medically compromised prosthodontic patients

1. Presented byPresented by
Rani RanabhattRani Ranabhatt
Junior ResidentJunior Resident
Department of ProsthodonticsDepartment of Prosthodontics
Specific Concerns in
Complete Denture
Fabrication in Various
Medically compromised
situations
11

2. How is an older patientHow is an older patient
different?different?
 Some of these events can be modified by good lifestyleSome of these events can be modified by good lifestyle
habits and some can be managed therapeutically sohabits and some can be managed therapeutically so
that their impact on the patient’s ability to live fully isthat their impact on the patient’s ability to live fully is
minimized.minimized.
22

3.  The aged patient, from a medical perspective, is aThe aged patient, from a medical perspective, is a
combination of “normal” age-related changes,combination of “normal” age-related changes,
chronic diseases and resultant drug therapy.chronic diseases and resultant drug therapy.
 Systemic medical conditions like diabetes mellitusSystemic medical conditions like diabetes mellitus
and neuromuscular diseases may make successfuland neuromuscular diseases may make successful
wearing of complete dentures difficultwearing of complete dentures difficult
Jack SS, Reis P. Statistics. Current estimates from the National Health
Interview Survey United States. Washington, D.C.: National Center for
Health, 1979, DHHS(PHS).
33

4. Why Concern to aWhy Concern to a
Prosthodontist ???Prosthodontist ???
Various systemic conditions affectVarious systemic conditions affect
oral mucosal conditionsoral mucosal conditions
Minimize the Adaptive response of the patientMinimize the Adaptive response of the patient
44

5. 55

6.  OsteoarthritisOsteoarthritis
 OsteoporosisOsteoporosis
 Osteopetrosis etc….Osteopetrosis etc….
 Oral submucous fibrosisOral submucous fibrosis
 SclerodermaScleroderma
 Papillon LevefrePapillon Levefre
syndromesyndrome
 Vesiculoerosive lesionsVesiculoerosive lesions
 Systemic lupusSystemic lupus
erythematosuserythematosus
 Burning Mouth syndromeBurning Mouth syndrome
Joint movement
disorders
Oral mucosal
lesions
66

7.  Sjogren’s syndromeSjogren’s syndrome
 HypersalivationHypersalivation
– Parkinson’s diseaseParkinson’s disease
– Down’s syndromeDown’s syndrome
– AutismAutism
– Cerebral palsyCerebral palsy
– Amyotropic lateral sclerosisAmyotropic lateral sclerosis
 HyposalivationHyposalivation
– DehydrationDehydration
– Therapeutic medicationTherapeutic medication
– Head & neck radiation therapyHead & neck radiation therapy
– Autoimmune disordersAutoimmune disorders
– Age related salivary glandAge related salivary gland
functionfunction
 Diabetes mellitusDiabetes mellitus
 nutritionnutrition
Salivary
Dysfunction
others
77

8. Medical evaluation of theMedical evaluation of the
geriatric patientgeriatric patient
88

9. 99

10. Oral movement disordersOral movement disorders
 Clinical presentation as excess orClinical presentation as excess or
diminished movement may bediminished movement may be
– hyperkinetic ( bruxism, dystonia,hyperkinetic ( bruxism, dystonia,
dyskinesis)dyskinesis)
– Hypokinetic ( Parkinson’s disease)Hypokinetic ( Parkinson’s disease)
Reduced ability of patients to controlReduced ability of patients to control
muscular movements of the jaws thereby,muscular movements of the jaws thereby,
seriously impacting the prognosis forseriously impacting the prognosis for
complete denture therapycomplete denture therapy
1010

11. Problems in patients with oralProblems in patients with oral
movement disordersmovement disorders
1.Pain
2. Compromised function
3. Depression
Early Recognition & Appropriate
medical Referral
Patients with systemic conditions
have limited dexterity to handle
removable prosthesis , therefore
Removable prosthesis should
only be considered after careful
review of the patient’s limitations
and capabilities
1111

12.  Osteoporosis is defined by the WHO as boneOsteoporosis is defined by the WHO as bone
mineral density (BMD) greater than 2.5mineral density (BMD) greater than 2.5
standardstandard deviationsdeviations below that of the youngbelow that of the young
adult BMD.adult BMD.
 Osteoporosis is common in aging individuals,Osteoporosis is common in aging individuals,
especially post menopausal women when theespecially post menopausal women when the
estrogenic blood level is low.estrogenic blood level is low.
 In elderly men and women, osteoporosis is causedIn elderly men and women, osteoporosis is caused
by a variety of factors such as calcium loss,by a variety of factors such as calcium loss,
calcium deficiency, hormonal deficiency, change incalcium deficiency, hormonal deficiency, change in
protein nutrition and decreased physical activity.protein nutrition and decreased physical activity. 1212

