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A survey of referred patients experiencing problems with complete dentures
A survey of referred patients experiencing problems with complete dentures J. P. Smith, M.D.S., F.D.S.R.C.S.(Eng.),* and D. Hughes, B.D.S.** C:harlesClifford Dental Hospital, Sheffield, England
A
prosthodontic consultant service exists in dental schools and hospitals in the United Kingdom. It is available either to give advice 1.0practitioners or to treat patients. Yemm’ reviewed the records of referred denture patients over a 5-year period. He noted that there are no reports of the types of patients referred with prosthodontic problems. Various other studies have investigated the links between the success or failure of dentures and the psychologic state of the patients.2-5 Nairn and Brunello’ commented “In the work previously done with denture wearers, no attempt seems to have been made to assessthe quality of the dentures.” This article describes an investigation of edentulous patients referred to a prosthodontic department during 1 year. An attempt has been made to assesswhether the referrals were justified and whether they were the result of failure on the part of the referring practitioner, the patient, or the technical service.
STUDY POPULATION .During the period Feb. 1, 1984 to Jan, 31, 1985, a defined group of patients was admitted to the study, namely edentulous patients who had been referred by a general dental practitioner who had attempted treatment before seeking the advice of the specialist. Patients who were referred by hospital colleagues and general medical practitioners were excluded. Over the study period 461 new patients were seen in the department; 144 with temporomandibular joint dysfunction and the remaining 317 individuals required prosthodontic treatment. A total of 53 of these patients met the criteria for the present study. Eight patients were excluded from the analysis. Three did not attend for treatment, three did not keep their follow-up appointments, and two did not complete all of the questionnaires, nor did they respond to telephone and postal enquiries. Forty-five patients remained for analysis. The group included 28 women (average 70 years of age, range 50 to 64 years) and 17 men (average 63 years of age, range 40 to 83 years).
‘Consultant Dental Surgeon (Prosthodontics). ‘*Associate Specialist (Prosthodontics). ‘IHE JOURNAL
OF PROSTHETIC
DENTISTRY
METHODS Consultation
visit
At the first visit the main complaints of the patients were recorded. It was noted whether the patient’s previous denture-wearing history was successful and what steps the referring dentist had taken to satisfy the patient before referral A technical assessmentof the dentures was made, with special attention to retention, stability, occlusion and articulation, vertical dimension, and the border extension of the denture bases. The anatomy of the denturebearing areas was noted. The findings were recorded on previously .tested data sheets according to our agreed criteria (Appendix 1). The patients also completed two questionnaires requiring yes/no answers. One recorded the patients’ assessment of their dentures (PAD/A-Appendix 2). The second questionnaire, the Ten Question Index (TQI/A-Appendix 3), was derived from the Cornell Medical Index by Abramson et al.’ This questionnaire assesses the emotional status of the responder. The patient was then put on the waiting list.
Second visit After impressions were made, the patients were asked to complete the Ten Question Index for a second time (TQI/B). The dentures were then completed.
Follow-up
visit
After the insertion of new dentures, a follow-up appointment was given for reexamination in 4 to 6 weeks. At this visit the patients were asked to assessthe new dentures by using PAD/A again with an additional question, “Are these dentures an improvement on your previous dentures?” (Appendix 2).
Referring dentists When a patient was enrolled in the investigation, the date of qualification of the referring dentist was found from the Dental Register. The dentists were contacted and asked for information about the technical services they used.
RESULTS Referring dentists There were 32 referring dentists. Eighteen had qualified before 1974 (senior) and 14 had qualified after 583
SMITH AND HUGHES
Table I. Length
of time before
referral
>3 Months
4-6 Months
7-9 Months
3 5
3 7
5 3
Junior dentist Senior dentist
Table II. Faults found in referred
patients’
Retention
Maxillary Junior dentist Senior dentist Total
10 Months-l
year
1 1
6 11
dentures Stability
Mandibular
Maxillary
Extension
Mandibular
Vertical ,dimension
Occlusion
Mandibular
Maxillary
4
11
7
13
12
10
18
17
6
18
14
16
13
7
27
27
10
29
21
29
25
17
45
44
Table III. Patients’ assessment
of their
dentures
Appearance PAD/A (NO) PAD/B (NO)
16 4
(PAD/A
and B) “No” answers
recorded
Fit
Foods
Speech
Comfort
38 10
32 18
23 13
40 13
1974 (junior). Six junior and eight senior dentists had used their own laboratories whereas nine junior and nine seniors had used commercial laboratories.
by a reline. Three had relined dentures. One dentist had provided a soft lining and microvalves and one had tried a soft lining alone.
