Prosthodontics-3: University of Jordan Dentistry Lecture Notes

University of Jordan Dentistry 019 Prosthodontics- 3 WE ARE JUST FEW STEPS AWAY! Written by: Yossor AlHaidar , Mohammad Hashem Corrected by: Yossor ALhaidar , Mohammad Hashem Doctor: Wijdan AL-manaseer 020 / corrected by: Dana...

University of Jordan Dentistry 019 Prosthodontics- 3 WE ARE JUST FEW STEPS AWAY! Written by: Yossor AlHaidar , Mohammad Hashem Corrected by: Yossor ALhaidar , Mohammad Hashem Doctor: Wijdan AL-manaseer 020 / corrected by: Dana Nabeel Sheet# In this lecture we will talk about treatment outcomes in patients with CD and RPD, as we previously learn about how we design and construct RBD and CD properly. Also, we will talk about 2 studies, the first have been done in USA about patient satisfaction with complete dentures: an update. Patient perceptions are fundamental to improving Health Care Quality, so methods for assessing patient feedbacks on satisfaction, care experience, and treatment outcomes are very important. The same holds through true for complete denture therapy patients: satisfaction with their complete Dentures may be considered the ultimate goal of the therapy as it was strongly associated with oral health related quality of life. Although the vast majority of patient centered publication on satisfaction with complete dentures have shown that patients usually present High satisfaction levels, the articles are not in consensus. Additionally, there's a small number of patients that are unable to adapt with to their Dentures the number of patients unable to adapt those who are not satisfied with their Dentures for some reason, ranges from 3% up to 40% among uh RPDs wearers. Considering that there are numerous factors influencing patient satisfaction with complete dentures, the present review divided the factors into three main groups:  Technique-related.  Patient-related.  Dentist-related. 1|P a ge  1- Technique-related factors: a) Therapy choice. b) Fabrication techniques. c) Impression techniques. d) Occlusal schemes. e) Chewing surface designs. f) Aesthetics-related procedures. g) Dentures maintenance and follow-up. h) Number of post-delivery appointments. i) Denture quality. a) Therapy choice: So the therapy of choice depends mainly on General Health, oral health and socioeconomic status. So we have to consider all these factors when we want to deliver to the patient whatever it is either goes into CD, or implant, or RBD or fixed partial dentures, or implant retained complete Dentures whatever, it depends on these three factors. b) Fabrication techniques: Dentures fabricated either by:  Simplified technique: in which, we skip One of the steps of CD construction (either to skip the secondary impression or we made the to make secondary impression in bite registration step. 2|P a ge   Comprehensive or conventional technique (face-bow and remount). These are 3 studies (above) comparing the difference between simplified and conventional technique  and there was NO significant difference between the two groups’ techniques. Dr mentioned another study done by dr.erifij with same results. c) Impression techniques:  There is NO EVIDANCE that the use of two impressions (a preliminary impression with stock trays and a final impression with custom trays) improves denture quality and/or patients’ satisfaction with their dentures. The same holds true for different border molding techniques. Note: definitely better results for retention achieved by using of 2 impressions. But no difference in patient satisfaction because the patient isn’t aware about different techniques and having a denture with satisfying results is a multifactorial thing. d) Occlusal schemes:  A recent randomized clinical trial (RCT) comparing patient satisfaction among fully balanced bilateral occlusion, lingualized occlusion, and buccalized occlusion demonstrated higher patient satisfaction rates with balanced occlusion. A similar result was achieved by another study comparing balanced occlusion to canine guidance, though using a different methodology. 3|P a ge  Conversely, in a six-month follow-up study, lingualized occlusion provided higher patient satisfaction rates compared to balanced occlusion. In the same study, lingualized occlusion increased masticatory performance and maximum voluntary contraction, as measured by electromyography.  