DIAGNOSIS AND TREATMENT PLAN OF AN EDENTULOUS PATIENT

CASE STUDY

A 65 year old man came to your clinic requesting for a complete denture, how will you arrive at a diagnosis and treatment plan.

• Gerodontology is the branch of dentistry that deals with the oral health problems of the old people.

“No diagnosis, no treatment.”

If you don’t know where you go,

you never get lost.

WHAT IS DIAGNOSIS?

• Diagnosis is defined as the examination of the physical state, evaluation of the mental or psychological make up, and understanding the needs of each patient to ensure a predictable result.

• It is the identification of an illness or disorder in a patient through physical examination and medical test.

• It could also be the analysis of the nature or cause of a disease.

• Diagnosis is a key to treatment planning.

WHAT IS TREATMENT PLANNING ?

• Treatment planning can be defined as the process in which the dentist and patient identify and rank problems needing resolution, establish agreed upon immediate and long- term goals, and decide on the treatment method and resources to be used.

• Treatment planning thus means developing a course of action that encompasses the ramifications and sequelae of treatment to serve the patient's needs.

DIAGNOSIS

• Diagnosis for prosthetic care requires the use of general diagnostic skills and accumulated knowledge from other aspect of dentistry and its supporting sciences.

It includes

• Patient evaluation

• Clinical history taking

• Clinical examination of the patient

• Radiographic and imaging examination

• Examination of the existing prosthesis

PATIENT EVALUATION• This is the first step to be carried out as soon as the patient

enters the clinic.

• This helps the dentist to have an ideal of the necessary treatment for the patient.

• The patient evaluation includes

1. Sex: male patients are only bothered about comfort and nothing else in contrast to female patients who are more critical about aesthetics

2. Age: patient in their 40’s have good healing ability compared to patients in their 60’s who have compromised healing ability.

3. Gait: neuromuscular disorder evident by abnormal gait usually result in difficulty in adapting to denture

4. Complexion and personality: evaluating the complexion helps to determine the shade of the teeth.

5. Cosmetic index: patient can be classified based on cosmetic index

class 1:high cosmetic index

class 2:moderate cosmetic index

class 3:low cosmetic index

6. Mental attitude: patients attitude and opinion can influence the outcome of the treatment. therefore a brief interaction with the patient reveals his or her mental attitude .

Mental attitude of patients can be classified into the following

• Exacting patient: this kind of patient requires extreme care effort and patience on the part of the dentist. They are some times methodical, precise, accurate and makes severe demands.

• Indifferent patient: The indifferent patient pays no attention to instructions, will not cooperate and is prone to blame the dentist for poor dental health.

• Philosophical patient: the best mental attitude for denture acceptance is the philosophical type. This patient is rational, sensible, calm and composed in different situations. His motivation is generalized as he desires dentures for the maintenance of health and appearance and feels that having teeth replaced is a normal, acceptable procedure.

• Hysterical patient: the hysterical type is emotionally unstable, excitable, excessively apprehensive and hypertensive. The prognosis is often unfavourable and the help of a psychiatric will be required prior to and during treatment.

• Patient can also be classified under the following categories

• apprehensive patient

• cooperative patient

• uncooperative patient

CLINICAL HISTORY

This is defined as the patient bio data and its include the following:

Name: the patient name should be recorded, and he should be addressed by his name which bring some confidence and psychological security.

Sex: the patient mentality is generally determined by gender. it also help to rule out certain systemic conditions.

Age: some diseases are limited to certain age groups.

Race: helps to determine the colour of the teeth.

Occupation: unskilled workers tends to require rugged teeth, while professionals require good aesthetics.

Location: some endemic disorders like fluorosis are confined to certain localities .people from that locality may want characterization in their teeth for natural appearance.

Religion and community: it gives an idea about the dietary habits and helps to design the denture accordingly

Medical history

The medical history provides important insights regarding the patient's dental prognosis. A patient in good general health is generally able to accept and adjust to a complete denture better than one who is in poor health.

