DIAGNOSIS

The act or process of deciding the nature of a diseased condition by examination.

The determination of nature, location & causes of disease.
More specifically, diagnosing involves identifying, and making judgments about, departures
from a healthy state.
Diagnosis in complete dentures is a continuing process, and a practical, careful diagnosis
must be carried on as it is needed at each step in the fabrication of the prosthesis.
Treatment planning is consideration of all diagnostic findings- systemic and local, which
affect the subsequent steps in fabrication of dentures.
The objective of the process is the development of a treatment plan that specifically addresses
the diagnosed needs of the patient and accommodates treatment as it progresses.
Primary objectives of prosthetic treatment planning:
In case of partially edentulous patient
1. Secure stable occlusal conditions by natural tooth contacts.
2. Maintain or restore a functional vertical dimension of occlusion.
3. Apply biologic principles of prosthetic therapy to minimize direct treatment sequelae
& long-term negative effects.
4. Apply simple treatment procedures that result in comfort & good esthetics.
5. Choose a financially acceptable treatment plan.
The need for prosthetic rehabilitation in partially edentulous patient may be
due to
a. Functional disturbances of masticatory system.
b. Poor masticatory performance.
c. Poor esthetics/ phonetics.
d. To prevent development of functional disturbances.
In case of edentulous patient
1. Restoration of esthetics.
2. Chewing function.
3. Comfort.

Successful complete denture therapy begins with : thorough assessment of patients
physical & psychological condition determining a treatment that will deliver
functional complete denture therapy & satisfies patients expectations.

Risk factors for partially edentulous Patient :
1. Progression of periodontal disease
2. Caries activity espl. Root caries
3. Residual ridge resorption Mainly because of rate of previous bone loss,
excessive occlusal forces during mastication, & bruxism.

Risk factors for edentulous patient:
1. Chewing problems Residual ridge resorption, Muscle atrophy.
2. Burning mouth syndrome Poor denture design, Systemic disease, Allergy to
denture base components.
3. Dissatisfaction with existing dentures- Neurotic personality, Negative attitude
towards denture.

First Visit
Helps attain mutual trust & understanding of the problems to be addressed, the
procedure to be followed & their likely outcomes. Enough time must be given to it, to allow
the dentist and the patient to appraise and asses each other properly.
Placing a patients prosthodontic needs in the broader contexts of general health,
socioeconomic status, lifestyle, and dental expectations will allow the dentist to deliver
treatment specifically appropriate for that patient.
During the initial appointment, clinical data, psychosocial and dental/ medical history,
and the patients expectations should be recorded. A thorough examination and consultation
ensures that the patient understands his or her problem and responsibility for a successful
outcome.
General History:
o Social & Behavioural information:
Data gathering starts as the patent enters the dentists office.
Patients social information establishes and verifies the identity; help dentist understand the
patient expectations & dental status.
A health questionnaire: used as convenient method to record basic information & personal
data.
Patients chief complaint: i.e. the reason to seek treatment which may be influenced by past
dental experiences as well as current systemic & oral health concerns.

Period of edentulousness: If the patient is=
a. Partially edentulous Condition of oral & perioral tissues, Periodontal status of
remaining teeth, duration of edentulousness, any previous prosthesis.
b. Completely edentulous duration of edentulousness, reason of tooth loss. Greater
amount of bone can be expected in case of tooth loss due to rapid caries than in case
of long periodontal disease.
c. Long-time denture wearer - Patient should be informed of any possible changes
/resorption of residual ridges that may occur & need for refitting/relining.

Its important to know patients views & remarks for old dentures. Patients
perceptions of the causes of the loss of their teeth can provide insight into their
appreciation of dentistry & contribute to prognosis for prosthodontics success.

Reason of edentulousness: Expectations for amount of alveolar bone remaining would
be greater for patient with H/o Rapid tooth loss from decay than from long
periodontal disease.

Patients Habit: Patient should be educated about the detrimental long term systemic
& local effects of unfavourable habits s/as Tobacco smoking & alcohol consumption
s/as delayed wound healing, deterioration of soft tissue health.
Para-functional habits: s/as bruxism should be evaluated during intraoral & existing
denture examination.
Oral & denture hygiene by patient be assessed: Patients oral manipulative skills
partly reflect their ability to use their existing prostheses.

