Although new techniques and new materials are creating new opportunities, and new challenges for clinicians to meet and overcome - not to mention new dentolegal risks to deal with - there are still plenty of familiar 'old chestnuts' that crop up with monotonous frequency in claims and complaints against dentists.
One such problem is the provision of full (complete) dentures. This article deals specifically with their provision for patients who are already edentulous, in one or both arches as opposed to immediate replacement full dentures.
Daunting dentures
Most clinicians will have experienced the humbling and soul destroying experience of multiple retrys (trial insertions) of full dentures or endless adjustments/eases of newly-provided dentures, or even the indignity of having to remake the dentures on one or more occasions, only for the patient to send back, declaring the new dentures to be unwearable. Most of the complaints and claims associated with full dentures can be categorised into three groups:
- the oral cavity
- the patient
- the clinician
The oral cavity
Although it may seem self-evident, an essential prerequisite of successful full denture construction is a properly detailed assessment of the patient's mouth - the quality and suitability of the edentulous ridges and the soft tissue of the denture-bearing areas, the occlusion and vertical dimension, the musculature, and any complications introduced by the lips, tongue or cheeks, for example. Additionally, the quality and quantity of the patient's saliva may have a direct impact on the retention and comfort of the denture.
Although it may seem self-evident, an essential prerequisite of successful full denture construction is a properly detailed assessment of the patient's mouth - the quality and suitability of the edentulous ridges and the soft tissue of the denture-bearing areas, the occlusion and vertical dimension, the musculature, and any complications introduced by the lips, tongue or cheeks, for example.
Additionally, the quality and quantity of the patient's saliva may have a direct impact on the retention and comfort of the denture.
Recording the assessment
Surprisingly few dental records for complete denture cases confirm that these essential first steps have been taken, so it becomes easy for patients (or their lawyers) to argue that the clinician has failed in his/her duty of care to carry out a full examination and assessment prior to constructing the dentures.
When things go wrong in the later stages of denture construction, it is easy to be wise after the event and not uncommonly a dentist will say 'this was always going to be a difficult denture because of the patient's bite' (or the lack of edentulous ridges, or dry mouth etc). This then invites the question of whether these problems were ever discussed in sufficient detail with the patient before proceeding.
If you do anticipate problems for any reason, then take the time to warn the patient, and record these warnings in a dated entry in the clinical notes.
Without such record card entries, the way is left open for the patient to argue 'I would never have gone ahead with these dentures if the dentist had only explained to me that...'.
This is essentially a consent issue, although it may not have appeared so at first sight.
That same line of thinking begs the question, 'had the patient been appropriately and adequately warned, would they have preferred a referral to a prosthodontic specialist, or perhaps to someone with special expertise or experience in full denture construction?'
In short, if the initial examination reveals anything about the patient's mouth that would limit the prospects of constructing full dentures successfully, then discuss these constraints with the patient in advance.
The patient
As we all know, different patients present with different problems. Some are extremely demanding and difficult to satisfy and it may be impossible to deflect them from unrealistic expectations of treatment outcomes.
Some talk too much and are apparently determined to control the treatment at every stage, while others talk too little and fail to give us crucially important information about their previous history or current problem. With some patients we are on a hiding to nothing from the outset - because of our age, or sex, or appearance, or ethnicity, and because they come to us with preconceptions and perceptions of what they want, what they expected, and what they need.
Clinical confidence
All of these problems - and more - can prejudice the prospects of success when providing complete dentures. A patient, who is confident in the clinician providing the dentures, is more likely to be happy with the dentures; conversely once a patient loses confidence in the clinician who is providing the dentures, the prospects of a successful outcome can be slender or non-existent.
Getting to know them
It is short-sighted to focus exclusively on the dentures themselves; an important aspect of the equation in full denture construction is to maintain the relationship between dentist and patient.
Time spent at the outset in getting to know the patient and understanding their expectations, is seldom wasted. If nothing else, it can alert you to situations where the best option is not to become involved in the treatment at all, or where the additional experience of a specialist is advisable.
The emotional component associated with full dentures is not often appreciated. It is worth considering why the patient has chosen this particular moment to seek the replacement of the dentures they have been wearing for so many years. An understanding of the patient's motivation often provides the key to understanding their needs and expectations. It may also alert the clinician to the potential difficulties.
Getting used to them
A patient's ability to adjust to their new dentures, which differ significantly from others they have been wearing for a long time, can be influenced by events in their life which are quite unrelated to the dentures themselves.
The dentures become a convenient scapegoat for an unhappy patient to focus their problems on. Adapting to the new dentures may simply represent one challenge too many for a patient who is already under stress for one reason or another, and whose 'coping' mechanisms are already compromised for reasons outside the clinician's control.
The clinician
There is still a lot of wisdom in the old adage that an extra five minutes spent at each stage of the construction of a denture, saves ten minutes at the next. Anyone who has accepted a less-thanoptimal impression, or who has rushed the 'bite' stage of a full denture, will probably relive a few nightmare cases upon reading this. Similarly, adjustments that are easily and inexpensively made at the wax 'try-in' stage are a costly and time consuming frustration once the dentures have been completed.
Easy does it
'Eases' and other adjustments of full dentures are a matter of fine judgement. They are quick and easy enough to achieve, but each successive removal of acrylic needs to be considered very carefully.
Before removing any acrylic from a completed denture, it is worth asking yourself what it is designed to achieve, and for whose benefit the material is being removed. After several eases, there is a danger you will have removed much of the retention initially achieved by denture flanges, or the accuracy of the fitting surface. Adjustments in the 'post-dam' area should be approached with caution. Many such adjustments made at the patient\s insistence have eventually led to the need for a complete remake.
When to stop
If patients return time and time again, complaining that they are unable to wear their dentures, it is tempting to dismiss them as patients who will never be satisfied, whatever is done for them. It is salutary to remember that the majority of these patients subsequently go on to have perfectly satisfactory dentures constructed by another dentist.
Dentists who have remade dentures on one or more occasions, or who have invested a great deal of time over many visits, may feel that they have done everything humanly possible to achieve a satisfactory outcome for the patient. This makes it all the more frustrating and hurtful when the patient throws all this commitment back at the dentist, saying that they had attended twenty times, and allowed the dentist to have three attempts, but the dentist was still unable to make a denture that they could wear.
A new start
One learns with experience when that stage has been reached when it makes more sense for the patient to make a fresh start with another dentist, than to persevere with a case when the confidence and patience is wearing very thin on both sides.
Denture wearers should be advised about the need to return for a periodic oral examination so that the soft tissues under the denture can be checked .