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Procedures preceding the prosthodontic prescription
COMPLETE
DENTURES
PROCEDURES
PRECEDING
THE
PROSTHODONTIC
PRESCRIPTION
M. M. DEVAN, D.D.S.+ University Philadelphia,
of Pennsylvania,
The Graduate
School
of Medicine,
Pa.
DENTIST is a synthesis of two kinds of dentists: vocal and instrumental. He is vocal during certain phases of prosthodontic service ; he is instrumental during the other phases of the services. He is vocal and invites his patient to be vocal during the diagnostic study. He encourages his patient to tell what is on his mind. He will allow his patient to evaluate his own conditions before he evaluates the patient. He knows that personal communication is vital to mouth rehabilitation. Talk will not only reveal helpful information, but what is perhaps more important it permits the patient to get a glimpse of the person behind the dentist. And likewise the dentist gets a better chance to see the person behind the patient.
A
GOOD
LIMITATIONS
IN
COMPLETE
DENTURE
SERVICE
The years have taught me that complete dentures have functional limitations that no prosthetic skill or sagacity can overcome. In the absence of absolute confidence and complete trust, these limitations may be ascribed to the dentist’s lack of skill and understanding. During the trying period when the dentures are first inserted, the patient may lose confidence in his ability to cope with the dentures, and he will carry on only because he has not lost confidence in the man who prescribed them. This added perseverence may make the dfference between failure and gratifying success. The wise dentist knows that what he prescribes is a composite of what he knows and what he is ; his professional knowledge, plus his mood, background, and temperament. The prudent dentist will sense, when he meets a certain type of Read before the American Prosthodontic Society, Chicago, Ill. and the Oregon State Dental Association, Portland, Oregon. This article is beinrr aublished simultaneously in The Journal of Prosthetic Dentistrv and the Oregon State DentalJkrnal by special arrangement between the Editors. *Professor of Clinical Prosthetic Dentistry and Chairman of the Department of Prosthetic Dentistry.
; pt&
‘6”
PROCEDURES
PRECEDING
PROSTHODONTIC
1007
PRESCRIPTION
pc:rson, that his mood and temperament will not enable him to rehabilitate that patient. To be sure, he can make dentures for the patient, and, with his professional experience, they will be good substantial dentures. Wet he knows he will encounter difficulties in patient acceptance of the dentures; difficulties that will try his patience and his peace of mind. The prudent dentist will be careful not to make commitments until he has studied the physical, physiologic, and psychologic foundations upon which he must build dentures. For basically what he is prescribing is a structure (that is what a denture is), a structure to withstand the stresses of mastication, enunciation, and deglutition. The construction of a denture is essentially a venture in structural engineering. On this score it must be sound. However, a sound structure may also delight the eye; it may radiate quietness, peace, and harmony. The sculptor-dentist may mold a denture-structure to support the mouth to pleasing fullness and harmony with the cheeks, chin, and nose. In the old, the mouth will look attractively quiet and pfsaceful; in the young, seductively curved as though the lips were asking to be touched. Many prosthetic appliances do not continue to dwell in the oral cavity. This waste of monej and time is primarily due to cursory and incomplete diagnostic procedures prior to the prescription. TYPES
OF
PROSTHODONTIC
SERVICE
There are three types of service a dentist may render to a patient. First, to find out what the condition is; second, to decide what can be done about it, if anything; and third, to execute the treatment planned. The first two types of service fall in the category of the diagnostic-to ascertain what physical equipment the patient possesses with which, and upon which, we can attach dentures. It also includes an evaluation of the patient’s neuromuscular skills that will enable him to use his equipment adequately. Last, we must ascertain the patient’s psychologic makeup ; his motivations, his willingness, his determination to take advantage of his own physical and biologic capacities. 013 JECTIVES
OF DIAGNOSTIC
SERVICE
During the diagnostic service we should do three things :
--
1. We should study the suitability of the jaws, joints, ridges, muscles, mucosa, and salivary glands for supporting and sustaining artificial dentures. 2. We should evaluate the patient’s muscle tonus, tissue tone and time of recovery from pressure, neuromuscular skill, and the stamina of the residual bone. 3. The diagnostic study should classify the patient psychologically. I recommend the use of the classification suggested by House.* The patient is stamped as philosophic, exacting, hysterical, or indifferent. *Personal
communication:
diagnostic
form
devised
by
Dr.
