the patient are very important. Prosthetic treatment
should not be considered if there is evidence of an underlying
psychiatric disease, if there are no major prosthetic faults of
existing dentures, or if the patient does not accept the
diagnostically altered dentures.www.indiandentalacademy.com

PROGNOSIS: DENTAL AND PROSTHETIC CARE :
Regular recall of denture wearers should take place for the
following reasons :
• In order to control development of microbial plaque on tooth
surfaces and on dentures. A denture is a predisposing condition
to caries, periodontal disease and denture-induced stomatitis .
• In order to control development of functional disorders of the
masticatory system resulting from changes of occlusal
relationships. Such changes may occur due to breakage of clasps
and rests, wear of denture teeth and atrophy of the alveolar
ridge.
• In order prevent mechanical injury to periodontal and denture-
supporting tissues.

PLAQUE CONTROL :
Plaque control is planned by proper motivation and
instruction of the patients and secured by employing an individual
recall system for the professional care of the oral hygiene. Most
elderly denture wearers will respond favorably to motivation and
instruction in oral hygiene. It is, therefore, usually sufficient to
arrange appointments for check-ups of oral and denture hygiene at
6-month intervals.
Special brushing techniques are essential to control plaque
on tooth surfaces adjacent to denture saddles and of the abutment
teeth supporting overlay dentures.
Chemical agents may be important adjuncts in oral hygiene
care of elderly patients who cannot be motivated or who are
physically unable to maintain sufficient oral and denture hygiene.
Thus, daily mouthrinsing with chlorhexidine solutions or the
application of chlorhexidine gel as well as the immersion of
dentures in chlorhexidine are effective means in chemical plaque
control.

Topical treatment with fluoride is an important means of
reducing caries activity, especially on tooth surfaces particularly
exposed to caries.
A wide range of commercial products of chemical denture
cleansers are available but they are not a substitute for mechanical
cleansing. Peroxide cleansers have only limited effect on denture
plaque; hypochlorite cleansers are effective but may cause
bleaching and tarnish and have a bad taste, acid cleansers that are
based on hydrochloric acid are hazardous to use and should not be
recommended. Recently, enzyme-based denture cleansers have
been introduced. These are efficient adjuncts to mechanical
cleansing, and have no negative effects.www.indiandentalacademy.com

FIXED PROSTHODONTICS IN GERIATRIC DENTISTRY :
Patients with advanced oral diseases and multiple missing
teeth jeopardizing an optimal masticatory function can now be
treated successfully irrespective of age. Furthermore, treatment
success can be maintained for many years provided an adequate
maintenance care program is established.
CAUSE-RELATED THERAPY :
Besides improving chewing comfort fixed reconstructions
generally offer better accessibility for oral hygiene than do
removable prosthetic appliances.www.indiandentalacademy.com

A detailed medical and dental history and a thorough clinical
examination are prerequisites for a comprehensive treatment
planning in the elderly patient. The following documentation
is generally needed for successful treatment planning,
especially in a patient with multiple problem:
• A set of full mouth intraoral radiographs.
• A complete chart of the periodontal status including pocket
probing depths and levels of probing attachment.
• An assessment of the caries activity, prevalence, incidence
and history. Special emphasis should be given to root surface
caries.
• An evaluation of pulp vitality of all teeth.
• An analysis of the occlusion and function of the masticatory
system. www.indiandentalacademy.com

It is important to gain a clear perception of the patient’s
motivation for dental treatment and desire to maintain teeth, as well
as his/her ideas of chewing comfort and the need for improved
esthetics. Also, information about the willingness to maintain a
healthy dentition is of utmost importance. Every single tooth
should be diagnosed for caries, periodontal and pulp disease as well
as for masticatory function.
A comprehensive treatment plan for the elderly patient
encompasses four distinct phases:
1. SYSTEMIC PHASE :
Due consideration is given to the medically compromised
patient. The risks for the patient and for the operator are identified.
If necessary , the patient’s physician is consulted and possible
medication administered.www.indiandentalacademy.com

2. HYGIENIC PHASE :
The goal of this treatment phase is the establishment of
optimal oral hygiene. Instruction of oral hygiene is accompanied by
motivation of the patient and by thorough scaling and root planing.
“Hopeless” teeth are extracted.
3. CORRECTIVE PHASE :
This includes further periodontal treatment, endodontic
therapy, restoration of teeth with alloplastic material and the
incorporation of fixed or removable partial restorations.
Occasionally, occlusal therapy, such as the application of a bite
splint followed by occlusal adjustment, or orthodontic therapy may
also be performed during this phase. Prior to reconstructing the
partially edentulous patient retained and/or impacted teeth/roots
should be removed, if indicated. During the entire corrective phase
oral hygiene is monitored.

4. MAINTENANCE PHASE :
A maintenance care program with regular recall visits at
frequent intervals (3-4 months) should be established in order to
assure a favorable prognosis. During this phase attention should
also be given to possible technical failures in the reconstruction.
The necessity of a complete dentition with 14 antagonistic
occlusal units for maintaining adequate function of the masticatory
system is important as a shortened dental arch may act as an
etiologic factor for functional disturbances in the masticatory
system. This is necessary for providing a subjective chewing
comfort.
The need for replacing lost teeth beyond the second
premolar might not be indicated as previously thought, and so
limited and individual treatment planning should be given
preference over ‘ideal’ professional concepts of optimal function.

