Prosthetic considerations for the aging

PROSTHETIC

CONSIDERATIONS

FOR THE

AGING

JAMES W. SCHWEIGER, D.D.S., MS.” State University of Iowa, College of Dentistry, Iowa City, Iowa

of the human population is ever increasing, attention is being focused more critically upon the needs and problems of the aging person. The geriodontist has learned that he must study and be familiar with the aging process in order to cope with the problems of the aged.lp2 Dental care for the aging patient presents a number of problems not encountered in younger age groups. The prosthodontist is in a position to reduce the number of prosthetic failures by a thorough understanding of the physical, mental, and metabolic changes that occur during aging.lJ The oral changes that occur during aging should be recognized, understoocl, and under treatment before prosthetic replacements are constructed. Also, certain conditions of the oral cavity should be recognized before construction and some special considerations made during construction of dentures for the aged patient.

S

INCE THE LIFE SPAN

TISSUE

CHANGES

The oral tissues, like other tissues, change as an individual grows older. The oral mucosa of the aged is friable and easily injured. According to Massler’J tissue friability arises from three sources: ( 1) a shift in water balance from the intracellular to the extracellular compartment and diminished kidney function result in a dehydration of the oral mucosa, (2) a progressive thinning of the epithelial layers which leaves the tissue vulnerable to mild stresses, and (3) nutritionally deficient cells. Even under the best circumstances, the cells of the aged do not enjoy the optimal nourishment and vitality of youthful cells. The results are : (1) reduced cohesiveness and integrity of the epithelial layer due to a vitamin A deficiency, (2) reduced metabolism of the cells due to a vitamin B deficiency, and (3 j poorly differentiated connective tissue cells and fibers due to a vitamin C deficiency. The clinical result is epithelium that tears easily and connective tissue that heals slowly. Canker sores, traumatic ulcers, and angular cheilosis may be produced.rJ BONE

CHANGES

Calcium deficiencies and a negative calcium balance are common in the older person. The normal bone metabolism cannot be maintained, and osteoporosis may result. Received for publication Oct. 31, 1958. *Assistant Professor, Department of Prosthetic 555

Dentistry.

556

SCH WEIGER

Excessive ridge resorption under excellent prosthetic restorations suggests that a systemic factor such as negative calcium balance is involved. The excessive residual ridge resorption and negative calcium balance require consideration by the prosthodontist.ls3 ABNORMAL

TASTE

SENSATIONS

Burning sensations and an abnormal taste in the mouth are found frequently in the geriatric patient. These symptoms might be related to vitamin B complex deficiencies and low estrogenic levels. Atrophy of the taste buds could result from the gradual decrease in the production of saliva or from iron and vitamin B complex deficiencies.1~s~4 DECREASED

SALIVARY

FLOW

Decreased salivary flow is a common complaint of the aged patient. With this decrease, the ptyalin content of the saliva is also reduced. About sixty per cent of ingested cooked starch is digested in the mouth of a young adult, but in the aged relatively little starch is digested in the mouth. The pancreatic amylase is thought to be able to compensate for a ptyalin deficiency in the saliva. Insufficient salivary flow also makes denture retention difficult.1,3~4 CHANGES

IN

THE

INTERARCH

SPACE

AND

THE

TEMPOROMANDIBULAR

JOINT

With the loss of teeth, the patient may develop a prominent protruding chin, wrinkling which extends downward from the oral commissures, and an obtuse angle of the mandible. The esthetic characteristics which result from the absence of the teeth are of secondary importance. Of primary importance are the disturbed physiologic function and the pathologic changes which may occur in the temporomandibular joints. Failure to maintain the proper interarch space (occlusal vertical dimension) may-place undue stresses upon the temporomandibular joints. These changes can be prevented by good prosthetic replacements.4,5 CHANGES

IN

THE

EFFICIENCY

OF THE

MASTICATORY

APPARATUS

Efficiency of the masticatory apparatus is greatly decreased in the edentulous patient. With this decreased efficiency in the elderly individual, the gastrointestinal tract is less able to compensate for defective mastication of food. “Rodriques-0llers and Ray found that primary gastritis occurred eight times more frequently in the edentulous patient than in the patient with an efficient masticatory apparatus.“4 VAGUE

FEARS

AND

PAINS

Vague fears and pains are characteristics of the insecure individual at any age level. These fears and pains become exaggerated in the aged person. These persons can be helped by understanding, patience, and empathy.1+3

