CE: Set Yourself Up for Success by Dr. Leif Stromberg

Categories: Prosthodontics;
CE: Set Yourself Up for Success 

Use the initial consultation/ examination to glean essential information about candidates for complete dentures


by Dr. Leif Stromberg
Keys to Success and Predictibility With Fabrication of Complete Dentures
PART 1 (this month): The consultation/examination appointment
PART 2 (June): Simplified techniques for final impressions
PART 3 (September): Simplified techniques for accurate records
PART 4 (November): The wax try-in appointment
PART 5 (January): Delivery of successful complete dentures








Short description
This course focuses on how to effectively acquire critical patient information at the consultation/examination appointment for success with all types of tissue-supported complete dentures. It covers effective patient communication, the clinical examination and managing patient expectations for predictable and satisfying denture outcomes.

Abstract
This course focuses on essential elements of the consultation/ examination appointment for enhancing the predictability and success of complete denture fabrication. It breaks down this initial appointment into three phases: preexamination consultation, clinical edentulous examination and postexamination consultation.

  • In the preexamination consultation phase, the emphasis is on actively listening to the patient. Understanding their previous experiences with dentures, their adaptability to prostheses, and their specific desires and expectations for new dentures is essential.
  • The clinical examination involves an assessment of the patient’s oral conditions. This helps determine their restorative needs in alignment with their desires and expectations. The dentist evaluates oral health, anatomy and factors that may affect the success of the dentures, such as stability of the temporomandibular joints and potential airway obstructions.
  • The final phase, the postexamination consultation, includes a discussion of the findings from the consultation and examination. Here, various options and recommendations are presented, tailored to the patient’s individual needs, wants and expectations.
Additionally, a comprehensive informed consent process is crucial and should cover all treatment options and their benefits, risks and associated costs to ensure transparency and foster patient compliance.

Learning objectives
After completing this course, readers should be able to:

  1. Conduct a preexamination consultation that establishes open communication and patient rapport, leading to a better understanding of patient wants and expectations..
  2. Provide a practical clinical edentulous examination, including evaluating the patient’s oral health and identifying anatomic factors influencing denture success to determine the patient’s needs.
  3. Discuss the importance of patient-centered care, including: active listening and empathetic communication to create a comfortable environment where patients can express their wants, expectations and concerns; and incorporating information from the findings of the clinical examination to perform appropriate treatment.
  4. Conduct a thorough informed consent process, including a discussion of treatment options, risks, benefits and fees, and the recognition of the patient's right to choose no treatment.


Introduction
For dentists and their teams, providing a successful complete denture service requires a combination of technical expertise, communication skills and a deep understanding of the patient’s unique expectations and needs. The first step in this process is the consultation/examination appointment. This course examines key aspects of this initial appointment that can enhance the effectiveness and predictability of the complete denture experience.

All denture fabrication steps must be done competently by the dentist, dental assistant and dental laboratory technician to create well-made complete dentures that are stable; have adequate occlusal vertical dimension, retention and aesthetics relative to the patient’s anatomy; and have all posterior denture teeth contacting evenly in centric relation occlusion. However, the dentist should understand that even competently crafted dentures may face rejection by the patient. To mitigate this unpredictability, dentures should be skillfully made according to the patient’s wants and expectations.

Fundamental aspects of the consultation examination appointment
  • Preexamination consultation: Patient interview before the visual clinical examination. Establish a foundation for open communication and understanding patient expectations.
  • Visual clinical examination of the edentulous stomatognathic system: Comprehensive evaluation of patient oral health and anatomical factors influencing denture success.
  • Postexamination consultation: Patient consultation after the visual clinical examination. Discuss findings, thoughts, options and recommendations based on patient expectations and oral examination results.
Competently completing the denture fabrication steps leads to fewer problems after the delivery of the final dentures and greater predictability and success. Life is too short to routinely fabricate dentures that are unpredictable and unsuccessful! This course is the first of a five-part series about keys to success with tissue-supported complete dentures, which explores fundamental denture fabrication techniques surpassing those commonly employed by many dentists. Following these fundamentals should result in higher predictability and success for the dental team with analog, digital and implant-retained tissue-supported complete dentures. This course aims to inspire and encourage dentists and dental teams to incorporate the fundamentals covered and persist in their learning journey, fostering growth and continual improvement of their denture services.


