DENTURES are not an alternative to having natural teeth. Dentures are an alternative to having no teeth.
This well-worn advice reflects the fact that dentures, especially complete dentures, are normally provided when all else fails. Many patients, especially those who are experienced denture wearers, appreciate that there are bound to be limitations in terms of retention, function and aesthetics once the natural dentition is lost. Unfortunately, there are others who still look forward to a life of effortless and comfortable toffee chewing and it is this radical divergence of reality and expectation which makes for disappointment and conflict.
Obviously, the primary means of minimising such problems is to provide well-planned treatment of a good standard. Clinical advice as to how this can best be achieved is beyond the scope of this author. (In fact, if there is any reader who has discovered the secret of making “tight” full lower dentures – without resorting to implants – please feel free to drop me a postcard.)
Art of the possible
It would seem logical to assume that prosthetic excellence would always lead to patient satisfaction. But the sad truth is that, regardless of operator skill, it can be difficult to realise the hopes of edentulous patients. Therefore, before treatment commences, there must be a comprehensive consenting process, including explanation of what is actually achievable.
Experience tells us that practitioners who take the time to effectively communicate this point in the first instance will encounter fewer problems later on. Needless to say, this advice should be imparted in an empathetic, professional manner. The use of visual aids such as diagrams, together with accessible written advice upon which patients can reflect at their leisure, is often very useful and is strongly recommended by the GDC.
The doctrine of valid consent dictates that other subjects, such as treatment risks and alternatives, must also be discussed preoperatively. This begs two obvious questions. firstly, are there are any other risks of which the patient should be made aware when complete dentures are being considered (other than being entered into the 3 o’clock at Chepstow after the insertion stage)? In reality, denture provision is relatively safe and non-invasive. However, it would still be entirely reasonable to warn of potential complications such as traumatic ulcers or initial diction difficulties.
Secondly, where implant retention is beyond the patient’s means, are there any tangible options which can be offered to complete denture patients? It might be that a variety of materials or designs could be considered. However, the most likely choice would probably be between NHS and private standard dentures. NHS practitioners must ensure that this discussion complies with their terms of service which, amongst many other things, do not allow patients to be misled regarding the quality or availability of NHS treatment. If, having been accurately advised, the patient selects private treatment this must be recorded and signed for on a form GP17DC or equivalent.
Respecting patient concerns
Regardless of the quality of treatment, consenting and management of expectations, there will inevitably be patients who are disappointed with the outcome. It is critical that any such expressions of dissatisfaction are dealt with professionally and in accordance with NHS (where appropriate) and GDC requirements.
For an example of precisely what not to do, I need to reach back several decades to my student days. During one of the prosthetic teaching clinics, my undergraduate tutor was berated by an edentulous patient whose mandibular ridge resembled a billiard table and who had returned to the clinic to complain that her lower complete denture “moved”. My tutor could have re-explained that a period of perseverance and adaption would be required if the transition to this denture was going to be successful. Instead, however, he placed the off ending denture on the worktop and invited the patient and the entire student group to gather round. “Watch this denture”, he insisted. “Apparently, it moves”. We stood for some time in respectful silence gazing upon the inert denture, finally agreeing that it must be the patient and not the denture which was moving. One simply wouldn’t get away with that nowadays.
Clearly, in this instance, the complaining patient, while genuinely disappointed and deserving of a respectful explanation, was being unrealistic. However, many patients will return with concerns which are valid and require to be addressed, not only through careful discussion, but also by further treatment. for example, mucosal discomfort under new dentures may seem like quite a trivial problem, but can be severe and always requires early and careful relief of the denture. Leading on from this point, it is vital to satisfy yourself that the lesion is definitely of traumatic origin. As a rule, you should review these cases and, if the ulcer persists despite an appropriate amount of denture adjustment there should be an increased index of suspicion that it may be sinister.
Learning to recognise malignancy is a gradual process which will hopefully be expedited by the GDC’s recommendation that oral cancer awareness should now form an integral part of all registrants’ CPD. Even for an experienced practitioner, however, attempting to reach a definitive diagnosis without biopsy is fraught with dangers. Therefore, where there are concerns regarding any lesion, including persistent ulcers, the safest route is to make an urgent, documented referral.
Other soft tissue conditions, possibly caused by advancing years or long-term prescription medicines, are perhaps more prevalent in complete denture patients. Some, such as xerostomia, may have a profound effect on the prosthetic success. Therefore, as with every patient, scrutiny of a current, signed medical history followed by thorough examination of extra and intraoral tissues must be carried out, analysed and documented before treatment commences.
Goodbye old friend
With advancing years comes not only the increased likelihood of pathology and polypharmacy but also the circumstance that a patient’s existing dentures will date back to circa 1970 and will therefore have acquired the familiarity and comfort of a favourite pair of slippers. Introducing new prostheses at this stage can be a thankless task and, in some instances, the best treatment is no treatment.
However, where the old denture has been worn to the point it has begun to resemble a polo mint, its replacement is probably unavoidable. While replica techniques assist this process, it is important to remember that new dentures, quite possibly with some degree of increased vertical dimension, will present enormous challenges, especially for the older wearer. Patience and empathy must be the prevailing approach.
Despite your best efforts, there may be occasions when a reproachful patient returns wearing his or her old dentures and hands you a bag containing the ones which you have lovingly constructed. Try not to be off ended. Most practitioners have a small collection of orphaned dentures tucked away in some darkened recess of the surgery. It’s character building.
Doug Hamilton is a dental adviser at MDDUS