13.  Residual ridge resorption of the jaws is also moreResidual ridge resorption of the jaws is also more
rapid in increasing age group, depleted bone beingrapid in increasing age group, depleted bone being
prone to the injurious impact of mechanical forcesprone to the injurious impact of mechanical forces

15. The prosthodontic implications of osteoporosis wereThe prosthodontic implications of osteoporosis were
summarised bysummarised by Shapiro et alShapiro et al., including., including

17. Dental screening forDental screening for
osteoporosisosteoporosis
Mandibular and maxillary radiographs are suggestedMandibular and maxillary radiographs are suggested
in screening patients for osteoporosis for two reasonsin screening patients for osteoporosis for two reasons
potential frequency of dental radiographs comparedpotential frequency of dental radiographs compared
to the rest of the bodyto the rest of the body
the prosthodontic implications of osteoporosis.the prosthodontic implications of osteoporosis.
Bone density may be assessed by a prosthodontistBone density may be assessed by a prosthodontist
using linear measurements (using linear measurements (morphometric analysismorphometric analysis))
or by measuring optical density of boneor by measuring optical density of bone
((densitometric analysisdensitometric analysis),),

18. Call for detection of osteoporosis inCall for detection of osteoporosis in
India‑can a dentist help?India‑can a dentist help?
 A number of indices, image processing andA number of indices, image processing and
analyzing techniques based on panoramicanalyzing techniques based on panoramic
radiographs have been developed to discriminateradiographs have been developed to discriminate
individuals with and without osteoporosis.individuals with and without osteoporosis.
 Cortical width,Cortical width,
 panoramic mandibular index,panoramic mandibular index,
 alveolar crest resorption degree (M/M) ratio,alveolar crest resorption degree (M/M) ratio,
 cortical index andcortical index and
 fractal dimension are a few among themfractal dimension are a few among them
1818
Watanabe PC, Issa JP, Oliveira TM, Monteiro SA, Iyomasa MM,
Regalo SC, et al. Morphodigital study of the mandibular trabecular
bone in panoramic radiographs. Int J Morphol 2007;25:875 80‑

19. Prosthodontic managementProsthodontic management
..Management in removable denturesManagement in removable dentures
1.1.mucostatic and open mouth impression techniques,mucostatic and open mouth impression techniques,
2.2.use of acrylic non- or semi-anatomic teeth ratheruse of acrylic non- or semi-anatomic teeth rather
than porcelain ones,than porcelain ones,
3.3.narrowing the occlusal table and/or decreasingnarrowing the occlusal table and/or decreasing
number of posterior teeth,number of posterior teeth,
4.4. periods of extended tissue rest (by keepingperiods of extended tissue rest (by keeping
dentures out of the mouth for 10–12 h daily),dentures out of the mouth for 10–12 h daily),
5.5.optional use of soft liners and shorter recalloptional use of soft liners and shorter recall
intervals to facilitate early intervention could beintervals to facilitate early intervention could be
incorporated.incorporated.

20. Osteoarthritis & Prosthetic JointsOsteoarthritis & Prosthetic Joints
2020
 Arthritis is the most common chronic disease in older
adults.
 patients are managed medically, by physiotherapy
and drugs,
 the dentist should consult with the patient’s
orthopedic surgeon or physician on an individual
basis to determine the need for prophylaxis.

21. Concern in ArthritisConcern in Arthritis
 The dentist should try to ensure the patient’sThe dentist should try to ensure the patient’s
physical comfort in the dental chair by the use of aphysical comfort in the dental chair by the use of a
comfortable chair position, by allowing the patientcomfortable chair position, by allowing the patient
to change position or use physical aids such asto change position or use physical aids such as
pillows as needed, and by having shorterpillows as needed, and by having shorter
appointmentsappointments
2121

22. Problems in patients with mucosal problemsProblems in patients with mucosal problems
 Limits the ability of the oral mucosal tissues toLimits the ability of the oral mucosal tissues to
withstand the mechanical pressures that resultwithstand the mechanical pressures that result
from wearing the denturesfrom wearing the dentures
 Most common problems areMost common problems are
– Lichen planusLichen planus
– Erythema multiformeErythema multiforme
– Mucous membrane pemphigoid, etcMucous membrane pemphigoid, etc
poor prognosis for complete denture therapy, hencepoor prognosis for complete denture therapy, hence
use of fixed osseointegrated prosthesis is a prudentuse of fixed osseointegrated prosthesis is a prudent
alternativealternative
2222