In a recent systematic review on the topic, the authors concluded that currently there is NO EVIDENCE to support one occlusal scheme over another. It is, however, important to highlight that more research is also needed to provide evidence for clinical practice. For now, dentists may consider that many of the proposed occlusal schemes can be used, and none can claim superior results. e) Chewing surface designs:  RCT (randomized clinical trials) about posterior occlusal forms, authors found that patient satisfaction and self-perceived chewing ability was higher for dentures with lingualized or anatomic occlusal surfaces when compared to zero-degree (cuspless) teeth. f) Aesthetics-related procedures:  Majority of denture patients are seeking esthetic improvement, among other demands (mastication, comfort, etc.). Esthetic expectations are usually very high among complete denture and RPD patients. Patients also expressed their desire to have more information and discussion with their dentists about teeth selection. g) Dentures maintenance and follow-up:  Regular maintenance and relining seemed to improve patient satisfaction with complete denture therapy as well as in RPD therapy. Those studies focused on the relining procedure; however, further research is needed to evaluate how regular check-up visits and patient education about denture maintenance influence patients’ satisfaction with their dentures. 4|P a ge So, it’s important to tell the patient about expected results with CD or RPD (benefits and limitations) and about maintenance. So, the gold standard for success is keeping the patient with continuous visits and we have to tackle has a high adaptive capability, problems that happens. Otherwise, if the patient have he will be more satisfied, but if the patient seems to be critical or sceptic then the maintenance is better solution.  The provision of new dentures usually results in increased patient satisfaction and quality of life, even when pre-existing dentures are merely duplicated, demonstrating that patient satisfaction and its impact on quality of life are not related to the denture fabrication technique. h) Number of post-delivery appointments:  The number of post-delivery appointments may influence patient satisfactions with their complete dentures in many ways. It may be considered an indication of quality, as the better the denture the fewer appointments needed. It also may be considered a burden for the patients to return to the office for adjustments. However, some patients consider the adjustment as considerate care from their doctors and appreciate the adjustments.  In a recent study among RPD wearers, NO association was found between the number of adjustments and patient satisfaction. In a sample of complete denture wearers, however, the number of post-delivery adjustments correlates negatively with patient satisfaction rates. Both studies were done among Brazilian patients. Considering the differences among the samples, no conclusions should reliably be drawn. i) Denture quality:  Dentists should not be inhibited in their efforts to make the best dentures possible, despite the lack of evidence about the impact of denture quality and fabrication process. One technique is hardly superior to another, and usually different methods produce similar final results. Considering that, 5|P a ge  practitioners may choose less time-consuming techniques and less expensive materials to make complete dentures accessible to a larger population. 2- Patient-related factors: a) Age. b) Gender. c) Educational level. d) Socioeconomic status. e) Personality and psychological factors. f) Previous denture experience. g) Expectations before denture fabrication. h) Oral conditions. a) Age:  Dentists usually associate patients’ age with their ability to cope with new dentures, and this association was based on a common assumption that older patients take longer to adapt to dentures. None of the articles evaluated for the present review confirm this association, however. A reasonable number of studies found no association among complete dentures or RPD, patients’ age, and patient satisfaction. b) Gender:  It is usually taken for granted that women are more demanding about esthetics than men, and so women are usually less satisfied with their dentures. Although one can argue that such cultural thinking is more suitable to old-fashioned macho mentality, some modern articles have observed significant differences between genders regarding patient satisfaction with dentures. 6|P a ge This was common in the past. However, nowadays, women and men are equal about esthetic demands.  An RCT (randomized clinical trials) specially designed to elucidate gender differences in denture satisfaction and deserves further attention. It tested if there are differences between men and women (n = 256) regarding satisfaction with implant-retained overdentures and conventional dentures 6 and 12 months after denture delivery.  There was NO difference between genders among implant-retained overdentures recipients; but among conventional complete denture recipients, females were less satisfied with their dentures than males regarding esthetics and ability to chew.  In contrasting studies, there was no significant difference between genders in patient satisfaction, both among complete dentures and RPD patients.  