Achieving Emotional and Technical Success With Denture Patients

The emotional aspects of receiving dentures can be a major factor in many patients’ experiences. A patient who is not mentally prepared for the transition to dentures, or who has unrealistic expectations about what life will be like after receiving them, may end up unsatisfied with his or her dentures—regardless of how well crafted they may be. Because of this, dentists must play the role of counselor when helping patients make this transition.
      Prosthodontics is a specialty that requires the ability to meet patients’ needs when creating well-fitting and aesthetic dentures and partial dentures. No matter how many dentures are delivered in the course of a month, it is important to ensure that these creations are technically superb so the patient can have both excellent function and an attractive smile. It is important not to overlook the fact that it takes more than technical success to give a patient a successful denture experience overall.
      In spite of a patient’s previous dental care, their physiological makeup may lead to gradual loss of teeth; possibly from caries, trauma, or periodontal disease. For an edentulous patient who is in need of complete dental prostheses, the ultimate goal is to give them a renewed sense of confidence via a healthy smile and the ability to communicate with others without embarrassment. This should be the collaborative goal of everyone involved in this treatment—the patient, dentist, hygienist, and the dental laboratory technician. All parties should be prepared to communicate clearly with the patient every step of the way to ensure the easiest transition to a life with dentures.

Figure 1. Using a tooth shade guide (Vita Zahnfabrik) will help ensure a more natural and accurate tooth color in the denture. As today’s society grows increasingly concerned about aesthetics, this is a simple step to achieve technical success and patient satisfaction. Figure 2. Using a gingival shade guide (Lucitone 199 Light Reddish Pink [Dentsply]) to match the color of the denture to the patient’s natural gingiva. Figure 3. After delivering the prosthesis (Portrait Interpenetrating Network [IPN] [Dentsply]), examine the mouth for overall comfort, lingualized occlusion, pressure spots, and any other areas of concern.

Being a Listener and a Teacher
It is easy to forget that it is a major life event for patients to receive dentures. When compared to other life adjustments, research has shown that patients rank this process higher than marriage, retirement or changing jobs.¹ Patients may experience anger during and after the process—directed at themselves for not taking better care of their teeth. Sometimes this anger is even directed at their dental professional, who they feel could or should have saved their teeth, or might have better prepared them for their transition.²
      In order to help patients feel more prepared to face the changes that come with dentures, good communication is vital from the very beginning of the process. Prior to diagnosis and treatment, it is helpful, though often difficult, for the dental professional to analyze the personality of the patient. This can help in anticipating the issues and questions that the patient may have throughout the continuing process of diagnosis and fabrication.
      In addition, patients may not proactively communicate their questions or concerns during the process, so anticipating their needs and asking questions is especially important. Some patients believe the dentist should know their needs and wants without having to be told, and they adopt a very passive attitude.³ Asking questions about patients’ lifestyles and aesthetic wishes can help solidify the goals for treatment for both the dentist and the patient prior to placement of the denture.
      Dentists should also be aware of their patient’s socialization habits and overall lifestyle, in order to discuss the changes that might result, and compare patients’ habits in follow-up visits. If a patient reveals that he or she is not taking part in the same activities as before, or has made any unexpected lifestyle changes, this can be an indication that a denture adjustment or additional counseling is necessary.

Know the Patient
A personal interview and consultation with the patient is the most valuable tool in our diagnostic armamentarium. The value of all other diagnostic aids should not to be minimized, but they cannot be substituted for a sincere face-to-face talk with the patient. An exploratory discussion concerning the health of the patient is significant. An understanding of their expectations, attitude toward care, and previous dental and medical experiences, is important.
      No phase of diagnosis is more difficult than analyzing the personality of the patient. The impression of an individual’s personality that registers with the examiner is dependent upon the perceptive ability of the observer. As you conduct the interviewing process with the above information in mind, initial responses will lead to other questions. Asking open-ended questions, such as what you can do to help them or what their main concerns are, can help assess their expectations. Inquiring about their dental history and denture experiences can reveal their base of knowledge regarding dentures. If they have had dentures before, ask specific questions about how they felt about their dentures with regard to appearance, function, and comfort. This will help you craft the best dentures possible by keeping these concerns in mind.⁴
      When assessing the patient’s responses in the interview, you can often determine at least a basic level of the patient’s intelligence, behavior, and comfort in this situation. This information often helps in determining how technical to get when discussing the patient’s dental options, or if extra care will need to be taken by the dental team to ensure that the patient is at ease during the visit.

Crafting a Denture for Technical Success
Creating a well-made denture is a process that has many steps to ensure that the patient receives the best fitting and functioning prosthesis possible. By paying close attention to procedure and patient concerns, you can produce a product that can greatly improve your patient’s life.

Diagnostic Work-Up
The shade of denture teeth has become more critical issue in today’s appearance-conscious society. When working with older patients, most want to look younger so it is important to discuss their feelings when selecting an appropriate shade (Figure 1). Matching the gingival shade accurately will help create a more natural appearance as well (Figure 2).
Once the shade is selected, the focus then shifts to the denture design and fit. It is important to pay attention to cuspal height and inclination. If posterior teeth are too steep, they can create muscular dysfunction by placing undue stress and damage on the joint complex.

Diagnostic Wax-Up
Next, the diagnostic wax-up helps demonstrate what the final prostheses will look like. At this time, we must evaluate fit and stability, aesthetics, phonetics and the occlusal relationship of the denture teeth from static to excursive movements. This is the time for both the dentist and the patient to evaluate, and discuss the fit, function and appearance of the denture. Often a diagnostic wax-up is beneficial to show the patient what the final prosthesis will look like, and changes can be made prior to processing the denture. Photos can be taken of the shade of the teeth/gingiva to use as communication tools with both the dental technician and the patient.