23. Microstomia producing conditionsMicrostomia producing conditions
 Microstomia is defined asMicrostomia is defined as
an acquired or congenitalan acquired or congenital
condition involving acondition involving a
reduction of the oralreduction of the oral
aperture severe enoughaperture severe enough
to compromise esthetics,to compromise esthetics,
nutrition, and quality ofnutrition, and quality of
life.life.
 Oral submucousOral submucous
fibrosisfibrosis
 SclerodermaScleroderma
2323

24. Oral SubMucous FibrosisOral SubMucous Fibrosis
 Oral submucous fibrosis is a chronic,Oral submucous fibrosis is a chronic,
progressive, scarring disease,thatprogressive, scarring disease,that
predominantly affects people of Southpredominantly affects people of South
East Asian originEast Asian origin
 Considered as a Premalingnant conditionConsidered as a Premalingnant condition
Why of Prosthodontist’s concern???Why of Prosthodontist’s concern???
--microstomiamicrostomia
-glossitis and stomatitis-glossitis and stomatitis
-band formation and impairment of tongue-band formation and impairment of tongue
movementmovement
2424

25. ModificationsModifications
At impression making and materialAt impression making and material
-sectional tray-sectional tray
-use addition silicone-use addition silicone
-ZoE irritates the mucosa-ZoE irritates the mucosa
At border moldingAt border molding
-Restricted movements-Restricted movements
At jaw relationAt jaw relation
-Fragile mucosa-Fragile mucosa
-Unstable record bases-Unstable record bases
DenturesDentures
-Sectional / collapsible/ hinged-Sectional / collapsible/ hinged 2525

26. Management options forManagement options for
microstomiamicrostomia
2626

27. Hinged mandibular completeHinged mandibular complete
denture with swing lockdenture with swing lock
2727

28. Collapsible dentureCollapsible denture
2828

29. Burning mouth syndromeBurning mouth syndrome
 Majority of patiens are POSTMENOPAUSALMajority of patiens are POSTMENOPAUSAL
WOMEN who describe a painful, burning sensationWOMEN who describe a painful, burning sensation
affecting the oral mucosaaffecting the oral mucosa
 Affects tongue lips buccal mucosaAffects tongue lips buccal mucosa
Floor of mouthFloor of mouth
2929

30. 3030

31. Management of BMSManagement of BMS
 Salivary alterations like xerostomia, orSalivary alterations like xerostomia, or
increased salivary viscosity and alteredincreased salivary viscosity and altered
tastetaste
 Usually Palliative NOT curativeUsually Palliative NOT curative
 Patient education and encouragementPatient education and encouragement
- BEST approach to improve Patients- BEST approach to improve Patients
quality of lifequality of life 3131

32. Salivary dysfunctionSalivary dysfunction
 salivary changes, may inducesalivary changes, may induce oral alteration andoral alteration and
discomfort with the removable prosthesisdiscomfort with the removable prosthesis
 The normal salivary function is an important factorThe normal salivary function is an important factor
for the maintenance of health, with positivefor the maintenance of health, with positive
consequences on the functionality and tolerance ofconsequences on the functionality and tolerance of
the removable denturesthe removable dentures
 Xerostomia, a subjective symptom consisting inXerostomia, a subjective symptom consisting in
dry-mouth sensation, is frequently associated withdry-mouth sensation, is frequently associated with
quantitative and qualitative changes of the salivaryquantitative and qualitative changes of the salivary
flowflow
3232

33. Causes of XerostomiaCauses of Xerostomia
 MedicationMedication
 Primary and secondaryPrimary and secondary
Sjogren’s syndromeSjogren’s syndrome
 RadiotherapyRadiotherapy
 VasculitisVasculitis
 HIV infectionHIV infection
 Medullar transplantMedullar transplant
 Renal dialysis , etcRenal dialysis , etc
3333

34. Consequences of xerostomia inConsequences of xerostomia in
denture wearersdenture wearers
-Caries of abutment-Caries of abutment
-Discomfort and burning sensation-Discomfort and burning sensation
-Poor retention of denture-Poor retention of denture
-Soreness of denture bearing tissue-Soreness of denture bearing tissue
-Difficulty in chewing and speech-Difficulty in chewing and speech
3434

35. Medical ManagementMedical Management
 SialogoguesSialogogues
 Dry mouth sprayDry mouth spray
 Sugar free gumsSugar free gums
 Salivary substitutesSalivary substitutes
– Carboxymethylcellulose basedCarboxymethylcellulose based
– Mucin basedMucin based
3535