So, there isarea differences among studies Cultural differences in education for men and women vary worldwide, and these differences should help to clarify this divergence among different studies. Qualitative research methods may be useful to capture those cultural differences. c) Educational level: Education is an important component of the cultural package of any individual, and it is no different for denture wearers. Considering that, it is a typical belief in Brazil that more educated patients are more demanding and usually less satisfied with their dentures. A Croatian study confirmed this common assumption: it found a negative correlation between educational levels and patient satisfaction for esthetics, speech, and comfort. 7|P a ge  In contrast, a Turkish and two Brazilian studies did not find any differences among educational level groups regarding denture satisfaction. Considering that education may be in conjunction with other confounding variables, multiple regression models may be more suitable for this analysis than the statistical methods employed by the aforementioned studies. Besides, in a study where structural equation modeling was applied, educational level was not considered. The idea here is about to have a better conclusion => we change the method that used in analyzing data (we use a multiple regression models instead of statistical methods). Dr mention that this information for who cares about research, others don’t care about it. d) Socioeconomic status: Two studies have considered socioeconomic status as a possible factor influencing denture satisfaction. Both of them revealed a correlation between socioeconomic status and denture satisfaction ratings: the lower the socioeconomic status, the higher the denture satisfaction. Due to the small number of studies dealing with socioeconomic status, future research should also consider socioeconomic status as an interfering variable. e) Personality and psychological factors: Although some personality tests were not able to disclose any relationship with patient satisfaction with dentures, as happened with locus of control and the Eysenck short scale personality test (these are scales used to test personality), it seems clear that neuroticism negatively affects patient satisfaction with dentures. Another study disclosed a relationship between Type A Behavior Pattern Test and patient satisfaction in a sample of 239 patients. In this study, the lowest 8|P a ge levels of denture satisfaction were achieved among Type A patients. Type A patients are very anxious, ambitious, and rigidly organized. Other psychological issues, as depression, general anxiety, and emotional aspects related to tooth loss, negatively correlate with patients’ satisfaction with their dentures. Given these results, it is not surprising that a recent study showed that psychoeducation provided by specialists significantly improved patient satisfaction. So, we should observe patients from first session especially those lose their who lost their teeth and affected psychologically by that to come up satisfied results. Also, to restore function and esthetic aspects along their expectations  our treatment driven by patient’s demands and expectations. f) Previous denture experience: Dentists tends to believe that patients’ previous experience with dentures, if positive, may help them adapt to new dentures; if negative, previous experience can have a negative effect on adaptation. Furthermore, time of denture usage was associated with higher satisfaction rates. This It isisnot in general it’s not a rule, some a rule, request patients in some new patients we provide dentures becausethem a denture they then cannot tolerate they request their another old ones, then,new oneyou when andprovide still have a problem a new with denture coping they (confusing complain that they have to adapt -all over again- to this new one, so it is a tricky situation attitudes). But, overall denture wearers who satisfied with their dentures for 10. ys for example, if we construct a new denture => we expect to get them satisfied. Recent research on the topic presented ambivalent results )‫(متناقضة‬. In a sample of 100 denture wearers, patients’ previous experiences with dentures presented positive but weak correlations with both patients’ expectations and satisfaction regarding new dentures. In contrast, in a sample of 104 denture wearers, patients’ perceptions of complete denture therapy were not influenced by previous denture experiences. Although these two samples are comparable regarding size and origin, the methodologies applied are different and the results may not be directly comparable; further research is needed to clarify this issue. 