Patient Care in Prosthodontic Rehabilitation

Teeth play a very important role in the overall health of any individual. The health of our teeth reflects the health of our body. Missing several teeth can severely influence our daily life. It can affect our general health, our appearance, and even our self-esteem. In patients with partial or complete tooth loss, prosthetic therapy is important to maintain or restore masticatory and aesthetic functions.

Globally, the geriatric population is growing at a faster pace than any other age group; therefore, denture therapy is in high demand for such patients. Although edentulism (complete loss of teeth) is declining but there is a higher rate of loss of teeth due to caries, periodontal diseases and inability to perform proper oral hygiene by the patients.

Importance of Nutrition in Geriatric Patients

Proper nutrition is essential to the health and comfort of oral tissues and healthy tissues to enhance the possibility of successful prosthodontic treatment in elderly patients. Adequate nutrition is a very important factor in promoting the health and well-being of patients. Disorders of the oral cavity have contributed to poor eating habits in old aged patients. Therefore, loose painful teeth or ill-fitting dentures may result in a reduced desire or ability to eat.

The main objective of having a proper nutritional guide to the patient is to provide temporary dietary supportive treatment, directed towards specific goals such as caries control, post-operative healing, or soft tissue conditioning.

Food Pyramid

• This is a modified food pyramid for older adults and is being designed by the USDA Human Nutrition Research Centre on Aging in 1999. It is being extensively designed to highlight the unique dietary challenges in older adults. This pyramid stresses on fewer servings of grain products and more servings of dairy and emphasizes adequate water intake. Elders should be encouraged to have six to eight glasses of fluid daily. The recommended dietary allowance for vitamin B-12 for adults is set at 2.4 micrograms. Due to the high prevalence of vitamin B-12 deficiency in the older population, older people should receive their vitamin B-12 from fortified foods (eg- cereals) and /or vitamin supplements.

• Vitamin D deficiency, in turn, is a major cause of metabolic bone disease in the elderly. The elderly are frequently deficient in Vitamin D because of a lack of sun exposure and an inability to synthesize Vitamin D in the skin and convert it in the kidney.
• Calcium is a very important element in diet as it helps in maintaining good bone health. Elderly patients with complete dentures sometimes experience a rapid and excessive ridge resorption which may be related to negative balance of calcium, which contributes to the development of osteoporosis. Milk and milk products, dried beans and peas, leafy green vegetables and tofu are rich sources of Calcium.
• Declines in gastric acidity occur with age and can cause mal-absorption of food-bound vitamin B-12.
• Many nutrient deficiencies common in the elderly, including zinc and vitamin B-6, seem to result in decreased or modified immune responses.
• Over deficiency of several vitamins is associated with neurological and/or behavioural impairment B1 (thiamine), B2, niacin, B6 [pyridoxine], B12, foliate, pantothenic acid, vitamin C and vitamin E).
• Most of the elderly patients take several prescriptions and over-the-counter medications daily. Prescription drugs are the primary cause of anorexia, nausea, vomiting, gastrointestinal disturbances, xerostomia (dryness in the mouth), loss of taste and interference with nutrient absorption and utilization. These conditions can lead to nutrient deficiencies, weight loss and malnutrition.

Challenges faced during the Prosthodontic treatment:

In an older individual, loss of teeth earlier in life has often brought about disruption in the dental arch over times as a result of drifting, tipping and supraeruption. These in turn, lead to prosthodontic challenges such as hygiene difficulties, periodontal problems, nonparallel abutments, long preparations and potential food traps. So the design and execution of prosthesis must take these factors into account.

Regarding the clinical management of older individuals, certain points should be taken into consideration.

• The elderly have both the greatest level of need of prosthodontic service and the greatest degree of complicating dental, medical and behavioural factors.
• Age is not a contraindication to complex prosthodontic treatment. So patients with advanced age appreciate the aesthetic and functional advantages.
• The dental aspects of planning prosthodontic treatment for the older focuses on the integrity of individual tooth on the potential contribution of each tooth to the masticatory system. Hence we should anticipate restorative, occlusal and functional challenges likely to arise on the course of the treatment.
• Removable prosthodontics, whether with complete or partial dentures requires attention to procedures that provide greater precision for occlusal, dental, mucosal and aesthetic relationship that can develop over a lifetime.
• The partial and completely edentulous patient is unable to recover normal function, aesthetic comfort or a speech with traditional removable prosthesis. Improvement in oral function has been demonstrated after prosthetic rehabilitation with implant-supported prosthesis due to enhanced stability and retention.