36. Prosthodontic modificationProsthodontic modification
3636
Maxillary and mandibular salivary reservoir denture

37. NutritionNutrition
 Elderly population at particular risk forElderly population at particular risk for
MALNUTRITIONMALNUTRITION
 Nutritional deficienciesNutritional deficiencies
– Angular chelitisAngular chelitis
– MucositisMucositis
– GlossitisGlossitis
3737

38. DiabetesDiabetes
 Diabetes mellitus is aDiabetes mellitus is a
diverse group of disordersdiverse group of disorders
that producethat produce
hyperglycemia as ahyperglycemia as a
prominent manifestation,prominent manifestation,
ultimately as a function ofultimately as a function of
the inability to secretethe inability to secrete
enough insulin to meetenough insulin to meet
metabolic needs.metabolic needs.
 Clinically -classic triad ofClinically -classic triad of
polydipsia, polyphagiapolydipsia, polyphagia
and polyuriaand polyuria 3838

39. 3939

40. Diabetes — Disease ClassificationDiabetes — Disease Classification
by Clinical Symptomatologyby Clinical Symptomatology
Associated with Control ofAssociated with Control of
Diagnosed DiabetesDiagnosed Diabetes
 Class I-asymptomaticClass I-asymptomatic
 Class II- occasional mild hypoglycemiaClass II- occasional mild hypoglycemia
 Class III-occasional mild or severe hypoglycemia orClass III-occasional mild or severe hypoglycemia or
hyperglycemiahyperglycemia
 Class IV- frequent hypoglycemia* or hyperglycemiaClass IV- frequent hypoglycemia* or hyperglycemia
as a function of brittle diabetes, non- complianceas a function of brittle diabetes, non- compliance
or concomitant acute illness (e.g., infection)or concomitant acute illness (e.g., infection)
4040

41. Key dental treatmentKey dental treatment
considerations for diabeticconsiderations for diabetic
patients include:patients include:
1) Medical history :1) Medical history :
· Take history and assess glycemic control at initial appt.· Take history and assess glycemic control at initial appt.
· Glucose levels· Glucose levels
· Frequency of hypoglycemic episodes· Frequency of hypoglycemic episodes
· Medication, dosage and times.· Medication, dosage and times.
2) Establishing the levels of glycemic control early in the2) Establishing the levels of glycemic control early in the
treatment process:treatment process:
· Patients recent glycated Hb values· Patients recent glycated Hb values 4141

42. 3) Stress Reduction3) Stress Reduction
· Profound anesthesia reduces pain and minimizes· Profound anesthesia reduces pain and minimizes
endogenous epinephrine release.endogenous epinephrine release.
4) Oral hygiene instructions, frequent prophylaxis &4) Oral hygiene instructions, frequent prophylaxis &
monitoring of periodontal health, as there ismonitoring of periodontal health, as there is
increased risk of periodontal disease.increased risk of periodontal disease.
5) Treatment: The use of antibiotics in case of5) Treatment: The use of antibiotics in case of
infection and Diet Modification.infection and Diet Modification.
··
4242

43. Appointment timingsAppointment timings
 Diabetic patients can receive dental treatment inDiabetic patients can receive dental treatment in
the morning.the morning.
 Diabetic Emergencies ManagementDiabetic Emergencies Management
Signs and symptoms of hypoglycemia include;-Signs and symptoms of hypoglycemia include;-
Confusion ,sweating, tremors, agitation, anxiety,Confusion ,sweating, tremors, agitation, anxiety,
dizziness, tingling or numbness, and tachycardia.dizziness, tingling or numbness, and tachycardia.
Severe hypoglycemia may result in seizures or loss ofSevere hypoglycemia may result in seizures or loss of
consciousnessconsciousness.. 4343

44. Why is of prosthodontistsWhy is of prosthodontists
concern???concern???
MENIFESTATIONSMENIFESTATIONS
Hyposalivation / xerostomiaHyposalivation / xerostomia
Fungal infection ( candidaFungal infection ( candida
albicans)albicans)
Altered taste sensationAltered taste sensation
Burning mouth syndromeBurning mouth syndrome
Delayed or impaired healingDelayed or impaired healing
Glossitis and angular cheilitisGlossitis and angular cheilitis
Increased residual ridgeIncreased residual ridge
resorptionresorption
4444

45. Prosthodontic ManagementProsthodontic Management
 Salivary reservoir dentureSalivary reservoir denture
 Metal denture basesMetal denture bases
 Tissue conditionersTissue conditioners
 Fabrication of denture withFabrication of denture with
minimal pressureminimal pressure
 Lingualised or monoplaneLingualised or monoplane
occlusionocclusion
4545