Preexamination consultation
Understanding patient expectations
The consultation/examination appointment is not solely about assessing the patient’s oral health; it’s also an opportunity to connect with and learn more about the patient. Engaging in open and empathetic communication helps to create a comfortable and safe environment for patients to express their wants, expectations and concerns. The dentist should ask patients about their experiences with former dentures and denture services. Understanding their history and experiences with dentures will help the dentist gauge the potential for successful treatment and assist in deciding if referral of the patient is the best option.

It’s important for the dentist to understand the patient’s expectations concerning their desired upcoming dentures. Consider a scenario where an edentulous patient anticipates eating a hamburger wearing tissue-supported prostheses as effortlessly as they did in their teenage years with healthy natural teeth. Such elevated expectations may lead to dissatisfaction with new dentures. The dentist and patient must recognize that dentures are prostheses with differences from natural teeth and gums, and the patient must adapt to changes in speech, function and feel.


Active listening

The preexamination interview with the patient should occur before the visual clinical examination. A good opening for the dentist with a new patient is asking, “How can I help you?” and then listening attentively. Ask the patient to assess and describe the conditions with their existing dentures (e.g., aesthetics, comfort, retention, function) and discuss their likes and dislikes with present and past dentures. Also, inquire about the patient’s wants and expectations with new dentures. Listen with the intent to understand the patient.

The preexamination consultation is a time to understand the patient, rather than educate them about dentures. Education should occur after the clinical examination to inform the patient about restoring their conditions and needs in relation to their wants and expectations. At the preexamination consultation, the dentist should take the time to actively listen to the patient’s concerns and expectations. Many patients seeking new complete dentures may have had negative experiences or fears associated with dental procedures. By empathetically listening, the dentist can gather valuable information and establish trust, a crucial factor in the success of any dental treatment.


The comprehensive clinical oral examination
The clinical examination begins only after completion of the preexamination consultation, where the patient has discussed their wants and expectations and the dentist has listened and spoken briefly in general terms. After understanding the patient’s wants and expectations and the conditions and restorative needs learned at the oral examination, the dentist will discuss their findings, impressions, options and recommendations at the postexamination consultation.

A thorough oral examination of the edentulous patient is a cornerstone of successful complete denture treatment. Beyond assessing the patient’s oral health, it provides insights into the anatomical and physiological factors that may affect the success of dentures.

For predictability and success with complete dentures, it’s essential to treat patients who have stable (not changing) stomatognathic systems; this includes stable (noninflamed) denture-supporting tissues and temporomandibular joints (TMJs). If final impressions are made of unstable inflamed, swollen tissues (Fig. 1a), the denture will not fit well to the healed, unswollen tissues (Fig. 1b). Other conditions that can lead to unpredictability include the absence of retromolar pads, hypertrophied maxillary tuberosities, large tori or exostoses (Fig. 2), salivary hypofunction and mobile (displaceable) alveolar ridge soft tissues (Fig. 3). Also, any pathologic areas detected during the oral cancer screening, which should be part of the oral examination, should be addressed before beginning denture fabrication.

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Fig. 1a
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Fig. 1b
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Fig. 2
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Fig. 3

Evaluate the TMJs and masticatory muscles, looking for red flags indicative of problems and instability. Evaluation can include using palpation and a stethoscope to notice if clicking, popping or crepitus of the joints is present. Discuss current or past pain of the patient’s TMJs and ears, including their history of headaches and neck aches. The TMJs can be assessed with manual bilateral mandibular guidance and load testing of the right and left TMJs to verify centric relation or detect possible temporomandibular disorders and instability (Fig. 4).
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Fig. 4

Stable TMJs are crucial for attempting successful and predictable edentulous restorations. A thorough understanding of TMJ anatomy, function, and disorders and diagnosis of temporomandibular disorder (TMD) is beneficial with this step.

Another important element of the clinical oral examination is screening the patient for obstructive sleep apnea. The dentist can use the STOPBANG questionnaire and a home pulse oximeter for screening. The vertical dimension of occlusion of the edentulous restoration may affect the patient’s airway and should be assessed. If the edentulous patient uses a CPAP (continuous positive airway pressure) machine, implants may be needed for denture support or retention for a seal of the CPAP face mask. Be sure to consult with the patient’s physician regarding these matters.

