Patient evaluation, diagnosis and treatment planning

transcript

Engelmeier RL, Phoenix RD.DCNA 1996;40(1)

PATIENT EVALUATION, DIAGNOSIS AND TREATMENT

PLANNING FOR COMPLETE-DENTURE THERAPY

IntroductionPatient evaluation

History: The Patient’s Storyo Personal Datao Dental Historyo Medical History

Examination: Dentist’s Observationso Extraoralo Intraoralo Existing Dentureo Radiographico Study Casts

Contents

Treatment planningo Preliminary Phaseo Surgical/ Restorative Phaseo Rehabilitation Phaseo Maintenance Phase

Contents

All the patients seeking dental services have some degree of experience and understanding which should be recognized by the dentist and address it in the treatment planning.

First visit is very important because explanations given to the patient at this appointment form the implicit agreement between the dentist and the patient:

“Seeds of Success and Failures are Sown”

Introduction

The collection of medical and dental histories and their careful analysis, coupled with a thorough orofacial examination are the essential and integral part of the prosthodontic management as these are necessary for the selection of the optimal treatment protocol.

Introduction

A health questionnaire is a convenient method of collecting the basic information and personal data which can be sent to the patient before the appointment or administered in the reception, dentist then review and clarify the information provided in the private operatory which is comfortably equipped, tastefully decorated, free of distractions so as to provide the patient with the sense of security and privacy that will allow them to communicate honestly and completely.

Introduction

Data collected should be well documented.

A logical method to accomplish this is to use a checklist.

NameAgeSexRaceOccupationContact detailsCosmetic IndexPersonality and Mental AttitudeSocio-economic StatusOral hygiene habitsOther habits

Personal Data

Conversing with the patient addressing him with his name is a good way of gaining the patients confidence. The patient feels he is dealing with a friend and not a stranger and It is easy to get information concerning his medical and dental histories.

A. Adaptability and physiological Condition of Supporting Structures

Younger: Adapt rapidly and high esthetic requirementsBeyond fifth decade: Doesn’t adapt readily

B. Mental AttitudePostmenopausal women: hysterical or exacting with high

esthetic requirementsMen at this age: Preoccupied with their career – indifferent – concerned only with comfort or function

Females: more concerned with appearanceMales: though young male are concerned with

appearance but they grow indifferent to their appearance and shift focus to comfort and

health.

Lack of Oestrogen in postmenopausal women creates Osteoporosis as oestrogen have anti-

absorptive effect on bone. HRT is given.

The occupation of an individual may demand special consideration in denture construction from the

standpoint of esthetics, phonetics, or function or other special qualities in

dentures.

OCCUPATION

Critical factor in the characterization of dentures (i.e., choice of denture base shade, placement of denture base stains, etc.)

Classify the patient as class 1: high cosmetic index class 2: average cosmetic index class 3: low cosmetic index Patients with high cosmetic indices, though

often exacting, usually are appreciative and cooperative. Conversely, patients with low cosmetic indices often are indifferent, uncooperative, and place little value on the efforts of the prosthodontist.

Cosmetic Index

Dentist should assess it all the way during history taking and examination.

Much of this can be revealed through the discussion of the chief complaint, reason of teeth loss, importance of any remaining teeth and the patient’s experience with the dentistry especially with the previous denture.

MENTAL ATTITUDES

Personality difficulties become exaggerated under the influence of ill health, old age, menopause or flair up

because of unfavorable social or business environment or the state of dominating or

being dominated by others.

MENTAL ATTITUDES

Danger lurks at both the ends of positive negative spectrum. Overly optimistic may have unrealistic expectations and on the other end the patients who expect nothing more than another failure.

In any case dentist must strive to bring the patient to the reality.

“Complete Denture is not the replacement of teeth but it is the replacement of NO TEETH”

MENTAL ATTITUDES

It is an general agreement that the complete denture success or failure is not exclusively determined by the patient’s oral anatomy or the efforts of the dental team but also on the patient’s attitude towards the prosthesis.

MENTAL ATTITUDES

Loss of teeth in both the general groups, weather they are morphologically or emotionally maladaptive, is an obstacle they cannot surmount easily despite provision of excellent prosthetic replacements.