46. 4646
RADIOTHERAPY CHEMOTHERAPY

47. Degenerative diseases of theDegenerative diseases of the
nervous systemnervous system
 Normal aging does not result in significant declineNormal aging does not result in significant decline
in memory and learning abilityin memory and learning ability
 Mild Impairment- benign senescent forget fullnessMild Impairment- benign senescent forget fullness
 DEMENTIA- organic brain syndrome / SenileDEMENTIA- organic brain syndrome / Senile
dementia , a clinical condition characterized by adementia , a clinical condition characterized by a
general decline in memorygeneral decline in memory
 Most are irreversible , most common beingMost are irreversible , most common being
Alzheimer’s diseaseAlzheimer’s disease
4747

48. Our concernOur concern
 CHALLENGE – to assess the degree of cooperationCHALLENGE – to assess the degree of cooperation
that can be expected, with the aid of sedation.that can be expected, with the aid of sedation.
 Complete major dental work in the early phase ofComplete major dental work in the early phase of
the disease to gain maximum cooperation &the disease to gain maximum cooperation &
adaptability.adaptability.
 Caregivers can be asked to chose a suitable time ofCaregivers can be asked to chose a suitable time of
the day at which patient can help at his/ her ownthe day at which patient can help at his/ her own
best cooperation.best cooperation.
 Denture LabelingDenture Labeling
 Reduced manual dexterity-Assisted oral hygieneReduced manual dexterity-Assisted oral hygiene
maintenancemaintenance
4848

49. To summarise……….To summarise……….
 Although the dental treatment will require a littleAlthough the dental treatment will require a little
modification, the informed dentist will recognizemodification, the informed dentist will recognize
the need for more information on the identificationthe need for more information on the identification
and management of chronic diseases in this ageand management of chronic diseases in this age
group.group.
 Increased knowledge and concern for the patientIncreased knowledge and concern for the patient
should allow better treatment planning andshould allow better treatment planning and
effective patient care management.effective patient care management.
4949

50. ReferencesReferences
 Prosthodontic treatment of edentulous Patients ,Prosthodontic treatment of edentulous Patients ,
Zarb,Hobkirk,Eckert and Jacob.13Zarb,Hobkirk,Eckert and Jacob.13thth
editionedition
 Watanabe PC, Issa JP, Oliveira TM, Monteiro SA,Watanabe PC, Issa JP, Oliveira TM, Monteiro SA,
Iyomasa MM, Regalo SC,Iyomasa MM, Regalo SC, et alet al. Morphodigital study. Morphodigital study
of the mandibular trabecular bone in panoramicof the mandibular trabecular bone in panoramic
radiographs. Int J Morphol 2007;25:875 80.‑radiographs. Int J Morphol 2007;25:875 80.‑
 Jack SS, Reis P. Statistics. Current estimates fromJack SS, Reis P. Statistics. Current estimates from
the National Health Interview Survey Unitedthe National Health Interview Survey United
States. Washington, D.C.: National Center forStates. Washington, D.C.: National Center for
Health, 1979, DHHS(PHS).Health, 1979, DHHS(PHS).
5050

51.  Kumar P, Singh SV, Aggarwal H, Alvi HA. Call forKumar P, Singh SV, Aggarwal H, Alvi HA. Call for
detection of osteoporosis in India can a dentist help?‑detection of osteoporosis in India can a dentist help?‑
Indian J Endocrinol Metabol 2014;18: 871.Indian J Endocrinol Metabol 2014;18: 871.
 Kilmartin CM. Managing the medically compromisedKilmartin CM. Managing the medically compromised
geriatric patient. J Prosthet Dent 1994;72:492-9.geriatric patient. J Prosthet Dent 1994;72:492-9.
 Harris MI, Hadden WC, Knowler WC, Bennett PH.Harris MI, Hadden WC, Knowler WC, Bennett PH.
Prevalence of diabetes and impaired glucose tolerancePrevalence of diabetes and impaired glucose tolerance
and plasma glucose levels in U.S. population aged 20and plasma glucose levels in U.S. population aged 20
to 74 years. Diabetes 1987;36:523-34.to 74 years. Diabetes 1987;36:523-34.
 Diabetes in America: diabetes data compiled 1984.Diabetes in America: diabetes data compiled 1984.
National DiabetesNational Diabetes Data Group. Bethesda, Md: NationalData Group. Bethesda, Md: National
Institutes of Health, Publication No. 85.1468, RA645Institutes of Health, Publication No. 85.1468, RA645
D5D6,1985.26.D5D6,1985.26.
5151

52. 5252