Adaptation to new complete dentures is a complex process and it is difficult to anticipate

the result of such treatment (Van Waas, 1990a, 1990b). For patients who are about to lose their
teeth at an advanced age, or who for some reason have lost the ability to cope with conventional
complete dentures, treatment with implant supported mandibular overdentures is an excellent
options. These patients profit most from the benefits of overdentures. Indeed, this treatment is
applicable for older person who are still in fair health, as well as for those who have become
frail, dependent and in need of daily health care (mericske-Stern, 1994).
Some wearers of complete dentures may develop a retracted tongue position. In the
normal at rest position the lip of the tongue contacts the lingual surface of the mandibular
anterior teeth, and the lateral borders of the tongue are in contact with the lingual flanges and
surfaces of the posterior teeth. A lingual border seal is established, and the muscle mass of the
tongue keeps the denture in position over the residual ridge. In a retracted tongue lost contact
with the denture. And the floor of the mouth is usually lowered (Fig 4-4). In this situation, there
is no retention of the denture, which moves when the patient speaks or tries to eat : hence, food
goes under the denture base. It is important to identify this problem during clinical examination
of the patients. By educating the patient, the tongue may be able to assume a more normal
position. It is important to start the education process before prosthetic treatment begins, because
the problem is related to the patient and not the existing denture.
A particular risk group among denture wearers are those who complain of burning and itching in
the mucosa underlying the denture (burning mouth syndrome), which is also frequently
associated with psychiatric disorders such as anxiety, depression, obsession, and hostility (Rojo
et al, 1994). The oral and prosthetic element that may be etiologic cofactors are :
1. Increased vertical dimension od occlusion (usually)
2. Unstable occlusal conditions
3. Reduced space for the tongue
4. High posterior occlusal plane
5. Overextended denture borders
6. Allergy (rare)
7. Xerostomia
Before starting prosthetic treatment of older patients who have had consecutive,
unsuccessful prosthetic treatments, it is important to conduct a careful interview and
examination. For example, patients with diseases of the central nervous system or psychiatric
disorders need much higher number of recall visits than healthy individuals (Carr et al, 1993).

Thus, in the treatment planning for the disease/drug complex patients , additional time should be
allowed for post insertion visits.
A poor prognosis for treatment with complete dentures should be expected if the patients
has an underlying mental disorder, if there are no major prosthetic faults of the existing dentures,
or if the patients cannot wear the diagnostically modified dentures. Major pre prosthetic surgery
or treatment with implants should not be considered before the metal/psychiatric status of the
patients has been clarifies and before the actual dentures have been evaluated by a colleague. In
this context. It should be emphasized that pre prosthetic surgery should be restricted to patients
with poor anatomic conditions and not be applied in patients with underlying psychiatric
disorder. For older patients with poor anatomic conditions difficulties in adapting to complete
dentures, treatment with implant retained complete dentures is generally an excellent solution.

General health, socioeconomic aspects, and attitude

General health factors have the greatest impact on prosthetic therapy in medically
compromised patients. In older patients in reasonably good health , some risk factors for the
outcome of prosthetic therapy are related to general health and should be taken into
consideration. The typical systemic disorders reported in a population of independent living
people over 65 are arthritis (44%), hypertension (31%), cardiovascular disease (25%0, diabetes
(7%) and other health problems (87%) (MacEntee, 1994).
Arteriosclerosis
Arteriosclerosis is the major cause of death in old age, It may manifest clinically in a
variety of ways (such as angina pectoris, myocardial infarction, hypertension, and congestive
cardiac failure) and with increasing incidence and severity as the patients ages. The management
of medically compromised older patients has been reviewed (Kilmartin, 1994).
Patients with arteriosclerosis cerebral disease often have reduced motor skills and may be
absent-minded and confused. These patients are difficult to treat and protracted and complex
treatment should be avoided. Because they have difficulty coping with removable dentures, the
natural dentition should be maintained, if possible. For patients with symptomatic arteriosclerotic
cardiovascular disease, dental/prosthetic treatment should not be carried out without consultation
with their physician to ensure optimum management of the patients. Appointments should be non
stress full, at the best time for the patients with good pain control but judicious use adrenalin a
hemostatic agent in gingival retraction cords. Because many older patients have asymptomatic
arteriosclerosis, it is wise to use these common management strategies for most geriatric patients.
Arterial hypertension is often treated with diuretics or anti hypertensive drugs, which may have
secondary effects such as a reduction of the salivary flow rate. Sedation may be indicated to