So, there are many critical element to be considered in managing all the patients, the two most important are the behavior of the doctor and a thorough patient interview both of which involve the skillful handling of verbal and nonverbal communication

MENTAL ATTITUDES

The interview can comprise four parts:i. The recognition and acknowledgement of

the problemii. Its identification and explorationiii. Its interpretation and explanationiv. The offering of a solution to the problem

MENTAL ATTITUDES

This iatrosedative interview creates indispensable trusting relationship in the process of determining the factors responsible for the problem and seeks to offer a solution.

Dentists tend to very rapidly become masters in technical skills and adept at providing quick solution to problems, however many clinical challenges require significant commitment to “patience with patients”

MENTAL ATTITUDES

There are some who have significant psychological problems the require professional help.

These patient should be referred to the appropriate professionals. Because of sensitive nature of such referrals, it usually is best to start with the patient’s physician.

MENTAL ATTITUDES

Philosophical

Exacting

Hysterical

Indifferent

CLASSIFICATION OF MENTAL ATTITUDES

Philosophic: Those patients are• easygoing, • congenial, • mentally well-adjusted, • cooperative, and • confident in the dentist

Prognosis is excellent

Exacting: These patients are • precise, • above average in intelligence, • immaculate in dress and appearance, • often dissatisfied with past treatment, doubt the

ability of the practitioner to satisfy him or her, and

• often want written guarantees or remakes at no additional charge

Once satisfied, an exacting patient may become the practitioner's greatest supporter

Hysterical: These patients • submit to treatment as a last resort, • have a negative attitude, • are often in poor health, • are poorly adjusted, • often appear "exacting" but with unfounded complaints, • have failed at past attempts to wear dentures, and • have unrealistic expectations (hysterical patients often

demand esthetics and function equal to or greater than natural teeth).

Prognosis is poor.

Indifferent: These patients are • not concerned with appearance, • often go without dentures for years (or wear

poor or worn-out dentures far beyond serviceability),

• do not persevere, and • do not adapt well. • Such patients have no desire to wear dentures

and do not value the efforts or skills of the dentist.

Anupama MS, Nair KC. Graphoanalysis: an aid in patient evaluation. KDJ. 2009; 32: 14-9

Mental Attitude: Handwriting

Determined by OccupationIncomeEducation

Socio-economic Status

Method and frequency of oral hygiene should be asked by the patient.

These factors may affect denture-base contouring (e.g, closed interdental contours versus open interdental contours) and tooth arrangement (e.g., presence or absence of diastemata).

Hygiene should be classified as (1) good, (2) fair, or (3) poor

Oral Hygiene Habits

Other potentially unfavorable habits• Tobacco smoking and alcohol consumption• Patient should be informed about their

systemic effects, potential local impacts e.g. detrimental effect on wound healing, soft tissue health, or the durability of tissue conditioners

Parafunctional habits• Like bruxism and clenching• Must be considered and their presence must be

considered while forming a treatment protocol

Other habits

Chief ComplaintReason of teeth lossDuration of complete edentulousnessWeather a previous denture wearer

Patients comments on present denturesPresent dentures evaluation

Patient’s expectations with the new dentures

Dental History

According to DeVan, "The dentist should meet the mind of the patient before he meets the mouth of the patient."

Hence, the dentist must determine the reason the patient is seeking prosthodontic treatment. The patient should be questioned regarding his or her chief complaint.

Chief Complaint

There are several reasons for seeking this information.

First, if this is not done, the chief complaint may be overlooked during therapy.

Second, the response allows the practitioner to assess whether the patient's expectations are "realistic" or "attainable."

And finally, the response provides information regarding the patient's psychological classification (for House's personality classification scheme).

Chief Complaint

Provide insight into their appreciation of the dentistry and contribute to the prognosis for prosthodontic success.

Patients who lost their teeth in an accident might be more unhappy about their edentulous state than those who lost teeth as a consequence of decay resulting from neglect.

Reasons for Teeth Loss

Expectations for the remaining alveolar bone would be great for the patients with a history of rapid teeth loss from decay than for the patients with the long history of progressive periodontal diseases.

Reasons for Teeth Loss

Provide information regarding the resorption pattern.

Large, rapid changes occurs in the alveolar ridge morphology during the first year after extraction.

