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Trouble Shooting Complete

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Title: Trouble Shooting Complete


1
Trouble Shooting Complete Removable Partial
Dentures
  • Robert W. Loney, DMD, MS
  • Professor Director
  • Graduate Prosthodontics
  • Faculty of Dentistry, Dalhousie University

2
The Gunshot Approach
  • If it hurts - GRIND
  • If its loose - RELINE

3
Problem for Albert Einstein
  • Avert Imminent World Disaster
  • Time Constraint One Hour
  • His solution
  • 55 minutes identifying problem
  • 5 minutes fixing the problem

4
Lesson
  • Spend more time thinking, less time grinding

5
Five Principles For Troubleshooting
  • Establish differential diagnosis
  • Identify variations from normal
  • Have patient demonstrate problems
  • Always use indicating medium when adjusting
  • Have patient rate improvement after adjustment

6
Principal 1Establish a Differential Diagnosis
  • Form a list of possible causes
  • Try to prove problem is not caused by X by
    eliminating possible causes
  • Expect resolution within 10-14 days
  • If no resolution, eliminate something else

7
Principle 1 Differential Diagnosis
  • Prioritize from common to rare
  • Eliminate common etiologies first, because

Common things occur commonly Rare entities occur
rarely
8
Differential DiagnosisCD or RPD Pain
9
Principles of Diagnosis
  • Dont limit list too early in diagnosis
  • Keep an open mind
  • Revisit possible causes when contradictory
    evidence is found

10
Information Gathering
  • Chief Complaint
  • History of C.C.
  • History
  • Medical
  • Dental
  • Clinical Exam

11
Dental and Medical History
  • Often inadequately investigated
  • Spend more time talking to narrow possibilities

12
Gathering Information
  • Ask open ended questions
  • How does that feel?
  • Not
  • Does that feel better?

13
History of Chief Complaint Where?
  • Have patient point to problem
  • Partially ignore patients position
  • Dentist locate with stick, instrument or paste

14
History of Chief Complaint When?
  • Chewing only - Occlusion
  • Gets worse throughout day - Occlusion
  • When first insert dentures - Denture Base

15
History of Chief Complaint Details
  • How long?
  • does it last?
  • since it began?
  • Anything make it better/worse?

16
Principle 2 Identify Variations from Normal
Tissues Dentures
17
Loose Denture
18
Dealing with Variations From Normal
  • If denture alone is not normal - correct
  • If anatomy/patient not normal, vary method to
    address variation

19
Principle 3 Have Patient Demonstrate Problem
  • Eliminate cause - should resolve in 10-14 days

20
Principle 4 Always Use Indicating Media
  • Never adjust without locating exact position of
    the problem
  • Use paste, indelible stick, or articulating paper

21
Principle 5 Rate Improvement
  • After adjustment
  • Ask patient to rate improvement
  • 0-100

22
Denture PainCD RPD
  • Occlusion
  • Denture base (fit contour)
  • Vertical dimension
  • Infection
  • Systemic disease/condition
  • Allergy (rare)

23
Most Overlooked Problem
  • Occlusion
  • Dont want the problem to be occlusion - so we
    look for other causes

24
Occlusion
  • Takes time to remount (prep time)
  • Reduces adjustment time
  • Net savings of time

25
Pain OcclusionDiagnostic Strategies
  • Eliminate as potential cause
  • Remount denture on an articulator
  • Centric relation protrusive records
  • Mark centric and excursive contacts, adjust

26
Dont Adjust Occlusion Intraorally
  • Contact on inclines can cause denture movement
  • May cause pain, or reflex avoidance
  • May make interference difficult to mark

27
Adjusting Occlusion Intra-Orally
  • Net Result
  • Cant see real Problem
  • Cant eliminate the Problem

28
Adjusting Occlusion
  • Use an articulator
  • Eliminates denture movement
  • Can visualize interferences easily
  • Saves time removing replacing dentures

29
Pain OcclusionDental History
  • Only when chewing
  • Gets worse with chewing
  • Gets worse during the day
  • May have to remove late in the day

30
Pain OcclusionClinical Exam
  • Patient demonstrates problem by biting where pain
    occurs

31
Pain OcclusionClinical Exam
  • Occlusal contact not centered over ridge
  • Tilting forces cause displacement, abrasion,
    ulceration
  • Worse if xerostomia, malnourished, debilitated
    or poor adaptability