reduce endogenic adrenalin production , the use of local anesthesia with adrenalin should be
restricted, and gingival retraction cords with adrenalin should no be used.
Endocarditis
Infective endocarditis is relatively rare disease, nut there is a progressive increase in the
susceptibility to this disease in older adults. This is mainly due to two predisposing conditions an
increased incidence of cardiac defect, Which are the site of infection and decreased
immunocompetence . In patients with known risk factors of endocarditis, antibiotic prophylaxis
should be used in associations with interventions that may give rise to bacteremia and as a
preventive measure, oral hygiene should be optimized. These precautions also happy to elderly
patients with no documented risk factors of infective endocarditis.
Respiratory disorders
Patients with respiratory disorder such as asthma or bronchitis characteristically have
hyperreactive airways and diffuse airway obstructions, with intermettient symptoms of chest
tightness, wheezing, dyspnea, and cough. Such patients should always be treated sitting upright
in the dental chair and never in a supine positions. It is important to protect the patients from
water spray and air bone particles such as acrylic resin when adjusting a complete denture.
Diabetes
The are two types of diabetes insulin dependent diabetes mellitus (IDDM). Which occurs mostly
in childhood and the teenage years, and non insulin dependent diabetes mellitus (NIDDM),
which occurs in older people. There presentation of diabetes in the elderly is often insidious .
Patients may complain of weakness, fatigue, weight loss, or minor skin or mucosal infections
such as oral candidiasis (Dorocka- Bobkowska et al, 1996). The majority of older diabetics have
mild to moderately severe NIDDM, which is most often controlled by died alone. These patients
can be treated for the most part as healthy individuals, and because the dental appointment with
food intake, there if minimal risk of hypoglycemic reactions. Patients with NIDDM should have
good masticatory function in order to maintain an appropriate diet. In edentulous patients, this
may indicate treatment with dental implants to improve masticatory ability. There are no
significant contraindications for osseo integrations surgery in there patients and postoperative
complications are rare (Smith et al, 1992)
Arthritis
Arthritis is the most common chronic disease in older adults. Many of these patients receive long
term drug therapy. Such as aspirin or corticosteroid, that can affect dental case and possible side
effects should be taken into consideration. Oral hygiene procedures may become difficult
because of reduced manual dexterity, and the us of an electric tooth brush and mouth rinses with

chlorhexidine and fluoride may be indicated. Such patients may have particular difficulty in
removing or inserting removable partial dentures and in retaining their dentures during brushing,
Increasingly, for patients with severe arthritis , surgical replacement of joints by
prostheses has become more and more commonplace. In principle this has the same result as the
placement of prosthetic heart valves, that is in patients with oral infections, preventive measured
should be taken against bacteremia and secondary joint infections with prophylactic antibiotic
therapy. At the least, the dentist should consult the patients orthopedic surgeon or physician to
determine the need for antibiotic prophylaxis.

Cancer
Cancer in the oropharyngeal region is usually treated with a combination of surgery, radiation
and chemotherapy. To reduce the risk of osteoradionecrosis, hopeless teeth or teeth with doubtful
prognosis should be extracted prior to radiotherapy. It is important that prosthetic treatment
planning is carried out before the extractions, and that an effort is made to keep the key teeth for
the prosthesis. Serious side effects of radiation therapy are xerostomia, mucositis, and rampant
caries. It is important to inform the patients of these consequences and to introduce the necessary
preventive measures prior to radiation therapy.