Referral pattern
Chief complaints
Ten of the junior group referred one patient each and four referred two. The senior group made 13 referrals; three made two referrals and two referred four patients each. The length of time between the insertion of the dentures and referral is shown in Table I. The junior group referred six patients within 6 months of the provision of their dentures, whereas in the same period the senior group referred 12 patients. For the period of 7 months or more, the junior group referred 13 patients. In the same time period 14 were referred by the senior group.
The most frequent complaints were those of pain (35) and looseness (25). Difficulty in eating was noted in seven patients; five had burning mouths; three complained of retching; two disliked the appearance of their dentures; and two had difficulty in speaking.
Table II shows that incorrect extension of the denture borders was universally present. Retention, stability, and occlusion of the mandibular dentures were poor. The distribution of the faults between the junior and senior groups was even.
Histories of denture-wearing
Anatomy of the denture-bearing surfaces
Twenty-one patients had previous difficulty in wearing dentures. Six patients were wearing dentures for the first time.
Maxillary ridge shqbe. It is generally accepted that v-shaped or flat palates present difficulty. One palate was rated as v-shaped and one as flat. The palates of the remaining 43 patients were rated as u-shaped or between u- and v-shaped. Border tissue attachment. In the maxillae, a low border attachment is considered to present difficulty. Only five patients were found in this category. In the mandible, a high attachment is. considered unfavorable. This condition was recorded in three patients. General medical conditions. Two junior dentists had
Attempted improvement of the dentures Seven dentists in the junior group had made attempts to rectify errors in the dentures before referral. Five remade the dentures after using tissue conditioner in two patients. Two had relined the dentures following the use of tissue conditioner. In the senior group, the dentures for four patients were remade, in one instance preceded 584
Technical faults
NOVEMBER
1988
VOLUME
60
NUMBER 5
SURVEY
OF REFERRED
PATIENTS
treated one patient who had a thyroid imbalance, and another patient suffered from depression, conditions that might have influenced the successor failure of treatment. In the senior group, three patients had histories of psychiatric illness and one had Parkinson’s disease. Evaluation
of patients’
assessment of dentures
Table III compares the answers given in the two questionnaires. PAD/B indicates an overall improvement in the patient’s condition by the replies to the additional question. Questions 2, 5, and 6 are a true indication of success because the questionnaire was administered at t.he follow-up visit, when it was to be expected that some minor adjustments would have to be made. An additional analysis of these answers was therefore made to give an estimate of the successof the treatment. Successwas recorded when all of the answers to PAD/B were in the affirmative. Twenty-nine such answers were noted. Failure was recorded if entirely negative answers were found. There were five patients in this category. The remaining 11 prostheses were evaluated by reference to the patients’ records. Five patients had answered yes to the additional question on PAD/B together with yes answers for satisfactory fit and denture comfort, (questions 2, 5, and 6). Subsequent to this follow-up visit the records showed that they had attended only for the usual postinsertion adjustments. Accordingly, they were classified as improved. Five individuals who did not satisfy the above criteria (although they said that the dentures were an improvement) were classified as fail. One patient denied that the dentures were an improvement but answered all the other questions in the affirmative. She was classified as “improved.” Only one patient who had a poor prognosis due to a general medical condition was ranked as fail. Evaluation of the Ten Question Indexes The Ten Question Index purports to measure emotional stability. Estimates of the relative reliability of the questions is shown in parenthesis after each question. One positive answer suggests instability. In this study the questionnaire was administered on two occasions, TQI/A and TQI/B. Thirty-three patients gave positive answers and seven gave negative answers on both occasions. Three were positive only at the first administration and two were negative only at the second. Table IV shows that, compared with a control group, the patients gave positive answers more frequently, 78% (35,/45) compared with 50% (27/54). Positive answers were found to be equally distributed in the control group. It is noteworthy that the patients gave consistent answers although several months separated the administration of the questionnaires. If emotional instability is a factor in the failure to wear dentures it was not confirmed in this study using the methods described. Those patients whose dentures were finally rated as ‘ailures were found to give positive answers in equal PHE JOURNAL
OF PROSTHETIC
DENTISTRY
Table IV. Ten Question Index (TQI) answers for patients on two occasions and controls Positive
TQIIA TQIIB Controls
Negative
No.
