Consequences of tooth loss and challenges managing older patients

Question 1

Percentage of edentulous adults 1968, 2008 and 2018

Answer 1

30%
8%
5%

Question 2

What increases with age of px?

Answer 2

Problems relating to treatment and patient management

Question 3

Why is getting to know who needs treatment a problem?

Answer 3

• Elderly may be reluctant to seek treatment until absolutely necessary
• Medical health issues might take priority so dental health is ignored

Question 4

What pathologies do elderly patients have? Is this why they attend dentist?

Answer 4

-Denture stomatitis (red raw under denture)
-Oral cancer
-Denture granuloma (fold in tissue)
-Lichen planus
-Oral infections
Rarely, only if there is pain involved

Question 5

What are the problems with physically providing treatment?

Answer 5

• Visit in homes? (difficult - equipment)
• Provide ambulance / taxi to bring them to surgery? (expensive)
• Could they drive? Parking
• Use bus? (pass restrictions)
• Neighbour or family could bring them? (difficult)

Question 6

What are the problems with having them in the dental surgery?

Answer 6

Easier for clinician but is surgery suitable for the elderly? E.g. calm enough, enough time, bright light, access

Question 7

How to improve dental experience for elderly in surgery

Answer 7

Seating: keep upright or slowly alter position
Noise: low tones, reduce noise and speed
Confusion: reduce speed, less instruction, call GP first
Timing: medication, convenience

Question 8

How to help elderly adapt to change

Answer 8

1. Make small changes to existing dentures (reline / adapt existing denture)
2. Copy existing dentures with alterations
3. Make new dentures similar

Question 9

What would tooth loss affect in the appointment?

Answer 9

Impression taking
Jaw registration
Retention and stability of denture
Ability to wear denture

Question 10

What happens after tooth loss?

Answer 10

Remaining alveolar bone forms alveolar ridge
-gives denture support
-part of denture-bearing area
Bone resorbs very quickly after tooth loss

Question 11

Does mandible or maxilla resorb faster?

Answer 11

Approx. 4 times as much resorption of mandible as maxilla

Question 12

General pattern of bone loss around individual tooth

Answer 12

Resorption greater where cortical plate is thinner

Question 13

General pattern of bone loss in the maxilla

Answer 13

Greater loss of thinner buccal cortical plate with gradual reduction in wifth and length of residual ridge

Question 14

General pattern of bone loss in mandible

Answer 14

Anteriorly: buccal plate slightly thinner so residual ridge apparently moves slightly lingually
Premolar region: buccal & lingual plates are of = thickness and residual ridge maintains position
-Molar: buccal plate reinforced by external oblique ridge, resorption of thinner lingual plate occurs, apparent movement of residual ridge buccally

Question 15

Clinical effects of too little resorption

Answer 15

-Bulky alveolar ridges with little space in which to place dentures (inadequate interalveolar space)
Leads to frequent denture fracture or excessive face height

Question 16

How can frequent denture fracture be prevented?

Answer 16

By increasing size of denture but this

• compromises appearance
• encroaches the free way space
• compromises function (speaking, eating)

Question 17

What is the free way space?

Answer 17

Space between occluding surfaces of maxillary and mandibular teeth when mandible is in physiologic resting position

Question 18

What are clinical effects of irregular resorption?

Answer 18

Bone may be sharp, soft tissues may get traumatised under denture

• Leads to ulcers & discomfort
• Surgical reduction of knife-edge ridge may be needed

Question 19

Clinical effects of excessive resorption

Answer 19

Relationship of posterior teeth may be changed
> of mandible posteriorly produces ‘posterior crossbite’
-Edge-to-edge incisor relationship or prominent mandible may occur anteriorly, where buccal resorption of maxilla predominates

Question 20

Effects on mandible from excessive resorption

Answer 20

-atrophy of alveolus –> superficial mental foramen
-mylohyoid ridge on lingual aspect becomes sharp & prominent
Pain (& numbness) during denture wear

Question 21

Clinical effects of normal resorption

Answer 21

• Resorption occurs a few months after extraction

- Dentures start to feel loose. Must be relined or replaced

Question 22

Useful clinical techniques to help prosthetic treatment

Answer 22

• Check record
• Windowed trays
• Neutral zone impression technique
• Retained roots
• Polycarbonate
• Soft liners

Question 23

What is check record?

Answer 23

Take occlusal impressions with silica on working model

Question 24

What are windowed trays used for?

Answer 24

For anterior flabby ridges
Windowed tray constructed on primary impression
-when impression is in mouth window is filled with fluid impression material e.g. silicone with syringe

Question 25

What is neutral zone?

Answer 25

Space in oral cavity where forces exerted by tongue are equal to forces exerted by buccinator of cheek laterally and orbicularis oris anteriorly
-Determines horizontal location of teeth

Question 26

What is neutral zone impression technique?

Answer 26

• Anterior section of mandibular registration rim from old dentures replaced by impression material
• Ask px to gurn
• This used as template for siting lower anterior teeth

Question 27

Why are retained roots useful for dentures?

Answer 27

They preserve alveolar bone

Question 28

What is polycarbonate (or stainless steel) used for in prosthetics?

Answer 28

To reduce likelihood of midline fracture (stronger)

Question 29

What are soft liners used for in prosthetics?

Answer 29

• More comfortable base over irregular ridges
• Processed onto denture in lab
• Doesn’t last long (6m - 3y)
• Harbours bacteria

Question 30

Which oral surgeries may be necessary for difficult cases?

Answer 30

Implants (if some bone left)
Sulcus deepening (not really recommended)
Ridge augmentation (put extra HAP on ridge)