THE DEMANDING DENTURE PATIENT R.J.C.Wilding. BDS, Dip Pros. M.Dent. Ph.D

This review is about patients who are more than usually demanding of our time and effort to manage⁽¹⁾. It is about the patient, well known to us all, whose name on our day's schedule, immediately causes our spirits to drop. We feel inadequate, ineffective and powerless, our self esteem takes a dive, and we may get so fed up that we decide to give up making dentures. That will be a pity, especially when we consider that most of our efforts are successful. How can we manage or dispose of our demanding patients?

There are no easy answers to dealing with people who want to make our life difficult. Unless we are prepared to lay our vulnerability at their feet, hoping for mercy, we had better be prepared to defend ourselves. So here are some guidelines, for self defense, which start off, by helping us identify the demanding patient, and then follow some tactics which we can use to build up our defenses, as we go through the stages of making a new denture..

I am going to approach this problem as though we were going to set out on a journey by air together. There are three main stages of the journey where trouble can occur, on take off, in-flight and on landing.

TROUBLE BEFORE TAKE OFF

We know that pre-flight checks of all vulnerable systems are essential in minimising take-off problems. We need our check list and flight plan, as much as any airline pilot. Here are a few questions which help us to check out whether the flight is going to me a smooth or a bumpy one.

How is the patients general health?

There are a number of general medical conditions which adversely handicap denture wearers. It is not my intention to ignore the truly medically compromised patient, but here, we are specifically looking for clues which will help us identify the emotionally compromised patient, who is over stressed, anxious or depressed. Some of the frequently occurring stress related disorders are low back pain, headaches, TMJ symptoms, insomnia, gastric acidity, constipation, spastic colon, allergies and asthma. If our patient has one or more of these types of disorders it is worth explaining that stress-related disorders, are manifestations of anxiety and depression. Ordinary common health sense, indicates that cumulative damage may occur if stress is not reduced. More than common sense, is offered by Yemm, who reported that stress is associated with muscle hyperactivity, which in turn can cause denture soreness. So it is not out of place, to suggest that our patient see a psychologist or family counsellor in order to decrease their stress levels. This dialogue with the patient is extremely valuable. It may take some time, but the listening we do, and the searching questions we ask, are of great value, both to the patient, and to our future relationship. If we detect stress related disorders, we can point out, that all our problems, even uncomfortable dentures, are made worse when we are anxious, unhappy and depressed. This evaluation of other minor ailments sets the tone of much of the rest of the interview, by gently bringing into focus our patient's life-baggage, which they have unknowingly dragged into our surgery. We will be pointing out bits and pieces of this life history, and reminding our new patient when necessary, that it is their's and not our's. In summary, a list of other ailments and complaints should activate the first warning light.

What is the patient's track record of success?

Several sets of dentures and a trail of many unsuccessful attempts should trigger off the second warning light. We need to ask how our patient feels about having lost her teeth. Tooth loss caries with it emotional consequences, in particular loss of body image, youth and sex appeal, which few patients are prepared for. Some patients have never acknowleded this loss and are still angry about having had their teeth extracted. They may be so hostile to the artificial replacements that they are unable to accept them. A patient's reluctance to remove his dentures in the surgery, gives us a hint that he is still hurt by the shame of being toothless. This is a good time to confirm the emotional effects of tooth loss, a subject well reviewed by Fiske and others in their recent publication. We need to ask about the relationships with the past dentists. How does our patient feel about these past attempts, angry, resentful or reconciled? If it looks bad, ask if the previous dentures were paid for. We need to know how bad it could get for us. Some patients will crucify the last dentist, but smother you with praise and compliments... how your reputation positively glows, how you have helped so many of his/her friends, and how s/he is just certain that you are the one who is going to make her/him happy. Well, resist the flattery. Alex Koper calls these denture birds "carnivorous", but it is worth a moments introspection. Are we really the victims of these voracious feeders? Perhaps, as Carl Jung suggested ".. the enemy is within". We are all susceptible to praise, and want to feel effective; so much so, that we succumb to the flattery and miss the manipulation. Which brings us to the first real trap we do not want to fall into. That trap is to think we are going to be the knight who slays the dragon. We have to acknowledge our mortality, acknowledge that our colleagues are not all hopeless prosthetists, and resist the temptation to rush to the rescue. This may be a good time to educate the patient about the limitations of denture wearing;. This should go something like this;

"Can I remind you that when you had your own teeth, you had a total of about 200 square centimetres, that is about the area of a postcard, of a tough fibrous ligament which supported your teeth in the jaw bone. Having lost your teeth you have lost that ligament, and now you have about 12 square centimetres, a match-box area, of soft fragile skin, to support your false teeth. The skin covering your remaining bone is not all the same thickness. Over areas of thin skin, particularly where the underlying bone is sharp, the skin is easily pinched and damaged.