9|P a ge So, this a common problems in comparing studies with different methodologies applied  the comparison isn’t fair and we can’t get a clear conclusion. g) Expectations before denture fabrication: It is often cited that patients’ expectations about their dentures should impact their reaction to new dentures and consequently affect their satisfaction. However, there is little research about patient expectations regarding complete dentures therapy. h) Oral conditions: Poor oral conditions may lead to dentures that are more difficult to wear which, consequently, reduces patient satisfaction. The influence of oral conditions on patient satisfaction has been reported. The most influential factor seems to be the mandibular ridge; the poorer the ridge, the lower the satisfaction. 3- DENTIST-RELATED FACTORS a) Dentist experience. b) Patients’ perception of the dentist. c) Communication issues. a) Dentist experience: More experienced professionals usually can integrate all the information discussed here in order to understand patients’ expectations and communicate better to ensure adequate understanding. b) Patients’ perception of the dentist: 10 | P a g e  Patients’ perceptions of the dentist influence their likelihood to trust the dentist which builds a relationship in which the dentist’s explanations are fully considered and directions given by the dentist are fully followed. For example, You may start feel this point, because some patients don’t trust students, and the way they treat the supervisor differs completely. So patient perception or satisfaction differs according to the doctor experience. In addition, patients also feel free to ask questions and present their feelings regarding procedures or conditions, helping the dentist to identify possible issues. ‫هاي كمان الحظتوها إنه لم بيجي السوبرفايزر بيسأل المريض فبيحكي الطالب إنه المريض ما‬ ‫ انو السوبرفايز عنده خبرة أكتر فرح يفهم علي أو رح‬assumption ‫حكاله هالمعلومة عندهم‬ ‫يقدر هاي المعلومة اللي أنا بحكيها‬ There is reasonable evidence to support this common sense assumption. In a sample of RPD wearers, there are higher patient satisfaction ratings when patients reported that their dentists gave a more complete explanation. In a qualitative study, patients expressed that their relationships with their dentists are of great importance to achieving good results, and the fact that dentists are more open to dialogue today is considered a huge improvement. Another qualitative approach showed that patients value caring dentists, as well as dedicated dental teams. This is very important for your career, that you provide enough time for patients (it builds confidence between you and your patient because it highly affects perception and satisfaction). c) Communication issue:  It was shown that patients and dentists have different expectations and satisfaction rating importances regarding the same denture. ‫إحنا دائما إلنا نظرة للطقم تختلف تماما عن نظرة المريض‬ 11 | P a g e  Therefore, Therefore, the importance establishing of communication good establishing good communication with with be the patient cannot the patient cannot be overstated. overstated. Several articles have reinforced that effective communication and ensuring patients’ understanding of denture limitations before starting  are essential for achieving success with complete denture therapy, as well as with RPD. There is a very good report about communication skills in recent literature. Although communication skills may help improve the patient-dentist relationship, the fundamental rule is to treat your patient the way you would like to be treated: with kindness and genuine consideration This Study Reports The Effect Of Gender And Location (Maxilla Vs. Mandible) On The Clinical Performance Of Removable Partial Dentures (RPDs). It is important to realize that conventional fixed prostheses and dental implants have limitations. A major obstacle to these treatment options is the financial consideration which may preclude some patients from receiving these treatments. A careful assessment of patient compliance regarding oral hygiene and routine maintenance should be completed before considering rehabilitation using RPD. The overall success rates of RPDs as reported in the literature are at a respectable level. 12 | P a g e  One study found a 71.3% success rate for RPDs with a circumferential clasp design and 76.6% success rate for RPDs with an I-bar clasp design after 5 years of usage. A different study, which defined failure as the patient not wearing the original RPD, reported 74.7% of patients were still wearing their RPDs. The authors divided RPDs usage into 5 year intervals. They reported success rate of 85.7% for 5 - 10 years period, 62.8% for 10 - 15 years period, and 57.1% for over 15 years period. Other researchers evaluated RPDs with an average 2.5 years of service and found 43% of RPDs to be acceptable and 46% could be made acceptable with modifications, such as a reline or adjustment. As is evident in the literature, success rates of RPDs are reasonable and they remain a justifiable option for the treatment of partially edentulous patients. ‫إذًا