CONSEQUENCES OF TOOTH LOSS WHEN MANAGING OLDER PATIENTS

has the life expectancy of males and females increased or decreased since the 1900s

increased

what factor significantly influences life expectancy

• socio-economic status

table showing % of edentulous adults in the UK

problems relating to treatment and patient management often ________ with the age of the patient

problems relating to treatment and patient management often increase with the age of the patient

why may older people neglect oral health

• elderly may be reluctant to seek treatment until absolutely necessary

• medical health issues may take priority so dental health is ignored

what issues may there be physically providing treatment to the older population

• do we visit them in their own house?

• do we provide an ambulance/ taxi to bring them to the surgery for treatment?

• do we rely on their own capability of travelling?

• do we rely on their ability to get family or close ones to bring them in?

outline domiciliary dentistry provision

• easy for the patient but more difficult for clinician

• taking all equipment necessary including light is difficult

• not feasible for complex procedures

• chaperone needed

why may the dental surgery environment be difficult for the older patient to manage

• busy environment

• bright lights

• noise

• postural problems

• long procedures

may lead to:

• confusion

• lack of compliance

how can the dental experience be made easier for the elderly

• seating: keep upright or slowly alter position

• noise: low tones, reduce noise and speed

• confusion: reduce speed, less instruction, check medical history

• timing of appt.: medication, convenience 

how can you help older patients adapt to denture changes

• make small changes to existing dentures

• copy features of existing dentures after making alterations

what problems can affect treatment during complete denture construction (2)

• age

• consequences of tooth loss

which stages in denture construction can be affected by patient age

• rapport with patient

• getting a clear medical history

• understanding the patient’s problems

• deciding on appropriate treatment

• deciding on where best to treat the patient

• ability to adapt to denture wearing

which stages in denture construction can be affected by consequences of tooth loss

• impression taking

• jaw registration

• retention and stability of the denture

• ability to wear the denture

outline the relationship between tooth loss, alveolar resorption and denture retention

• after tooth loss, the remaining alveolar bone forms the alveolar ridge 

  • this gives support to a denture and forms the denture bearing area

• following tooth loss, the alveolar bone resorbs rapidly at first but decreases with time

graph showing mandibular midline bone loss against time following extraction

what is the relationship between the maxilla and mandible in terms of bone resorption

there is approximately x4 more resorption in the mandible than the maxilla 

around an individual tooth, where is resorption greater

where the cortical plate is thinner

in the maxilla what does the loss of the teeth lead to in terms of the cortical plate

in the maxilla the loss of the teeth leads to:

• greater loss of the thinner buccal cortical plate

• with gradual reduction in the width and length of the residual ridge

in the anterior region of the mandible, in which direction does the residual ridge move and why

anterior region of mandible

• the buccal plate is slightly thinner so the residual ridge apparently moves slightly lingually

in the premolar region of the mandible, in which direction does the residual ridge move and why

premolar region of mandible

• the buccal and lingual plates are of equal thickness and the residual ridge maintains its position

in the molar region of the mandible, in which direction does the residual ridge move and why

molar region of mandible

• the buccal plate is reinforced by the external oblique ridge, resorption of the thinner lingual plate occurs 

• there is apparent movement of the residual ridge buccally

to what degrees can alveolar resorption occur

• too little resorption

• irregular resorption

• excessive resorption

• normal resorption

outline the clinical effects of too little resorption

• leads to bulky alveolar ridges with little space in which to place dentures

• inevitable consequences are either frequent denture fracture or excessive face height

  • excessive FH can compromise functions like speaking and eating as well as appearance

outline the clinical effects of irregular resorption

• bone may be sharp and the soft tissues may get traumatised under the denture

• this leads to ulcers and discomfort

• surgical reduction of the ‘knife-edge’ may be needed

outline the clinical effects of excessive resorption

• the normal relationship of the posterior teeth may be changed

• with the increase in width of the mandible posteriorly, a ‘posterior crossbite’ is produced

outline the clinical effects on the maxilla due to excessive resorption

maxilla

• anteriorly, where buccal resorption of the maxilla predominates, an edge-to-edge incisor relationship or prominent mandible may occur

outline the clinical effects on the mandible due to excessive resorption

mandible

• atrophy of the alveolus causes the mental foramen to become superficial

• the mylohyoid ridge on the lingual aspect of the mandble becomes sharp and prominent

• both may cause pain during denture wear

outline the clinical effects of normal resorption

• a few months after extraction, the dentures start to feel loose

• dentures need relining or replacing to improve retention

what are useful clinical techniques to help prosthetic treatment

• check record

• windowed trays

• neutral zone impression technique

• retained roots

• polycarbonate

• soft liners

how can windowed trays improve prosthetic treatment

• used for anterior flabby ridges

• with the primary impression done and in the mouth, the ‘window’ is filled with a fluid impression material such as silicone, plaster

what is a common reason for lower dentures moving whilst in function

• lower anterior teeth not being in the neutral zone

how can the issue of lower anteriors not being in the neutral zone be fixed

• get patient to move their lip and tongue

• this moulds the impression material into a shape where you can set the anteriors in the best position

what anatomical feature can preserve alveolar bone

retained roots

outline the use of polycarbonate

• polycarbonate is a plastic

• reduces the likelihood of a midline fracture

what does this image show and what is a disadvantage of it

• chrome palate

• makes denture heavy so not really opted for

outline the use of soft liners in prosthodontics

• cushions the effect of dentures on the mental foramen

• processed onto denture in laboratory

• lasts 6-12 - 3yrs

what are some disadvantages of soft liners

• soft liners sacrifice a bit of retention

• sometimes not as permanent as we would like

• the material can dry out quickly so even after as little as 6 months it may need to be replaced

what surgical options are there to improve denture retention

• implants - usually provided in lower 3 area

• sulcus deepening surgery

• ridge augmentation