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.