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2 of th e ed en tu lo us pa Assessment of the edentulous ti patient en t Minas Salah

Khalid Al-Hamad

29-9-2013

Assessment of the edentulous patient
In today’s lecture we will be speaking about the way of assessing an edentulous patient. We will be speaking about the following: 1-Pattern of bone loss in edentulous arches. 2-How to gather information. 3-The presenting complaints and relevant history. 4-Dental history. 5-Medical history. 6-Social history. 7-Extra-oral assessment. 8-Intra-oral assessment. 9-Assessment of the dentures. 10-Specific investigations. 1- For the edentulous patient losing teeth will end up in losing bone and bone becoming fragile. You have to understand what happens after the patient becomes edentulous in order to provide the patient with a set of complete dentures .So here in an edentulous patient you are not only replacing teeth you may end up replacing the teeth and the supporting structures like soft tissue and bone. What happens when the patient becomes edentulous? Maxillary resorption occurs posteriorly, superiorly, and medially and mandibular resoption occurs anteriorly, laterally, and inferiorly. This will have a direct effect on the supporting structures, the muscles and the aging appearance. The maxillary lip will tilt inside and become more acute ranging from 90-110 degrees. The opposite in the lower the angle will be more obtuse ranging from 137-142 degrees. The muscle will lose attachment to the underlying bone due to resorption, the soft tissue changes characteristic of severely resorbed mandible in that the lower lip will curve

inwards, there will be loss of vermilion border visibility and lines will start radiating from the mouth. Your treatment decision will be based on three steps evaluate, educate and estimate. you have to evaluate the case through the steps you are going to follow, the chief complaint, gathering information from history and examination. Then you formulate your treatment plan and options and educate the patient accordingly and estimate the cost. These are the 3 main steps you need to follow through your treatment course. So what is diagnosis? Diagnosis is the examination of the physical state, evaluation of the mental or the psychological makeup, understanding the needs of each patient to ensure predictable results. After the diagnosis we develop accordingly a treatment plan which is course of action that includes the squelae of treatment to serve patient’s needs. As the patient moves from a dentate patient to an edentulous patient there are costs which are loss of bone, loss of support to the underlying tissues (the muscles) and the aging appearance. 2- Starting to assess the patient is first done by gathering information, you should start by observing the patient not just on the dental chair you can observe the patient in the waiting area, or if you have time you may escort him or her to the clinic through that you can get some idea about the patient you are dealing with. For example how he walks to the clinic, how he gets up from the chair, if dizziness occurs it might indicate the effect of drugs (medication), or cerebrovascular accident or low blood pressure ext… observe other signs like lack of breath, facial movement, hearing or vision problems and accordingly you can start collecting information. You can evaluate speech during this early phase of examination. Is the patient suffering from speech problems? Is this related to the complete denture or not? The doctors tip is that in such an early stage you should avoid answering questions on fees not because you still don’t know the final treatment plan, it is because you haven’t finished your work yet, you still have not completed the examination phase nor have you finished collecting your information. So you cannot answer such specific question as early as that (the first clinical visit) this is

in future in your private practice. After finishing your assessment you will be able to answer such questions. An old saying says “let the patient speak he will tell you the diagnosis” you have to have a good conversation with the patient, this conversation should be structured. You should let the patient speak freely because he/she will tell you about the needs but make it structurally because some patients will go off the line. A good conversation with the patient will help to develop a good relation with the patient. As we said in the first the success of the denture depends off course on your work but largely depends on the patient himself how he accepts the complete denture can he manage to wear 2 sets of complete denture his adaptation has an aim in this area. 4- So we then move to the medical and dental history. Why is medical history important? It is important because it will give you an idea about the oral condition and the patient’s attitude. You should know why the teeth where lost mainly periodontal problems or caries. if it is a periodontal reason then you may be facing a problem with bone support. In the case of fresh edentulous patients you would expect undercuts and may need surgical intervention. If the patient is a new denture wearer then he has no experience with wearing a denture this might be an advantage or a disadvantage. How is it a disadvantage because sometimes a patient will come holding a bag of complete dentures in your chair you should assess and know why your denture will not end up in that bag. Patients with bad experience or such a scenario might have other problems not related dentally that you should assess. On the other hand new denture wearers don’t have experience in wearing dentures, they don’t have neuromuscular skill so they need time to develop such skills. you have to tell the patient that they will take time to develop neuromuscular control, that mastication will be different and saliva will increase at the beginning. Educate your patient and tell him to be patient with your treatment. Otherwise treatment will not be successful even if clinically your mark is fine this does not affect your work now as a student because the supervisor can help you and at the end of the day the supervisor will evaluate your work clinically patient potentiality will not affect the mark, from the mark point of view but in the future it is really important.

