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Diagnosis and Treatment Planning for Partially Edentulous Patients
First Appointment
Keys to a successful Interview
Dentist’s attitude Caring Understanding Respectful
Phrasing of questions Open-ended
questionsWE SHOULD MEET THE MIND OF THE PATIENT BEFORE WE MEET
THE MOUTH OF THE PATIENT
Health Questionnaire: Diabetes
Decrease resistance to infection
Patients often display reduced salivary output.
Health Questionnaire: Arthritis
If it is in TMJs, may produce changes in occlusion
Very rare in TMJ, and if it is in TMJ it is usually a secondary site
Health Questionnaire: Parkinson’s Disease
Oral hygiene and handling of dentures will be impaired
Difficult impressions due to excessive quantities of saliva
Health Questionnaire: Paget’s Disease
Patients may present enlargement of tuberosities.
Frequent recall program.
Quite rare
Health Questionnaire: Acromegaly
Enlargement of the mandible
Frequent exams to evaluate fit and function of removable prosthesis
Health Questionnaire: Epilepsy
Removable dentures may be contraindicated if they are small and seizures are frequent and severe: choking
If patient takes phenytoin (common drug to take), make sure that RPD does not irritate gingival tissues.
Health Questionnaire: Pemphigus Vulgaris
Common symptoms: oral discomfort and dryness.
Establish smooth and polished borders to reduce soft tissue harm.
Greater follow up is anticipated.
Health Questionnaire: Treatment for Cancer
Most common oral complications: Xerostomia Irritations Bacterial and fungal
infections 40% of patients who
have cancer outside of the mouth have repercussions inside the mouth.
Cardiovascular Disease
Require medical consultation: Acute or recent MI Angina pectoris Congestive Heart
Failure Arrhythmia Hypertension
Take blood pressure as soon as you see patient (180/110 and you shouldn’t see patient)
Health Questionnaire: Transmissible Diseases
Hepatitis TB Influenza HIV
Make sure impressions are disinfected
Effects of drugs on treatment
Anticoagulants (coumadin, aspirin) Post-surgical bleeding
Antihypertensive agents Orthostatic hypotension Xerostomia if patient is
on diuretics Endocrine Therapy
Xerostomia
Structure of the interview
Dental HistoryHow did he/she
lose his/her teeth? Caries? Perio?
Gather information about existing dentures.
Old x-rays.
Structure of the interview
DietFrequent usage of
mints, soft drinks, sugar-containing products
Structure of the interview
Habits Bruxism and
clenching Tongue thrusting
Structure of the interview
Expectations of treatment, get the chief complaint
Questions from patient
Initial Examination
Problems requiring immediate attentionEvaluation of oral hygiene. Explain:
Signs and symptoms of dental diseaseMaterials and techniques for home carePatient’s responsibilities (you can only do
50% of the job, the patient has to do the other half, i.e. the OH)
Initial Examination
Eval. of caries susceptibility
Oral prophylaxis to clear things up
Radiographs (Pan and FMS)
Diagnostic impressions and casts
Second appointment
Facebow transferTake centric relation registrationTake protrusive recordMount casts
Centric relation record
Recommended method
Recording CR position
Occlusal vertical dimension
Centric relation record: using wax?
We can also use elastomeric registration materials (wax tends to change dimension over time and can become brittle)
Centric relation record: Using Record bases
If patient does not have enough teeth to mount lower cast to upper (i.e. no posterior teeth), fabricate record bases.
Wax-up, take relation in centric relation.
Setting condylar elements
Protrusive record: with either wax or elastomeric material.
Ask patient to put front teeth edge to edge for practice, then using PVS ask them to repeat.
Setting condylar elements
Too shallow
Correct inclination
Too steepThe condylar setting is…
Diagnostic Wax-up
Definitive Oral Examination: Caries and existing restorations
Countours of potential abutments
Occlusion Possible extractions.
Definitive Oral Examination: pulpal tissues
Possible pulp testing in teeth to be used as abutments that have decay or crowns or extensive work.
Selection of endodontically treated tooth as abutments is NOT contraindicated. Better prognosis with full crown coverage restoration.
Definitive Oral Examination:tooth mobility
Unstable occlusion Tooth in traumatic
occlusion PA abscess Acute pulpitis Cracked tooth
syndrome
Definitive Oral Examination: tooth mobility
Trauma of occlusion Inflammation of
periodontum Loss of bone support
Niether is useful as an abuttmentfor a partial Useful for an abuttment for
an overdenture
Definitive Oral Examination
oral mucosa hard tissues
abnormalities soft tissues
abnormalities space for mandibular
major connector
Definitive Oral Examination
radiographic evaluation of prospective abutments
Evaluation of mounted diagnostic casts
Interarch distance Occlusal plane
Irregular occlusal plane
Malpositioned occlusal plane
Evaluation of mounted diagnostic casts
Malrelation of arches Tipped or malposed
teeth Occlusion
Interferences need to be corrected
To treat or not to treat at centric relation….that is the question.
We will construct our prosthesis at CR if:CR=MIAbsence of posterior tooth contacts (tissue-
borne)Few remaining posterior contacts
Otherwise, we will construct our RPD’s at maximum intercuspation position. We will not introduce new interferences by a RPD.
Finally….
Diagnostic wax-up Consultation to other
specialties Development of
Treatment plan.
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How do I develop a Treatment Plan????
Developing a sequenced treatment plan
Phase I:evaluation, immediate treatment,diagnostic mounting, wax-up, partial
design,referral to other specialties (endo, ortho,
etc.), patient education (OHI, etc).
Developing a sequenced treatment plan
Phase II: Removal of caries, extractions, perio tx, occlusal equilibration, placement of temporary restorations
(temporary crowns, etc).
Developing a sequenced treatment plan
Phase III (continuation of Phase II): Pre-prosthetic surgeries, root canal therapies, definitive restoration of teeth,RPD mouth preparation, final impressions, metal
try-in, records (if needed).Phase IV:
Delivery of RPD, Instruction for patient.
Phase V: Periodic recall, reinforcement of education.