Braz Dent J (1998) 9(2): 109-116 ISSN 0103-6440
| Introduction | Case Report | Discussion | Conclusions | References |
A 76-year old female patient came to the Specialized Clinic for Long-Lasting Dentures of the Dental School of Ribeirão Preto, USP, for prosthetic treatment for the correction of the absence of several teeth. The patient's medical history and examination revealed the presence of psoriasis that had progressed to a rheumatoid arthritis-like condition causing motor deficits such as difficulty in picking up and holding a toothbrush. We proposed two acrylic removable partial dentures, with a chromium-cobalt metal support planned for the lower denture. For the maintenance of oral hygiene we proposed an acrylic resin device coupled to the toothbrush in order to increase the volume of the toothbrush, and consequently facilitate tooth brushing. This device, although simple, has permitted the patient to have a more independent and healthy life style.
Key Words: geriatric dentistry, maintenance of prosthetic treatment, elderly patients.
With the improved life expectation brought about in part by improved health conditions and more accessible programs, the population of the aged is increasing. An increase in the proportion of this population is occurring in industrialized countries. Thus, the pyramid-shaped population is being transformed into a column (Barnes, 1994). By about 2025, 8 of 11 Third World countries will have an elderly population exceeding 16 million (Barnes, 1994). As a consequence, there will also be an increased demand for dental treatment, with the growing need for programs covering not only the population in general but also the aged, as suggested by epidemiologic data (Dolan and Etchinson, 1993). Over the next few decades, the rapid growth of the aged segment of the population will affect dental practice (Berkey et al., 1996).
It is important to define the meaning of "aged". The Bureau of Health Professions defines it as a "population with health conditions and needs significantly different from those of young people that are frequently complicated by physical, behavioral and social changes associated with age" (Dolan and Etchinson, 1993). This group includes people older than 60 years, but also refers to young people with physical and mental conditions similar to those described above for the aged. According to Drummond et al. (1995), the basic concept of aging is the loss of adaptability of the organism with time, although this is not an intrinsic characteristic of all organisms. This means that not all depends on age and, furthermore, the wide variability of the physical, medical and mental conditions of persons older than 60-65 years renders the chronological criterion inappropriate for the identification of geriatric patients (Dolan and Etchinson, 1993). According to Berkey et al. (1996), authors who habitually generalize geriatrics according to chronological age may be considered to be obsolete.
Even though the aged may keep their teeth over the years, their oral health is far from optimal (Paunovich, 1994), requiring the development of treatment plans that consider psychosocial, socioeconomic and medical/medication variables which should somehow determine not only immediate success but also successful long-term treatment (Mulligan and Wood, 1993). The aged should receive special consideration with respect to their needs and each case should be judiciously examined since a patient may have a single problem that affects the organism as a whole (Dolan and Etchinson, 1993) or that causes changes in the protocol of the treatment plan. Treatment of the aged should be based on their real needs. The treatments commonly used by most dental surgeons do not satisfy these requirements; in addition, after the treatment is proposed and performed, one of the major concerns is its maintenance, often impaired due to the physical and mental conditions of the patients.
The objective of the present study was to describe a form of maintenance proposed for a simplified prosthetic treatment for an elderly person in an attempt to relieve physical difficulties and to provide satisfactory conditions of oral health.
A 76-year-old female patient came to the Specialized Clinic for Long-Lasting Dentures of the Dental School of Ribeirão Preto, USP, for prosthetic treatment. A detailed history of the patient was taken and clinical and radiographic examinations were carried out. She had few remaining teeth (14-12-11-21-22-27 and 42-41-31-3243-42) and her periodontal condition was precarious. During examination she reported that tooth loss occurred due to her difficulty in brushing since she had psoriasis arthritis for the past 6 years leading to rheumatoid arthritis-like symptoms (Figure 1), with consequent difficulty in holding a toothbrush.
A significant alteration of the vertical dimension had occurred, the maxillary front teeth underwent anteriorization and distalization, and the mandibular teeth were occluded in the palate provoking ulcerations and pain. In addition, the patient had difficulty eating which led to malnutrition.
In addition to periodontal treatment, we proposed a recuperation of the vertical dimension with the use of temporary removable partial dentures (RPD) mainly using the phonetic and esthetic method. The lower RPD was made without teeth, only consisting of a posterior plane platform for periodic abrasion for adjustment of the vertical dimension and for the patient's comfort.