5-Medical history also it is common sense that medical history is important in gathering information. You can obtain that through a pre-form and patient fills it in at home and brings it with him to the clinic or fills it while waiting in the waiting area, you can review that form before the patient enters the clinic then you have to discuss it again with the patient (which is the best scenario) remember it is your duty as a clinician to obtain an updated medical history. Patients with debilitating diseases would have a deceptive effect on your work, like diabetes and nutritional deficiencies because this will affect the response of the patient to healing causing a delay in healing and sore spots due to the fragile quality of the mucosa. In patients with diabetes bone will be resorbed and you will be planning for relining and rebasing. Some drugs may affect saliva flow and saliva has a major role in retention of complete denture. Stroke and Parkinson’s disease may compromise patient’s ability to be dealt with or the patient ability to deal with the denture later on. Examples of medication are 1- antihypertensive drugs which cause xerostomia 2diuretics which cause change in tissue fluid 3-psychological drugs which cause uncontrolled tongue and fluid movement. So obtaining a clear medical history will give you an image about the patient’s life. Patient who is suffering from severe illness but is still optimistic is a good sign for you, that you are treating a patient with good attitude. A mental classification was developed by House in 1950 for the classification of patients. From good too bad they are philosophical patient, an exacting patient (as the picture in the slide number 21), a hysterical patient, and an indifferent patient. Philosophical: patient willingly accepts the dentist’s judgment without question. They pay attention and follow instructions. They have the best prognosis (8085%). Exacting: patient is methodical, precise and demanding. They ask a lot of detailed questions and like each step explained in detail. They have an excellent prognosis if intelligent and understanding. Such patients require more attention from you.

Indifferent: patient has a low motivation and desire for dental care. They show little appreciation for the dentist’s efforts and will give up easily if problems are encountered. Hysterical: patients who are emotionally unstable and unfit to wear dentures. They blame the world for their present condition. They’re never satisfied and always complaining 6-Social history is important as well you have to understand the need for your patient if he is a shy person, does he need privacy, some patients don’t want their relatives to attend, while some will value the opinion of a relative. So you have to understand what type of patient you are dealing with. So we spoke about bone loss, information gathering through chief complaint that you have to let the patient speak freely and writing it down in the patient’s own words, medical history, dental history and social history know we will begin with the extra oral examination. 7-Extra oral examination you have to evaluate generally the head and neck generally looking for any pathology. Report any nodules, nevi, ulceration, changes in face colour and tone, symmetry, neuromuscular activity. Palpate the face and neck for any masses or enlarged nodules. Check if the patient has a lack of mobility that is will the patient need help getting in or out of the clinic, or into the chair and out of the chair. Are there deficiencies in hearing or vision. Some students will be unfortunate with patients that have hearing problems because all your work will depend on good communication so a relative may be helpful in such a situation. The facial profile is it a class 2 or a straight profile that might affect your future tooth positioning (set up of teeth) and also it might affect denture stability. TMJ ranges of movements, you do palpation to the TMJ, and auscultation is also done but maybe in the future not at our teaching level. It is also important to evaluate the speech of the patient (it was done while we were dealing with history), also you should observe the movement of the mandible and the tooth position. You can have an idea now before looking into patient’s oral cavity about the occlusal vertical dimension is there a lack or an increase in it.

