A Systematic Approach to Problem Solving for Elderly Patients Wearing Complete Dentures

Review Article

Austin J Dent. 2018; 5(2): 1102.

A Systematic Approach to Problem Solving for Elderly Patients Wearing Complete Dentures

Ettinger RL* and Lindquist TJ

Department of Prosthodontics, University of Iowa College of Dentistry, USA

*Corresponding author: Ettinger RL, Department of Prosthodontics, University of Iowa College of Dentistry, Iowa City, Iowa52242, USA

Received: December 06, 2017; Accepted: January 08, 2018; Published: January 31, 2018


This paper describes a systematic approach to identifying and managing problems encountered by elderly patients wearing complete dentures. Although the percentage of elderly persons in the U.S. Population will increase; persons who are edentulous will decline. However, the total number of edentulous persons will remain at about 10 million for the next 15 years. These older edentulous persons will be more diverse, frailer with more medical problems and will take a greater variety of medications which can influence their ability to wear dentures. Thus they will be less adaptable and so will have more problems. The diagnosis and treatment of these problems will require systematic questioning of the patient and a careful examination to determine if the problems are due to 1. Intra-oral anatomical problems; 2. Clinical factors; 3. Technical factors; 4. Esthetic problems; 5. Speech problems; or 6. Adaptational or psychological problems, so an appropriate treatment can be instigated.

Keywords: Complete dentures; Diagnosis; Problem solving; Treatment; Elderly


A systematic approach to problem solving for elderly patients wearing complete dentures

Edentulism or the loss of all natural teeth has been an important indicator or measure of the oral status of a society. Thompson [1] has called it the “end stage of oral disease;” and it is a multifactorial process which is influenced by a number of sociodemographic factors such as age, gender, education, income, and being a member of an ethnic minority group [2,3]. The percentage of older edentulous patients in the U. S. population is decreasing; however, the total number of older persons will increase over the next 20 years [4]. Currently about 14.1% of the U.S. population is over the age of 65 years [5]. It has been estimated that due to the aging of the baby boomers (persons born between 1946 and 1964) approximately each day for the next 12 years 10,000 persons will turn 65 years of age [6]. It has been reported that between 1971 and 2001 persons in the lower socioeconomic group aged 65-74 had a decrease in edentulousness from 58% to 32%; for those in the high socioeconomic group it decreased from 30% to 9% [7]. In a comparison of two National Health and Nutrition Surveys (NHANES) 1998-1994 and 1999-2004, among adults aged 65-74 the prevalence of edentulism declined from 29% to 24% [8]. In 2002 Douglass, et al. [9] predicted that the total number of edentulous persons over age 65 would stay constant at about 9 million persons until the year 2020. Slade, et al. [10] in 2014 stated that edentulouness has declined because of “the passing of generations born in the mid- 20th century” however they project that the predicted number of edentulous persons in 2050 will be between 8 to 10 million persons which is less than the 12.2 million which existed in 2010. Ettinger, et al. [11] surveyed general practitioners in Iowa and found that 68.1% had made at least one set of complete dentures in the last 3 months. Thus, elderly edentulous persons will still be a significant part of many general practices over the next 20 years.

Characteristics of the edentulous population

The elderly population will become increasingly more diverse in terms of ethnicity, financial resources, and living conditions; however, many older adults who have been edentulous for a long time will have these projected personal characteristics which can be summarized as:

They will be medically compromised and physically frail and will take medications which are potentially xerostomic and may compromise their ability to wear new dentures [12-16].

They will have neurological diseases which will cause neuromuscular deficits, and make it difficult for them to learn to adapt to new complete dentures particularly the mandibular denture [17,18].

Nearly 50% will have been edentulous for more than 30 years [19,20].

The majority will be wearing dentures which are more than 20 years old.

A significant number will be on fixed income and will be in the lower income groups [2,3].

Many will no longer drive and may have transportation problems which will translate into access problems [21-23].

If questioned, more than 60 percent will respond that they have no treatment needs and will not have seen a dentist for at least five years [24,25]. A number of older adults will have much lower expectations of their complete dentures and will be more tolerant of functional deficiencies because tissue changes under their dentures are progressive allowing them to accommodate to the deteriorating fit of their dentures by eliminating from their diet foods that they find difficult to eat [26-29].

More than 30% will have mucosal lesions in the mouth which are denture-related and a few may need a biopsy and a clinical follow-up [30-33].

Sadly, many will be mildly confused but the older they become the higher the risk of some form of dementia [34-36].

Diagnosis of denture problems

Over the years, many authors [37-44] have presented systematic approaches to problem solving for patients wearing complete dentures. Young [37] presented a three-part check during insertion of complete dentures. Morstad and Peterson’s [38] approach was a list of problems and solutions and divided the complaints into; comfort, function, esthetics and phonetics. Luebke and Scandrett [42] emphasized that it takes time to diagnose and solve patients’ problems. They present an extensive table which evaluates the problem, diagnoses the problem and offers a treatment. Watt and MacGregor [40] also developed an excellent classification for the diagnosis of complete denture complaints. This paper presents a modification of all of these systems with an emphasis on some specific common problems.

Systemic issues

Older edentulous adults are susceptible to a variety of chronic debilitating diseases which either by themselves or their treatment causes a decrease in tolerance of wearing complete dentures. An accurate medical history is important, but more important is an understanding of the oral consequences of that medical and drug history [45-47]. For example, the medical treatment of a patient with hypertension, coronary artery disease, and depression would include a diuretic, a calcium channel blocker, an angiotensin-converting enzyme (ACE) inhibitor and a selective serotonin uptake inhibitor and possibly nitroglycerin as required. This therapy may induce hyposalivation and xerostomia. The depression acts on the salivary centers in the brain and each of the medications can potentially induce a dry mouth. The xerostomia reduces the flushing and lubricating action of the saliva, changing the oral environment, so that the tissues are more susceptible to trauma and infection by Candida albicans.

Another example is a patient with Parkinson’s disease who has facial tremors, even when controlled by levodopa. Such a person loses a great deal of neuromuscular control -so necessary for the successful wearing of mandibular complete dentures. He/she also has a tendency to clash and grit his/her teeth, resulting in damage to the supporting tissues and making denture wearing difficult.

Dental and Denture Problems

The dental and denture history and expectations influence a patient’s tolerance to dentures, and this knowledge often may help a dentist interpret the patient’s symptoms or his/her complaints. For example, an older patient who has successfully worn dentures for 20 years will not easily accept that new dentures require the learning of new manipulative skills, even when there has been adequate communication between the dentist and the patient.

When an edentulous patient seeks treatment, it is important to establish clear communication with that patient. However, many edentulous older adults are unable to give a clear description of their difficulties, and may simply state “my teeth are worn and I cannot chew anymore.” This complaint may mean the dentures have poor stability or retention, or that the teeth are worn and the vertical dimension has changed so that they can no longer chew comfortably. It may even mean that the patient is dissatisfied with his/her appearance. The diagnosis and treatment will depend on: