Prosthodontics 101

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Prosthodontics 101
January/February 2007
Karen Kulikowski, DMD
Contemporary Dental Assisting

Prosthodontics is an interesting and varied dental specialty. The many removable and fixed prosthodontic procedures can provide dental assistants with an interesting career. Providing lifelike reproductions of hard and soft oral tissues for patients who are missing these structures can be a rewarding aspect of dentistry. Whether the teeth were lost because of trauma, dental caries, or disease, the oral anatomy should be replaced for optimum dental health, overall general health, and social well-being.1 Replacing the teeth and oral structures provides for proper mastication and enables patients to maintain a healthy diet.2 Replacing the soft tissues of the oral cavity maintains the shape of the lips and face and the vertical dimension of occlusion.3 Prosthetic replacement of oral tissues will keep the temporomandibular joint in a comfortable position, preventing the overclosure of the joint and avoiding undue stresses on the temporomandibular, sphenomandibular, and stylomandibular ligaments, as well as the fibrocartilaginous disk. Replacing the missing anatomy also will reduce the depth of the nasolabial folds and labiomental groove to help the patient retain a more youthful appearance.3 Comfortable, well-fitting dental prostheses allow for proper pronunciation. Patients with spaces from missing teeth or a speech impediment may become less outgoing and more self-conscious.4 Paients who do not replace missing teeth also may develop health problems caused by inadequate dietary intake.2,5(p261)

During my 10 years as a dental assistant before attending dental school, prosthodontics was one of my favorite dental specialties in the general dental office. Developing a relationship with each patient and helping them through sometimes difficult decisions is very rewarding for dental team members and is often comforting for patients.

Removable Prosthodontics
Removable prosthodontics offers dental assistants numerous opportunities to facilitate optimal dental care: preparing for and making preliminary alginate impressions, fabricating custom-made impression trays, mixing various rubber impression materials, fabricating record bases with occlusal rims, providing input during the selection of the shape and shade of replacement teeth, assisting with the face bow transfer, and providing detailed instructions for the care of a new prosthesis and the oral cavity. Dental assistants also complete laboratory prescription forms, disinfect and package impressions or record bases with the set teeth from the try in, and make arrangements for pick up with the dental laboratory.

Providing a realistic and undetectable prosthesis is both a science and an art. A dental prosthesis can be costly, and much time and effort is spent preparing the replacement teeth to replicate the form and function of missing structures while being comfortable for the patient. Dental assistants should provide home-care demonstrations and written take-home instructions with illustrations to prolong the life of the prostheses and enhance the longevity of the patient's investment. Supply patients with product samples, such as denture cleanser, storage containers, and denture brushes.

Emphasize that a separate denture brush should be used on the removable prosthesis and that patients should not use the same toothbrush that they use on their remaining natural teeth.5(p263),6(pp859-860) Denture brushes are specifically designed to fit into the clasps and grooves of the appliance. Denture brush bristles are shaped differently and are stiffer than the typical soft-bristled toothbrush. The typical toothbrush is not intended to clean prosthetic appliances and only should be used on natural or nonremovable prosthetic teeth.

There is nothing better than seeing patients smile at their insertion visit. Proud patients are not shy about admiring their new smiles from all angles. Make sure to provide patients with a good sized hand-held mirror. If your office has an intraoral camera, giving patients a final photo would be a nice gesture.

To prepare patients for long-term oral health, dental assistants should instruct patients about the proper care of their remaining oral structures and their new prosthetic device. Remind patients to keep a regular schedule of dental examinations for their soft tissues and remaining teeth as well as an annual oral cancer screening. Edentulous patients may mistakenly rationalize that because they do not have any natural teeth, they no longer need to visit the dentist. Nothing could be further from the truth. Instruct patients to expect their tissues to continue to change over the years. Also relay that no restoration or prosthesis is permanent. Relined or replacement prostheses may be required in the future.

Inform patients that they should not adjust their prostheses with pliers or any other household tools or chemicals. If patients feel their removable partial denture is loose, they should call the dental office to make an adjustment appointment. If a full denture cannot be maintained on the oral tissues, patients should not use over-the-counter (OTC) reline materials, but should call the office for a reline appointment. An in-office chairside denture reline can be completed in about an hour, and patients can go home with their denture fitting properly without the use of adhesives. OTC reline materials may become sticky and, if patients do not remove previously added layers of adhesives and continue to add more reline materials, occlusion may be affected and the tissue surface of the denture may harbor microbes.5(pp258,263),7

Patients who wear dentures can develop oral yeast infections if their denture is not removed from their mouth, adhesive products removed, and the denture cleaned daily.5(pp258,263),8 Patients with a removable prosthesis should be instructed to remove the appliance from their mouth for cleaning. Cleaning is usually done at bedtime, but can be done after meals as well. Patients also should be instructed not to sleep with the removable appliance in their mouths, no matter how well the removable prosthesis fits. The oral tissues need rest. Full and partial dentures should be soaked in a denture cleaning solution or at least in water overnight.

It is gratifying to see that patients have maintained their prostheses and have continued to follow your home-care directions when they return for their postinsertion and 6-month follow-up visits.

Fixed Prosthodontics
Fixed prosthodontics also offers dental assistants a variety of opportunities to provide patients optimal oral health care. In addition to preparing and mixing preliminary and final impression materials, dental assistants can place and remove retraction cord, fabricate provisional crowns and bridges, make occlusal records, and manipulate temporary and permanent dental cements.

