Fixed Prosthodontics in Dental Practice

Chapter 1

Patient Assessment and Presentation of Treatment Options

Aim

The aim of this chapter is to outline the process from initial patient contact to arrival at a treatment plan. An algorithm is suggested to assist methodical data collection and diagnosis.

Outcome

After reading this chapter, the clinician should be able to provide a framework within which to accumulate and interpret clinical findings in order to formulate a relevant treatment plan for individual patients.

Introduction

During the first consultation, both the patient's presenting complaint and its history should be recorded in the patient's own words and be as detailed as possible. The record should act as a focus during examination, and the final treatment option must fully address this complaint. A record must be made of any previous treatment for the same complaint to assist in the analysis of success or failure. A complete patient record consists of three phases:

• patient history

• dental examination

• special tests.

Patient History

A complete patient history should include:

• Dental history - a record of past attendance, treatments and associated complications following treatment. It should address any history of trauma and reasons for extraction of teeth. The former is significant as teeth may, as a consequence, be compromised, and the prognosis for treatment involving these teeth can be less favourable. Loss of teeth may be an indicator of caries or periodontal disease susceptibilities and suggest difficulties with replacement of missing teeth from ongoing caries or soft tissue recession and attachment loss.

• Medical history - this can be recorded using a variety of methods, but before treatment the following questions must be addressed:

  • Will any element of the patient's medical history affect dental treatment?

  • Will any element of the patient's dental treatment affect his or her medical status?

  • Is the patient taking any medication that will affect dental treatment?

  • Will dental treatments affect the patient's current medication regimen (including prescription medication)?

• Social history - provides a background to the patient and identifies habits (for example, smoking and alcohol consumption) or pastimes (for instance, contact sports or hobbies involving hyperbaric conditions) that may influence treatment options.

Dental Examination

A dental examination should address:

• Disease - the first step in preparation for prosthodontic treatment is to identify and eliminate disease in order to establish health. Disease should encompass both past experience and current status.

• Periodontal health - a complete periodontal examination identifies the current status of the supporting tissues. Active disease must be addressed prior to prosthodontic treatment. The periodontal examination should also highlight areas that influence treatment outcome, such as teeth with furcation involvement or poor prognosis. The effects of previous periodontal disease should be taken into consideration - in particular, attachment loss and resulting recession, tooth mobility, irregular gingival margin heights and the absence of attached gingivae in any area (see Chapter 3). Effectiveness of home dental care should also be assessed and modified, if necessary, prior to definitive treatment planning (Fig 1-1).

• Caries assessment - this should identify existing lesions and restorations present. The number and extent of restorations indicates past caries experience, and location may suggest rampant caries if the mandibular incisors or mandibular lingual surfaces are restored. Based on this exam, a preventative regimen can be targeted to the individual patient's needs.

• Pulpal health - the pulpal health of individual teeth should be assessed if they are heavily restored or have been traumatised. Tests should include cold/hot/electric pulp testing, in addition to percussion and radiographs. Findings from retrospective studies have determined that many prosthodontic failures occurred as a result of having to complete endodontic treatment after placement of the definitive prosthesis, so careful preoperative assessment is necessary. If teeth are endodontically treated, the following questions should be addressed:

  • Is the tooth restorable?

  • Are there signs or symptoms of periapical inflammation?

  • Is there associated pain?

  • Radiographically is there an intact lamina dura and is there apical bone loss?

  • If pathology is identified, is it resolving, static or worsening (Fig 1-2)?

  • Is the canal obturation homogenous, well condensed and extending throughout the length of the canal?

Fig 1-1 Periodontal tissue breakdown, as a result of (a) poor local hygiene or (b) iatrogenic causes.

Fig 1-2 Endodontic treatments must demonstrate resolution of periapical infection prior to restoration of teeth. (a) Pre-op radiograph of tooth 36. (b) Immediate post-op radiograph. (c) Three month post-op recall radiograph, demonstrating resolution of the apical pathology.

If concerns exist about the status of an existing endodontic treatment then re-treatment, or extraction, should be considered.

• Mucosal health - the oral mucosa must be healthy before restorative treatment. Loss of mucosal continuity or discomfort must be controlled prior to definitive treatment planning. Such conditions include areas of ulceration or erosion, allergies and altered sensation such as 'burning mouth syndrome'. Consultation with an oral physician may be required to treat the condition prior to restorative care. If the mucosal condition is not controlled it will cause discomfort during treatment and may hinder oral hygiene procedures, making treatment and its maintenance more difficult.

• Craniomandibular articulation (CMA) health - a screening examination for joint derangement and muscle dysfunction must be completed to determine the need for more extensive investigation. The proposed screening exam acts as a good patient record and also brings any functional deficits to attention at an early stage (Table 1-1).

1. Anterior tooth relationships: Class I, II, III (vertical and horizontal overlap).

2. Number of functional units in maximum intercusping position (MIP).

3. History of:

1. CMA noise, locking, pain

2. muscle fatigue /discomfort

3. difficulty in opening mouth, chewing, talking.

4. Tooth measurements.

5. Co-ordination of voluntary movements:

depression:             good, poor
    left lateral:              good, poor
    right lateral:            good, poor.

The CMA screening exam should address the following questions:

• Does a satisfactory end-stop exist in the MIP? Are there sufficient numbers and distribution of functional units?

• Are the overlap relationships/dynamic occlusions/anterior guidance satisfactory? Can they be improved?

• Is the patient excessively clenching or grinding the teeth? Does this pose a difficulty for the proposed treatment plan?

• Is there evidence of tooth mobility or fremitus? Is there evidence of damage in the dentition as a result of parafunction?

• Are teeth/CMA being overloaded?

• Is there evidence of intracapsular discomfort/pain during function or during the testing mandibular movements and/or manipulations?

• Is the range of mandibular depression and CMA comfort adequate for restorative procedures to be completed on posterior teeth over long treatment sessions?

• Is further functional assessment of the CMA status required? If the answer is yes, a more detailed examination/referral to a specialist practitioner is indicated.

Special Tests

Mechanics

Mechanics can be subdivided into micro- and macromechanics. These are best evaluated in conjunction with mounted study casts of the patient.

Micromechanics

Micromechanics are concerned with individual teeth and, in particular, proposed abutments. The strength of any individual crown is primarily determined by the amount of dentine remaining coronal to the finish line. The main features of the preparation include height, width and irregularity and are summarised in Table 1-2.