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Assessment of Edentulous Patients

Introduction

A critical and somewhat perplexing aspect of the management of the edentulous condition is the prediction of therapeutic outcomes and patient satisfaction. The most fundamental factor determining a precise prognosis is a thorough and accurate pretreatment examination [1-3]. Even though patients may receive the best therapy, the treatment will fail if underlying conditions remain undiagnosed.

This chapter reviews a method for the pretreatment evaluation of edentulous patients and existing prostheses to arrive at a sound understanding of factors that will affect therapy and the probability that the treatment's objective can be achieved. Using appropriate assessment tools, the practitioner can better determine if the patient's expectations can be met.

Much has been published in the dental literature regarding anatomic [4, 5] and psychological variations [6, 7] in edentulous patients. Before considering management of these challenging patients, objectives include thorough examination, diagnosis of existing conditions, consideration of available therapy, and assessment of the prognosis of each available treatment option [1, 2]. Both subjective and objective patient factors must be taken into consideration [1]. A rational stepwise pretreatment protocol will help to prevent critical diagnostic information from being overlooked. Detailed documentation of findings is essential from a dento-legal standpoint.

The pretreatment protocol provided is relatively easy to follow, quick to perform, and easy to reproduce. It yields summary findings that correspond with specific prognostic conclusions. The protocol is divided into: (i) patient interview; (ii) examination of existing facial characteristics; and (iii) examination of edentulous conditions, i.e., anatomic, morphologic, and muscular status.

The Patient Interview

Successful therapy is facilitated by the provider coming to know the patient, from both personal and logistical perspectives; this includes how the patient arrived in the practice. If the patient was referred, the referral source should be known and contacted, and the reason for the referral noted. If the patient arrived due to marketing of the practice, care must be taken to investigate if the patient's needs are consistent with therapy provided by the practitioner.

The initial patient interview permits the patient and the practitioner to know one another [8]. Quality time spent at the beginning sets the stage for an optimized patient-provider relationship. Both the physical and psychological status of the patient should be triaged during the first appointment [8]. Anticipation of communication problems and interception of commonly encountered interpersonal problems are frequently as important as clinical findings. Discerning the primary etiology of existing patient dissatisfaction is essential for breaking the cycle of unsuccessful treatment attempts. Complaints and expectations expressed by the patient, and treatment obstacles encountered by previous dentists, can provide a critical influence on the acceptance of the patient into the practice and the treatment offered.

Be aware that the pretreatment protocol provided might initially appear to consume an inordinate amount of time and effort. Some might say that this is financially unjustifiable. However, once understood and skillfully conducted, the protocol reduces overall management time, permits appreciation of the treatment rendered, and significantly contributes to overall therapeutic success.

Some patients may be fearful, nervous, or shy, and inadvertently fail to respond directly to questions. Recognition of these individuals early in the interview process is critical. In many cases, a dental auxiliary can better elicit patient responses than the practitioner. Obtaining honest and accurate patient responses will affect outcomes. The pretreatment protocol and associated electronic documentation presented incorporate data-gathering processes designed to elicit thorough, concentrated, and accurate answers from patients.

Patient Interview: Age

The patient's chronological age should be critically compared with general physical health and existing oral conditions. Older patients may be afflicted with poor neuromuscular coordination [9, 10], suboptimal nutritional status [11, 12], diminished adaptability [9, 10], and salivary secretion (both quantity and quality) [11], and highly vulnerable denture-bearing tissues [10, 11]. These factors adversely influence aging edentulous patients' ability successfully to tolerate and function with conventional complete dentures, which should be discussed prior to initiating treatment [8]. Analogies such as "when dentures move and there's limited saliva, the pink plastic acts like sand paper against your gums creating irritation" help patients to understand better the problems that they face.

Patient Interview: Attitude

Coming to appreciate patient attitude may be as simple as presenting nonleading questions and permitting the patient time to respond. Questions that may be used to gauge patient attitude include:

• How are you feeling today?
• How was your experience with the previous dentist that treated you?
• What do you think about your current and previous dentures?

Based on patient responses and ensuing discussions, qualifications of patient attitude as good, average, or poor may be made. Of course, additional questioning may be necessary to arrive at a reasonable determination.

Patient Interview: Expectations

If not thoroughly investigated prior to initiating treatment, patient expectations may not be apparent until problems unexpectedly emerge in the course of therapy, and the patient's demeanor begins to decline [9, 13]. Direct and specific questioning of the patient regarding expectations will permit documentation of responses and qualification of expectations as high, medium, low, or still unsure. Patients can also be asked the following questions to understand further the nature of their expectations:

• What kind of improvement in appearance do you expect from your new dentures? In response to this question, a 50-year-old patient may provide a picture of an 18-year-old celebrity stating, "I want my teeth to look like hers." This would indicate that the patient possesses unrealistic expectations. A subsequent patient may suggest, "I want perfect teeth," necessitating a better understanding of what is meant by "perfect."
• What kind of improvement in chewing ability do you expect from new dentures?
• What kind of improvement in fit do you expect from the new dentures?
• How long do you expect new dentures to last?
• How often do you expect to return to the dentist for examinations and adjustments?

The nature of the patient's desires and demands relative to proposed treatment must be considered by the practitioner within the context of his?/?her level of experience and expertise. If the patient expects more than the practitioner can comfortably provide, definitive treatment should not commence and referral to a more experienced colleague should be in order. Additionally, if the patient is unable to appreciate the limitations of the therapy offered, it is inappropriate to initiate treatment.

It is the responsibility of the practitioner to address unattainable expectations fairly and honestly, through frank discussion with the patient, communicating what can and cannot be accomplished with treatment; this is particularly true with complete denture therapy. Failure to address unrealistic expectations often leads to treatment failure and rapid deterioration of the patient-provider relationship. Patients that refuse to accept known limitations of therapy and express inflexibility in this regard are generally challenging to manage successfully. Not initiating definitive treatment for these individuals is ethically, professionally, and financially appropriate.

Patient Interview: Chief Complaint

Providing state-of-the-art treatment that does not manage the patient's main concerns may provide a level of personal satisfaction for the provider but is rarely successful in the long run. It is therefore important to: (i) request that patients specifically voice their greatest dental concern?/?concerns; (ii) document these chief concerns using the patients' exact words, and (iii) review the chief concern?/?concerns, as documented, with the patients to confirm accuracy [13].

Most dental patients are not familiar with professional and dental terminology. It is therefore important to ensure that the practitioner understand clearly the patient's chief concerns as expressed. Asking the following questions may permit a greater appreciation for the nature of the chief concerns:

• Are your dentures loose?
• Can you eat most foods?
• Do your gums get sore?
• Do you have pain now?
• Are you happy with the appearance of your smile?
• Is there anything else that bothers you?

Patient Interview: General Health

General health is a significant factor that can affect the overall success of...