Diagnosis and Treatment Planning

Diagnosis:
Definition: Determination of the nature of a disease.
Diagnosis involves patient evaluation, history, and examination.

Patient evaluation:
This process commences as the patient walks to the dentist’s chair as well as
during the introductory and history taking conversation.
The following characteristics are observed:
Gait:
Observations regarding the patient’s walk, steadiness and the level of coordination
can help in gaining an insight into the patients’ motor skills and any systemic
disease.
 Stooped shoulders—spinal changes.
 Tremor of head—Parkinson disease, tranquillizers.
 Dragging of one leg—stroke.
 Staggering—excessive alcohol and medication, hyperventilation, damage to
brain and spinal cord
Age:
This refers to the physiologic age and provides information about the patient’s
expectations and care for the dentures. A young patient who appears old may
indicate disinterest, while an old patient who appears young indicates willingness
to adapt and look good.
Facial expression:
This provides information about the mental attitude and presence of any disorders.
Absence of any expression indicates loss of muscle tone, trigeminal neuralgia,
plastic surgery, or disorders of central nervous system
Complexion:
 It is used to select the color of the teeth.
 It may also be indicative of the following conditions:
 Pale—anemia, lack of nourishment.
 Ruddy—polycythemia, chronic alcoholic.
 Bronze—radiation therapy, Addison disease.
 Bluish purple—vitamin deficiency, cyanosis.
 Lemon-yellow—jaundice.
Speech:
The fluency and quality of the speech should be noted, as it will help in arranging
artificial teeth. If speech is altered due to poor denture construction, it should be
rectified.
Speech can also be altered due to the following pathologies:
 Hypernasality—paralysis of palatal musculature.
 Hoarseness—paralysis of both vocal cords, excessive smoking.
Breathing pattern:
Abnormal breathing patterns may indicate the following:
 Heavy sighing- emotionally disturbed
 Wheezing-asthma
 Shortness of breath- lung disease, heart failure
 Shallow breathing at rapid rate- pulmonary fibrosis
 Erratic breathing- continuous hyperventilation
Personality:
The personality may be vigorous or delicate, and it guides teeth selection and
arrangement.

Mental attitude:
Dr M.M. House (1950) classified patients as philosophical, exacting, indifferent
and hysterical. This is the most widely used classification.
Class I: Philosophical patients
 They are rational and composed in difficult situations.
 They desire treatment for maintenance of health and appearance and accept
the complete denture treatment as a normal procedure.
 They learn to adjust rapidly.
 These patients have the best mental attitude for acceptance of the treatment.
Class II: Exacting patients (critical)
 They are very methodical, precise, and accurate, making severe demands
and alternative treatment for dentist.
 They are comfortable when each procedure is explained and discussed with
them in detail.
 They require extreme care, effort, and patience on part of the dentist.
 The intelligent and understanding category in this class can be the best type
of patient, but for those lacking the same, extra time should be spent in
education and treatment started only after an understanding is reached.
Class III: Indifferent patients
 These patients are identified by their lack of concern and motivation and
apathetic attitudes.
 They may not pay any attention to instructions, will not cooperate and are
prone to blame others including the dentist for their poor health. In many
cases, the lack of interest on part of the patient is the reason for their
edentulousness.
 A patient education program is recommended before treatment.
 If their interest cannot be stimulated, it may be best to refuse such patients.
  They present a questionable or unfavorable prognosis
Class IV: Hysterical patients (skeptical)
 They are emotionally unstable, excitable, and apprehensive.
 They may not be aware that their symptoms may be more related to their
systemic health.
 They often present an unfavorable prognosis and additional psychiatric
counselling is required prior to the treatment.

History:
A record of all the information obtained from the patient must be made and kept
for further study and later use. The health history is an extremely important part of
the patient’s overall diagnosis and treatment planning. It is best obtained by a
combination of questionnaire and direct interrogation. It should include the
following:

General information:
Name: This is important for documentation and record maintenance. Patients are
more comfortable and confident when addressed by their names.
Age: Younger patients usually show better healing ability. They also adapt easily
to treatment and a new prosthesis. However, they can be exacting in nature and be
very concerned about their appearances. Older patients need more care and
patience on part of the dentist. Systemic diseases and medications may be more
relevant in older age. Their previous experiences may lead them to be very
apprehensive of the treatment. Proper nutritional care is very important in geriatric
patients. This is an important consideration in the selection and arrangement of
artificial teeth
Sex:
Generally, appearance is a higher priority for women. Males may be more
concerned about comfort and function of the dentures. This is also an important
consideration in the selection and arrangement of artificial teeth.
Occupation/Social information:
Particulars such as the occupation can help in setting up a convenient appointment
for the treatment procedure and in tooth selection and arrangement.
Executives in high stress jobs may exhibit bruxism.
People who work in places with high physical exertion and factories where
abrasive dust abounds require rugged teeth which do not wear easily. For
professionals, appearance and retention may be more important than efficiency.
Public speakers and singers may need greater attention to palatal shape and
thickness and perfect retention. Wind instrument players may require special
positioning of anterior teeth.
Patients in high socioeconomic groups may be more demanding and critical, while
those of low economic status may show disinterest and poor hygiene maintenance.
If the patient has been widowed, preparing food, and eating alone can well take all
the enjoyment out of mealtimes and an unbalanced diet could lead to tissue
changes in the oral cavity.
Habits:
Pan chewing, smoking, chronic alcoholism may modify the systemic status and
evoke concerns regarding the hygiene, maintenance, and wear of the denture.
Habits like pencil biting and nail biting may cause denture instability.
Parafunctional habits like clenching and bruxism should also be verified as they
affect teeth selection and prognosis.
Nutritional history:
It is important to obtain a record of food intake of the patient over a 3– 5 days
period. This helps in evaluating the nutritional status of the patient. The ability of
the oral tissues to withstand the stress of dentures is greater in a well-nourished
patient. Dietary counselling is necessary in malnourished patients.