M.
M.
House,
1918.
1008
DWAN
MUSCLE
TONUS
A good indication of muscle tonus is attained when the dentist puts his index finger in a corner of the patient’s mouth and snaps it as a violin string. Firm resistance is indicative of hypertonicity. Hypertonicity of the musculature is desirable except when coupled with resorbed ridges and low ligamentous attachments. TISSUE
TONE
AND
TISSUE
RECOVERY
Tissue tone and tissue recovery time are observed by noting the color of the mucosa and magnitude of the force required to blanch the mucosa and its recovery time. These observations are important in evaluating the capacity of the oral mucosa to resist pressure. NEUROMUSCULAR
SKILL
A convenient way to appraise the degree of neuromuscular skill a patient possesses is to note his speech. Is it clear and distinct? Does he give each word its full phonetic value, pronouncing each syllable and consonant; or does he slur his words? It takes a high degree of neuromuscular skill to speak distinctly. Those who possess this skill can adapt to dentures more easily than others. The problem that faces the dentist is not whether he can make a set of dentures for the patient. The problem he must resolve is whether he can rehabilitate the patient, and what will be involved in the rehabilitation, in time, energy spent, materials, and technical costs. I doubt whether a dentist is being fair when he tells a patient that he cannot wear dentures. A dentist may only conclude that he cannot rehabilitate the patient. What someone else can do, someone else with a different background, mood, and temperament is not for him to say. I have encountered a number of patients who were saddened and chagrined by dentists who were not charitable enough to say, “I cannot do it, but perhaps someone else can.” I am told that elsewhere in the human body a prosthesis, such as an artificial arm or leg, is seldom prescribed without a definite program of rehabilitation accompanying the prescription. The making of the prosthesis is less than half of the battle; its acceptance and successful manipulation is the greater half. In fact, the rehabilitation really begins at the time of insertion. COST
OF THE
PROSTHODONTIC
TREATMENT
The cost of the entire prosthetic treatment should be based on the time, energy, technical, and material costs required to successfully rehabilitate the patient. It should not be based on the cost of constructing a set of dentures. A fee that is fair to both the patient and the dentist cannot be arrived at without a prior diagnostic service. The cost of this service must be met by the patient. If we cannot induce a patient to meet the cost of this diagnostic service, there is lacking, to start with, the degree of intelligence, understanding, and mutual trust essential for mouth rehabilitation.
VNEtEi “6” MEANS
FOR
PROCEDURES
OBTAINING
PRECEDING
THE
PATIENT’S
PROSTHODONTIC
PRESCRIPTION
1009
CONSENT
It may interest you to know how the need for diagnostic service is presented to the patient so as to secure his consent. He is told that if dentures were constructed without the benefit of the information the diagnostic service would provide, they could not be other than average dentures-dentures that may later try his patience since he is not an average person. He is a specific person with subtle physical, biologic, and psychologic differences. He may well be unhappy with average dentures. Perhaps he cannot wear them at all with comfort. The diagnostic study will enable us to incorporate his subtle differences in the design of the dentures and thus preclude a painful and trying episode with them. The patient is told that a denture is a structure similar to a bridge or a building. It requires a study of the foundation it will rest upon and with which it will function. In fact, it is much more coliplicated because of the biologic and psychologic aspects of the situation. A structure is seldom built without prior specifications. During the diagnostic service we serve as oral architects drawing up structural plans best suited for a specific patient. We must not only meet his physical requirements but also his esthetic needs. In meeting his esthetic needs, we play the role of sculptor and artist. Some years ago Dr. Hoyt Sherman of the Department of Fine Arts at the Ohio State University advanced a concept that has never ceased to interest me. The concept is called “perceptual unity” : that all great works of art are first seen as a w’hole in the mind of the artist before they are carved in marble or painted on canvas. The true artist does not develop his composition as he goes along. He sees it completely composed within his mind’s eye before he expresses it in stone, clay, or canvas. Likewise, if suitable and beautiful compositions are to result, the dentist-artist must see the complete composition in his mind’s eye before he begins the construction of the dentures. The molding of the diagnostic denture models will help him to achieve “perceptual unity” ; to see the completed restoration before he begins construction. STEPS
IN
DIAGNOSTIC
SERVICE
The steps in a detailed diagnostic service include (1) roentgenograms of the residual bone, (2) alginate (irreversible hydrocolloid) impressions, (3) diagnostic denture models which incorporate the maximum occlusal vertical dimension permitted by the musculature, (4) the mounting on an articulator of the denture models in centric relation, (5) transillumination of the sinuses and examination of the patient’s lips, cheeks, throat, and tongue, (6) recording of the denture history, and (7) the prescription and presentation of the findings to the patient. Our high percentage of acceptance of the diagnostic service may result from the fact that if the patient decides to go ahead with our prescription, the diagnostic fee will be a part of the total fee. It provides casts and information that will help to reduce the cost of subsequent denture construction.
