By Leila Jahangiri, BDS, DMD, MMSc,
and Ashok Soni, BDS, MDS
Do you have denture patients? You should, according to the following statistics compiled by C.W. Douglass, A. Shih, and A.J. Watson:
Although edentulism is declining, a steadily rising aged population will lead to an increased need for dentures as well as increased productivity potential for your practice. Like any area of dentistry, effective denture treatment requires a reliable clinical technique and proper attention to the practice management side of your business. This article provides recommendations for appropriate denture care for patients and tips to effectively manage expectations through the pre-treatment, treatment, and maintenance and post-treatment stages. It also features an economic formula designed to help make dentures profitable for your practice.
During pre-treatment, evaluate the patient's needs and understand his or her expectations, personality, and lifestyle, because these may affect the treatment. Then, educate the patient — remember, when a patient is properly educated regarding dentures or any clinical procedure, he or she will know what to expect and a high level of trust will be established.
Accordingly, the pre-treatment period should include patient education and communication as well as your gaining a proper understanding of patients' expectations.
During the pre-treatment stage, conduct an intraoral assessment and, if applicable, an assessment of the patient's existing prostheses. This stage provides the patient a sense of what to expect during the procedure and gives you an idea of whether you can treat the patient successfully. Use the following checklist as a guide:
Denture evaluation checklist
Before evaluating the patient, ask yourself the following:
1) Clinically, what do I need to know about the patient's existing dentures?
2) What questions am I going to ask the patient?
3) What am I trying to determine based on the intra-oral assessment?
After answering those questions, go to the next phase of evaluating the prosthesis. Careful attention to the following will help you evaluate patients' existing dentures:
• Size, shape, and wear of any existing teeth
• Color of the denture base material
• Denture base adaptation to tissue
• Extension — is it adequate or short?
• Evidence of repair
Besides answering these questions and referencing the checklist, it's a good idea to make two columns on a piece of paper — one for patient "likes" and the other for "dislikes." The responses will help in developing the new dentures and building rapport with the patient.
For example, if ridges are poor and resorbed, you may refer the patient to a prosthodontist or specialist. When appropriate, referral helps you appear confident to the patient.
Remember that waiting to tell a patient something could compromise the dentist-patient relationship. To aid in these efforts, a chart detailing common denture problems along with various related causes has been included.
To successfully manage and treat a denture patient, begin with healthy tissues. If a patient has ulcerations, irritations, or areas of redness, you must diagnose the cause and recommend proper tissue conditioning and treatment. Evaluate the patient's existing condition before proceeding with denture fabrication.
Once an assessment has been made, tell the patient how many steps are involved in providing dentures. Remember that denture-making is a combination of art and science. Shortcuts will not help you or your patient. For example, pre-fabricated occlusal rims may be used, but they still have to be modified.
Denture treatment checklist
Go over the steps in fabricating the dentures with the patient. Educational materials such as flip charts are available for patient education. Your dental assistant can go over these steps and answer any questions prior to starting the treatment.
Besides the clinical steps, it is important to have good communication with the dental laboratory. The laboratory is an integral partner in producing a successful outcome. Before sending the case to the laboratory for denture fabrication, make sure the technician has the information to set the teeth properly.
• Occlusal rim should indicate the length of anterior teeth and location of the smile line (width-to-width).
• Determine if the patient shows from canine to canine or premolar to premolar.
• The rim should be trimmed so that it has the correct amount of lip support.
• Determine the shape, mold, and shade of the teeth.
During the try-in appointment, assess aesthetics, phonetics, and occlusion before getting patient approval and sending for processing. Remember that this set-up might need to be modified. Especially with regard to aesthetics, you may want to incorporate some irregularities in the denture set-up — which will make the dentures look more natural. The best type of denture is one no one notices. Nevertheless, some patients may want straight, regular tooth arrangements, so discuss this with the patient and only then incorporate irregularities. Further, dentures ideally should complement a patient's gender and age. Before proceeding with fabrication, have a frank discussion with the patient regarding his or her desired aesthetic results. This will help manage expectations and result in a happier patient.
During the try-in appointment, re-check the aforementioned denture treatment checklist. When evaluating trial dentures, advise the patient to have a spouse, family member, or caregiver in the room with him or her to offer moral support and confirm the visual appearance. The patient should wear the trial dentures for 10 minutes in the waiting room, then look in the mirror as he or she gets used to the new dentures. Once satisfied that all the required information is obtained, proceed with the processing and insertion.
If all is satisfactory, during the next visit — following examination and applicable corrections of fit, border extensions, and occlusion — the dentures may be delivered. Remounts may be necessary. A remount is where the processed dentures are remounted in the centric relation position and where a dentist or technician can refine and correct all occlusal discrepancies that may have been created during the denture processing.
Inform patients that five to eight patient visits may be required for the entire treatment.
Maintenance and post-treatment
Now that the dentures are processed and properly inserted, clearly communicate how best to care for and maintain dentures because this will impact patient comfort level. Dentures require regular home and professional maintenance. Encouraging correct usage of denture care products is essential, according to David Roessler. To keep dentures fresh, clean, and effective, it is important patients follow a simple, daily routine. And because the supporting bone and tissues in the patient's mouth need regular rest from denture-wearing, recommend daily removal.