Medical history:
No prosthodontic procedure should be commenced without evaluating the systemic
status of the individual.
The following need to be assessed
Debilitating diseases:
The most common is diabetes mellitus. Patients are at a higher risk of opportunistic
infections such as candidiasis and show delayed wound healing. Salivary flow may
also be impaired. Their medication and mealtime should be given due importance
while scheduling appointments. Special emphasis on denture hygiene, recall and
maintenance is also necessary for such patients.
Diseases of the joints:
Rheumatoid arthritis and osteoarthritis are common diseases affecting the joints. If
fingers are affected, patient will find it difficult to insert and clean dentures.
When the temporomandibular joint (TMJ) is affected, special impression trays are
required due to poor mouth opening and frequent occlusal correction may be
necessary as jaw relations are difficult to record due to painful mandibular
movements.
Cardiovascular disease:
Patients with stable cardiac problems under the regular care of a cardiologist are
not contraindicated for procedures.
Short appointments may help the patients to manage stress better.
A consultation with the physician is required if any invasive preprosthetic
procedure is contemplated, along with premedication and stoppage of
anticoagulants.
Neurological conditions:
Conditions like Bell palsy and Parkinson disease will present problems related to
denture retention, maxillomandibular records and support for the musculature.
Patients need to be educated regarding these anticipated problems.
Oral malignancies:
Construction of CD may be commenced depending on the tumor prognosis, the
healing of tissues following the treatment and the amount of radiation.
After CD construction, the tissues should be evaluated constantly for any evidence
of radiation necrosis. Patient should be advised to use the dentures on a limited
basis.
Epilepsy:
Patient may aspirate or break the denture during the seizure. It will influence the
selection of denture base material and teeth.
Patient and close relatives may also need to be educated on quick removal of the
dentures prior to or during seizures.
Diseases of the skin:
Dermatological diseases like pemphigus have painful oral manifestations like
ulcers and bullae. Medical treatment may or may not provide relief to these
patients. The constant use of dentures in such patients must be discouraged.
Medications:
It can be an indication of a systemic problem or dental treatment may be modified
and influenced by the effect of the drug.
Xerostomia is a common side effect of antihypertensives and antidepressants. This
can decrease denture retention and cause increased soreness.

Dental history:
This should include the following:
Chief complaint:
The chief complaint is recorded in patient’s own words. It should be
determined if the complaint is justified and realistic.

 After noting personal particulars such as name, address, age and occupation,
the clinician should record the concern or complaint in the patient’s own
words. For example, if the patient says that the denture is loose, it may be
positively misleading if the clinician records the comment as ‘the denture
lacks retention’. The denture may, in fact, exhibit excellent physical
retention but is being displaced by an uneven occlusal contact.
Patient’s desires and expectations:
It is important to find out what the patient expects from the treatment. Unrealistic
expectations will be detrimental to success of treatment. Patient education
regarding what is possible is very important in such cases.
Past dental history: The following information should be elicited:
1. Reason for tooth loss (when the natural teeth were extracted): If periodontal
disease was the reason, more bone loss is anticipated. It also helps in prognosis.
2. Period and sequence of edentulousness (Reasons for the extractions): Longer the
period, more will be the bone loss. By understanding the sequence, bone resorption
pattern can be identified.
3. Previous dental and denture experience (Occurrence of any surgical
complication): Traumatic experiences will affect the attitude of the patient towards
dental treatment, and they will require more counselling and education. Patient’s
experience with previous dentures will give an insight into their attitude, desire,
and expectation.
4.How many dentures have been worn subsequently.
5.The degree of success or failure with the dentures.

This history can provide important information on the following:

The rate of bone resorption:
The history of tooth loss provides a basis on which to assess the current rate of
bone resorption. If extractions were carried out in the previous few months,
resorption will still be continuing at a rapid rate, so that if dentures are provided at
this time, they will soon become loose and require rebasing. The patient should
therefore be warned of this likelihood. If, however, the teeth were extracted several
years ago, the alveolar bone will have reached a relatively stable state and the life
of a replacement denture will be considerably extended.
Retained roots:
If there is a history of difficult extractions, it is advisable to obtain radiographs in
order to check for the presence and location of retained roots.
The adaptive capability of the patient:
Clues can be obtained as to the adaptive capability of the patient. For example, if
three sets of dentures have been worn successfully over a period of 15 years, it
may be assumed that adaptation has been satisfactory, whereas if the same number
have been provided over the last 2 or 3 years – and each has been troublesome –
the ability to adapt will be suspect.
It is thus a wise practice to ask the patient to bring all available sets of dentures
when attending the initial assessment, as inspection of them can yield valuable
clues and increase the accuracy of the diagnosis.

Diagnostic casts:
They confirm and sometimes reveal new information obtained from intraoral
examination. It may be of immense benefit to keep the cast ready during intraoral
examination.
Diagnostic casts should be mounted on an articulator following a facebow transfer.
This allows for dynamic evaluation of interarch relations, most importantly the
interarch space (interridge distance), which is very essential in determining if space
exists to place artificial teeth.
Undercuts and their significance can be evaluated with a dental surveyor.
Preprosthetic surgeries can be planned, and surgical templates can be made on the
diagnostic cast.