1010
DeVAN
SUMMARY
A toothless person is a handicapped person, sensitized to a degree by his handicap; the degree depends on his personality. The loss of the natural teeth is not a minor loss ; no animal in Nature survives the loss of his teeth. Man survives because of artificial methods of food preparation before ingestion. Man’s physical survival points up the need for psychologic adjustments to lessen the feeling of toothlessness. The procedure outlined in this article will help us to rehabilitate the patient, to help him live more philosophically with his handicap. If your objective is to deal with each edentulous patient amicably, pleasurably, and profitably, this objective will have a better chance of fruition if you insist on a detailed diagnostic study before arriving at the prosthodontic prescription. In prosthodontics, it is easy to mistake a difficult mouth situation for a difficult patient. Difficult patients are few ; difficult mouth situations many. CONCLUSION
I am happy to report that in most instances, when the diagnostic information is evaluated with the adroitness of your mind and then seasoned with the tenderness of your heart, you will come up with a prescription which, when filled, may even surprise you because of the adequate degree of mouth rehabilitation. 269 S. 19~~ PHILADELPHIA
STREET 3, PA.
DENTURES
PROCEDURES
PRECEDING
THE
PROSTHODONTIC
PRESCRIPTION
M. M. DEVAN, D.D.S.+ University Philadelphia,
of Pennsylvania,
The Graduate
School
of Medicine,
Pa.
DENTIST is a synthesis of two kinds of dentists: vocal and instrumental. He is vocal during certain phases of prosthodontic service ; he is instrumental during the other phases of the services. He is vocal and invites his patient to be vocal during the diagnostic study. He encourages his patient to tell what is on his mind. He will allow his patient to evaluate his own conditions before he evaluates the patient. He knows that personal communication is vital to mouth rehabilitation. Talk will not only reveal helpful information, but what is perhaps more important it permits the patient to get a glimpse of the person behind the dentist. And likewise the dentist gets a better chance to see the person behind the patient.
A
GOOD
LIMITATIONS
IN
COMPLETE
DENTURE
SERVICE
The years have taught me that complete dentures have functional limitations that no prosthetic skill or sagacity can overcome. In the absence of absolute confidence and complete trust, these limitations may be ascribed to the dentist’s lack of skill and understanding. During the trying period when the dentures are first inserted, the patient may lose confidence in his ability to cope with the dentures, and he will carry on only because he has not lost confidence in the man who prescribed them. This added perseverence may make the dfference between failure and gratifying success. The wise dentist knows that what he prescribes is a composite of what he knows and what he is ; his professional knowledge, plus his mood, background, and temperament. The prudent dentist will sense, when he meets a certain type of Read before the American Prosthodontic Society, Chicago, Ill. and the Oregon State Dental Association, Portland, Oregon. This article is beinrr aublished simultaneously in The Journal of Prosthetic Dentistrv and the Oregon State DentalJkrnal by special arrangement between the Editors. *Professor of Clinical Prosthetic Dentistry and Chairman of the Department of Prosthetic Dentistry.