Nutrition: If denture bearing tissues are nutritionally deficient, prosthesis will be
uncomfortable. If mouth is dry (lacking saliva), tissues have burning sensation (espl.
Tongue) & are friable (espl. Buccal & Lingual mucosa). Following nutritional factors
are considered
a. Negative calcium balance Osteoporosis affecting alveolar bone
Resulting bone-loss, espl., the spongy spicules of bone which support the weight
bearing parts of the skeleton. s/as maxillae.
Osteoporosis is common in aging person espl postmenopausal women (due to
decreased estrogen levels). This is due to lack of calcium intake & absorption,
lack of Vit. C
b. Nitrogen-protein balance muscle weakness & tissue fragility
Protein deficiency suspected if observations are fragile soft tissues, fissures on
lips, cracks in periphery of dentures. Loss of muscle strength can be tested by
placing finger in vestibule of the mouth & asking patient to clench the teeth.

o Psychological considerations:
Patient seeking prosthodontics care arrives with an accumulation of experiences &
resulting attitudes. Its important to determine if the psychological approach of the
patient is positive / negative towards the therapy. These may range from optimism,
through resignation, to despair. Dentist should assess their attitude towards wearing of
dentures or receiving new one.
Success / failure in fabricating dentures is not exclusively predicted on
patients oral anatomy or dentists skill but also on patients attitude towards their
dentures.
Dentist must seek to improve patient understanding & strive to adjust expectations to
reality.
The International Prosthodontic Workshop identified the following factors which produce an
adaptive or maladaptive response:

Factors which produce an adaptive response to complete dentures -
1. The acceptance of the dentist and confidence in the dentist which could also be
described as trust.
2. Previous favorable experience with authority figures.
3. The capacity to cope favourably with change. A positive attitude increases this
capacity.
4. Favourable physical conditions- youth & good general health.
5. Realistic expectations of patient.
6. Good learning capacity
7. Patient recognising the limitations of complete denture and acceptance of this fact.
8. Good physical coordination of patient.
9. Therapeutic alliance of the patient with the doctor. Patient plays active role in
cooperative treatment effort.


Factors which produce maladaptive response to complete dentures -
1. Lack of trust in the dentist
2. Poor communication between the dentist & his patient.
3. Negative previous experience.
4. Unrealistic expectations of patient.
5. Resistance to change arising from severe anxiety/ depression.
6. Low tolerance for anxiety/pain.
7. High level of anxiety on part of the patient.
8. Inadequate tissue tolerance.
9. Muscle incoordination.
10. Chronic dissatisfaction.
11. Disapproval of the dentures or of the individual with dentures by people important to
him.

o Medical History & Systemic health Status:

The primary objective is the identification of conditions or incidents that have
implications for current treatment.

Observation Of The Patient -
The observation and evaluation of the patient begins when he or she enters the dental
office.
Motor Skills: The observation of the patient's physical abilities and motor skills is an
important part of the overall evaluation.
Dizziness may be a side effect of medication or a cerebrovascular accident.
Vertigo may also be due to orthostatic hypotension or be a signal of low blood
pressure, overcorrected high blood pressure, or cerebral ischemia.
Observe the patient's walk, level of coordination, and steadiness. An unusual
gait can -be the result of a neurologic disorder such as Parkinson's disease (body
rigidity and short dragging steps) or possibly severe arthritis.
In case of shortness of breath -The dentist should suspect emphysema, asthma,
congestive heart problems, or heavy smoking.
After being seated in the dental chair, the patient's ankles should be observed
for swelling. Ankle edema is often associated with congestive heart failure, poor
circulation, or kidney disease.
The facial movements noted. A cerebrovascular accident, Bell's palsy, or
nerve blocks for trigeminal neuralgia will result in hemiplegia or dyskinesia. Any
facial tremors or spasms are indicative of Parkinson's disease, nervous habits, or
possibly a drug-induced tardive dyskinesia. Patients treated with psychotropic drugs
may have clinical manifestations which include uncontrollable chewing movements,
licking and smacking of the lips, uncoordinated tongue movements, tongue tremors,
twitching of the nose, or puffing of the cheeks.

Determination of vital signs- helps establish base line data to evaluate any
deviation from normal or in case of any medical emergency that occur during
treatment. It also serves as a context for counselling about inert-relationship of
systemic health & denture wearing experience.

Systemic factors that may affect complete denture treatment include; anaemia, arthritis,
Bells palsy, carcinomas, diabetes, nicotinic stomatitis, Pagets disease, Parkinsons disease,
and therapies that cause xerostomia and infectious diseases.

Generalised osteoporosis: M/c systemic condition. Loss of body ht. & face ht. Atrophy of
residual ridges, more so when ridge is subjected to the continuous pressure of dentures.

Debilitating Disease:
Diabetes - diagnostic features are in evidence in diabetes: a dry feeling in the mouth; a
coated tongue, with swollen edges and tooth impressions along the borders; fissures on the
tongue; small abscesses throughout the mouth, poor tissue tone; and a burning and metallic
taste in the mouth.
-use nonpressure impression technique
-occlusal correction should be made
-periodical adjustment
Tuberculosis
-diet important so efficient dentures
-irritating projections removed
Extra instruction: Oral hygiene, Eating habits, Tissue rest, Recall appointments- well
adapted bases & occlusion corrections.

Transmissible disease - Tuberculosis, AIDS, hepatitis, herpes

Potential hazards in prosthodontic phases of treatment are:

o Contamination of impression trays & material during impression making

o Contaminated polishing wheels. Pumice & pumice pans as well as grindings
from patients prosthesis cause aerosols contamination

o Take precautions to prevent contamination & transmission of disease.