%
No.
%
35 35 27
78 78 50
10 10 27
22 22 50
Table V. Ten Question Index (TQI) answers by patients classified as failed after treatment
TQIIA TQI/B
Positive
Negative
7 7
4 4
proportions (Table V). Their occasions were identical.
answers on the two
DISCUSSION A survey of 45 consecutive edentulous patients referred with denture problems revealed that fundamental faults were responsible for referral (Table II). All of the dentures were found to be underextended, which could account for the complaints of poor retention and stability. Faulty occlusion and articulation were noted in half of the patients, whereas in one third, the occlusal vertical relation was incorrect. Few attempts to rectify the faults were noted. No weight could be attached to the relative clinical experience of the referring dentists. There were no outstanding anatomic or medical conditions that would have compromised successful treatment. Generally, the patients were not found to be personally difficult. The origin of the technical work did not appear to be related to the faults, the work being about equally divided between commercial laboratories and the individual practitioners. The new dentures were provided by specialists using customary techniques (Table III). Lawson* reported that the main cause of denture failure in his experience was underextension of the denture bases. Smith’ suggested how this particular problem could be overcome. He recommended that the outline for the denture borders should be drawn on the casts by the clinician at the try-in stage. This presupposes that the impressions are correct. The deficiences in denture base extension found in this survey may be the result of failure on the part of the dentists to recognize the underextension of the impressions. Malocclusion and articulation, together with faulty occlusal vertical relation, could be an indication of the speed at which dentists must carry out clinical prosthodontic procedures induced by an unrealistic fee structure. This factor might also discourage the rectification of obvious faults. 5R5
SMITH AND
No conclusion could be reached on the emotional state of the patients seen in this study. The Ten Question Index was used because it was thought that the Cornell Medical Index and similar questionnaires would prove to be too long and difficult for the type of patient commonly seen in the department. Although the TQI was answered consistently by the patients, if emotional instability is a factor in denture failure, then the Index was not thought to be sufficiently discriminating. It is a demanding instrument because patients could be classified as emotionally disturbed merely on the basis of their answers to a single question on their weight. Although the sample was small it was judged to be representative of patients seen over a number of years at the out-patients’ department sessions. It is disappointing to find that the work seen in this study was substandard by common-sense prosthodontic standards. A specialist prosthodontic service should be both advisory and the place for the treatment of the truly difficult patient. It is to be hoped that such services do not become a repository for the clinical failures of referring practitioners possibly induced by financial constraints beyond their control. REFERENCES 1. Yemm R. Analysis of referred patients over a period of five years to a teaching hospital consultant service in dental prosthetics. Br Dent J 1985;159:304. 2. Smith M. Measurement of personality traits and their relation to patient satisfaction with complete dentures. J PROSTHET DENT 1976;35:492-503. 3. Levin B, Landesman HM. A practical questionnaire for predicting denture success or failure. J PROSTHET DENT 1976;35:12430. 4. Bolender CL, Swoope CC, Smith DE. The Cornell Medical Index as a prognostic aid for complete denture patients. J PROSTHET DENT 1969;22:20-9.
5.
6.
7. 8. 9.