Removal of excess cement after cementation is crucial for periodontal health.5(p180),6(pp833-834),9 After the cement has hardened, use a scaler to remove any remaining cement from the facial, lingual, and interproximal surfaces. Dental floss should be threaded through all embrasures and passed under all pontics to insure the removal of all remnants of excess cement from those areas. You can place several knots along the length of dental floss or use yarn or dental tape to assist with the removal of small pieces of dental cement from under the fixed prosthesis. If excess cement is not removed from the interproximal area, the cement can work its way into the sulcus and cause periodontal irritation and possibly lead to a gingival abscess.10 Patients should be made aware that any pain, swelling, or redness in the area of the newly cemented prosthesis should be reported to the office immediately.11 To maintain the periodontal health in the areas of the crowns or fixed partial dentures, evaluate patients' self-care techniques at the postoperative and subsequent recall visits.

Patients with fixed partial dentures or bridges also need individualized home-care instructions. Dental assistants should demonstrate the use of dental floss, floss threaders, and interproximal or unitufted brushes as needed. Demonstrate these new home-care instructions intraorally on the patient's new fixed prosthesis as well as extraorally on a demonstration model. To ensure that patients understand the techniques, allow them to practice while you observe. Inform patients that because plaque can accumulate under a fixed prosthesis, flossing under their fixed partial denture is now an essential part of their home care. Because rinsing after flossing can help clear loosened plaque and debris from the oral cavity, patients should add this step to their daily oral care routine. Providing samples of floss, floss threaders, interproximal brushes, and mouthrinse can help patients get off to a good start. Printed home-care instructions with illustrations can help patients with new fixed prostheses attain optimal, long-term oral health.

The Circulating Assistant
The addition of a circulating assistant to the practice can reduce the patient's chair time and keep visits to a minimum. During prosthodontic or any other dental procedures, using a circulating or floating assistant also can enhance productivity because the dentist and chairside dental assistant can continue providing procedures while the circulating dental assistant sets up the armamentarium for the next sequence of treatment or removes equipment and materials from completed procedures. All the team members need a comprehensive understanding of the procedures and armamentarium to keep the procedures moving. For example, during the final impression the chairside dental assistant can prepare the patient while the circulating assistant can prepare the impression material and load the impression tray. Retraction cords can be removed by the chairside assistant, and the dentist can make the final impression. After the impression material is set and removed from the patient's oral cavity, the chairside assistant can examine the oral cavity for any remaining pieces of impression material and begin to prepare and cement the provisional restorations. Simultaneously the circulating assistant can disinfect the impression and complete the laboratory prescription as per the dentist's directives. The ability to anticipate procedures and have the proper armamentarium ready to be transferred or exchanged when and where it is needed is invaluable.

Conclusion
Experienced dental assistants are valued members of the dental team. Chairside and circulating dental assistants work in concert with each other and the dentist in the treatment area to facilitate the provision of quality dental care in the least amount of time. This not only helps to keep everyone on schedule, but also benefits the patient by a quicker, smoother appointment. Chairside assistants work hand in hand with the dentist during patient treatment, andcirculating assistants hand off materials and instruments and keep the treatment area clear of extraneous items. This process can increase the dental office production by enabling the dentist to treat more patients and generate more income in less time. It is virtually impossible for a dentist to provide ideal treatment in a timely fashion without a knowledgeable dental assistant or 2 on the other side of the dental chair.

References
1. Novak D. Contemporary Dental Assisting. St. Louis, Mo: Mosby; 2000: 770.

2. Touger-Decker R. Nutrition and oral health: promoting healthier aging. UMDNJ Research [serial online]. Fall 2006. Available at: www.umdnj.edu/research/publications/fall06/12.htm. Accessed Dec 12, 2006.

3. Mohindra NK, Bulman JS. The effect of increasing vertical dimension of occlusion on facial aesthetics. Br Dent J. 2002; 192:164-168.

4. Garrett NR, Kapur KK, Perez P. Effects of improvements of poorly fitting dentures and new dentures on patient satisfaction. J Prosthet Dent. 1996; 76:403-413.

5. Hatrick CD, Eakle WS, Bird WF. Dental Materials: Clinical Applications for Dental Assistants and Dental Hygienists. Philadelphia, Pa: Saunders; 2002.

6. Bird DL, Robinson DS. Torres and Erlich Modern Dental Assisting. 8th ed. Philadelphia, Pa: Saunders; 2005.

7. Shay K. Treatment of an edentulous patient with dry mouth: use of denture adhesives. Available from: Procter & Gamble Resource Net, Cincinnati, Ohio: www.dentalcare.com/soap/ce20ca/20_04j.htm . Accessed Dec 12, 2006.

8. Perry DA, Beemsterboer PL. Periodontology for the Dental Hygienist. 3rd ed. Philadelphia, Pa: Saunders; 2006: 115.

9. Torres HO, Ehrlich A, Bird D. Essentials of Dental Assisting. 2nd ed. Philadelphia, Pa: Saunders; 1996: 410-411.

10. Weinberg MA, Westphal C, Palat M, et al. Comprehensive Periodontics for the Dental Hygienist. Upper Saddle River, NJ: Prentice Hall; 2001.

11. Serio FG. Manual of Clinical Periodontics: A Reference Manaul for Diagnosis & Treatment. Hudson, Ohio: Lexi-Comp; 2002: 105.