Cardiovascular Diseases-
Consult patients physician and take written approval.
Plan short appointments with premedication in case of patients with history of
angina and cardiac arrest.
Antibiotic prophylaxis in patients with rheumatic heart disease, congenital value
disorder, etc. if some kind of surgery required.

Infectious diseases Fungal infections s/as Candida albicans are common in
edentulous patients, particularly in maxillary denture- related stomatitis.
/angular cheilitis it is inflammation of the corners of mouth.

Papillary hyperplasia Its Cauliflower-like in appearance & occurring in anterior
region of palate in long term denture wearer. These deep crevices are prone to
frequent infections by C. albicans.

Extra oral Examination:
This is concerned principally with facial contours & symmetries, appearance of teeth
& their relationships with the lips in repose & function & pattern of jaw movements.
Also evaluate by palpation TMJ & submandibular & cervical lymphnodes.

a. Good muscular control & coordination help correctly design and construct
dentures.
Observation: Ask patient to open mouth abt. Halfway & move mandible Left &
Right. Also move tongue Left & Right cheek in succession, protrude & retrude
tongue.
b. Observation of jaw relations-Estimate VDR, VDO and anteroposterior jaw
relation.
c. Tone of facial muscles:
a. Too tense will be difficult to manipulate.
b. Too slack will be displaced easily.

Intraoral Examination:
Tongue In case of prolonged period of edentulousness the tongue musculature
becomes hyperactive while perioral muscles s/as lips & cheeks loose muscle tone and
activity.
Tongue expands in size in edentulous space by reorientation of its intrinsic muscles.
Evaluate the tongue habits s/as retruded and tongue thrusting as this tends to dislodge
lower denture by raising the floor of mouth.
Floor of mouth visual examination of depths of mucosal folds, evaluate position of
floor of mouth when contraction of mylohyoid muscle occurs.

Saliva- Quality & quantity of saliva affects patients ability to tolerate dentures.
Evaluate salivary glands by bidigital palpation. Patency of whartons duct. Identify
abnormalities s/as sialoliths, fibrosed glands. Note any medication that affects salivary flow
& radiation therapy in the salivary gland region.

Bony ridge morphology
Six orders of mandibular anterior residual ridge form: ( Atwood et al)
Order I, pre-extraction;
Order II, postextraction;
Order III, high well-rounded;
Order IV, knife-edge;
Order V, low well rounded;
Order VI, depressed.


Residual Ridge Morphology: Residual ridge morphology is the most objective
criterion for the maxilla, because measurement of the maxillary residual bone height
by radiography is not reliable. The classification system continues on a
logical progression, describing the effects of residual ridge morphology and the
influence of musculature on a maxillary denture.
Type A (most favorable) -
Anterior labial and posterior buccal vestibular depth that resists vertical and
horizontal movement of the denture base.
Palatal morphology resists vertical and horizontal movement of the denture
base.
Sufficient tuberosity definition to resist vertical and horizontal movement of
the denture base.
Hamular notch is well defined to establish the posterior extension of the
denture base.
Absence of tori or exostoses.
Type B -
Loss of posterior buccal vestibule.
Palatal vault morphology resists vertical and horizontal movement of the denture
base.
Tuberosity and hamular notch are poorly defined, compromising delineation of the
posterior extension of the denture base.
Maxillary palatal tori and/or lateral exostoses are rounded and do not affect the posterior
extension of the denture base.
Type C -
Loss of anterior labial vestibule.
Palatal vault morpholog~7 offers minimal resistance to vertical and horizontal movement of
the denture base.
Maxillary palatal tori and/or lateral exostoses with bony undercuts that do not affect the
posterior extension of the denture base.
Hyperplastic, mobile anterior ridgc offcrs minimum support and stability).-of the denture
base.
Reduction of the post malar space by the coronoid process during mandibular opening and/or
excursive movemcnts.
Type D -
Loss of anterior labial and posterior buccal vestibules.
Palatal vault morpholoa does not resist vertical or horizontal movement of the denture base.
Maxillary palatal tori and/or lateral exostoses" (rounded or undercut) that interfere with the
posterior border of the denture.
Hyperplastic, redundant anterior ridge.
Prominent anterior nasal spine.





Based on Muscle Attachments: Mandible
The effects of muscle attachment and location are most important to the function of a
mandibular denture. The classification system follows a logical progression to describe the
effects of muscular influence on a mandibular denture. The clinician examines the patient and
selects the category that is most descriptive of the mandibular muscle attachments.
Type A-
Attached mucosal base without undue muscular impingement during normal function in all
regions.
Type B -
Attached mucosal base in all regions except labial vestibule.
Mentalis muscle attachment near crest of alveolar ridgc.
Type C -
Attached mucosal base in all regions except anterior buccal & lingual vestibules canine to
canine.
Genioglossus and mentalis muscle attachments near crest of alveolar ridge.
Type D -
Attached mucosal base only in the posterior lingual region.
Mucosal base in all other regions is detached.
Type E -
No attached mucosa in any region.