Diagnosis & Treatment Planning for Edentulous Patients
Diagnosis: The determination of the nature of a disease.
Prognosis: A forecast as to the probable result of a disease or a course of therapy.
Treatment plan: The sequence of procedures planned for the treatment of a patient after diagnosis:
History Taking, Examination & Recording the Information:
Purpose
The purpose of taking a history is to discover the reason why the patient is seeking treatment. The history will expose the patient's previous history, and present attitude to dental treatment.
The examination of the patient's mouth allows you to collect data that will assist you to make a diagnosis of the nature of the patient's problem. The diagnosis is an essential first step in establishing a treatment plan for the patient.
Social information:
Knowledge of a patient's social setting can help the dentist understand the patient's expectations & how their dental status has evolved.
Occupation
Habits
Smoking
Relatives & friends opinion
Medical History
Close attention must be paid to those conditions and/or medications which:
Contribute to slow healing or the patient being more prone to denture irritation.
Contribute to changes in the fluid content of the oral tissues.
Require special precautions during treatment
Dental History
The chief complain: Probably the most important information.
History of the chief complains: Patients attitudes to dentistry and the dental profession will be influenced by their experiences, and the reasons for their loss of teeth. Tooth loss is debilitating, disabling and depressing. So, note when tooth loss occurred, the reasons for the loss, and the patients attitude to that loss.
Expectations: Unrealistic esthetic and functional ideas must be recognized and made known to the patient prior to the treatment so that poor experiences occurring after the delivery do not come as a surprise. Explanations made after the delivery often seem to be nothing more than excuses for poor dental treatment. The prognosis is poor if the patient's expectations cannot be met.
Denture experience: Patients who have had previous good experience with dentures generally present a better prognosis than those who have not. Also, what the patient likes about previous dentures and wishes to keep and what the patient dislikes and wishes to change is very important information. This covers a number of factors, e.g. the number of years that dentures have or have not been worn since the teeth were extracted; previous use of partial dentures, immediate dentures, or complete dentures and their success or failure; pre-prosthetic surgery performed, etc. The manner in which this information is given to you will again give you insight into the attitude of your patient towards denture wearing, and their expectations.
Radiographic Examination:
A panoramic radiograph is usually adequate for an edentulous patient.
You should note any abnormalities detected, as some may in fact affect your subsequent treatment plan.
It is not indicated for each patient.
Extra-oral examination: As a dentist your examination and diagnosis is not limited to the inside of the patients mouth. There is a whole human being attached to that mouth.
Look at the patients head, neck and face. Note anything that might affect the mouth, or indicate pathosis, such as asymmetries, scars, lesions, as well as the outward appearance of the mouth.
Whilst talking to the patient you will be able to start to assess their current dental appearance, which may well relate to their main complaints.
Record clicks or crepitus during jaw opening, closing or protrusion. Deviations on opening or closing may be significant. Pain during jaw movement or restriction of movements may stem from the temporomandibular joints, or from the muscles, or both.
Note the details of the symptomatology and palpate the muscles concerned to establish tenderness to pressure or spasm..
Intra-oral examination:
Ridge shape and size: Cawood and Howell classified potential denture-bearing bone as follows:
Class I dentate
Class II immediately post extraction
Class III well rounded ridge form, adequate in height and width
Class IV knife-edge ridge form, adequate in height, and inadequate in width
Class V flat ridge form, inadequate in height and width
Class VI depressed ridge form, with some basal bone loss evident
Quality of the mucosa: inflamed, firm or flabby, thickness, mobility, attachment to bone.
Position and size of the fraenula, especially if they will interfere with retention.
Presence of undercuts
Check for any bony protuberances and if they create any undercuts: again, this will help you decide if a denture can extend over them or if surgery may be required to reduce undercuts.
Bony ridges may also need to be reduced and should be recorded, such as the mylo-hyoid ridge.
Check for the mandibular tubercles, especially in Class V and VI ridges, where they may be higher than the crest of the ridge.
Test the tuberosity sulcus place a finger buccal to a tuberosity and ask the patient to move their jaw to the other side. You will feel the influence of the coronoid process. Then remove your finger, retract the cheek and peer into the sulcus and ask the patient to repeat that movement. The idea is to see how narrow that sulcus is likely to be under function. Record your findings, for this will help you with understanding the expected extensions of the flanges of the impressions.
