Complete denture Diagnosis and treatment Plan

Diagnosis is the evaluation of the existing condition, more specifically; it requires identifying and making judgment about departures from normal. It is:
·        The act or process of deciding the nature of a diseased condition by examination.
·        A careful investigation of the facts to determine the nature of a thing.
·        The determination of the nature, location and causes of a disease.

Diagnosis for the prosthodontic care requires the use of general diagnostic skills and accumulation of knowledge from other aspects of dentistry and its supporting sciences. Diagnosis in complete denture is a continuing process and is not accomplished in a short time. The dentist should be the first to recognize the problem and be ready to change the treatment plan to meet the new findings. These findings will be governed by:
1)   Patient's mental attitude.
2)   Patient's systemic status.
3)   Past dental history.
4)   Local oral conditions

Mental attitude (psychological factor)
The success of dental prosthesis is related to many factors, including functional, biological, technical, esthetic and psychological factors. Psychological factors include the preparedness of the patients and their mental attitudes towards dentures, their relationship with the dentist and their ability to learn how to use the dentures. Prosthodontists must fully understand their patients because such understanding predisposes the patient to accept the kind of the treatment they need. De Van said "meet the mind of the patient before meeting the mouth of the patient".
Patients seeking prosthodontic care usually arrive with accumulation of experiences and resulting attitude. These may range from optimism through resignation to despair; all may be set against a background of psychosis. In the discussion with the patient, the dentist must seek an understanding of the patient's health, particularly their attitude toward receiving new dentures. House classified the patients into 4 categories:
1.   Philosophical patients.
2.   Exacting patients.
3.   Indifferent patients.
4.   Hysterical patients.

Philosophical patients
These patients are rational, sensible, and calm and composed in a different situation. Their motivation is generalized as they desire dentures for the maintenance of health and appearance and feel that having teeth replaced is a normal acceptable process. These patients usually overcome conflicts and organize their time and habits; they eliminate frustrations and learn to adjust rapidly. The best mental attitude for denture acceptance is the philosophical type.
Exacting patients
These patients may have all of the good attributes of the philosophical type, however, they may require extreme care efforts and patience on the part of the dentist as they like each step in the procedure to be explained in details, and they require extra hours spent prior to the treatment in patient education until an understanding is reached.
Indifferent patients
These patients are apathic, uninterested and lack motivation. The do not care to their self image; they manage to survive without dentures and pay no attention to the instructions. They do not cooperate and mostly blame the dentists for their poor dental health. In most of them, questionable or unfavorable prognosis may be expected. For such patients, educational program in dental conditions and treatments is recommended before denture construction.
Hysterical patients
These patients are excitable, apprehensive, emotionally unstable and hypertensive. They are neglectful of their oral health and unwilling to try to adapt to wear dentures. Additional professional help is required prior to and during treatment. Although these patients may try to wear the denture, they fail to use it as they expect it to look and function like the nature teeth.
Social information
It is necessary as a first step of all patients. It is the establishment of their identity. Personal information as the name, address, telephone number, work and hours of work might help the dentist in the primary estimation of the dental health and prognosis. Social setting can help to understand the patient's expectation and the dental status developed. Social information may clarify some habits, specifically those might contribute of their present conditions and those might help ensure success or failure for the treatment. Modifications or reinforcements of these habits should be noted for the inclusion in the treatment plan.