; pt&
‘6”
PROCEDURES
PRECEDING
PROSTHODONTIC
1007
PRESCRIPTION
pc:rson, that his mood and temperament will not enable him to rehabilitate that patient. To be sure, he can make dentures for the patient, and, with his professional experience, they will be good substantial dentures. Wet he knows he will encounter difficulties in patient acceptance of the dentures; difficulties that will try his patience and his peace of mind. The prudent dentist will be careful not to make commitments until he has studied the physical, physiologic, and psychologic foundations upon which he must build dentures. For basically what he is prescribing is a structure (that is what a denture is), a structure to withstand the stresses of mastication, enunciation, and deglutition. The construction of a denture is essentially a venture in structural engineering. On this score it must be sound. However, a sound structure may also delight the eye; it may radiate quietness, peace, and harmony. The sculptor-dentist may mold a denture-structure to support the mouth to pleasing fullness and harmony with the cheeks, chin, and nose. In the old, the mouth will look attractively quiet and pfsaceful; in the young, seductively curved as though the lips were asking to be touched. Many prosthetic appliances do not continue to dwell in the oral cavity. This waste of monej and time is primarily due to cursory and incomplete diagnostic procedures prior to the prescription. TYPES
OF
PROSTHODONTIC
SERVICE
There are three types of service a dentist may render to a patient. First, to find out what the condition is; second, to decide what can be done about it, if anything; and third, to execute the treatment planned. The first two types of service fall in the category of the diagnostic-to ascertain what physical equipment the patient possesses with which, and upon which, we can attach dentures. It also includes an evaluation of the patient’s neuromuscular skills that will enable him to use his equipment adequately. Last, we must ascertain the patient’s psychologic makeup ; his motivations, his willingness, his determination to take advantage of his own physical and biologic capacities. 013 JECTIVES
OF DIAGNOSTIC
SERVICE
During the diagnostic service we should do three things :
--
1. We should study the suitability of the jaws, joints, ridges, muscles, mucosa, and salivary glands for supporting and sustaining artificial dentures. 2. We should evaluate the patient’s muscle tonus, tissue tone and time of recovery from pressure, neuromuscular skill, and the stamina of the residual bone. 3. The diagnostic study should classify the patient psychologically. I recommend the use of the classification suggested by House.* The patient is stamped as philosophic, exacting, hysterical, or indifferent. *Personal
communication:
diagnostic
form
devised
by
Dr.
M.
M.
House,
1918.
1008
DWAN
MUSCLE
TONUS
A good indication of muscle tonus is attained when the dentist puts his index finger in a corner of the patient’s mouth and snaps it as a violin string. Firm resistance is indicative of hypertonicity. Hypertonicity of the musculature is desirable except when coupled with resorbed ridges and low ligamentous attachments. TISSUE
TONE
AND
TISSUE
RECOVERY
Tissue tone and tissue recovery time are observed by noting the color of the mucosa and magnitude of the force required to blanch the mucosa and its recovery time. These observations are important in evaluating the capacity of the oral mucosa to resist pressure. NEUROMUSCULAR
SKILL
A convenient way to appraise the degree of neuromuscular skill a patient possesses is to note his speech. Is it clear and distinct? Does he give each word its full phonetic value, pronouncing each syllable and consonant; or does he slur his words? It takes a high degree of neuromuscular skill to speak distinctly. Those who possess this skill can adapt to dentures more easily than others. The problem that faces the dentist is not whether he can make a set of dentures for the patient. The problem he must resolve is whether he can rehabilitate the patient, and what will be involved in the rehabilitation, in time, energy spent, materials, and technical costs. I doubt whether a dentist is being fair when he tells a patient that he cannot wear dentures. A dentist may only conclude that he cannot rehabilitate the patient. What someone else can do, someone else with a different background, mood, and temperament is not for him to say. I have encountered a number of patients who were saddened and chagrined by dentists who were not charitable enough to say, “I cannot do it, but perhaps someone else can.” I am told that elsewhere in the human body a prosthesis, such as an artificial arm or leg, is seldom prescribed without a definite program of rehabilitation accompanying the prescription. The making of the prosthesis is less than half of the battle; its acceptance and successful manipulation is the greater half. In fact, the rehabilitation really begins at the time of insertion. COST
OF THE
PROSTHODONTIC
TREATMENT
The cost of the entire prosthetic treatment should be based on the time, energy, technical, and material costs required to successfully rehabilitate the patient. It should not be based on the cost of constructing a set of dentures. A fee that is fair to both the patient and the dentist cannot be arrived at without a prior diagnostic service. The cost of this service must be met by the patient. If we cannot induce a patient to meet the cost of this diagnostic service, there is lacking, to start with, the degree of intelligence, understanding, and mutual trust essential for mouth rehabilitation.