The lips are supported from the underlying bone it is very common to assess the lips for cracking tissue at the corners or ulceration this could be due to vitamin B complex deficiencies, Candida infection or the lack of vertical dimension. Also assess lip support, fullness, thickness and length. The lack of support will cause the lips to collapse and wrinkle. Dentures can correct anything related to support of the oral cavity but not the aging skin. Patients with bruised bridge of the nose due to wearing glasses indicate tissue fragility. Angular cheilitis may alert to poorly controlled Diabetes or dietary deficiency, Anaemia or the Presence of poorly fitting dentures or denture induced stomatitis. 8-Iintra oral examination you should have a general overview, notice the coloured mucosa ranging from healthy pink to angry red. Angry red is an indication of illfitting denture, underlying infection, systemic disease like diabetes or chronic smoking. White patches are an indication of keratosis from denture irritation. Other colour changes should be recorded if present like pigment spots or lesions ranging from light to dark brown. As a dentist you should biopsy any suspected colour change and send it to the pathologist. Saliva should also be assessed are you facing a dry mouth? If so you should expect poor retention and will also be susceptible to injures or you might have excessive saliva so it will be difficult to work with especially during taking an impression. The saliva consistency will be thin, thick, ropy or serous (which is the commonest in patients and the best to work with). We look at the arch size to get an indication of support, because the greater the arch size the more support you have. Discrepancies in arches is indicative of problems or difficulties in the jaw relation registration stage this can be due to early loss of teeth in one jaw, development, trauma, severe class 2 or class 3 malocclusions. The form of the arch should be indicated is it square, ovoid, or tapered. The ridge contour is it a v-shaped ridge, a knife ridge, flat ridge, or a ridge with multiple speckules. The relationship between the ridges should be noted if the distance between the ridges increases (inter ridge distance) this will increase leverage on the denture and you might expect instability. The best scenario is to have almost parallel ridges. While treating any case you noticed that the ridges for example are not parallel or far apart so you have to develop a

design of a complete denture to help minimize that inter ridge distance. For example you are facing a case with resorbed ridge and there is too much space between the ridges and the ridges are not parallel so you would expect instability for example therefore you would change the form of the teeth and would use non anatomical teeth, small size, and up to 6 (tooth number 6 in each quadrant) and also changing your impression technique. Classification of ridges (Attwood, 1971):  Class I: good ridge before extraction.  Class II: Immediate post extraction  Class III: well-rounded ridge form.  Class IV: Knife edge ridge  Class V: flat ridge  Class VI: negative or concave form

Redundant tissues occur when bone resorbs there will be lack of support for the supporting tissues so these tissues will end up flabby (mobile tissue). The combination syndrome occurs which is a maxillary complete denture against RPD replacing Kennedy class 1. So ending up with the following :  Over-eruption of the mandibular teeth  Bone resorption and hyperplasia of the anterior maxilla  Large redundant maxillary tuberosities (fibrous tissues)  Bone resorption under the RPD  Drop of the occlusal plan posteriorly  Papillary hyperplasia of the palate

Pre-prosthetic surgery and special impression techniques are needed to overcome these problems. Areas requiring relief: tender to palpation, superficial ID in the region of the mental foramina, enlarged tuberosities and frenal attachment close to the crest of the ridge. All these will cause problems to your patient and accordingly to you if you don’t notice them and modify your complete denture accordingly. Denture induced stomatitis is relatively common finding in denture wearers. It is characterized by erythema on the denture-bearing areas, and also may be accompanied by varying degrees of papillary hyperplasia. Some definitions:  Retention: resistance of displacement away from the tissues  Stability: resist displacement non vertically  Support: resist displacement towards the tissues

The palatal throat form has 3 classes.

These cases are usually accompanied by a relatively large resilient type of tissues (5-12mm) and these are good for the post dam area. So you can make a wide post dam to help complete the seal.

In class 2 the resilient immobile tissue is 3-5mm this is still good enough for the post dam area.