After this initial period of adjustment, a lower RPD was made using a spaced mesh in place of a lingual plate in the form of a chromium-cobalt framework (Figure 2) with the extensions toward the saddle, and 0.8 mm steel clasps were used in place of retention clasps to facilitate insertion/removal by the patient.
In an attempt to maintain this treatment, we made an acrylic resin device coupled to the toothbrush in order to provide a better hold. This device was made by molding the patient's hand with molding material consisting of condensation polymerizable silicone (3M do Brasil Ltda., São Paulo) while she held the toothbrush of her preference (Figures 3, 4, and 5). The mold was sectioned in half to facilitate inclusion in a flask in the same way as full dentures and the preparation of the colorless heat-polymerizable acrylic device (Lucitone, Dentisply Indústria e Comércio Ltda, Rio de Janeiro) was as described by Mattos et al. (1998).
With the fall in birth and mortality rates observed over the last few decades, there has been an increase in the adult population and consequently in the aged; this aging is characteristic of both developed countries and of Third World countries (Franks and Hedegard, 1973; Kilmartin, 1994; Shay, 1994).
From a medical viewpoint, the age of the patient involves a combination of several factors such as physiological changes due to advancing age, chronic disease and the use of medications (Kilmartin, 1994), as well as traumatic injuries and iatrogenic changes in dentition (Shay, 1994). Physiological decline and the associated chronic diseases may contribute to a significant decrease in the therapeutic response and in the safety margin of many medications (Berkey et al., 1996).
Chronic disease is defined as any condition lasting more than 3 months and is more common among the aged (Jack and Reis, 1979), the most frequent being heart disease, diabetes and arthritis (Bradley et al., 1993). These are long-term, usually progressive and incurable diseases which in most cases are controlled with drug treatment (Bradley et al., 1993).
The patient described here reported a history of psoriasis arthritis lasting approximately 6 years, a disease that had already caused her countless physical and emotional problems. Psoriasis belongs to a group of chronic diseases characterized by erythematous and desquamating plaques whose etiology and pathogeny are unclear. A polygenic pattern of genetic inheritance has been suggested for this condition. The time of skin renewal is extremely rapid, 3 to 4 days, in contrast to normal skin (Robbins et al., 1986).
Psoriasis arthritis occurs in 7% of patients with psoriasis, with symptoms similar to rheumatoid arthritis and symmetrically affecting multiple articulations, especially the small joints of the hands and feet, which become swollen, sensitive and painful when moved. As the disease becomes chronic, the joints undergo progressive hardening and rigidity with loss of function, with a fusiform appearance and atrophy of surrounding muscles. A clawlike deformity arises in the hands, with flexion contractures and ulnar deviation of the immobilized fingers (Robbins et al., 1986; Wyngaarden, 1988). This causes loss of mobility and difficulty in performing hand movements necessary for dental hygiene. Psoriasis arthritis associated with other factors such as psychic and social alterations had been causing enormous discomfort for this patient and a growing dissatisfaction with her oral condition.
From the viewpoint of dental surgeons, the treatment of the aged requires more attention since most geriatric patients have physical disabilities such as changes in vision, hearing and mobility which require appropriate adjustments on the part of the dental team that treats them (Kilmartin, 1994; Shay, 1994), with an understanding of the needs and priorities of each patient (Berkey et al., 1996).
The aged tend to control information in a conscious or unconscious manner and many avoid dental treatment for fear of losing their remaining teeth (Kilmartin, 1994). Studies by Brody (1985) have demonstrated that patients of highly advanced age report less than 1% of the 2000 symptoms listed on a health questionnaire, and the non-reported symptoms include more than 50% of the 20 potentially serious symptoms. The dental surgeon should ask specific questions concerning possible problems, their severity and the subsequent impact on the quality of life of the patient (Berkey et al., 1996).
According to Hildebrant (1995), patients with an independent life style are significantly healthier than hospitalized patients or persons in nursing homes, and the quality of dentition is also better. The preservation of natural teeth may greatly affect health, whereas the use of dentures may delay or prevent the negative effects on general health by increasing the number of functional units.
Some studies have suggested a discrepancy between the need for treatment and the perception of this need, with 78% of patients being considered to require some dental treatment whereas only 42% of them thought they needed such treatment (Christensen, 1992).