Treatment options available after Full or partial loss of teeth

Dental Implant:- A dental implant is an anchor used to attach a crown. The implant is placed in the lower or upper jaw and acts as a root. Implants tend to be stable and secure and feel like natural teeth.

Removable Partial Dentures:-  These dentures consist of replacement teeth and a base. Besides, the dentist will affix a clasp that attaches the denture to the natural teeth to improve stability and function. People who have removable partial dentures need to keep them in during the day but take them out at night. Follow-up appointments are necessary with these dentures to ensure the proper fit.

Fixed Crown/Bridges:-  Fixed bridges are also a viable option after an extraction. The bridge is cemented or bonded in place and cannot be removed by the wearer.

Importance of Fixed Prosthodontics for Elderly

• It strengthens the tooth’s structure and restores its original physical integrity
• Eliminates the discontinuities at the dentin-enamel junction.
• It restores proximal contact morphology. For the successful outcome of the rehabilitation of the teeth with crown, the proximal contact points play a significant role.
• It balances out tooth positions and occlusal relationships.
• It creates a good aesthetic harmony between restoration and surrounding structures.

Denture Care and Diet recommendations for New Denture wearers

• After the denture is delivered to the patient, the patient is taught to remove and wear the prosthesis repeatedly. Post Denture insertion instructions regarding maintenance of denture, its cleaning protocol using a denture cleaning brush using any toothpaste/soap water or use of chemical cleansers using Chlorhexidine, Sodium Perborate/ Nystatin should be done.
• Flossing can be advised to the patients but not excessive as it can result in pop out of teeth from the denture.
• Patient should be instructed to avoid nightwear of prosthesis. The dentures should be stored in water or any dilute medicinal solution at night. If the patient wears denture during sleep, the mucosa does not have any rest to improve its blood supply and it can lead to bone resorption and mucosal degeneration.
• With Patients with Fixed Partial Dentures, Even with desirable pontic design and favourable material selection, by applying oral hygiene measures is very important to prevent plaque accumulation and bacterial Infection leading to mucosal inflammation. In addition to regular tooth brushing, using of interdental aids like flossing, inter-dental brushes, water flossers and improve biological maintenance of fixed prosthesis. We in our department provide proper oral hygiene education to the patients and motivate them so that they practice good oral hygiene measures.
• With nutritional guidance, denture wearers can easily consume nutritionally -adequate diets.
• Most patients with new dentures should initially consume a soft diet while they become accustomed to the new denture.
• These patients should also begin adaptation to their new dentures by cutting foods into small pieces and chewing them with the molars.
• They can then progress to biting and incising food.
• New denture wearers will need to chew longer, eat more slowly, and cut fibrous foods such as apples and carrots into bite-sized pieces.
• Explaining the importance of generous fiber, calcium, Vitamin C and Vitamin D intakes, and reducing saturated fat intake for the prevention of chronic diseases may also help to motivate patients to adapt rapidly to well-balanced diets.

Conclusion :-

Caring for the edentulism in geriatric patient is a major challenge that the profession face and proper adaptation of prosthesis to oral tissues is the key to sucess for a prosthodontic treatment. Our team at Manav Rachna has a broad base of knowledge and select features from different treatment modalities that suit each patient best. We provide high-quality dental treatments with affordable rates. Case history of the patients is taken into account to know their physical condition, presence of any systemic diseases, like hypertension, diabetes, any cardiovascular disease, any renal disorder, or any other disease prevalence which will help carry out the dental procedure effectively. So an older adult’s medical, functional and psychological status is considered in each phase of different prosthetic treatments. Proper oral hygiene instructions are given to the patients to maintain good oral health.

Written By:- Dr. Madhuri Bhatia Ralhan, Dept. of Prosthodontics, MRDC