Dr. Jeffrey Cummings, D. M. D.
The following
article is reprinted on the Internet with the permission of and
Copyright © 1995 by the Editorial Council of The Journal of Prosthetic
Dentistry,
All Rights Reserved
Differential Diagnosis and Treatment Planning For Edentulous Implant Candidates
by Jeffrey
Cummings, DMD, and
Albert Yurkstas, DMD
Researchers have demonstrated that many patients are not completely satisfied with removable partial dentures.(1,2,3) With the discovery of osseointegration and tissue-integrated prosthesis, many dissatisfied denture wearers have received implant therapy to improve their dental condition.
Public awareness of dental implants has become so pronounced that many dissatisfied denture wearers now make their own diagnosis and present to dental offices requesting dental implants.
The Denture Diagnostic Center was established at Tufts University School of Dental Medicine to assist patients having problems wearing complete dentures. Many patients present to this clinic requesting implants. After a thorough examination, it is often noted that many of these patients have marginally acceptable complete dentures. Therefore, a pilot study, evaluating patient satisfaction, was conducted on 11 patients who requested implants but were treated with conventional complete dentures.
MATERIALS AND METHODS
Five men and six women presented to the Denture Diagnostic Center from 1988-1989 requesting dental implants. Six patients were under age 65 while five patients were overage 65. Seven patients had been totally edentulous for over 10 years. All 11 patients wore their upper denture, while only 7 patients wore their lower denture.
Patients were treated with conventional complete dentures using the technique described in the Tufts University Complete Denture Prosthetics Manual.(4) This technique requires preliminary impressions, custom trays for final impressions, centric relation record, occlusion using monoplane teeth with centric relation coinciding with centricocclusion, try-in, and delivery adjusting the occlusion withintraoral balancer.
Two clinicians worked with each patient with every step requiring both clinicians approval. Laboratory work was done at the center by both the clinicians and a full-time technician. This approach was used to make the highest quality dentures possible.
Patient satisfaction was evaluated both before and after treatment using the psychosocial questionnaire described by Branemark.(5) Responses from this pilot study were compared with the responses of patients treated in a Branemark study.(5)
Treatment groups were defined as pretreat denture, GroupI; denture diagnostic center, Group II-posttreatment denture; denture diagnostic center, Group III-conventional complete denture; Branemark study, Group IV-full denture, lower implant fixed bridge; Branemark study. Responses from each group were compared statistically.
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RESULTS
Group II and Group III differed statistically on 23 of 24 possible responses even though both groups were treated with complete dentures. The patients treated in the Denture Diagnostic Center were satisfied with fit, appearance, ability to eat, and function. The patients treated with complete dentures in the Branemark study were not satisfied.
Group II and IV gave statistically the same responses to questions regarding fit, appearance, ability to eat and drink satisfactorily. Therefore, patients treated conventionally at the Denture Diagnostic Center were satisfied much the same as patients treated with full arch implant fixed bridges by the Branemark group. Patients treated with full arch implant fixed bridges, however, did show the greatest increase inself-esteem and improved way of life.
DISCUSSION
The results from this pilot study demonstrate that conventional complete denture therapy under specialconditions (two clinicians per patient demanding meticulous attention to detail), can provide satisfactory treatment for patients dissatisfied with their dentures.
Group II patients were very satisfied with conventional dentures, almost as satisfied as the Branemark implant treatment group. Patients treated with implant fixed bridges did demonstrate the greatest increase in self-esteem and improved way of life.
Group II and IV showed no difference in ability to eat or drink different foods. Both groups were equally satisfied with the foods that they were able to eat. Certain foods aggravate implant bridge wearers much the same as they do complete denture wearers. Food traps seem to be a nuisance factor for both treatment groups and, therefore, prescribing implants for patients complaining of food getting under their denture seems inappropriate.
Neither Group II or Group IV showed any difference with regard to esthetics. It is difficult to enhance esthetics with implants. In fact, implants can get in the way of esthetics. Prescribing implants to improve esthetics is usually poor treatment planning.
Akagawa(6) reported that there is a significant relationship between dissatisfaction with present prosthesis and positive attitude toward implant therapy. Patients dissatisfied with comfort and ability to eat desired implants.
Disappointed patients presented to the Denture Diagnostic Center and discovered that well-made complete dentures satisfactorily improved comfort and ability to eat. Patients assume that because they don't like their current prosthesis, that any similar prosthesis will fail. A qualified health professional recognizes that the patient is unable to determine his/her treatment, and, therefore, the good dentist does not provide treatment based solely upon patient request.
Conventional therapy did prove satisfactory for problem denture wearers because it was possible to make the patient better dentures. By using a team approach and scrupulous technique, it was possible to treat these patients successfully.
Treatment planning at the Denture Diagnostic Center requires that good conventional therapy fail before implants can be considered. At examination, if it is possible to improve the support, the stability, or the retention of the patient's dentures, conventional therapy must be tried.
This treatment approach is advantageous for many reasons. One, it is a chance to avoid a surgical procedure. Most denture patients are older, with many medical considerations and, therefore, avoiding surgery is ideal.
Secondly, it is less expensive. Eighty-nine percent of edentulous patients in 1986 had a household income less than $20,000.00 per year, making implant therapy financially impossible for most of the edentulous population.(7)
Also, even if conventional therapy fails, the patient is left with the best prosthesis to wear during the healing phase of implant treatment. Additionally, it is possible to convert these dentures to implant prostheses. Without prescribing dental implants, there is no placement trauma, placement cost, or need for follow-up examination.
As health professionals, we are obligated to satisfy our patients' dental needs. Given the results of this pilot study, we believe that many patients can be satisfied with minimal treatment.
It is possible that implants are being over prescribed because the profession has not yet been able to define who truly needs them. This research suggests that patients who are unable to wear ideal complete dentures make the best candidates for dental implants.
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CONCLUSION
The results from this pilot study support atreatment approach for denture wearers that requires ideal conventional therapy to fail before implants are prescribed. Edentulous patients dissatisfied with complete dentures requesting implants should be treated conventionally especially if their dentures exhibit features that can easily be improved upon.
REFERENCES
- Guckes, A.D.; Smith, D.E.; Swoope, C.C. Counseling and related factors influencing satisfaction with dentures. JProsthet Dent. 39:259-67, 1978.
- Bergman, B., and Carlsson, G.B. Clinical long-term studyof complete denture wearers. J Prosthet Dent. 53:56-61,1985.
- Magnusson,T. Clinical judgment and patient's evaluation of complete dentures five years after treatment. A follow-upstudy. Swed Dent J. 10:29-33, 1986.
- Cavalier, Neil. Dr. James Gallagher's handbook forcomplete denture prosthetics. 9th rev., 1988.
- Branemark, Zarb Albrecktson. Tissue integrated prostheses. Quintessence, 1985.
- Akagawa, Y.; Rachi, Y.; Matsumoto, T.; Tsuru, H.Attitudes of removable denture patients toward denture implants. J Prosthet Dent. 60:363-67, 1988.
- Oral Health of U.S. Adults. NIDR. 1985.
Copyright ©
1995 by the Editorial Council of The Journal of Prosthetic Dentistry,
All Rights Reserved