Suppose the patient has an unstable condition such as TMD, obstructive sleep apnea or irritated, inflamed, ulcerated denture-supporting tissues. In that case, it is important for the dentist to decide how the condition will be resolved before proceeding with the fabrication of new final denture prostheses.

Aside from the patient’s physical conditions, remember that their attitudes and adaptability toward their new dentures are critical regarding predictability and success with tissue-supported complete dentures.

Assessment of oral health and anatomy
During the oral examination, evaluate the overall health of the oral tissues, including the condition of the oral mucosa. Identify and address any current oral health issues that may affect the success of the complete denture treatment. Also, evaluate existing prosthetic appliances and their effects on the stomatognathic system. Some positive characteristics of an edentulous maxilla regarding the fabrication of tissue-supported complete dentures include:
  • Abundant keratinized attached tissue. Thick denture-supporting tissues make wearing dentures more comfortable for the patient.
  • Palate U-shaped in cross-section.
  • Absence of undercuts and tori.
  • Adequate residual alveolar ridge bone for denture retention, stability and support.
  • Frenum and muscle attachments below the crest of the ridge.
  • Well-formed tuberosities.
  • Well-defined hamular notches, which indicate the location of the posterior extension of the denture and help with denture retention.
Some positive characteristics of an edentulous mandible regarding the fabrication of tissue-supported complete dentures include:
  • Well-defined retromolar pads.
  • A well-formed buccal shelf to support the mandibular denture.
  • Frenum and muscle attachments below (apical to) the crest of the alveolar ridge.
  • Absence of undercuts and tori.
  • Abundant attached keratinized mucosa.
  • Adequate residual alveolar ridge vertical height and buccolingual thickness, similar to the cast in Fig. 5.
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Fig. 5

Assessment of facial characteristics
Appraise the patient’s facial characteristics, including lip support and length, the vertical dimension of occlusion and the aesthetics of their smile. Look for red flags indicative of challenges that may present during the denture fabrication. This assessment can help achieve patient satisfaction with their new dentures or may lead the dentist to refer the case because of complex conditions.

Radiographic evaluation
Incorporate a radiographic evaluation to assess bone density and the overall oral anatomy. Radiographs provide valuable information about the underlying structures and aid in treatment planning and detection of pathology. The dentist or radiologist should carefully evaluate and diagnose any radiographs taken. If the patient is considering placement of dental implants in the future, consider recommending 3D cone beam computed tomography.

POSTEXAMINATION CONSULTATION
Considering the clinical findings and patient expectations, the dentist should decide if they can achieve acceptable results and would like to treat the case or if they want to refer it. It is important to emphasize that referring patients to colleagues is acceptable and encouraged when appropriate.

Considering the patient’s wants, expectations and restorative needs, inform them about the available treatment options, what to anticipate with each course of action, the associated fees and the recommended treatment. Advise the patient about conditions with potential for improvement (e.g., retention, aesthetics). Be positive and realistic.

Discuss options regarding dental implants with the patient, such as:
  • Placing dental implants after the dentures have been fabricated. However, inform the patient that bone reduction may be needed if implants and attachments are placed. Ensure they are aware of the additional costs for these added services.
  • The denture base will weaken in the areas of implants and attachments, and denture fracture may require repair or refabrication of the denture.
  • The patient may need to have the current new dentures remade or rebased after bone reduction when implants and attachments are added.
The dentist should understand and accept the limitations of dental implants and digital technology related to complete denture success. While it is exciting that implants can often improve a denture, they usually will not transform a poorly made denture into a suitable denture. Digital denture technology can only produce adequate dentures if accurate information is input (e.g., accurate impressions, records of tooth position and vertical dimension of occlusion, etc.). In other words, garbage in, garbage out. Also, the digital denture technology must be sufficiently advanced to produce adequate dentures. The dentist should strive to choose an excellent digital denture manufacturing system and input quality data.