"When you lost your teeth you also lost the nerve supply to the ligament, and these nerves were essential for your muscles to work properly. So even if there is no pain, you cannot bite with more than 15% of the muscle power you had before you lost your teeth.

" So I am afraid that dentures are likely to be sore, and loose, and there is less muscle power, to chew hard food."

"The best solution to this problem is to have implants placed in the jaw bones, as they transmit the bite force direct to the bone, do not pinch the skin, and keep the denture firm. Wearing a lower denture without implant support is like trying to run over sharp pebbles with bare feet. Dentures are a compromise, because they are easy to make and require no surgery, but they are a compromise nevertheless. They require skill, and tolerance in learning how to live with them. Not everyone has these qualities in sufficient amounts". And just as a reminder, add, that when we are stressed, little troubles become bigger troubles.

This lecture may sound rather lengthy, but it continues the theme of our interview. Our potentially demandingt patient is going to be faced with taking responsibility for his/her problem. We are going to be saying .. the problem is yours not mine. I can help, but you are going to be the one to make new dentures work, not me.

This approach may sound callous, so it must be delivered in the most compassionate tone and terms. It may evoke an angry response from our patient " Are you telling me there is nothing you can do for me then?"

So we have to tease out our separate roles. We can do our best to see that the dentures are made well, but that will not be enough. The puppet will not dance and move until someone pulls the strings. In the end it is the patient who has the job of making the dentures work. We can guarantee to do our best, but we cannot go further than that. There are some more questions.

2. Does the patient have any habits, like clenching?

If they do, we should spend a few more moments in educating our patient.

"When you chew or swallow, your teeth come together momentarily and they squeeze the gum between the denture and the bone. That's okay usually, because the force is cyclic, press, release, press, release, and this allows the gum tissue to maintain an adequate blood supply. But if you clench, there is no release, and soon the blood supply of the gum tissue is cut off, and permanent damage is done. Most people are not aware that they clench, and so this damage happens without you realising it"

If you see a swollen lower mucosa, slightly blue, with some areas of ulceration, you can be fairly sure that this patient clenches his/her teeth. Sometimes just making the patient aware of this habit, helps to reduce it. But once again, it places the problem squarely with the patient, and sets limitations on the degree of comfort which might be possible with new dentures.

3. Does the patient have sharp bony ridges?

If you cannot press firmly down on either the upper or the lower ridge with your finger, without causing the patient pain, they have a sharp underlying ridge. If they cannot tolerate finger pressure, they will not tolerate a hard denture. Naturally, in making this diagnosis, you would exclude areas ulcerated by an ill fitting denture, or the generalised tenderness of mucosa caused be clenching. The ideal solution is pre-prosthetic surgery. Once again any alternative, such as a soft base, is a compromise, and must be owned by the patient, as his/her responsibility.

4 Does the patient have a flat lower?

While your heart may sink, as your examining finger fails to locate any alveolar bone, the absence of a lower ridge does not always predict problems ahead. Perhaps because patients are very aware of their problem, or perhaps because demanding patients do not always have the most challenging clinical problem. The flat lower is a challenge but I will address it in another review, specifically related to difficult clinical problems.

LODGING A FLIGHT PLAN

We need to lodge a treatment plan with our new patient before we begin making new dentures. Some old hands, recommend that a requirement be set which, apart from being quite sensible, tests out the degree of cooperation you can expect. Carl Boucher used to require his patients to leave their denture out for a week before the first impressions. He would explain to the patient that it was no good making an impression of bruised and distorted mucosa. "You want the best foundation for you new dentures don't you?" This is quite a demand to make. If the patient would not comply, he refused to proceed. Perhaps he also knew although he never admitted this, that if the patient refused to comply, he had just identified, and as rapidly disposed of, a difficult patient.

We need to write a letter, recording the main complaint, the anatomical and physiological problems we recorded during the examination, our estimation of the problems of the old denture, and the improvements the patient can expect in the new denture. A repeat of the disclaimers made about dentures being a compromise, can be followed by some more optimistic outlook for the patient if they are prepared to work with you. You will need to work together but the final outcome, is up to the patient. And finally , unfortunately no guarantee is possible, but you will do your best. This sounds like rather a lot of desk work but it can be cut down by drafting out some commonly used phrases, and sticking them in a flip file or compact photo album with codes for your typist/secretary. So the letter you draft just has a sequence of paragraph codes. Some you always use, but others may be specific for example" I believe new dentures should be made with a greater freeway space. The upper teeth can be set further forwards so that your lip is well supported. You will have an opportunity at this stage to comment on the appearance, and I advise you to take the wax teeth home for a few days, so that you can be satisfied with the appearance before the teeth are finished"

The letter concludes with a fee quotation, and includes the method of payment which should have been agreed on at the first visit. That, by the way should be payment at the final visit. There is no reason why you should not ask for this, as by then you have done your part. Most patients accept this, provided you assure them that they can come for as many adjustments as they like. And if they do not accept this arrangement, perhaps you will lose a few awkward, untrusting, and manipulative people, and that will be fine.