So in class 3 you have 3-5mm anterior to the line drawn at the distal ends of the tuberosities across the palate so you don’t have much area to work with. (PPS stands for posterior palatal seal). Summary:  Hard-Palate  U-shaped (favorable)

 V-shaped palatal vault (un-favorable)  Flat-palatal vault (un-favorable)  Soft-palate  Class I: horizontal with little muscular movement (most favorable for posterior palatal seal)  Class II: turns dawn at 45 to the hard palate( less favorably than class I)  Class III: turns dawn sharply at 70 to the hard palate (least favorable)  V-shaped palate is usually associated with class III soft palate.  Flat palatal vault is usually associated with class I or II. You should know about any retained roots, any bony lumps or any undercuts. You should decide with your supervisor at this age whether to refer to a surgeon or modify your treatment accordingly. 9- Assessment of dentures you should assess the following:     Denture extensions: over-extensions/under-extensions Retention Stability Teeth arrangement o Relation to underlying ridge  Occlusal relationships o VD RCP  Free way space  Aesthetics Picture in slide 53 is lack of extension. Picture in slide 54 is checking for retention, by trying to rotate the denture from both sides to checking the retention, check post dam area by holding the anterior teeth and trying to raise the denture up this movement will deflect the posterior part of the denture down words so you can evaluate the posterior palatal seal. With the lower denture you can take the probe putting it between the two central incisors and try lifting the denture up.

Picture in slide 55 is for stability and support, you can alternate pressure on both sides and see if the denture will rock if it does then this is an indication of lack of support or mobile tissues. Especially in the lower arch the teeth arrangement should be that the fossa of the teeth are aligned with the ridge. In the picture in slide 57 we need balanced occlusion because the denture that is sitting there has different occlusion from natural teeth during movement, we have canine guidance of groove function so teeth are altered in bone so we don’t have a problem with stability with natural teeth. But you have a problem if you provide a denture with canine guidance because every time the denture will move the denture will be deflected by the canal guidance of groove function. So instead you have continuous contact all the way around left and right between the upper and the lower posterior teeth to balance the movement (we will discuss this more in upcoming lectures).
canine guidance (kā'nīn gī'dăns)
Occlusion in which occlusal contacts of the cuspids cause contacts of posterior teeth to separate in excursive mandibular movements.

Assessing the denture outside the mouth will give you a lot of information about the material used for example porcelain or any lining material, any signs of tooth wear also the quality of work, an idea about hygiene is the patient keeping the denture clean, also the size shape colour and arrangement of teeth. Specific Investigations     Radiological Haematological Micorbilogical Diagnostic appliances o Assessing patient tolerance/adaptation Diagnostic appliances for example if you suspect that you patient cannot tolerate raising the vertical dimension you might give him a trend raise to assess patient’s adaptation you can give him something to wear and increase the dimension over months before you fabricate your complete denture. Small note from the doctor at the beginning of the lecture .The requirements are 2 complete dentures and 1RPD for the entire year. There are 20 clinical

marks, 7 for each complete denture and 6 for the RPD out of 100 marks at the end of the year .During the five clinical visits for the complete denture both partners can bring in their patients together in the same day except in the second and third clinical visits. Please refer back to slides as not ever thing was covered in the script. Done by: Minas Salah.

# Please print the "Clinic Assessment Sheet" form and bring it with you to your "Removable clinic" next week. Do the following : 1- write your name, number, and patients name... after you finish your clinical work 2- ask your clinic supervisor to mark your work, and then give the form to the senior nurse in the clinic. 3- the Senior nurse will arrange all forms for each group in a folder For subsequent visits, please find your assessment sheet in that folder and ask your clinic supervisor to mark your clinical work. ** you have to do that for each clinical visit. You can download the assessment sheet form from the E-learning site. Please note that its your responsibility to make sure that your clinical supervisor has signed and marked your work. Download it : Clinic Assessment Sheet : http://www.scribd.com/doc/173330386/Clinical-Assessment-FormCD-2013-Copy

Assessment Policy
Intra-semester 40%: Intra-semester work for the 1st and 2nd semesters

as follows:

First Semester 15 Marks: Midterm written exam 15 marks: first Complete Denture 10 marks: RPD ( for the help of students, it is not mandatory to make the RPD in the first semester. You can still make it on the 2nd semester but its mark will count for the 10% of the 1st semester as above.) Second Semester 25 marks: second complete denture 15 marks: Practical spot exam. an average of the above 1st and 2nd semester will be counted according to the formula to give the intrasemester work out of 40% Final Exam 60 % 40%: Final: Written 20% Viva and/or Spot