احنا لسا بحاجتهم‬ As is evident in the literature, success rates of RPDs are reasonable and they remain a justifiable option for the treatment of partially edentulous patients. Males appeared to demand that dentures improve their mastication, whereas the concerns of females centred on problems related to pain, hypersensitivity and esthitics. The results from another study on RPDs revealed No Significant difference in general satisfaction between males and females, aside from men being less satisfied with the mastication with lower RPDs. A review of the literature also fails to produce evidence comparing the success rates of maxillary and mandibular RPDs. One study reported patient satisfaction to be equal between maxillary and mandibular RPDs, however, the authors found a significant difference in failure rates between maxillary and mandibular RPDs. In that study, the failure rate for mandibular RPDs was 33% compared to 12.7% for maxillary RPDs. 13 | P a g e  Another study showed greater patient compliance with maxillary RPDs possibly due to esthetics and comfort. A review of the literature also fails to produce evidence comparing the success rates of maxillary and mandibular RPDs. One study reported patient satisfaction to be equal between maxillary and mandibular RPDs, however, the authors found a significant difference in failure rates between maxillary and mandibular RPDs. In that study, the failure rate for mandibular RPDs was 33% compared to 12.7% for maxillary RPDs 14 | P a g e  Results An overall 70.5% success rate was observed for the RPDs over 15-year period. In general, failure of RPDs was mainly due to patient acceptance, poor retention, integrity of the prostheses and adaptation. A 75% success rate was observed in male patients compared with 67.2% for female patients. And for both genders patient acceptance of RPDs was rated the lowest among all the criteria. In male patients 23% of acceptance ratings were given Delta scores, mainly because these patients either found they were not able to adapt to wearing the RPD(s) or found they functioned sufficiently without the prosthesis. The other criteria with the highest Delta scores in male patients were adaptation and occlusion. In female patients 25% of acceptance ratings were given Delta scores, which in most cases was due to their perception of undesirable esthetics and poor retention, even though these criteria were assessed as acceptable to excellent during the comprehensive examination. The other criteria with the highest Delta scores in females, they include: retention, adaptation, integrity of prosthesis, rests and rest seats, and major connector design. Statistical analysis showed no significant difference in Alpha scores between female and male patients The maxillary RPDs showed a higher success rate of 78% compared with 70.1% in mandibular RPDs. Similarly, the patient acceptance criteria was rated the lowest for both maxillary and mandibular RPDs. 22% of acceptance ratings of maxillary RPDs were given Delta scores mainly due to improper adaptation of the RPD as patient was complaining from discomfort and food impaction 15 | P a g e  The other criteria with high Delta scores among maxillary RPDs were integrity of the prosthesis and major connector design. On the other hand, mandibular RPDs had 25% of their acceptance ratings given Delta scores as a result of patients not being able to adapt to wearing the RPD, even though these RPDs were generally assessed as acceptable or excellent. The other criteria with high Delta scores among mandibular RPDs were adaptation and retention. Statistical analysis showed no significant statistical difference in Alpha scores between maxillary and mandibular RPDs (p < 0.05). Conclusions The clinical performance of the RPDs showed higher success rates in male patients compared to female patients. Also, the maxillary RPDs showed higher success rates compared to mandibular RPDs. A critical determinant affecting success rates and the difference in success rates was the acceptance (or level of patient satisfaction). Therefore, it would seem that patient factors would be as important, if not more influential, as factors controlled by the practitioner. Practitioners must identify and keep in mind all the factors that affect RPD treatment outcomes. Despite the gender of the patient or the intra-oral location of the prosthesis, the importance of proper treatment planning and proper patient education is emphasized as an essential role of the practitioner. Patients must be educated and made aware of the limitations and shortcomings of RPDs to ensure realistic expectations. If patient expectations and attitudes are realistic, then acceptance of the new prosthesis could be improved, potentially resulting in higher success rates. 16 | P a g e  ‫فقط المعلومات بالساليدز هي المطلوبة‬ ‫ال تنسوا الدعاء ألهلنا‬ ‫في غزة ‪.‬‬ ‫‪17 | P a g e‬‬