TROUBLE IN MID FLIGHT

It is disconcerting to find a she-wolf emerging as the visits go by. It is usually at the try-in stage, when the worst problems are encountered. It is always useful to have the time to make adjustments to a try-in yourself, otherwise you can look forward to an endless series of visits. I like to make changes at the chair-side, until there is some consensus. When you get to something you both like, take a Polaroid close-up, and look at it together, perhaps with some pre-extraction photographs. I have never regretted giving a patient a try-in to take home. They are usually quite careful with it, and it makes a great deal of difference to their acceptance of the final denture.

However, the try-in visit can become a merry-go-round, with lighter, darker, larger, smaller, back and forward. While this seems rational and progressive I can go along with it, but I always hold in the back of my mind a trump card. That is disengagement. It is never too late during mid-flight to abort and turn back. It can be a quite honest expression of frustration, weariness, futility. There comes a time to say enough! I cannot go on. Goodbye.

TROUBLE ON LANDING

Like the take off, this is a crucial testing time. It is the moment when the patient has the greatest power to destroy our self image. This is when we are at our most vulnerable. All the careful preparations, agreements, and disclaimers must now hold up.

But before the patient gets a chance to utter a word, go through your landing procedure carefully. In short, it involves making a careful analysis of the fit of both dentures using pressure-indicating paste. It is then followed by an analysis of the occlusion using bite registration wax. This is followed by some test food (seedless raisins). All this before the patient has a chance to look or comment on anything else but that which you ask for. You can call this damage control, but it means that you take your time to check off, comfort, retention, bite, function, in that order. Solve problems as they occur, before going on to the next stage. Finally, the mirror. There should be no surprises. This does not guarantee that your patient will not moan, " Oh the teeth are so big! Why did give me such big teeth I will never wear them!" This should not happen to anyone, but it does. Your trump card can also be played now. Disengage.

"Well Mrs X, I am sorry we seem to have wasted each others time. You don't have to take the dentures."

I have on a few, memorable occasions, written a cheque out for a patient who had already paid for dentures, and taken the dentures back. I would do it again. It is empowering to be able to bring an unsatisfactory episode to an end. The financial loss is trivial, but it clears the palate of what is otherwise a lingering and unpleasant after-taste. We cannot win them all, but we can, and should be, proud of the effort we make to help patients. Don't let a few disgruntled and angry souls, spoil the pleasure of making dentures.

These advisory notes may insulate us from some of the heat, but making dentures is hazardous, and there is no insurance against failure. Although we might remind ourselves, when we record a failure, that our task was not to satisfy, but to make a prosthesis with all our skill. If we have done that we have not failed. Excellence is our objective, and within our grasp; perfection is not.

Recommended Reading

Basker R.M., Davenport J.C. and Tomlin H.R. (1983) Prosthetic treatment of the edentulous patient. 2nd Ed.Macmillan Press.

Fiske J., Davis, D.M., Frances C. and Gelbier S. (1998) The emotional effects of tooth loss in edentulous people. BDJ. 184. 90-93.

Koper A. (1998) Difficult denture birds - New sightings. J Prosth Dent. 60, 70-74.

Koper A. (!964) Why dentures fail. Dental clinics of North America. November , 721-734.

Marbach J.J (1985) Psychosocial factors for failure to adapt to dental prosthesis. Dent Clin North Am. 29, 215-233.

Newton A.V. (1975) The difficult denture patient, a review of psychological aspects. Brit Dent J. 138, 93-97.

Pitts. W.C. (1985) Difficult denture patiens: observations and hypothesis. J Prosth Dent. 53, 532-534.

Pound E. (1965) Preparatory dentures. A protective philosophy. J. Prosth Dent 15,5-18.

Yemm, R (1972). Stress-induced muscle activity: A possible etiologic factor in denture soreness. Journal of Prosthetic Dentistry. 28, 133-140.

Wilding (1997) The etiology and management of denture pain. Dental Practice. In Press.

Produced by Moorland Dentistry . Further information from