A “green ridge” may have bony spicules remaining from extraction sites or bony undercuts with a thin mucosal covering.

Duration of Complete Edentulousness and order of

teeth loss

The patient should be questioned regarding the number and types of previous dentures.

A patient with a history of several dentures over a short period of time is a poor prosthodontic risk.

If the patient is old denture wearer it is wise to know the weather the patient is satisfied with the old denture and dentist is dealing with the hostile or receptive attitude.

Previous dentures

Patient should be questioned about the duration, chewing efficiency, comfort, esthetics, speech related to the present denture.

Comments of the patient should be noted down as

1) Good 2) Fair 3) Poor

Patient comments on the present dentures

Teeth shade, mold and materialEsthetic, phonetics, retention, stability,

extensions, contoursCentric relation and vertical dimension of

occlusionOcclusal plane orentationPalatePostdamBase Adaptation

Present Denture Evaluation

MidlineBuccal vestibuleCrossbiteCharacterizationWearAttachment and hardwareDenture base extensionArch form

All the properties should be graded as1) Good, Fair and Poor2) Acceptable and unacceptable3) Adequate and inadequate

Dentist should be aware of each patient’s general health as they are responsible for their well being

Knowledge of medications that patient is taking is important to avoid any conflict in the therapy.

MEDICAL HISTORY

Much can be learned from watching the patient entering the operatory and sitting in the dental chair.

MEDICAL HISTORY

Cardiovascular disease Anaemia Respiratory Disorder Bleeding disorders Diabetes Asthma AllergyTuberculosis

MEDICAL HISTORY

Rheumatoid Arthritis/Bone disordersJaundice Neurological disorder Radiotherapy Palsy Drug history Epilepsy Skin disorders

MEDICAL HISTORY

The patient must have this condition under proper medical control. This is important, for the success of

dentures.

The operator should use an impression technique that will produce maximum physiologic compatibility of the

denture base with the supporting tissues

Careful occlusal corrections should be accomplished to remove all interferences.

The food table should be small and the patient should be given detailed instructions on eating habits and oral

hygiene.

Frequent evaluation of the dentures is necessary.48

MEDICAL HISTORYDIABETES

The limited movement of the mandible during impression making may necessitate special trays

and procedures. It may be difficult to get proper registrations.

Generally, the tactile method is the most satisfactory.

Occlusal corrections must be made often because of arthritic changes in the temporomandibular

joint. 49

MEDICAL HISTORYARTHRITIS

Retention is often hard to achieve, and an adhesive may be necessary.

The patient should be educated for mastication and oral hygiene.

MEDICAL HISTORYBELL'S PALSY

Control of the patient during fabrication of the denture can be accomplished with sedatives.

Retention is difficult, and an adhesive may be necessary.

It may be wise to remove dentures when they are not in use. This will add to the comfort of the

patient and eliminate the danger of swallowing them.

MEDICAL HISTORYPARKINSON’S DISEASE

If dentures are to be made, it in imperative that no abrasion or irritation be present on the

supporting tissues.An open lesion may be the start of a serious

condition, namely osteoradionecrosis.It is best not to use dentures at all over

irradiated tissues, but if dentures are necessary, they should not be used until at

least two years after radiotherapy.

MEDICAL HISTORYRADIATION

Extraoral

Intraoral

Existing Denture

Radiographic

Study Casts

CLINICAL EXAMINATION: DENTIST’S OBSERVATIONS

Facial symmetry Facial form (Frontal) Facial form (Profile) Facial features Skin color Lip

• Length• Thickness• Tonicity• Lip contact

Appearance• Cheeks• Lips• skin

CLINICAL EXAMINATION EXTRA ORAL EXAMINATION

Nose• Symmetry• Tip• Nasolabial fold

Philtrum Chin TMJ Neuromuscular Control Speech Lymph Node Examination

FACIAL SYMMETRY

SymmetricalAsymmetrical

FACE FORM (Frontal)(House and Loop, Frush and Fisher and

Williams)1. Square: in this case the face is about equally

wide in the temporal region, the area of the zygomatic arch and the angles of the jaw.

FACE FORM

2. Tapering: A decrease in width is generally found in these types as one progresses from forehead to chin.

FACE FORM

3. Square tapering: a combination of the square and tapering forms.

FACE FORM

4. Ovoid: the area of the zygomatic arch is widest in this case.

FACIAL PROFILE (Angle)

Class 1, Normal: that is the Nasion, Point A, Point B are in the same line.