Reprint
Carlsson GE, Otterland A, WennstrBm A. Patient factors in appreciation of complete dentures. J PROSTHET DENT 1967; 17:322-8. Nairn RI, Brunello DL. The relationship of denture complaints and level of neuroticism. In: Proceedings of the British Society for the Study of Prosthetic Dentistry 1972;12. Abramson JH. Cornell Medical Index as a health measure in epidemiological studies. Br J Prev Sot Med 1965;19:103. Lawson WA. An analysis of the commonest causes of full denture failure. Dent Pratt 1959;10:61-3. Smith JP. The peripheral outline of full dentures. A clinical responsibility. Dent Pratt 1962;13:111-3. requests
to:
DR. J. P. SMITH THE CHARLES CLIFFORD DENTAL WELLESLEY RD. SHEFFIELD SlO 2% ENGLAND
HOSPITAL
APPENDIX 1 Retention The resistance offered to vertical pull on the dentures in the incisor region was rated as good or poor. 586
HUGHES
Stability When pressure was exerted alternately in the premolar regions of the dentures, if they did not tip or rotate, stability was rated as good.
Occlusion and articulation On repeated closure, if the dentures occluded without interceptive occlusal contacts, the occlusion was rated as good. Articulation was tested by observing lateral movements with the first molars in contact. It was rated as good if even contact was observed.
Vertical relation If the facial contours were restored together with interocclusal distance of 5 mm, the dentures were rated as good.
Anatomy of the denture-bearing
tissues
The shape of the residual ridges was noted. In the maxillae, a U-shaped palate and/or undercut tuberosities were considered favorable. In the mandible, a flat lower ridge was rated as unfavorable.
APPENDIX 2 PAD/A 1. Do you think your dentures have a pleasant, natural appearance? 2. Do your dentures fit satisfactorily? 3. Are you able to eat most foods? 4. Can you speak satisfactorily? 5. Are your dentures comfortable?
PAD/B additional
question
6. Are these dentures an improvement on your previous dentures?
APPENDIX 3 TQI/A and B (The estimate of the relative reliability of the questions is shown in parenthesis after each question.) 1. Are you easily upset or irritated? (55) 2. Do you suffer from nervous exhaustion? (33) 3. Do you usually have great difficulty in falling asleep or staying asleep? (17) 4. Are you definitely underweight? (12) 5. Do you often become suddenly scared for no good reason? (12) 6. Are you considered to be a nervous person? (11) 7. Are you constantly keyed up and jittery? (11) 8. Do you usually feel unhappy and depressed? (10) 9. Does life look entirely hopeless? (1) 10. Does every little thing get on your nerves and wear you out? (10)
NOVEMBER
1988
VOLUME
60
NUMBER
5
A
prosthodontic consultant service exists in dental schools and hospitals in the United Kingdom. It is available either to give advice 1.0practitioners or to treat patients. Yemm’ reviewed the records of referred denture patients over a 5-year period. He noted that there are no reports of the types of patients referred with prosthodontic problems. Various other studies have investigated the links between the success or failure of dentures and the psychologic state of the patients.2-5 Nairn and Brunello’ commented “In the work previously done with denture wearers, no attempt seems to have been made to assessthe quality of the dentures.” This article describes an investigation of edentulous patients referred to a prosthodontic department during 1 year. An attempt has been made to assesswhether the referrals were justified and whether they were the result of failure on the part of the referring practitioner, the patient, or the technical service.
STUDY POPULATION .During the period Feb. 1, 1984 to Jan, 31, 1985, a defined group of patients was admitted to the study, namely edentulous patients who had been referred by a general dental practitioner who had attempted treatment before seeking the advice of the specialist. Patients who were referred by hospital colleagues and general medical practitioners were excluded. Over the study period 461 new patients were seen in the department; 144 with temporomandibular joint dysfunction and the remaining 317 individuals required prosthodontic treatment. A total of 53 of these patients met the criteria for the present study. Eight patients were excluded from the analysis. Three did not attend for treatment, three did not keep their follow-up appointments, and two did not complete all of the questionnaires, nor did they respond to telephone and postal enquiries. Forty-five patients remained for analysis. The group included 28 women (average 70 years of age, range 50 to 64 years) and 17 men (average 63 years of age, range 40 to 83 years).