Systemic factors that may affect complete denture treatment include;

anemia;

Arthritis;

Bell's palsy;

Carcinomas;

Diabetes;

nicotinic stomatitis;

Paget's disease;

Parkinson's disease;

and therapies that cause xerostomia and infectious diseases.

• DENTAL HISTORY

Past dental history include the following

• has he been to a dentist before for treatment.

• If yes the treatment he did were they eventful.

• Helps us to ascertain his level of dental awareness and to know if he will keep coming.

• Expectations- end results. Is he concerned about aesthetics, masticatory or just a good denture that won’t give him problems.

• Period of edentulousness- this will give us an idea about the amount and the pattern of bone resorption. Helping us in making informed decisions on course of treatment.

• Pre- treatment

• Previous denture- why did it fail

• Current denture- why does he want to change it

• Pre- extraction records which includes pre-extraction radiographs, photographs and diagnostic cast.

CLINICAL EXAMINATION

• The clinical examination should proceed in a logical and orderly sequence so that nothing is overlooked.

• It includes

• Extra oral examination

• Intra oral examination

• EXTRA ORAL EXAMINATION INCLUDES;

• Facial Examination:

• Facial form (frontal):

Classified according to House and Loop, Frush and Fisher

and Williams.

• Facial From (profile):

Classified according to Angle.

Class I - Normal (orthognathic)

Class II - Retrognathic

Class III - Prognathic

• Lip

Lip length can be classified as class I: normal. Class II: long. Class III: short.

Lip mobility can be classified as

normal (class 1):

reduced mobility(class 2)

paralysis (class 3).

• Temporomandibular joint examination

• Neuromuscular evaluation

• muscle tone defects

• Size of the oral cavity

• Texture of the skin

• Intra oral examination

• Limitation of mouth opening

• Halitosis

• Soft tissues:-

• Oral mucosa

• Tongue

• Gingivae

• Hard and soft palate

• Floor of the mouth

• Oral mucosa:-

• Colour

• Healthy pink colour

• Redness - Ulceration, candidias, stomatitis

• White – frictional keratosis

• Condition of mucosa

• Healthy

• Irritated

• Pathological – cyst, oral malignanacies

• Thickness of mucosa:-

• Normal uniform density of mucosal

• Thin membrane

• Twice as thick as normal

• Excessively thick investing membrane filled with redundant

• Saliva:-

• Patency of the salivary gland

• Normal quality saliva

• Excessive saliva esp mucuinous type

• Xerostomia- poor retention and excessive tissue irritation.

• Alveolar ridge examination

• Arch size:-

• Large

• Medium

• Small

• Arch form

• Square

• Tapering form

• Ovoid form

• Ridge contour:-

• Palpate for bony spicules, check for tender region.

• inverted U – shaped ridge

• Flat ridged

• Inter arch space:- Gives us an idea of the degree of bone resorption

• Hard Palate:-

• U shaped

• V shaped

• Flat

• Soft palate

• Class i- horizontal and displays little muscular movement.

• Class 2- makes an angle of 45 degrees with the hard palate. muscular movement greater than that in class 1

• Class 3 – makes an angle of 70 degrees with the hard palate. muscular movement greater than that in class 2.associated with the flat shaped vault.

• Tongue-

• Size of tongue-whether enlarged or normal.

• Health status – diseased(ulceration, candidias) or healthy

• Status of the frenum

• Hard tissue:- none in an edentulous patient

• Oral hygiene index:-

RADIOGRAPHIC AND IMAGING EXAMINATION

• Amount of ridge resorption

• Screening of Jaws to check for retained root fragment, unerupted teeth, TMJ disorders.

• Quantity and quality of the bone

• Examination of the existing prosthesis

• Panoramic radiographic images are the only studies that define the full scope of maxilla and mandible as well as accompanying vital structures.