Systemic-medical status
No prosthodontic procedure should be planned until the systemic status of the patient is evaluated. It must be realized that dentistry is part of health services and that oral health is closely associated with the general health of the patient. The dentist is not entitled to just make dentures; they are responsible on the well-being of the patient as a health professional. Except in cases of accident, individuals who are losing their teeth are manifesting pathological conditions because their loss may be as a result of systemic factors or associated with unfavorable systemic condition. Furthermore, these systemic factors must be considered in the treatment plan by the dentist. Many of the systemic diseases have local manifestations with no systemic symptoms and others have both local and systemic reactions. Some systemic diseases have a direct relation to the denture success even though, no local manifestations are apparent.
Debilitating diseases
These patients requires extra instructions in the oral hygiene and tissue rest, also frequent recall appointments should be arranged because the supporting bone may be affected to keep the denture bases adapted and the occlusion corrected. Debilitating diseases include, for example, diabetes, tuberculosis, blood diseases… etc.
Cardiovascular diseases
Patients with cardiovascular diseases may require consultation with cardiologist as some denture procedures may be contraindicated. Such patient must be controlled before dental treatment.
Joint diseases
Joint involvement, particularly osteoarthritis, presents different problems. If the disease involves the TMJ, alteration in the treatment plan may be essential. In extreme conditions, special impression tray and technique are often necessary because of the limited access from reduced ability to open the jaws. Furthermore, jaw relation records are difficult and occlusion correction must be made often because of the subsequent changes in the joints.
Neurological disorders
Some neurological involvement, as Bell's palsy or Parkinson's disease, requires some attention. The dentist has to deal with some problems related to the denture retention, maxillomandibular records and supporting musculature.
Skin diseases
Many of the dermatological diseases may have oral manifestations such as pemphigus vulgaris. Medical support mostly needed because these oral lesions are painful that prevent proper work. Other conditions, as congenital diseases, endocrine diseases, malignancy, menopause, psychological, nutritional deficiencies, and infectious diseases may require disease understanding to prepare for successful work.
Past dental history
Success or failure in the provision of prosthodontic care is frequently the direct result of the adequacy of taking the patient's dental history. By talking, the patients would provide the essence of a diagnosis of their dental health and needs.
An understanding of the etiology of teeth loss by a patient would help a dentist to estimate the patient's appreciation of the dentistry and contribute to the prognosis for prosthodontic success. Although patients can change their attitude and habits, it is reasonable to be suspicious that patients were lost their teeth in an accident might be much unhappy about their edentulous state than patients who lose their teeth as a consequence of decay resulting from neglect. Similarly, expectation of the amount of alveolar remaining would be greater for the patients with a history of rapid tooth loss from decay than for patient with a long history of progressive periodontal diseases.

Dental experiences may be the source of both good and bad habits. Patients may reveal instances of traumatic experiences dating to their first visit to the dentist. Traumatic experiences have very lasting effects and make the patient tense in the dental chair, this may lead to neglecting of the oral health by the patient and lead to negative attitude. Experiences with previous prosthodontic restorations, whether partial or complete, are important in determining the patient tolerance, tissue tolerance and esthetic acceptability and what the patient expect from the denture.
Any existing prosthesis must be examined thoroughly in an objective manner. Quality of the denture material, teeth type, occlusion and occlusal discrepancies between the teeth, occlusal plan, retention and stability, and the age of the denture can be estimated from the old denture. Patient oral hygiene can be reflected well by the old denture and the condition of the supporting tissues also can be expected. Evaluation of the esthetic of the existing denture should be approached from a professional judgment of the dentist and to correlate with the information about the natural teeth; this evaluation must take into consideration the patent's view.
Although it is important to strive to raise the quality of care to match the highest of the patient's expectations, also is appropriate to lower patient's expectations through education about denture wearing.
Local factors
Unfortunately, local factors are the only ones considered by many dentists. However, it is not enough to make a cursory examination and note the presence and absence of the teeth. Local factors that are considered to afford the ideal environment for complete dentures are:
1)   Broad square ridges devoid of undercuts and bony abnormalities.
2)   Definite cuspid eminences and alveolar tubercles, broad palate with uniform depth of vault in the maxillary arch.
3)   Broad buccal shelves and firm retromolar pads in the mandibular arch.
4)   A definite vestibular fornix devoid of muscle attachments.
5)   Frenum attachments high in the maxillary and low in the mandibular arches.
6)   A clearly defined and well-developed lingual sulcus.
7)   A lateral throat form that allows suitable extension into the retromylohyoid space.
8)   A firm mucosal covering over the denture-bearing area.
9)   Mucous membrane in the vestibular fornix and floor of the mouth, which is loosely movable and attached for denture seal.
10)   A gradually slopping palate with a passive reflection at the junction of the hard and soft palate.
11)   A tongue is normal in size, position and function.
12)   A normally-related maxilla to the mandible.
13)   Good muscular tone and coordination in the mandibular movement.
14)   Adequate inter-ridge space for a favorable placement of the teeth.
15)   Saliva is suitable in viscosity and quantity.
16)   Hard and soft palate tissues devoid of any signs of pathological disorder.