‘Consultant Dental Surgeon (Prosthodontics). ‘*Associate Specialist (Prosthodontics). ‘IHE JOURNAL
OF PROSTHETIC
DENTISTRY
METHODS Consultation
visit
At the first visit the main complaints of the patients were recorded. It was noted whether the patient’s previous denture-wearing history was successful and what steps the referring dentist had taken to satisfy the patient before referral A technical assessmentof the dentures was made, with special attention to retention, stability, occlusion and articulation, vertical dimension, and the border extension of the denture bases. The anatomy of the denturebearing areas was noted. The findings were recorded on previously .tested data sheets according to our agreed criteria (Appendix 1). The patients also completed two questionnaires requiring yes/no answers. One recorded the patients’ assessment of their dentures (PAD/A-Appendix 2). The second questionnaire, the Ten Question Index (TQI/A-Appendix 3), was derived from the Cornell Medical Index by Abramson et al.’ This questionnaire assesses the emotional status of the responder. The patient was then put on the waiting list.
Second visit After impressions were made, the patients were asked to complete the Ten Question Index for a second time (TQI/B). The dentures were then completed.
Follow-up
visit
After the insertion of new dentures, a follow-up appointment was given for reexamination in 4 to 6 weeks. At this visit the patients were asked to assessthe new dentures by using PAD/A again with an additional question, “Are these dentures an improvement on your previous dentures?” (Appendix 2).
Referring dentists When a patient was enrolled in the investigation, the date of qualification of the referring dentist was found from the Dental Register. The dentists were contacted and asked for information about the technical services they used.
RESULTS Referring dentists There were 32 referring dentists. Eighteen had qualified before 1974 (senior) and 14 had qualified after 583
SMITH AND HUGHES
Table I. Length
of time before
referral
>3 Months
4-6 Months
7-9 Months
3 5
3 7
5 3
Junior dentist Senior dentist
Table II. Faults found in referred
patients’
Retention
Maxillary Junior dentist Senior dentist Total
10 Months-l
year
1 1
6 11
dentures Stability
Mandibular
Maxillary
Extension
Mandibular
Vertical ,dimension
Occlusion
Mandibular
Maxillary
4
11
7
13
12
10
18
17
6
18
14
16
13
7
27
27
10
29
21
29
25
17
45
44
Table III. Patients’ assessment
of their
dentures
Appearance PAD/A (NO) PAD/B (NO)
16 4
(PAD/A
and B) “No” answers
recorded
Fit
Foods
Speech
Comfort
38 10
32 18
23 13
40 13
1974 (junior). Six junior and eight senior dentists had used their own laboratories whereas nine junior and nine seniors had used commercial laboratories.
by a reline. Three had relined dentures. One dentist had provided a soft lining and microvalves and one had tried a soft lining alone.
Referral pattern
Chief complaints
Ten of the junior group referred one patient each and four referred two. The senior group made 13 referrals; three made two referrals and two referred four patients each. The length of time between the insertion of the dentures and referral is shown in Table I. The junior group referred six patients within 6 months of the provision of their dentures, whereas in the same period the senior group referred 12 patients. For the period of 7 months or more, the junior group referred 13 patients. In the same time period 14 were referred by the senior group.
The most frequent complaints were those of pain (35) and looseness (25). Difficulty in eating was noted in seven patients; five had burning mouths; three complained of retching; two disliked the appearance of their dentures; and two had difficulty in speaking.
Table II shows that incorrect extension of the denture borders was universally present. Retention, stability, and occlusion of the mandibular dentures were poor. The distribution of the faults between the junior and senior groups was even.
Histories of denture-wearing
Anatomy of the denture-bearing surfaces
Twenty-one patients had previous difficulty in wearing dentures. Six patients were wearing dentures for the first time.