32
Pain OcclusionAvoid Contact on Inclines
  • No teeth set over ascending portion of ramus

33
Occlusal Point of Loading
  • Browning, JPD 1986
  • Removable partial dentures
  • Loaded centrally, M, D, L, B
  • B caused unseating
  • Central loading better than distal loading

34
Clinically
  • Drop 2nd premolar if necessary
  • Ensures posterior contacts not too distant
  • Avoids ascending portion of ridge
  • Ensures adequate occlusal table (maintains 2
    molars)

35
Clinically
  • Place load over the mandibular ridge

36
Pain OcclusionAvoid Contact on Inclines
  • No contact on inclines of denture bases

37
Pain OcclusionClinical Exam
  • Severe Curve of Spee

38
Pain OcclusionClinical Exam
  • Minimal overjet (horizontal) of anterior and/or
    posterior teeth

39
Pain OcclusionClinical Exam
  • Severe disclusion of posterior teeth in
    excursions (lack of balance)

40
Avoid Setting Teeth in Tongue Space
  • Tongue

41
Denture PainCD RPD
  • Occlusion
  • Denture base (fit contour)
  • Vertical dimension
  • Infection
  • Systemic disease/condition
  • Allergy (rare)

42
Pain Denture BaseDental History
  • Problem starts in AM
  • tight, sore
  • Discomfort when not chewing
  • Often not progressive through day

43
Pain Denture BaseClinical Exam
  • Discrete area of inflammation or ulceration
  • Similar to appearance of occlusal problems

44
Pain Denture BaseIndicating Pastes
  • Place paste with coarse brush - leave streaks
  • Mostly colour of the indicating paste
  • Press FIRMLY over first molar - dont fulcrum

45
Pain Denture BaseIndicating Pastes
  • Burnthrough excessive pressure
  • No streaks proper contact
  • Streaks lack of tissue contact

46
Pressure Pastes Other Areas
47
Pressure Pastes Goal Relatively Even, Minimal
Streaks
48
Avoid Impinging on the Mylohyoid Ridge
X-section through Mandibular ridge in 2nd Molar
region
Buccal
  • A problem if prominent or sharp

Mylohyoid Ridge
Attachments To Hyoid
49
Pain Denture BaseClinical Exam
  • Indelible sticks show position but not degree
    of problem
  • Use in immediate denture (paste in sockets)

50
Pain Denture BaseClinical Exam
  • Expect some burnthrough close to undercuts
  • Denture should seat easily, otherwise adjust
    undercut

51
Pain Denture Base Retromylohyoid Overextension
  • Sore throat
  • Denture moves when swallow
  • From retromolar pad, flange should go straight
    down or angle forward, never backward

52
Pain Denture Base Severe Tissue Undercuts
  • If the ridge is severely undercut, the flange
    cannot be placed to the depth of the vestibule,
    otherwise the denture will not seat or ulceration
    will occur

53
Pain Denture Base
  • Hamular Notches
  • Commonly sharp flange
  • Sometimes long
  • Use PIP

54
Pain Denture Base
  • Labial frenum
  • Should be thin and deep, not broad
  • Round internal and external angles

55
Denture PainCD RPD
  • Occlusion
  • Denture base (fit contour)
  • Vertical dimension
  • Infection
  • Systemic disease/condition
  • Allergy (rare)

56
Denture PainOcclusal Vertical Dimension (OVD)
  • Excessive OVD
  • Sore over entire ridge
  • Gets worse during day
  • Muscle/joint pain
  • Dentures click
  • Esthetic complaints too full

57
Denture PainOcclusal Vertical Dimension (OVD)
  • Insufficient OVD
  • lack of chewing power
  • minimal ridge discomfort
  • angular chelitis
  • esthetic complaints
  • chin prominent
  • poor lip support

58
Denture PainOcclusal Vertical Dimension (OVD)
  • Solution
  • Check physiologic rest postion and phonetics
    carefully to confirm
  • Provide time to ensure no adaptation
  • Reset teeth as adjustment alone usually not
    possible

59
Denture PainCD RPD
  • Occlusion
  • Denture base (fit contour)
  • Vertical dimension
  • Infection
  • Systemic disease/condition
  • Allergy (rare)

60
Denture PainInfection
  • Poor denture hygiene
  • Localized (lack of tissue contact)
  • Generalized

61
Denture PainInfection Localized
  • Porous denture surface
  • Palatal relief chamber
  • Voids from chairside relines
  • If denture cleanser not rinsed, also get
    inflammation