Class 2, Retrognathic: that is Point B is placed posteriorly compared to Class 1

Class 3, Prognathic: that is point B is placed anteriorly compared to Class 1

Rugged

Delicate

Average

Facial Appearance:

ComplexionHair, eye, and skin color provide useful guides in

shade selection.

ComplexionSkin color also can reveal underlying

disease and pathology. Patients with significant sun damage warrant referral to a dermatologist.

Pale, anemic-looking patients may have underlying systemic diseases and may

require longer adjustment periods.

LIPContour• Adequately

supported• Unsupported

LIPMobilityClass 1: Normalclass 2: Reduced MobilityClass 3: ParalysisPatients with minimal lip mobility show very

little of the anterior teeth.

LIPMobility

Some stroke victims may have paralysis of half the lip, leading to unilateral mouth droop and facial asymmetry.

Patients must be counselled regarding treatment limitations when dealing with such physical challenges. Otherwise, patients may have unrealistic expectations regarding functional and esthetic results.

LIPLength Classify lip lengths as long, normal or

medium, and short.A long lip reveals little of the anterior teeth,

whereas a very short lip allows the display of the denture base.

Mold selection and denture characterization can be critical factors in these cases.

Cheeks, Lips, Skin: AppearanceFull/ Thin

NoseSymmetry: Present/ AbsentTip: Prominent/ DepressedNasolabial Fold: Deepened/ Normal

PhiltrumNormal/ Obliterated/ Deepened

CHIN• Prominent/ Not prominent

• Deviated/ Undeviated

Labiomental Sulcus Normal/Obliterated/Deepened

TMJ • Tenderness/

Discomfort • Crepitus• Deviation of

mandible in movement

Mandibular Movements Normal/Deviated/Restricted

Mouth Opening Normal/Reduced

Neuromuscular CoordinationClass 1: ExcellentClass 2: Fair Class 3: PoorPatients with good neuromuscular

control expected to learn to manipulate dentures relatively quickly

Muscular Tone (House)

Class 1: the patient exhibits normal tension, tone, and placement of muscles of mastication and facial expression.

Majority of edentulous patients have experienced some degree of degeneration.

Usually present only in immediate denture patients.

Class 2: the patient usually exhibits normal tension but impaired tone

Class 3: the patient exhibits greatly impaired tone and tension.

This impairment is usually coupled with poor health, inefficient dentures, and loss of vertical dimension, wrinkles, decreased biting force and drooping commissure.

Muscular Development(House)

Class 1: HeavyClass 2: MediumClass 3: Light

SpeechNormal / AffectedPatients with speech impediments or

those who cannot articulate optimally with their existing dentures require special attention when the dentist places the anterior teeth and forms the palatal portions of the denture base.

Lymph Node Examination

(Submandibular, Submental, Cervical, Preauricular, Mastoid)

-Palpable/Non palpable -Tender/Non tender -Movable/Fixed

Mucosa Tongue• Mucosa• Size• Position

Residual Ridge• Frenal Attachment• Arch Form• Vestibule

CLINICAL EXAMINATION INTRAORAL EXAMINATION

Palate• Incisive Papilla• Ruage• Compressibility• Fovea• Maxillary Tuberosity• Palatal Throat Form• Soft Palate

Floor of mouth• Lateral Throat Form

Mylohyoid Ridge88

Ridge RelationshipInterarch SpaceSalivaTorus

MUCOSA : COLORFrom healthy pink to angry red. Redness indicate: inflammationIll-fitting denture, underlying infection, a

systemic disease such as diabetes or chronic smoking.

Determine the cause and remove the irritant for success of denture.

MUCOSA : THICKNESSS(House)

Class 1: Normal uniform density of mucosal tissue (approximately 1-mm thick).

Investing membrane is firm but not tense and forms an ideal cushion for the basal seat of a denture.

Class 2: (a) Soft tissues have thin investing

membranes and are highly susceptible to irritation under pressure

(b) Soft tissues have mucous membranes twice the normal thickness.

Class 3: Soft tissues have excessively thick investing membranes filled with redundant tissues.