Zygomatic process may be prominent.
Mid line palatal raphae & palatal tori.
Note the size and activity of the tongue, its position, fraenum, and median sulcus.
Note what happens to the tongue when the patient is just asked to open their mouth does it retract towards the back of the mouth, or does it remain with the tip of the tongue anteriorly? If the former, the patient will need to re-train their tongue to behave as in the latter case. If the tongue naturally retracts to the back of the mouth, this will dislodge all but the most retentive of lower dentures.
Record the length and tonicity of the lips, presence of lesions, or scar tissue
Classify the skeletal and anterior ridge relationships (Class I, II or III) and note any discrepancies in size and relationships that may, for example, require teeth to be set in a cross-bite.
Salivary flow rate & viscosity.
Note oral pathology or other pathology which is not mentioned in the medical history.
The soft palate, the width of the post dam depends upon the curvature and functional activity of the soft palate.
The palate is classified into three classes (I, II, III).
Class I soft palate has a gentle curvature and demonstrates little muscular movement, hence it is the most favorable it allows more tissue coverage for producing the palatal seal.
Examination of existing dentures:
(Extra-oral) with the dentures out of the mouth, record your observations of the following:
cleanliness of the dentures
presence of wear of both the denture base acrylic and the teeth (occlusal and/or buccal surfaces)
the arch form and shape of the external surfaces
the incisor relationship
the external appearance of the patient with the dentures in the mouth, at rest and in occlusion: check the lip support, possible skeletal relationship, and if there appears to be excessive freeway space
(Intra-oral) the following aspects need to be evaluated:
Retention: place each denture in the mouth and test the retention. Test the resistance to a force applied in the direction away from the tissues as:
excellent (extremely difficult to dislodge and little or no movement before dislodgement)
good (difficult to dislodge but moved away from the tissues slightly before dislodgment)
fair (denture was dislodged easily)
Poor (denture offered little or no resistance to dislodgement).
Stability: this is tested by estimating the relative force necessary to move the denture, when applying a force in a direction towards the tissues. Two types of force are used, direct and rotary.
Assess the resistance to movement as:
excellent (little or no movement on application of strong direct or rotary force)
good (little or no movement of application of strong rotary force, but moved and was dislodged when strong direct force was applied to one side or to the front of the denture)
fair (considerable movement on application of rotary force and was dislodged by moderate direct force)
Poor (a slight force, either rotary or direct, caused the denture to move and become dislodged).
Centric occlusion: place the dentures in the mouth and close the patient into the centric relation position:
Assess the relative occlusion in centric relation as:
excellent (no fault in centric occlusion when the patient closed the jaw in centric relation)
Good (a slight objectionable contact, possibly caused by only one cusp, made the dentures slide slightly ( mm. or less) to get into centric occlusion from centric relation. The sliding is not sufficient to tip or dislodge the dentures)
fair (objectionable occlusal contacts on one side caused the dentures or the lower jaw to move about 1 mm to get the teeth into centric occlusion from the first contact in centric relation)
Poor (a gross error in the occlusal relations which could only be corrected by re-setting the teeth or by rebasing the denture or both).
Inter-occlusal (freeway) space:
Arch form: assess conformity or not, to the neutral zone.
Appearance: assess the amount of lip support, whether the size, color and shape of the teeth are acceptable to the patient. If they are not, ask the patient to bring an old photograph, if available, of them smiling. This will be of great value when selecting suitable artificial teeth.
Diagnosis:
This is not just the fact that the patient is edentulous!Record any pathology observed, and summarize the main problems observed for both the patient and their existing dentures.
Prognosis:
All that you have done up to now will lead you to developing a prognosis. This is the realistic interpretation of your ability to solve all the problems encountered and analyzed.This is vital for matching the patients expectations with yours, and will enable you to respond realistically to the patients needs and demands.
Much of this will need to be reinforced during subsequent appointments, especially if changes in habits, or attitudes, are required.
Treatment Plan:
In complete denture Prosthodontics this is fairly simple, and entails detailing any preliminary treatment that may be required, as well as specifying the type of dentures to be made, and summarizing the techniques appropriate to that patient.
Plan of treatment:
A plan of treatment sets out just what will be carried out at each visit. This is really useful for both you and the patient. The patient needs to know how many times to come, how long each visit will take, and therefore how long it will be before they receive their new dentures.