62
Denture PainInfection Generalized
  • Patient debilitated
  • diabetes, leukemia, AIDS, etc.
  • Drugs
  • chemotherapy, steroids, antibiotics
  • Poor nutrition
  • Xerostomia
  • drug/radiation induced
  • systemic condition (Sjogrens)

63
Denture PainInfection Generalized
  • Denture Stomatitis (Denture Sore Mouth)
  • Usually Candida albicans
  • Bright red, often no white plaques
  • Usually maxilla
  • Generalized pain

64
Denture StomatitisTreatment
  • 1. Remove source of infection
  • Tissue rest
  • Remove surface acrylic, soft reline
  • Reline frequently
  • Clean with
  • 2 Sodium Hypochlorite

65
Candidal Infections
  • Remove gross calculus or debris (scalers, lathe
    wheel)
  • Clean denture in ultrasonic
  • Soak in sodium hypochlorite redness disappears

66
Denture StomatitisTreatment
  • 2. Eliminate infection from tissues
  • Fluconazole 100mg
  • 200mg on 1st day then 100mg, once a day
  • minimum of 2 weeks to prevent relapse
  • Topical Nystatin ointment (less effective)
  • Nyaderm (15, 30 g tubes , 454g jar)
  • Apply 1-4 x per day
  • Oral suspension
  • Nyaderm (24, 48 ml bottle)

67
Denture StomatitisTreatment
  • Sometimes very persistant
  • May need to change drug
  • May need to use systemic medication

68
Denture PainInfection Generalized
  • Before Medicating
  • Improve hygiene
  • Consult present medications
  • Address nutrition

69
Nutrition
  • Quantity and quality of food
  • Comfort important for mastication
  • Neuromuscular control to chew
  • Patient able to use cutlery

70
Nutrition
  • Saliva important for taste
  • Vit C deficiency common
  • Bleeding (ulcers, hemorrhoids) causes loss of
    iron, protein

71
Drug Induced Xerostomia
  • Antiarrhythmics, Anticonvulsants,
    Antidepressants, Antihistamines, Diuretics,
    Hypotensives, Muscle Relaxants, Narcotics and
    others
  • Health history is important

72
Importance of Saliva
  • Retention
  • Lubrication
  • Removal of debris
  • Anti-bacterial, -fungal, -viral
  • Taste digestion

73
Burning Mouth Syndrome
  • Burning mouth (palate)
  • Burning tongue, lips
  • No clear cut cause
  • No uniformly successful tx

74
Burning Mouth Syndrome
  • Bacterial or fungal infection
  • Strep., Staph., C. albicans
  • Xerostomia, dysgeusia (taste)
  • Nutrition (Vit B complex, iron)
  • Anemias

75
Burning Mouth Syndrome
  • Neurologic or psychogenic problems
  • Diabetes
  • Hormonal
  • Mechanical trauma / other
  • Altered amount and makeup of saliva
  • Increased IgM IgG
  • Disturbed perception due to altered ionic
    composition
  • (Herschkovich Nagler, 2004)

76
Burning Mouth SyndromeTreatment
  • Try to eliminate potential causes
  • Cultures, nuitrition counselling, medications
  • Offer no great optimism or easy solution

77
Burning Mouth Syndrome Treatment
  • Patient may have to live with problem
  • Dont give up too soon - refer widely
  • If problem solved, grateful patient

78
Denture PainCD RPD
  • Occlusion
  • Denture base (fit contour)
  • Vertical dimension
  • Infection
  • Systemic disease/condition
  • Allergy (rare)

79
Systemic Disease or Condition
  • Comfort/Retention
  • Diabetes, Ectodermal Dysplasia, Sjogrens
    Syndrome, Neoplasm, Vesiculo-Bullous Diseases,
    STD,etc.
  • Coordination
  • Stroke, Muscle or Neurologic Disorders

80
Denture PainCD RPD
  • Occlusion
  • Denture base (fit contour)
  • Vertical dimension
  • Infection
  • Systemic disease/condition
  • Allergy (rare)

81
Denture Base Allergies
  • Extremely rare
  • Generalized reaction, wherever base touches
    tissues
  • Usually reaction to free monomer leaching out
  • Patch test, as last resort

82
Denture Base Allergies
  • Use porcelain teeth
  • Other material for base
  • Triad - Urethane dimethacrylate
  • Non-Nickel containing framework alloy
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