Brushing is a key step in the daily maintenance of dentures and should be performed manually on the insides and outsides of the dentures (gently on the inside), once a day, preferably in the evening. When the patient removes dentures in the evening, he or she also should brush the palate and soft tissue with a soft-bristle brush. Brushing also removes and replaces the outer mucosal epithelial layer of the intraoral tissue, removing dead cells. This task is typically accomplished through contact with the tongue's rough surface. When dentures cover these areas for 12- to 14-hour periods, the tongue no longer can perform this task. In addition to cleansing bacteria, brushing — like massaging aching muscles — helps stimulate the tissue and maintain proper circulation.
Denture adhesive use may be indicated in some patients because of excessive resorption and inadequate ridges. Obtaining the greatest advantage from adhesives depends on proper application.
For powder and cream products, the least amount of material that is effective should be used. This is approximately 0.5 to 1.5 grams per denture (more for larger alveolar ridges; less for smaller ones).
For powders, the clean prosthesis should be moistened and then a thin, even coating of the adhesive is applied to the tissue surface of the denture. The excess is shaken off, then the prosthesis is inserted and seated firmly. If the patient suffers from inadequate or absent saliva, the denture should be moistened lightly with water before insertion.
For creams, two approaches are possible. Most manufacturers recommend placement of thin beads of the adhesive in the depth of the dried denture in the incisor and molar regions, and, in the maxillary denture, an anteroposterior bead along the mid palate. However, more uniform distribution of the material can be achieved if small spots of cream are placed at 5-millimeter intervals throughout the fitting surface of the dried denture.
Regardless of the pattern selected, the denture is then inserted and seated firmly. As with powders, use of denture adhesive cream by the xerostomia patient requires that the adhesive material be moistened with water prior to inserting the denture. Patients must be instructed that daily removal of adhesive product from the tissue surfaces of the denture is essential, according to Kenneth Shay. If not properly removed, adhesive residue can build up and irritate soft tissue and negatively impact the denture fit because there is not the same intimacy of contact between the tissue and the dentures. Rinsing dentures over a sink filled with water prevents breakage if they are dropped.
Following appropriate brushing and removal of adhesive, the dentures should be stored overnight in some form of liquid — either a denture cleanser such as Polident® or a mouthwash such as Listerine®. Under no circumstances should patients use bleach, as this can affect the color of the dentures. Denture patients should remove their dentures in the evening before bed and change the cleansing liquid daily. Tell patients who complain of gagging that sleeping while wearing dentures for two to three consecutive nights will help them get used to their feel.
Denture patients should have follow-up visits with their dentists once a year. Every human body goes through changes and the mouth is no different. As these changes can impact denture fit, the dentures may have to be re-made every four to five years. During these follow-up visits, go back over the denture evaluation and treatment checklists and use the same evaluations to determine if additional treatment is necessary.
Once patients have become edentulous and are using complete dentures, their oral health needs do not cease. Jaws are not static and may continue to resorb. In addition, ill-fitting prostheses can adversely affect chewing and lead to poor nutrition. Your edentulous patients also will remain susceptible to oral cancer, mucosal diseases, and alterations in salivary gland function, according to Ira B. Lamster. It is imperative to encourage regular visits.
When it comes to dentures, too often dentists establish fees first, then figure out how many sessions it will take until final fabrication. Instead, calculate an average number of visits based on a recommendation. Then, calculate the time of each appointment. Based on that, determine what the particular treatment is worth. Remember that crowns and bridges are not completed in one visit; dentures are no different.
Beyond economic formulas, the time spent listening to the patient, making appropriate diagnoses, and managing expectations is critical in producing a satisfactory end result. Doing all legwork beforehand enables you to tell patients from the start if their needs can be met. Dentists can learn from physicians who run CAT scans, blood tests, and MRIs before deciding upon treatment. The best patient is well-educated, and keeping lines of communication open is crucial to continued success.
A rise in the U.S. aged population, among other factors, has led to an increased need for dentures and accordingly, more opportunities for dentists. But the numbers only tell half the story. As detailed throughout this article, successfully incorporating dentures into your practice requires a commitment to managing patient expectations and appropriately detailing the proper care and maintenance of dentures. This can be accomplished by following a distinct set of procedures, educating the patient whenever possible, and making yourself available to answer the questions that inevitably will arise.
From a practice-management standpoint, it is not enough to simply set a fee and then figure out all that the treatment incorporates. Dentures can be profitable, but only by basing fees on a thorough diagnosis. This combination of education, communication, proper procedure, and sound practice management will help make dentures work for your patients and practice.
• In 2002, 9.7 percent of the U.S. population older than 18 was considered edentulous, with this figure rising to 33.3 percent for those age 65 and older.
• Ninety percent of all edentulous adults wear dentures.
• Although edentulism has declined 10 percent every decade, there also has been a 79 percent increase in the adult population older than age 55.
• According to information from the Centers for Disease Control and Prevention, in 1991, 33.6 million people needed one or two complete dentures. In 2020, this number is predicted to reach 37.9 million.
Opinions expressed by the authors are not necessarily those held by New York University College of Dentistry. References available on request.