Volun1e Number

9 4

CONSIDERATIONS

POSTMENOPAUSAL

FOR

TIlK

AGlN(;

*-b. 3 .y

,

CHANGES

Tissue deficiencies are seen very often in postmenopausal women because of metabolic and endocrine disturbances which occur during the climacteric. Failure of prosthetic restorations must be assessed carefully during this period. A complete evaluation of (1) the prosthesis itself, (2) the condition of the oral tissue, and (3) the physical and emotional status of the patient must be undrrtaken before a diagnosis can be made. The tissue deficiencies and emotional factors are more likely to be the cause of the prosthetic failures than are the technical defects.1,3 CONDITION

OF

THE

ORAL

EAVITY

Before construction of a complete denture, a thorough oral examination should be completed. A few of the more important conditions that should be observed are : (1) the size of the dental arch and the size of the mouth opening, (2) the shape of the ridge and the appearance, thickness, and resiliency of the mucosa, (3) the size and shape of the tongue, (4) the distance from the attachment of the border tissues and the frenal attachments to the crest of the ridge, (5) the postpalatal seal area for width and displacement, and (6) the retromylohyoid fossae, the cheeks, anti lips to determine the type of muscle tone. A complete roentgenographic examina tion is made to locate impacted teeth, root tips, debris, or cysts, and the amount oi bone resorption and to determine type of bone structure. After the examination is completed, a treatment plan and prognosis are nlade. CONSIDERATIONS

IN

THE

CONSTRUCTION

OF

THE

DENTURES

In the construction of dentures for the aged, several factors should be givrvr consideration. The impressions should provide maximum tissue coverage without displacement of the border tissue during function, of the valve seal, tissue adaptation without displacement, and rounded borders which do not displace the denture during function. The physiologic rest position is used as a reference position to establish the vertical dimension of the face. 6 The vertical dimension of occlusion must not be increased beyond the physiologic rest position or decreased so as to create an excessive interocclusal distance. In most instances, 2 to 4 mm. of interocclusal distance is sufficient. However, this distance may vary from 1 to 10 mm. Care must be taken to record the correct centric relation. The condyles d patients who have been edentulous for some time may have assumed a protrudctl position in the glenoid fossae because of the change in the tissue surrounding the joint and abnormal chewing habits. Exercises such as protrusion, retrusion, and the moving of the mandible from side to side will help to correct this condition. A protrusive record should be made to permit the adjustment of the condylar guidances on the articulator. Thus, better working, balancing, and protrusive tooth CWItacts may be developed when the artificial teeth are arranged.

558

SCH WEIGER

J. Pros. Den. July-August, 1959

The anterior teeth should be arranged in the same position as the natural teeth that they are to replace. This establishes proper support for and function of the facial muscles, and normal esthetics and phonetics will be restored. The posterior teeth should be arranged in a manner that prevents excessive and unfavorable leverages.6 The esthetics of the completed dentures should be in harmony with the patient’s age, sex, and personality. The dentures should be capable of physiologic action (mastication) and be comfortable to the patient. CONCLUSION

The geriatrician must have a clear understanding of the tissue changes and psychologic problems as they pertain to the aged patient. The geriodontist must also understand these problems and the degenerative processes that affect the soft and hard tissues of the oral cavity.’ In the construction of complete dentures, emphasis should be given to a thorough examination and diagnosis. The best knowledge and principles of denture design should be used to achieve a satisfactory result. REFERENCES

1. Massler, M.: Geriatrics and Geriodontics, New York J. Den. 26:54-63, 1956. 2. Stieglitz, E. J. : Geriatric Medicine, ed. 2,. Philadelphia, 1949, W. B. Saunders Co. 3. Massler, M.: Tissue Changes During Aging, Oral Surg., Oral Med., & Oral Path. 9:11851196, 1956. 4. Burket, L. W.: Oral Medicine, Diagnosis and Treatment, ed. 2, Philadelphia, 1952, Lippincott. 5. Swenson, M. G. : Complete Dentures, ed. 3., St. Louis, 1953, C. V. Mosby Co. 6. Boos, R. H.: Physiologic Denture Techmque,. J. PROS. DEN. 6:726-740, 1956. 7. Ziegler, J. E. : Geriodontics, J. South. Califorma D. A. 24:29-43, 1956. STATE UNIVERSITY OF IOWA COLLEGE OF DENTISTRY IOWA CITY, IOWA