At the very least, this requires tissue treatment such as surgical correction.

Uneven thickness because of different timings of extraction.

Extremely thin: teeth have been missing for a long time

Normal: Teeth removed recently. Other areas may be excessively thick with localized

regions of redundant tissue.

Such variations make it difficult to equalize pressure under the denture and to avoid soreness.

MUCOSA : CONDITION(House)

Class 1: HealthyClass 2: Irritated

Class3: Pathologic

If class 2 or 3 is present, remove the cause of irritation and pathology.

TONGUE POSITION (Wright)

Normal: The tongue fills the floor of the mouth and is confined by the mandibular teeth.

Lateral surface rest on the occlusal surface of posterior teeth.

Most favourable prognosis. The floor of the mouth will be high enough to

cover the lingual flange of the denture producing a border seal. 96

Class 1: Retracted: The tongue is retracted.

The floor of the mouth pulled downward. The lateral borders are raised above the

occlusal plane and the apex is pulled down into the floor of the mouth.

Class 2: Retracted: The tongue is very tense and pulled backward and upward.

The apex is pulled back into the body of the tongue and almost disappears.

The lateral borders rest above the mandibular occlusal plane.

The floor of the mouth is raised and tense. 98

ARCH FORM ( House)

SQURARETAPERING

RIDGE FORM Height: RetentionParallel walls: Stability as lateral

movements ate limited by this even if vertical displacement occurs

Also, retention ∝ Surface Area

RIDGE FORM (Maxillary)

Class 1: square to gently roundedIdeal for retention and stability

Class 2: Tapering and V-shapedResults from bone loss in both width and

height, so poor in both retention and stability

Class 3: Flat

RIDGE FORM (Mandibular)

Class 1: Inverted "U" shaped(Parallel walls from medium to tall with

broad crest)

Class 2: Inverted "U" shaped (short with flat crest)

Inverted “W” short inverted “V” tall, thin inverted “V”

Class3: Unfavorable

Undercut

RIDGE FORM Defects: Ridge defects, such as exostoses

or divots, may pose problems for complete-denture patients or may warrant preprosthetic surgery.

MUSCLE or BORDER ATTACHMENTS (House)

Class 1: High in the maxilla or low in the mandible with respect to the crest of the ridge. ≥ 0.5 inches

Class 2: Medium. 0.25-0.5 inchesClass 3: ≤ 0.25 inches

FRENUM ATTACHMENTS (House)

Class 1: High in the maxilla or low in the mandible with respect to the crest of the ridge.

Class 2: MediumClass 3: Encroach on the crest of ridge and

may interfere with the denture seal. Surgical correction required.

FRENUM ATTACHMENTS (House)

Especially in case of mandible, if freni are present at both labial and lingual sides of the residual anterior mandibular ridge, surgical reposition of the freni is must because denture will be weaker in these area and fracture may result.

INCISIVE PAPILLA• Normal• Tender• Prominent

PALATAL RUGAE• Normal• Prominent• Faint

PALATAL COMPRESSIBILITY• Median area

o Rigido compressible

• Lateral areao Rigido compressible

FOVEA PALATINI • Prominent • Non prominent

MAXILLARY TUBEROSITY • Bulbous• Pendulous• Undercuts

o Unilateral o Bilateral

SOFT PALATE Class 1 – soft palate is rather

horizontal and demonstrates little muscular movement. It is the most favourable condition because it allows for more tissue coverage for the palatal seal.

Class 2 – soft palate turns downward at about a 45 angle to the hard palate and the amount of the potential tissue coverage for the palatal seal is less than that of the class1.

SOFT PALATE

Class 3 – A class 3 soft palate turns downward at about a 70 angle just posteriorly to the hard palate. Therefore this is the least favourable form of soft palate.

PALATAL THROAT FORMClass 1: Large and normal in form, with a

relatively immovable band of resilient tissue 5 to 12 mm distal to a line drawn across the distal edge of the tuberosities.

PALATAL THROAT FORMClass 2: Medium size and normal in form, with

a relatively immovable resilient band of tissue 3 to 5 mm distal to a line drawn across the distal edge of the tuberosities.

PALATAL THROAT FORMClass 3: Usually accompanies a small maxilla.

