ASSESSMENT OF THE EDENTULOUS PATIENT

KHALED Q AL HAMAD BDS Msc MRD RCSEd Associate Professor Department of Prosthodontics 4TH YEAR, Dent 445 2ND LECTURE

Pattern of bone loss in edentulous arches Information Gathering The presenting complaints and relevant history Dental history Medical history Social history Extra-oral assessment Intra-oral assessment Assessment of the dentures Specific investigations

Pattern of bone loss in edentulous arches

Information Gathering The presenting complaints and relevant history Dental history Medical history Social history Extra-oral assessment Intra-oral assessment Assessment of the dentures Specific investigations

Diagnosis: examination of of the physical state, evaluation of the mental or psychological make up, understanding the needs of each patient to ensure predictable results. Treatment Planning: develop a course of action that encompasses the sequelae of treatment to serve the patient needs

Pattern of bone loss in edentulous arches

Information Gathering
The presenting complaints and relevant history Dental history Medical history Social history Extra-oral assessment Intra-oral assessment Assessment of the dentures Specific investigations

Assessment

Information Gathering

The presenting complaints and relevant history Dental history Medical history Social history

Extra-oral assessment Intra-oral assessment Assessment of the dentures Specific investigations

Patient Observation

Is he able to get out of the waiting room?

This could give an indication of bony, joint, muscle problem.

Upon rising, is the patient steady or time is needed before gaining equilibrium

Dizziness might be an indication of possible side effects of drugs, cerebro-vascular accident, low blood pressure.

Observe the patients walk and assess the level of coordination and steadiness

Indication of Parkinson or arthritis

Is the patient out of breath?

Suspect congestive heart failure, asthma, or heavy smoking Ankle edema is an indication of kidney disease, congestive heart failure, or poor circulation Check for trigeminal neuralgia Facial tremor: Parkinson's disease If the speech problems is not related to the existing denture, it is not likely to be corrected or improved with the new dentures.

At the chair: observe patient ankle:

Observe facial movement:

Speech is best assessed at causal conversation:

Avoid answering specific questions (on fees or look) at an early stage

Information Gathering

At this stage, concentrate on the chief complaints Chief complaints: this should be recorded in the patients won words, but make sure that the meaning of the information being conveyed is clear. let the patient speak: he will tell you the diagnosis

clearer picture of patients expectations Create a rapport between the dentist and his patient. The interview should be structured.

Pattern of bone loss in edentulous arches Information Gathering

The presenting complaints and relevant history

Dental history Medical history Social history

Extra-oral assessment Intra-oral assessment Assessment of the dentures Specific investigations

Previous Dental History

Provides information about:

Oral conditions. Patients attitude. Why the teeth were lost: periodontal ? Expect more bone loss When the teeth were lost (history of edentulism)

Freshly edentulous (green ridge): expect

Specules Undercuts Thin mucosa Need for surgical intervention

New denture wearer:

The need to explain to the patient his state of edentulism

Old denture wearer:

Explain to your patient that the ability to refit his old dentures is not always possible.
Estimate the level of the patient satisfaction of his old dentures.

Medical History

Methods of obtaining the MH:

The use of Pro-forma which requires the patient to answer specific questions. Direct asking both Medical history may influence dental health and prosthetic treatment directly and indirectly Patient with a debilitating disease (diabetes, nutritional deficiencies) may be prone to delayed healing and sore spots due to the fragile quality of mucosa. Many drugs affect salivary flow History of stroke/ parkinson disease may compromise patient's abilities.

Medications:

Obtain a full list from the patient, and if this is not possible contact the patient physician. Evaluate the possible side effects:

Anti-hypertensive drugs: xerostomia Diuretics: changes in tissue fluidity Psychological drugs: uncontrolled tongue and facial movements.

Patient opinion about his state of health could give an image about the type of patient you are dealing with:

Optimistic patient-despite his sever illness is an indication of a cooperative and adaptive patient-a positive sign for prosthetic treatment success.

It is the dentist responsibility to obtain the medical history and update over time.

Houses psychological classifications

Philosophical: patient willingly accepts the dentists judgement without question. They pay attention and follow instructions. They have the best prognosis (80-85%).

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.
Indifferent: patient has a low motivation and desire for dental care. They show little appreciation for the dentists 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. Theyre never satisfied and always complaining.

Social History

Has the potential to influence the course and outcome of treatment. Some patients value the opinion of their relatives or friends but others want to hide their edentulous statetheir wishes for prosthodontic privacy should be respected. Other aspects include the potential influence of dentures on the selection of particular foodstuffs.

Pattern of bone loss in edentulous arches Information Gathering

The presenting complaints and relevant history

Dental history Medical history Social history

Extra-oral assessment Intra-oral assessment

Assessment of the dentures Specific investigations

Extra-oral Assessment

General examination of the head and neck for nondental pathology The presence of the following should be noted:

Nodules, nevi, ulcerations Facial coloring and tone, symmetry, neuro-mascular activity.

The face and neck should be palpated for any masses or enlarged nodules. Lack of mobility: needs for help to get in and out of the chair. Deficiencies in hearing or sight.