An appreciation of the influences of the local factors is based on the anatomy and physiology of the supporting tissues. Evaluation of the local factors would help in the selection of the type of the impression to be made, impression materials, method of making maxillo-mandibular relations, occlusion and even selection of the teeth.
Deviations from these ideal conditions are more often; this does not mean inability to do proper, successful dentures. Any deviations should be noted in the diagnosis, so appropriate procedures and modifications can be incorporated in the treatment plan. The local factors are usually evaluated during clinical examinations. Examination must divide into extraoral, which must exam the orofacial and oral surrounding structures (muscles of the face, TMJ, symmetry of the face, lips, and cheeks).
Intraoral examination must include the ridge form (square, round or v-shaped), mucous membrane (healthy firm, flabby, ulcerated, inflamed or normal or any other variations). Tongue position, size and function. The residual ridge if it is flat or not and palate height (high, shallow and medium). Saliva quality and quantity. The presence of retained roots and tori or any bony enlargement and sharpness.
Mostly, the clinical examination precedes radiographic examination, although in some cases, this order may be reversed. X-ray films (extra and intraorally) may provide additional information especially about the alveolar bone, joints, unerupted or retained roots and foreign bodies. It can be determined if the patient will accept or reject the dentures at the time of local factors evaluation. Other investigations may be decided individually according to the needs of the patient's case.
Diagnostic casts
In addition to the construction of the special tray, diagnostic cast is used for:
1.   It reveals new information or confirms that which has already been observed intraorally.
2.   It allows for an evaluation of the anatomy and relationships in the absence of the patient.
3.   The dentist will be able to look at each size and symmetry, interarch space, arch concentricity, anteroposterior jaw relationship, and lateral jaw relationships; especially posteriorly, where an occlusal crossbite might be present.
4.   Measurement and determination of other structures would assist in making a decision on preprosthodontic surgery.
5.   Undercuts may be observed unaided, or their significance can be determined more precisely with the aid of the dental surveyor.
6.   Education and explanation of some treatment steps would be easier by using diagnostic casts in some occasions.

Treatment plan
Treatment plan is a consideration of all of the diagnostic findings (systemic and local), which influence the surgical or any preprosthetic preparations of the mouth, impression making, maxillo-mandibular relations, occlusion, form and material of the artificial teeth and instructions in the use and care of the dentures. It is matching the possible treatment options with patient's needs and symmetrically arranging the treatment in order of priority but in keeping with logically or technically necessary sequences.
The process requires a broad knowledge of treatment possibilities and detailed knowledge of the patient's needs determined by a careful diagnosis, otherwise, the patient would be placed in jeopardy of receiving inadequate or inappropriate treatment. Treatment does not terminate with the construction and delivery of the complete denture and the patient should be so advised.
Treatment plan must have a parallel process of developing diagnosis; it is driven by the diagnosis but must take other factors, such as prognosis, patient health and attitude, into account. The patient must be informed about the time required for the procedure and expense. Limitation of the denture must be outlined for the patient with any expected problems.
Treatment plan is used to specifically state the treatment that would address a particular patient's need; this treatment must state in a logical sequences and care. Treatment plan is a problem-solving techniques; it involves a careful analysis of the problem, breaking to components, as possible, generating a list of possible component solutions are implemented; some believed that it is a mental exercise but written a list may assist thinking.
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