The curtain of soft tissue turns down abruptly 3 to 5 mm anterior to a line drawn across the palate at the distal edge of the tuberosities.

PALATAL SENSITIVITY(House)

Class 1: Normal Class 2: Subnormal (hyposensitive) Class 3: Supernormal (hypersensitive)

THROAT FORMLATERAL THROAT FORM Class I Low - 1/2 inch or more from the

mylohyoid ridge to the bottom of the retro-mylohyoid fold, visible when the tongue is in a slightly protruded position. Most favorable.

Class II Medium - Less than 1/2 inch under the same conditions as above.

Class III High - Retro-mylohyoid fold at same level as mylohyoid ridge. Least favorable.

THROAT FORM

Class 1 Class 2

Class 3

MYLOHYOID RIDGE• Normal• Resorbed• Sharp

INTERMAXILLARY RELATIONSHIP

If both the ridges are large, part the lips gently while the patient maintains a rest position and note if there is sufficient space for teeth.

If the space is limited remember to use very thin denture base over the ridges and use acrylic resin teeth.

INTERMAXILLARY RELATIONSHIP

A large intermaxillary space is also unfavorable because the teeth are present so far above the ridge that undesirable forces may be created on the ridges and also denture will be heavy.

RIDGE PARALLELISM Class 1: Both ridges

are parallel to the occlusal plane.

Class 2: The mandibular ridge is divergent from the occlusal plane anteriorly.

Class 3: The maxillary ridge is divergent from the occlusal plane anteriorly or both ridges are divergent anteriorly.

RIDGE RELATIONClass 1, Normal,The lower

ridge crest is very slightly to the inside of the upper ridge crest

Class 2, Retrusive,The lower arch is smaller than the upper and the lower ridge crest is inside the upper ridge crest considerably more than in the normal.

Class 3, Protrusive,The lower arch is larger all around than the upper; hence the upper ridge crest is inside of the lower ridge crest. 129

SALIVAClass 1: Normal quality and quantity of

saliva. Mixed Saliva. Cohesive and adhesive properties of saliva

are ideal.Class 2: Excessive saliva; contains much

mucus.Class 3: Xerostomia; remaining saliva is

mucinous.

SALIVAThin watery saliva may affect retention. Thick ropy saliva complicates impression

making and is annoying to the patient as it clings to the denture.

Abundant saliva is common when the denture is first inserted but usually improves with time.

TORIClass 1: Tori are absent or

minimal in size. Existing tori do not interfere with denture construction.

TORIClass 2: Clinical examination

reveals tori of moderate size. Such tori offer mild difficulties in denture construction and use. Surgery is not required.

TORIClass 3: Large tori are

present. These tori compromise the fabrication and function of dentures. Such tori usually require surgical recontouring or removal.

TORIDoes not require surgical

intervention unless large and bulbous.

The mucosa over tori is usually thin and unyielding.

Do not use arbitrary relief at the site of the torus. The correct relief can be obtained by a special impression procedure or with pressure indicator paste in the finished denture. 135

TORIMandibular Tori usually more of

a problem as they interfere with the lingual border seal and restrict the tongue space. If prominent, especially if undercut, surgical correction is indicated.

OPG should be advised.Check for:• Root pieces• Foreign bodies• Impacted/Embedded teeth• Rarefaction of bone• TMJ-Findings

INVESTIGATION RADIOGRAPHS

TREATMENT PLANTreatment planning is the process of matching

possible treatment options with patient needs and systemically arranging the treatment in order of priority but keeping with logical or technically necessary sequence.

The dentist must resist the natural tendency to include in a treatment plan the treatment that the dentist feels competent to deliver. Treatment plan must have a parallel process of developing a prognosis.

Treatment is driven by the diagnosis must take other factors like prognosis, patient health and attitudes into account

1. ZARB,PROSTHODONTIC TREATMENT FOR EDENTULOUS PATIENTS 12TH EDITION PAGES 73-99.

2. WINKLER S.,ESSENTIALS OF COMPLETE SENTURE PROSTHDONTICS,2ND EDITION ,Pg39-55.

3. ENGELMEIER R.L.,D.C.N.A.,VOLUME 40;1:18

4. WWW.CPMCNET\CHAPTER 1 PATIENT HISTORY.HTM

REFERENCES