Facial Profile
Skeletal malrelationship might influence teeth positioning or denture stability

TMJ assessment

Assessment of the masticatory system: to see whether a range of pain free movement is possible.

Palpation of the skin of the TMJ Auscultation if indicated- of joint using a stethoscope

Observation of the patient while they speak:

Mandibular movement Tooth position

Excessive occlusal vertical dimension

Careful observation of the patient while they are speaking will provide information on: mandibular movement, tooth position in relation to phonetics, vertical dimension.

Lip examination

Cracking, fissuring at the corners, or ulcerations: Vitamin B complex deficiency, candidal infection, lack of VD Lip support, fullness, thickness, and length.

Lack of support of the lips will cause collapse and wrinkles. Denture can correct

wrinkling present around the modilous of the mouth, weak, turned in, and not visible vermilion border

Labio-nasal, labio-mental, philtrum: hollowness or puffiness. Skin :

loose wrinkled skin that has lost its youthful tone may be difficult to correct with the new dentures. Thin tense skin is easily supported but very sensitive to small changes in anterior tooth position Rouph textured skin : deserve a more rugged anterior teeth set up than smooth light colored skin.

Skin texture:

Note the bruising on the bridge of the nose- suggestive of tissue fragility.

Angular Cheilitis
Angular cheilitis may alert to:

Poorly controlled Diabetes or dietary deficiency Anaemia

Presence of poorly fitting dentures or denture induced stomatitis.

Intra-oral Assessment

General overview Color of the mucosa

Ranges from health pink to angry red

Angry red is an indicative of

Ill fitting denture Underlying infection Systemic disease: diabetes Chronic smoking

White patches: keratosis from denture irritation Other color changes: pigmented spots or lesions ranging from light to dark brown. Dentist should biopsy any suspected color change and send to the pathologist

Saliva:

Amount

Dry mouth

Poor retention Susceptible to injuries Difficult to work with (especially in making impressions)

Excessive saliva

Consistency

Thin Thick Ropy Serous : the commonest in patients and the best to work with

Arch size:

The greater the size , the more support available for the dentures. Discrepancies in size between arches is an indicative of poor stability for the denture on the smaller jaw- this is possibly caused by

Early loss of teeth in one jaw developmental trauma Sever class II or III malocclusion

arch form:

Square, ovoid, tapered The form can affect support for the denture and perhaps tooth selection

Ridge contour:

The best is high ridge with flat crest and parallel or nearly parallel sides. Other forms include:

V shaped Knife edge (poor support) Flat ridge (poor resistance to lateral movement) ridge with multiple specules (poor support)

Ridge relation

Inter-ridge distance: increase distance will increase leverage on the dentures and decrease stability. Ridge that are not parallel will cause movement of the bases. Observe the antero-posterior and the lateral relationships.

This is determined by the amount and pattern of bone resorption and will affect teeth arrangement and possible leverage

Classification (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

Presence of flabby tissues will cause the denture to shift under force Combination syndrome ( maxillary complete denture against RPD replacing kennedy class I)

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 is needed to overcome these problems

Areas requiring relief: tender to palpation, superficial ID in the region of the mental foramina Enlarges tuberosities Frenal attachment close to the crest of the ridge

Denture induced stomatitis

Relatively common finding in denture wearers. Characterized by erythema o the denture-bearing areas, and also may be accompanied by varying degrees of papillary hyperplasia

Retention: resistance of displacement away from the tissues Stability: resist displacement non vertically
Support: resist displacement towards the tissues

Hard-Palate

U-shaped (favorable) V-shaped palatal vault (un-favorable) Flat-palatal vault (un-favorable) Class I: horizontal with little mascular 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)

Soft-palate

V-shaped palate is usually associated with class III soft palate. Flat palatal vault is usually associated with class I or II.

Retained roots. Bony lumps requiring relief of the master casts Undercuts dictating denture extensions or path of insertion. Torus Palatinus and Lingual torus mandibularis

Video : examination of maxillary & mandibular edentulous arches

Pattern of bone loss in edentulous arches Information Gathering The presenting complaints and relevant history Dental history Medical history Social history Extra-oral assessment Intra-oral assessment

Assessment of the dentures

Specific investigations

Denture Assessment Inside the mouth

Denture extensions: over-extensions/under-extensions Retention Stability Teeth arrangement Relation to underlying ridge Occlusal relationships VD RCP

Free way space Aesthetics

Extension

Retention

Stability/ Support

Relation to the underlying ridge

Occlusion

Denture Assessment Outside the mouth

Hygiene Materials used:

porcelain teeth Lining materials

Signs of wears Inspection of the impression surface:

Signs of relief

Tooth size, shape, color, arrangement

Pattern of bone loss in edentulous arches Information Gathering The presenting complaints and relevant history Dental history Medical history Social history Extra-oral assessment Intra-oral assessment Assessment of the dentures

Specific investigations

Specific Investigations

Radiological Haematological Micorbilogical Diagnostic appliances

Assessing patient tolerance/adaptation