• In addition periapical radiographic images or digital images like RVG are indicated for residual dentition. When in doubt computed tomography is indicated to properly evaluate the patient’s available bone.

• In some occlusal films, lateral cephalometrics may also be indicated for accurate assessment of patient’s anatomy.

TREATMENT PLANNING

• Treatment of edentulism constitutes one of the major aspects of modern dental practice .

• Treating partial or fully edentulous patient is one of the most demanding but also one of the most profitable component of private practice.

In treatment planning the following factors must be considered:

• Aesthetics and patient desires

• Type of support

• Amount of resorption and interarch space.

• Economics.

AESTHETICS AND PATIENT DESIRES

• Meeting patient expectations are paramount when treatment planning.

• Promising a patient a fixed reconstruction when diagnostic considerations present otherwise may result in a disappointed patient.

• Patients are also satisfied with the aesthetic appearance of a complete denture in particular the appearance of the soft tissues.

TYPE OF SUPPORT

With edentulous patient there are two categories of prosthesis, fixed and removable.

Fixed prostheses included metal ceramic restoration, depending on the severity of the bone resorption some pink porcelain may be required to simulate gingival contours.

In the removable category we have implant supported overdentures and implant retained and tissue supported overdentures

A removable prosthesis can be secured by different methods including, bar and clip, magnet, ball attachments or the use of a precision milled or spark eroded components.

• The Dentist is to decide which type of prostheses will be more suitable.

AMOUNT OF RESORPTION AND INTERARCH SPACE

• This parameter dictates the type of prosthesis to be fabricated. The clinician needs to evaluate if the patient exhibits, minimal, moderate or advanced resorption. Each type of prosthesis has a unique dimensional tolerance.

ECONOMICS

• Fabrication of a complete denture is costly whichever method is used to restore the patient.

• However cost needs to be considered not only during fabrication of the prosthesis but also during maintenance

Treatment plan include

• Adjunctive care

• Prosthodontics care

ADJUNCTIVE CARE

• Elimination of infection

• Elimination of pathology

• Pre-prosthetic surgery

• Tissue conditioning

• Nutritional counselling

ELIMINATION OF INFECTION

• Infective conditions like candidiasis, herpetic somatitis, angular cheiliosis and denture somatitis should be treated and cured before the start of treatment.

ANGULAR CHEILIOSIS

CANDIDIASIS

ELIMINATION OF PATHOLOGY

• Pathologies like cysts and tumors of the jaws should be treated before complete denture treatments commences.

• Some of these diseases may involve the entire bone. In such cases, an obturator may have to be placed along with the complete denture after surgery.

PRE-PROSTHETIC SURGERY

• Pre-prosthetic surgical procedures to alter hard and soft tissue morphology may be performed by the dentist to facilitate treatment.

• It enhance the success of the denture. These includes

• Excision of tori

• Lowering of mental foramen

• Removal of labial frenum

• Reduction of genial tubercle

• Reduction of mylohoidd ridge

• Augmentation of ridges

• Implant

• Reduction of enlarged tuberosity

• Removal of hyperplastic retromolar pad

• Removal of lingual frenum

• Excision of flabs

• Alveolectomy

• Alveoloplasty

TISSUE CONDITIONING

Special procedures should be done in patients that has adverse tissue reactions.

Tissue conditioners may be used by the dentist to facilitate treatment.

Treatment dentures or acrylic templates can be prepared to carry tissue conditioning material during the treatment of abused tissues.

NUTRITIONAL COUNSELING

• Patients showing deficiency of a particular minerals and vitamins should be counseled a proper balanced diet.

PROSTODONTIC CARE

The type of prosthesis, denture base material, anatomic palate, tooth material and teeth color should be decided as a part of treatment planning.

For the edentulous patient, a soft tissue supported denture can be given.

THANK YOU.

THANK YOU