Maxillary ridge shqbe. It is generally accepted that v-shaped or flat palates present difficulty. One palate was rated as v-shaped and one as flat. The palates of the remaining 43 patients were rated as u-shaped or between u- and v-shaped. Border tissue attachment. In the maxillae, a low border attachment is considered to present difficulty. Only five patients were found in this category. In the mandible, a high attachment is. considered unfavorable. This condition was recorded in three patients. General medical conditions. Two junior dentists had
Attempted improvement of the dentures Seven dentists in the junior group had made attempts to rectify errors in the dentures before referral. Five remade the dentures after using tissue conditioner in two patients. Two had relined the dentures following the use of tissue conditioner. In the senior group, the dentures for four patients were remade, in one instance preceded 584
Technical faults
NOVEMBER
1988
VOLUME
60
NUMBER 5
SURVEY
OF REFERRED
PATIENTS
treated one patient who had a thyroid imbalance, and another patient suffered from depression, conditions that might have influenced the successor failure of treatment. In the senior group, three patients had histories of psychiatric illness and one had Parkinson’s disease. Evaluation
of patients’
assessment of dentures
Table III compares the answers given in the two questionnaires. PAD/B indicates an overall improvement in the patient’s condition by the replies to the additional question. Questions 2, 5, and 6 are a true indication of success because the questionnaire was administered at t.he follow-up visit, when it was to be expected that some minor adjustments would have to be made. An additional analysis of these answers was therefore made to give an estimate of the successof the treatment. Successwas recorded when all of the answers to PAD/B were in the affirmative. Twenty-nine such answers were noted. Failure was recorded if entirely negative answers were found. There were five patients in this category. The remaining 11 prostheses were evaluated by reference to the patients’ records. Five patients had answered yes to the additional question on PAD/B together with yes answers for satisfactory fit and denture comfort, (questions 2, 5, and 6). Subsequent to this follow-up visit the records showed that they had attended only for the usual postinsertion adjustments. Accordingly, they were classified as improved. Five individuals who did not satisfy the above criteria (although they said that the dentures were an improvement) were classified as fail. One patient denied that the dentures were an improvement but answered all the other questions in the affirmative. She was classified as “improved.” Only one patient who had a poor prognosis due to a general medical condition was ranked as fail. Evaluation of the Ten Question Indexes The Ten Question Index purports to measure emotional stability. Estimates of the relative reliability of the questions is shown in parenthesis after each question. One positive answer suggests instability. In this study the questionnaire was administered on two occasions, TQI/A and TQI/B. Thirty-three patients gave positive answers and seven gave negative answers on both occasions. Three were positive only at the first administration and two were negative only at the second. Table IV shows that, compared with a control group, the patients gave positive answers more frequently, 78% (35,/45) compared with 50% (27/54). Positive answers were found to be equally distributed in the control group. It is noteworthy that the patients gave consistent answers although several months separated the administration of the questionnaires. If emotional instability is a factor in the failure to wear dentures it was not confirmed in this study using the methods described. Those patients whose dentures were finally rated as ‘ailures were found to give positive answers in equal PHE JOURNAL
OF PROSTHETIC
DENTISTRY
Table IV. Ten Question Index (TQI) answers for patients on two occasions and controls Positive
TQIIA TQIIB Controls
Negative
No.
%
No.
%
35 35 27
78 78 50
10 10 27
22 22 50
Table V. Ten Question Index (TQI) answers by patients classified as failed after treatment
TQIIA TQI/B
Positive
Negative
7 7
4 4
proportions (Table V). Their occasions were identical.
answers on the two
DISCUSSION A survey of 45 consecutive edentulous patients referred with denture problems revealed that fundamental faults were responsible for referral (Table II). All of the dentures were found to be underextended, which could account for the complaints of poor retention and stability. Faulty occlusion and articulation were noted in half of the patients, whereas in one third, the occlusal vertical relation was incorrect. Few attempts to rectify the faults were noted. No weight could be attached to the relative clinical experience of the referring dentists. There were no outstanding anatomic or medical conditions that would have compromised successful treatment. Generally, the patients were not found to be personally difficult. The origin of the technical work did not appear to be related to the faults, the work being about equally divided between commercial laboratories and the individual practitioners. The new dentures were provided by specialists using customary techniques (Table III). Lawson* reported that the main cause of denture failure in his experience was underextension of the denture bases. Smith’ suggested how this particular problem could be overcome. He recommended that the outline for the denture borders should be drawn on the casts by the clinician at the try-in stage. This presupposes that the impressions are correct. The deficiences in denture base extension found in this survey may be the result of failure on the part of the dentists to recognize the underextension of the impressions. Malocclusion and articulation, together with faulty occlusal vertical relation, could be an indication of the speed at which dentists must carry out clinical prosthodontic procedures induced by an unrealistic fee structure. This factor might also discourage the rectification of obvious faults. 5R5
SMITH AND
No conclusion could be reached on the emotional state of the patients seen in this study. The Ten Question Index was used because it was thought that the Cornell Medical Index and similar questionnaires would prove to be too long and difficult for the type of patient commonly seen in the department. Although the TQI was answered consistently by the patients, if emotional instability is a factor in denture failure, then the Index was not thought to be sufficiently discriminating. It is a demanding instrument because patients could be classified as emotionally disturbed merely on the basis of their answers to a single question on their weight. Although the sample was small it was judged to be representative of patients seen over a number of years at the out-patients’ department sessions. It is disappointing to find that the work seen in this study was substandard by common-sense prosthodontic standards. A specialist prosthodontic service should be both advisory and the place for the treatment of the truly difficult patient. It is to be hoped that such services do not become a repository for the clinical failures of referring practitioners possibly induced by financial constraints beyond their control. REFERENCES 1. Yemm R. Analysis of referred patients over a period of five years to a teaching hospital consultant service in dental prosthetics. Br Dent J 1985;159:304. 2. Smith M. Measurement of personality traits and their relation to patient satisfaction with complete dentures. J PROSTHET DENT 1976;35:492-503. 3. Levin B, Landesman HM. A practical questionnaire for predicting denture success or failure. J PROSTHET DENT 1976;35:12430. 4. Bolender CL, Swoope CC, Smith DE. The Cornell Medical Index as a prognostic aid for complete denture patients. J PROSTHET DENT 1969;22:20-9.
5.
6.
7. 8. 9.
Reprint
Carlsson GE, Otterland A, WennstrBm A. Patient factors in appreciation of complete dentures. J PROSTHET DENT 1967; 17:322-8. Nairn RI, Brunello DL. The relationship of denture complaints and level of neuroticism. In: Proceedings of the British Society for the Study of Prosthetic Dentistry 1972;12. Abramson JH. Cornell Medical Index as a health measure in epidemiological studies. Br J Prev Sot Med 1965;19:103. Lawson WA. An analysis of the commonest causes of full denture failure. Dent Pratt 1959;10:61-3. Smith JP. The peripheral outline of full dentures. A clinical responsibility. Dent Pratt 1962;13:111-3. requests
to:
DR. J. P. SMITH THE CHARLES CLIFFORD DENTAL WELLESLEY RD. SHEFFIELD SlO 2% ENGLAND
HOSPITAL
APPENDIX 1 Retention The resistance offered to vertical pull on the dentures in the incisor region was rated as good or poor. 586
HUGHES
Stability When pressure was exerted alternately in the premolar regions of the dentures, if they did not tip or rotate, stability was rated as good.
Occlusion and articulation On repeated closure, if the dentures occluded without interceptive occlusal contacts, the occlusion was rated as good. Articulation was tested by observing lateral movements with the first molars in contact. It was rated as good if even contact was observed.
Vertical relation If the facial contours were restored together with interocclusal distance of 5 mm, the dentures were rated as good.
Anatomy of the denture-bearing
tissues
The shape of the residual ridges was noted. In the maxillae, a U-shaped palate and/or undercut tuberosities were considered favorable. In the mandible, a flat lower ridge was rated as unfavorable.
APPENDIX 2 PAD/A 1. Do you think your dentures have a pleasant, natural appearance? 2. Do your dentures fit satisfactorily? 3. Are you able to eat most foods? 4. Can you speak satisfactorily? 5. Are your dentures comfortable?
PAD/B additional
question
6. Are these dentures an improvement on your previous dentures?
APPENDIX 3 TQI/A and B (The estimate of the relative reliability of the questions is shown in parenthesis after each question.) 1. Are you easily upset or irritated? (55) 2. Do you suffer from nervous exhaustion? (33) 3. Do you usually have great difficulty in falling asleep or staying asleep? (17) 4. Are you definitely underweight? (12) 5. Do you often become suddenly scared for no good reason? (12) 6. Are you considered to be a nervous person? (11) 7. Are you constantly keyed up and jittery? (11) 8. Do you usually feel unhappy and depressed? (10) 9. Does life look entirely hopeless? (1) 10. Does every little thing get on your nerves and wear you out? (10)
NOVEMBER
1988
VOLUME
60
NUMBER
5