VNEtEi “6” MEANS
FOR
PROCEDURES
OBTAINING
PRECEDING
THE
PATIENT’S
PROSTHODONTIC
PRESCRIPTION
1009
CONSENT
It may interest you to know how the need for diagnostic service is presented to the patient so as to secure his consent. He is told that if dentures were constructed without the benefit of the information the diagnostic service would provide, they could not be other than average dentures-dentures that may later try his patience since he is not an average person. He is a specific person with subtle physical, biologic, and psychologic differences. He may well be unhappy with average dentures. Perhaps he cannot wear them at all with comfort. The diagnostic study will enable us to incorporate his subtle differences in the design of the dentures and thus preclude a painful and trying episode with them. The patient is told that a denture is a structure similar to a bridge or a building. It requires a study of the foundation it will rest upon and with which it will function. In fact, it is much more coliplicated because of the biologic and psychologic aspects of the situation. A structure is seldom built without prior specifications. During the diagnostic service we serve as oral architects drawing up structural plans best suited for a specific patient. We must not only meet his physical requirements but also his esthetic needs. In meeting his esthetic needs, we play the role of sculptor and artist. Some years ago Dr. Hoyt Sherman of the Department of Fine Arts at the Ohio State University advanced a concept that has never ceased to interest me. The concept is called “perceptual unity” : that all great works of art are first seen as a w’hole in the mind of the artist before they are carved in marble or painted on canvas. The true artist does not develop his composition as he goes along. He sees it completely composed within his mind’s eye before he expresses it in stone, clay, or canvas. Likewise, if suitable and beautiful compositions are to result, the dentist-artist must see the complete composition in his mind’s eye before he begins the construction of the dentures. The molding of the diagnostic denture models will help him to achieve “perceptual unity” ; to see the completed restoration before he begins construction. STEPS
IN
DIAGNOSTIC
SERVICE
The steps in a detailed diagnostic service include (1) roentgenograms of the residual bone, (2) alginate (irreversible hydrocolloid) impressions, (3) diagnostic denture models which incorporate the maximum occlusal vertical dimension permitted by the musculature, (4) the mounting on an articulator of the denture models in centric relation, (5) transillumination of the sinuses and examination of the patient’s lips, cheeks, throat, and tongue, (6) recording of the denture history, and (7) the prescription and presentation of the findings to the patient. Our high percentage of acceptance of the diagnostic service may result from the fact that if the patient decides to go ahead with our prescription, the diagnostic fee will be a part of the total fee. It provides casts and information that will help to reduce the cost of subsequent denture construction.
1010
DeVAN
SUMMARY
A toothless person is a handicapped person, sensitized to a degree by his handicap; the degree depends on his personality. The loss of the natural teeth is not a minor loss ; no animal in Nature survives the loss of his teeth. Man survives because of artificial methods of food preparation before ingestion. Man’s physical survival points up the need for psychologic adjustments to lessen the feeling of toothlessness. The procedure outlined in this article will help us to rehabilitate the patient, to help him live more philosophically with his handicap. If your objective is to deal with each edentulous patient amicably, pleasurably, and profitably, this objective will have a better chance of fruition if you insist on a detailed diagnostic study before arriving at the prosthodontic prescription. In prosthodontics, it is easy to mistake a difficult mouth situation for a difficult patient. Difficult patients are few ; difficult mouth situations many. CONCLUSION
I am happy to report that in most instances, when the diagnostic information is evaluated with the adroitness of your mind and then seasoned with the tenderness of your heart, you will come up with a prescription which, when filled, may even surprise you because of the adequate degree of mouth rehabilitation. 269 S. 19~~ PHILADELPHIA
STREET 3, PA.