The subjective masticatory function and oral well being
should be the leading concept in treatment planning.
Extension bridges offer a valuable alternative to removable
partial dentures, especially if the dental arch is to be lengthened
unilaterally or by one occlusal unit only.
Success of advanced fixed bridgework depends on a
competently and successfully performed endodontic and
periodontal therapy of the abutment teeth and not on the amount of
remaining periodontal tissues.
In geriatric dentistry, the use of acid etch resin bonded
restorations may have a promising future. These require much less
chairside time and costs less.www.indiandentalacademy.com

POST THERAPEUTICAL MAINTENANCE :
Maintenance care should include the continuous monitoring
of the bridge work, assessment of pulp vitality and patients need for
fluoride treatment.
Recall visits will reemphasize the necessity for good home
care and correct any irregularities in optimal plaque control. Topical
fluorides should be applied at each recall.
ORAL IMPLANTS IN THE AGED :
An implant can be defined as an alloplastic device placed in
the body for a specific functional purpose. The purpose of the oral
implant is to create stable retention of prosthetic appliances.www.indiandentalacademy.com

In the aged patients, morphological pre-requisites for
retention of dentures are limited. New dentures with a low
retention capacity demand complicated functional patterns, the
aged patient often has a limited ability to learn. This warrants the
use implant dentures. Further, old age anxiety provides an
additional burden. In such clinical situations the development of
soundly documented implantology provides solutions and offers
real progress in oral relabilitation of geriatric dental patients.
The implant treatment in the aged must be performed by a
specially trained team including a prosthodontist, oral surgeon,
radiologist, physician and auxillaries.www.indiandentalacademy.com

SURGICAL AND MEDICAL ASPECTS :
Pre operative measures for improving the prognosis of
implant therapy should be undertaken, the nutritional status should
be improved, anti coagulation therapy stopped and antibiotics
administered for the prevention of infections.
Surgical procedures can be done under local anaesthesia.
Nervous patients should be sedated with an appropriate
preparation, for example a benzodiazepine.
Surgery must be performed as quickly and as atraumatically
as possible to reduce strain on the aged patient and tissues in
question. Asceptic surgical procedures should be followed to
prevent postoperative complications. When the osseous implant
sites are being prepared, heat due to friction has to be reduced to a
minimum by continuous irrigation with sterile saline and by
minimizing drill speed.

In aged patients susceptible to local infections, the area of
surgery should be protected by antibiotics.
During healing an optimal diet containing enough
calories, protein, vitamins and supplementary calcium is
essential.
It is also important to give the patient or his next kin
careful and detailed instructions to be followed during the post
operative period.
If all the above said principles are followed, implant
surgery seems to be successful.www.indiandentalacademy.com

INDICATIONS :
Indications for treatment with implants in the aged are as follows :
• A. Insufficient retention of prosthetic devices due to,
• Extensive resorption of the alveolar bone.
• Hypersensitive and highly vulnerable mucosal conditions.
• Defects of the jaw after trauma or tumour resection.
• Disturbed innervation of the oral and perioral muscles following
trauma of cerebrovascular diseases.
B. Functional disturbances, preventing the patient from wearing
prosthetic devices due to,
• Age related adaptation difficulties to dentures.
• Severe nausea and vomiting reflexes
C. Psycho-social inability to accept a prosthetic device in spite of
adequate morphological and functional prerequisites.

CONTRA INDICATIONS : These are
• 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.
• 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.www.indiandentalacademy.com

IMPLANT PROCEDURES :
There are at present two different, well-documented implant
designs which are shown to be successful in the aged patients.
They are,
1. Osseointegrated titanium implants ad modum Branemark
especially suitable for edentulous cases.
2. Enosseous implants of aluminium oxide ceramics ad modum
Schulte for single tooth loss.

IMPLANTS AD MODUM BRANEMARK :
After a careful pre operative analysis regarding the patients
general, physical and psychological health including an evaluation
of the oral condition from a prosthodontic surgical and radiographic
point of view, the treatment is performed in three stages.
Stage I : titanium threaded implants are installed according to an
elaborate surgical procedure.
An undisturbed and relatively long period (5-6 months) of
healing and osseointegration of the implants is necessary in the
treatment of the aged.
Stage II : after the healing period the abutment connection is
surgically achieved.
Stage III : about 2 weeks later, the prosthetic procedures should be
finished. www.indiandentalacademy.com

IMPLANTS AD MODUM SCHULTE :
These implants are made of aluminium oxide and produced
in different sizes.
The implants are inserted according to the surgical
principles to achieve osseointegration. During healing the implant is
not protected by covering mucosa. After a healing period of about 3
months, treatment is completed by application of a prosthetic
reconstruction on the implant.
The frequency of successful cases is about the same as for
titanium implants and covers a period of 8 years. Both systems have
their special advantages and indications.

CONCLUSION :
The outcome of prosthetic treatment in geriatric dentistry is
determined by several factors such as the general and oral health
status of the patient, the patient’s degree of cooperation, economic
resources, biologic and technical quality of prosthetic materials,
and the prosthodontist’s knowledge, judgment and technical
abilities. Thus, insight in clinical and technical aspects of prosthetic
treatment is important in order to be able to successfully treat
elderly patients who are partially or totally edentulous. However,
the greatest challenge to the clinician is to make a choice between
treating the patient, with the risk of producing iatrogenic disease, or
not treating the patient, with the risk of more damage occurring to
the masticatory system. www.indiandentalacademy.com

Thank you
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