Patient education
Engage in a discussion with the patient about what to expect with new tissue-supported dentures. Clarify that chewing function will notably decrease compared with healthy natural teeth. Additionally, emphasize that the new prostheses will initially feel “different” and potentially uncomfortable. Inform the patient their speech will be affected and this is a normal part of the adjustment process. Address that they will experience some movement of the dentures in their mouth. Assure the patient the dental team is committed to providing support throughout their adaptation to the new dentures, but accepting limitations of prostheses is essential. Furthermore, the dentist should decide the steps they will take if the patient encounters difficulties and does not accept the new dentures after delivery.

Empower patients by providing education about the complete denture fabrication process and obtaining informed consent. A well-informed patient is more likely to accept and be satisfied with the treatment outcome.

The informed consent process
Ensure a thorough informed consent process, explaining potential risks, benefits and alternatives to tissue-supported complete denture treatment. Address any questions or concerns the patient may have, and document the informed consent process in the patient’s clinical records. Have the patient and a witness sign and date a written informed consent form.

In the form, include the following issues if they were discussed:
  • The option of no treatment and its consequences. (Note that this option was presented but is not recommended.)
  • The option of small-diameter (less than 3 mm) implants or root-form (3 mm or more) implants in the maxilla and mandible to retain dentures.
  • The option of All-on-4-6 fixed (dentist-removable) restorations.
  • The option of implants with fixed bridges.
  • Benefits/advantages, risks/disadvantages and fees of all options.
  • The fact a denture can fracture and need repairs or replacement at additional fees.
  • The fact denture teeth can wear, necessitating replacement of teeth or remaking of the denture at additional fees.
  • The fact a patient should not attempt to repair their own denture but instead should return to the dentist for evaluation and discussion of repair options.
  • The fact the American Dental Association reports that, over time, dentures may need relining, rebasing, or replacing. The typical life of dentures is between five and 10 years.
Setting realistic expectations
At the postexamination consultation, inform the patient about the complete denture process, including the time required, potential challenges and the expected outcome. Discuss the possibility of additional appointments with laboratory time if more steps become necessary for the denture fabrication process. Be transparent about what complete dentures can and cannot achieve. Realistic expectations contribute to patient satisfaction and compliance throughout the treatment.

Visual aids such as models, diagrams and videos are useful when explaining the various stages of complete denture treatment. They can enhance patient understanding as well as facilitate better communication. If appropriate, provide printed or digital information about the treatment plan and supply denture and oral care instructions. These materials serve as valuable references for patients and reinforce the information discussed during the consultation.

Incorporating patient-centered care
Adopting a patient-centered approach is critical to the success of complete denture treatments. Strategies should be tailored to meet each patient’s individual needs and preferences. Develop individualized treatment plans based on the patient’s oral health, lifestyle and preferences. Consider factors such as the patient’s ability to adapt to new prosthetic appliances and their expectations regarding aesthetics and function.

Encourage open communication and seek patient feedback throughout the consultation/ examination and treatment process. Actively address concerns or discomfort the patient reports, fostering a collaborative and supportive dentist-patient relationship.

Conclusion
The consultation/examination appointment for complete dentures is a multifaceted process beyond traditional dental examinations. Success in this phase requires effective communication, examination skills and a patient-centered approach. By understanding the patient’s expectations, conducting a visual clinical examination, providing patient education and adopting a patient-centered care model, dentists can lay the groundwork for a successful and satisfying complete denture fabrication experience.

Taking the time to learn and master these fundamentals for success in the consultation/ examination appointment and for all phases of the fabrication process promotes optimal treatment outcomes and fosters positive long-term patient relationships.


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Do you prefer to take continuing ed in video format?
Dr. Leif Stromberg has also created a five-part series of video CE courses for Dentaltown about keys to success when creating complete dentures. Click here to check out the lineup.
Author Bio
Dr. Leif Stromberg Leif Stromberg, DDS, MAGD, FADI, FICD, practices restorative dentistry in Dallas. Highly respected among his peers, Stromberg was selected as a Texas Super Dentist in Texas Monthly magazine from 2005 to 2017. In 2022, he became a Texas Academy of General Dentistry Dentist of the Year Award nominee, and in 2023 he earned fellowship in the International College of Dentists.

Stromberg, who also served as a clinical assistant professor at Texas A&M University College of Dentistry from 2000 to 2005, is frequently solicited to present at dental conferences on techniques for predictably successful complete dentures and has written a textbook on the same topic.

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