Treatment of the aged does not differ much from treatment of younger adults, but it is important to know how to differentiate the peculiarities of the geriatric organism, how the diseases manifest and their response to the procedures instituted (Franks and Hedegard, 1973), often requiring more in-depth studies. Vogler et al. (1994) stated that advanced age does not increase the risk of complications associated with simple extractions, and encouraged dental surgeons to carry out these procedures on geriatric patients.
When planning treatment, the health-sickness relationship of the patient should be taken into consideration (Shay, 1994). However, the treatments commonly used by most dental surgeons, called normative, should be well analyzed so that they will not be overestimated. The real needs of the patient should be weighed and the treatment should be planned in such a way as to be as satisfactory as possible, providing function, esthetic appearance and comfort adequate to the conditions of each patient. To offer the best treatment, the dentist should make a clinical decision that will estimate not only the benefits for the patient but also the ability of the patient to deal with the stress of oral problems (Berkey et al., 1996).
Although the number of fully or partially edentulous individuals is decreasing, this should not necessarily reduce the demand for prosthetic treatment but should lead to more differentiated and perhaps more complicated services (HolmPedersen and Löe, 1996).
According to Fenton (1994), the replacement of lost teeth is influenced by the general health condition of the aged, by dental tissues, by financial condition and by access to a dental surgeon, with RPD representing a more versatile, economic and less invasive treatment. Some geriatric studies have reported that the teeth should be maintained and that RPD are indicated (Franks and Hedegard, 1973; Fenton, 1994), and that the treatment of partially edentulous patients with RPD is similar despite patient age (Fenton, 1994).
According to Drummond et al. (1995), the biological age of teeth is more important than the biological age of the patient. A simplified evaluation of patient needs should be avoided; however, the classification of dentition into widely accepted categories is helpful in the discussion of cases and in treatment planning.
Once treatment is proposed, it is important to plan its maintenance, emphasizing hygiene techniques and keeping in mind the limitation of the patients, who often depend on the help of others.
Many elderly persons have difficulty in holding a toothbrush firmly because of reduced muscle strength in their hands and fingers. In a survey carried out by Paunovich (1994), among individuals who maintained their own oral hygiene, 45% showed inadequate holding strength for the use of a toothbrush. In such cases, an acrylic resin device coupled to the toothbrush makes the handle thicker, allowing the user to hold the brush in a firmer manner, facilitating the hygiene of the teeth and of the denture, and making the person independent of third parties for such basic functions.
Oral health should be considered as part of the general health of the aged and of their quality of life, with oral health services being a primary component of health care. In addition, the aged should receive special consideration in terms of their needs (Dolan and Etchinson, 1993).
When providing geriatric care, changes in the planning and treatment protocol are often necessary (Mulligan and Wood, 1993; Shay, 1994) due to the wide gamut of psychosocial, socioeconomic and medical/drug variables involved, in order to obtain not only immediate success but also a longer lasting treatment (Mulligan and Wood, 1993). The need for prevention and treatment of chronic diseases is a high priority, together with the emphasis on treatment of the patient as a whole, considering the increase in the elderly population with multiple chronic medical complications, together with deficiencies in the health care system (Paunovich, 1994).
The objective of geriatric dentistry is to enable professionals to recognize and relieve the difficulties of the aged. For successful treatment, the dental surgeon should adopt a humanitarian attitude, develop a better relationship with, and a better understanding of the feelings and attitudes of the aged, understand their special dental problems, and consider them as different from other groups (Vincent et al., 1992).
The final objective of care should be the restoration or preservation of function in order to help the patient maintain not only an independent life but also his preferred life style within possible limits (Wyngaarden and Smith, 1988).
In the present study, a simple acrylic resin device coupled to a toothbrush created the possibility of obtaining and maintaining the prosthetic treatment performed as well as satisfactory conditions of oral health, in addition to new hope for individuals with similar problems.
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Correspondence: Prof. Dr. Maria da Gloria Chiarello de Mattos, Departamento de Materiais Dentários e Prótese, Faculdade de Odontologia de Ribeirão Preto, Universidade de São Paulo, 14040-904 Ribeirão Preto, SP, Brasil. E-mail: firstname.lastname@example.org
Accepted June 4, 1998
Electronic publication: April, 1999