Delivery and Post-Delivery of the Prosthesis
Once the case has been delivered and verified for overall comfort, it should be checked to ensure the patient has a well-balanced (lingualized) occlusion.
After a patient has begun life with dentures, it is important to keep an eye out for common issues associated with new prostheses such as sore spots, occlusal issues, and vertical dimension. One must also adjust the denture to resolve any sore spots that may be created during function by improper pressure points (Figure 3). For information on how these issues may be presented to you by the patient (Table). Properly fitted dentures should last from 5 to 7 years. Within that time frame, one or 2 relines to adjust the tissue-fitting surface may be necessary.

Patient Education and Instructions
For many edentulous patients, the aesthetic benefits of new dentures are equally as important as functionality. With continuous and open communication, as well as proper denture care following surgery, the patient’s quality of life can be significantly improved. It is important to review patient instructions throughout treatment, not only at the placement appointment.
      Instructions should be both written and oral, and should include specific information about the first 24 hours, care of the oral tissues and dentures, and changes that will occur over time in the residual ridges:
      The first 24 hours: Instruct patients not to remove their dentures during the first 24 hours, and to eat a soft but nutritious diet.
Care of the oral tissues: The oral cavity should be kept meticulously clean until healing is complete. Instruct patients to rinse their mouths thoroughly, but not vigorously, with a warm saline solution 4 or 5 times per day. Mouthwashes containing alcohol should be avoided during the first 10 to 14 days, or until the extraction areas are epithilialzed. Denture foundation areas, other than the most recent extraction sites, should be brushed with a soft toothbrush or wiped with a wet washcloth wrapped around the fingers. In addition, the tongue should be brushed thoroughly.
      Changes in the residual ridge: Instructions should also review what patients can expect as their mouths change. If the prosthesis was an immediate denture placed at the time of extractions, a relining of the denture is frequently necessary 2 to 6 months after placement and a new denture may be needed in one to 2 years. Reinforce that resorption will continue for the rest of the patient’s life, stressing that annual recare visits will be important for proper treatment over time.
Care of the dentures: Studies have shown that most denture wearers fail to keep their dentures clean.⁵ Educating patients about the importance of a daily cleaning and soaking regimen, as well as regular professional cleanings, can help ensure long-term patient satisfaction. It is also critical to simplify this information and to provide recommendations for excellent home care products. Patients should be advised to their clean dentures with a denture brush and a nonabrasive effervescent cleanser (such as Polident Fresh Cleanse [GlaxoSmithKline]) to eliminate harmful plaque and odor-causing bacteria. Unlike with many regular toothpastes, most denture cleansers do not contain abrasives which can scratch denture surfaces. Furthermore, daily use will help maintain the gloss and shine on dentures and partial dentures.⁶
      Instruct patients on use of a nonabrasive tablet cleanser (such as Polident or Efferdent [McNeil PPC]) to remove stains effectively and to eliminate bacteria that can cause denture odor. Recommending a waterproof case, to soak dentures when not worn, that includes a scrubbing brush with an oversized handle is also ideal.
      Precautions to avoid breakage and distortion of the denture should be reviewed. Even with well-fitting dentures, the use of an adhesive (such as Super PoliGrip [GlaxoSmithKline] or Sea-Bond [Combe]) can help patients feel more comfortable, increase bite force and chewing efficiency, and reduce food particle buildup under the denture.⁷ Studies have also shown that tissue irritation can be decreased with the use of an adhesive.⁸

SUMMARY
As we know, there is much more to a successful denture treatment than creating a well-fitting denture. However, with good communication and proper maintenance, patients can realize all of the benefits that dentures offer, including the chance to experience activities they may have been avoiding for some time. The key to ensuring a successful transition to dentures, both technically and emotionally, is to encourage open communication between the patient and the dental team, from the very beginning of the process. By managing patients’ expectations and being a good listener right from the start, you can establish yourself as a trusted advisor to denture patients, helping to ensure that their experience is a success.

References

1. Bergendal B. The relative importance of tooth loss and denture wearing in Swedish adults. Community Dent Health. 1989;6:103-111.
2. Fiske J, Davis DM, Frances C, et al. The emotional effects of tooth loss in edentulous people. Br Dent J. 1998;184:90-93.
3. Fiske J, Davis DM, Horrocks P. A self-help group for complete denture wearers. Br Dent J. 1995;178:18-22.
4. Data on file, GlaxoSmithKline.
5. Morgan TD, Wilson M. The effects of surface roughness and type of denture acrylic on biofilm formation by Streptococcus oralis in a constant depth film fermentor. J Appl Microbiol. 2001;91:47-53.
6. Lamfon H, Porter SR, McCullough M, et al. Formation of Candida albicans biofilms on non-shedding oral surfaces. Eur J Oral Sci. 2003;111:465-471.
7. Aggour S. Food Occlusion Study. GlaxoSmithKline NPD study 062_07.
8. Stern et al, Int Dent J. 2003; 53:347-348.

Dr. Moffitt is a graduate of the University of Washington and Creighton University Dental School. Before he received his certificate in prosthodontics and master’s degree in oral biology at the Baylor College of Dentistry, he practiced general dentistry for 3 years. He has lectured to dentists and prosthodontists in the United States and has taught dental students and residents at the Baylor College of Dentistry in Dallas. In dental school, he spent a summer setting up medical and dental clinics in the rural parts of the Dominican Republic. He can be reached at drmoffitt@moffittrestorativedentistry.com.

Disclosure: Dr. Andrew Moffitt is a consultant for Church and Dwight Co.