Introduction
The population over the age of 60 years has tripled in last 50 years in India and will relentlessly increase in future. According to census 2001, older people were 7.7% of the total population, which increased to 8.14% in census 2011. The projections for population over 60 years in next four censuses are: 133.32 million (2021), 178.59(2031), 236.01 million (2041) and 300.96 million (2051). The increase in the elderly population are the result of changing fertility and mortality regimes over the last 40-50 years.1, 2 There is decline in edentulism yet still there are oral health conditions that persist with age, such as caries, tooth loss and increased needs for prosthodontics treatment. Several factors should be taken into account in geriatric prosthodontics care, including quality of life and psychosocial needs. Elderly people are highly susceptible to mental morbidities due to ageing, problems associated with physical health, socio-economic factors such as breakdown of the family support systems and decrease in economic independence. The mental disorders that are frequently encountered include are dementia and mood disorders. Other disorders include neurotic and personality disorders, drug and alcohol abuse, delirium and mental psychosis.3 So, prosthodontist are hence in an ideal position to contribute to well-being of elderly population.
Prosthodontic considerations in geriatric patients
In many industrialized areas, more than 50% of the elderly population are edentulous.4 Various factors local or systemic determine the prognosis of patient’s treatment plan like:
Oral physiological changes: With the ageing, there is progressive atrophy of masticatory, buccal and labial musculature. Patient wearing dentures this process is accelerated. In progressive ageing there is atrophy of masticatory muscles which in resultant decreases the efficiency of chewing effecting the quality of life of patient.
Debilitating Diseases: Geriatric population usually neglect prosthetic care which they require the most at that point of time. Person’s general health is always the priority but the oral problems should not be neglected. For a chronic ill patient, maintenance of oral hygiene is a way to control and prevent the progress of diseases like caries and periodontal problems.5
Neurophysiological changes: Functional elements in the central nervous system degenerate with advancing age. These changes limit the person’s capacity to acquire new muscle activity pattern in brain. So, elderly people adapt slowly to prosthetic treatment modalities as it take more time to adapt to new muscle activity pattern which is being provided by prosthodontist as new oral rehabilitation.
Mental changes: In ageing population there is presence of mental disorders due to various physiological or biological causes which may complicate the prosthetic treatment outcome.
The effect of prosthetic management in geriatric dentistry is determined by various factors like patient’s cooperation, mental attitude, bio physiological changes due to ageing, financial resources etc.
Determining the mental attitude of elderly patients
So, mental attitude is one of an important factor in planning the treatment and improving its outcome. According to literature various researchers have found various classification of mental attitude of the elderly patient for prosthodontic treatment. Dr. M.M. House contributed in detailed expansion of classification and popularization of this system.6 Jamieson stated that “fitting the personality of the aged patient is often more difficult than fitting the denture to the mouth”.7
Various classifications for determining mental attitude of elderly patients are as follows:
House classification:8
A classification system based on the basis of patient’s psychological responses to becoming edentulous and adapting to dentures. Relying strictly on his clinical impressions, House classified patients into 4 types: philosophical mind, exacting mind, hysterical mind, and indifferent mind.
There was reason for reevaluation of House classification as it provides little attention to how the patient’s reaction and behaviors are codetermined by the treatment and behaviour of the dentist.
Winklers calssification:6
a) The Hardy elderly: Well-preserved physically and psychological, are active in their professional and social lives and quickly adapt to their age changes.
Last two categories have poor prognosis for prosthetic treatment.
Gamer classification:8
Simon Gamer et al in 2003 presented an expansion of House classification to include the behaviour of the dentist as a co determiner of the patient’s behaviour. It is based on two factors:
Heartwell classification:9, 10
a) The realists: These are philosophical, exacting type, alertness to change and realism in accepting to enjoy their old age. Take pride in their appearance and practice good oral hygiene, seek dental care and accept a proper diet.
Suzanne Riechard classification:11
a) The mature group: Well-integrated persons with self- awareness, satisfied people, realistic, flexible and adaptive and accept the normal physiological changes.
Due to high degree of variability among elderly, every patient should be treated individually in terms of their needs, wants and desires. The prosthodontist must understand how to deal with psychological issues as well as dental problems of patients.
Prosthetic treatment plan considering the geriatric psychology
Psychological disorders which prosthodontist come across in clinic are just tip of iceberg and we treat oral diseases without considering the presence of psychosomatic illness. If only dental diseases are being considered without taking notice of psychological disease then there can be recurrence of dental diseases. So, it is responsibility of prosthodontist to assess the possibility of any underlying psychological diseases in patient approaching in dental clinic for treatment.
The primary and best way to treat any psychological issue is “Let’s Talk” in which effective communication, good rapport, referral, counselling and peer influence all come in picture.
If the patient approaching is Anxious then Pre- Operative : Effective communication, Explanation of procedures, Making patient relax and oral sedation helps. Operative time : Keep answering the patient’s questions, Reassurance is big factor which play important role and effective local anaesthesia and oral sedation helps and Post- operatively: Explaining complications to the patient after completing the treatment and instructing the patient to take analgesics and adjunctive medications.12
If the patient approaching is Depressed then Pre- Operative: Consultation with physician, Examination of presence of any signs like: Abrasion of teeth, gingival injury, xerostomia, thrombocytopenia, leukopenia. Operative: use of local anaesthesia but with precautions. Post- Operative: Avoiding usage of sedatives or narcotics and management of xerostomia if it is there.13, 14
Any schizophrenic patient should always be accompanied by family member. Appointment should be schedule for morning session. Confrontation and authoritative attitude on part of prosthodontist should be avoided.12
Patient with Alzheimer’s dementia have tendency to often misplace, lose or wear their prosthesis. Best managed by an understanding and empathetic approach.12
Dentures should not be constructed if a patient is under extreme physical or mental stress. A patient with advanced degenerative disease is not ideal candidate for prosthesis.
Visits should be short with maximum amount of work completed during scheduled time. Morning appointments are preferable as patient has less tissue distortion in early morning. Geriatric patient should not be promised too much. Treatment plan should be well explained and discussed with patient’s family members before staring any dental treatment. It is always better to preserve the natural dentition in such patients.15
Future care strategies to address mental health
Training for health professionals in providing care for older people.
Preventing and managing age-associated chronic diseases including mental, neurological and substance use disorders.
Designing sustainable policies on long term and palliative care.
Developing age-friendly services and settings.
Mental health –specific health promotion for older adults involves creating living conditions and environments that support well- being and allow people to lead a healthy life.
Conclusion
The emotional and psychological makeup of the geriatric patient must be kept in mind during any prosthetic procedure. When treating geriatric patients, the prosthodontist must be confident of assessing, addressing and managing the psychological issues of patients. A thorough understanding of the mental state of the patient helps the prosthodontist to plan the treatment accordingly which will have the excellent prognosis and better outcome for the patient.
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