Preparing patients for partials

Patient expectations for partial dentures can be all over the place. Some might be realistic, others--not so much. Setting proper expectations is an essential part of the successful delivery of the partial appliance. 

Today, we take a closer look at what the literature has to say about the role patient expectations play in partial denture success. We also speak to an expert about how to set patient expectations that will make the transition easier for everyone, and help patients have the best possible experience getting used to their new teeth.

Studies say partial denture success relies on these factors.

Per the Journal of Prosthetic Dentistry, the success or failure of the delivery of a removable partial denture (RPDs) can depend on many things.¹ Like all things in dentistry, success starts with an excellent treatment plan, which should have its foundation in clinical and radiological evidence.² In other words, clinical procedures for guiding planes placement and rest seats and how you use crowns on abutment teeth for the removable partial denture are, of course, significant.

However, as early as the 1950s, the formula for success with the patient experience for the delivery of the RPD included patient education.³ Researchers emphasized the significance of the steps of the design process used in tandem with “intelligent and informed” patients who understood the importance of maintenance of the appliance and their surrounding teeth.⁴

Related reading: Choose the right patients for flexible removable partial dentures

In 2003, the Journal of the Canadian Dental Association published an article about the critical nature of setting patient expectations for their RPD.⁵ The review suggests patients are satisfied and compliant with their partial denture therapy when they are “fully informed about the limitations of the prosthesis they are about to receive.”⁶ Based on their research, the areas the authors said should be addressed with patients include:⁷

• Esthetics                                                                                

• Chewing                                                                               

• Overeruption 

• Post-insertion care

• Comfort

• Longevity of the prosthesis

• Speech effects

• Potential biological consequences of the appliance

Adequate preparation of the patient is delivering RPDs by the book, literally. McCracken’s Removable Partial Prosthodontics textbook advises dentists to get informed consent from patients to ensure patient cooperation and compliance.⁸ It describes the idea that a doctor will secure cooperation and compliance without education as “folly.”⁹

The authors also say patient education should begin at the first appointment and continue throughout the process. The authors emphasize the importance of discussing the treatment plan and prognosis with the patient, as ignoring that could result in limited success with the appliance. Furthermore, since patients won’t remember everything you say, they suggest supplying a written version as well.¹⁰

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How to set proper patient expectations.

Marc Wagenseil, CDT, DD has a lot of experience setting patient expectations for partials. The following three points are an essential part of how he sets patient expectations for an RPD.

• The RPD has a mix of teeth the patient can feel and teeth the patient cannot. It is a different sensation to eat when you cannot tell that all your teeth are functioning with each other. Your brain requires time to adapt.

• Your tongue needs to familiarize with the RPD. The tongue will learn it can touch the appliance and stop flinching when it feels it, but it also takes time.

• Patients should tell themselves these two things are occurring. By reminding oneself out loud that the RPD is a change, you can help your brain repeat the message and acclimate to the appliance.

Wagenseil usually begins by explaining a denture is an artificial appliance there to reproduce natural teeth. It is essential to remember a patient can feel their natural teeth, which have nerves in them that tell the brain where they are. However, the brain cannot feel the teeth that are part of the RPD.

“When you put a denture in the mouth regardless of the type, whether it be in cast frame, flexible or acrylic, the brain has to learn to function with teeth it can feel and a denture it cannot feel, directly,” Wagenseil explains. “It's difficult.”  

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Wagenseil compares it to a person who has a new artificial leg. If the patient can't feel that artificial foot on the floor, how did he or she know the foot has touched the ground? They feel the artificial leg compressing into the remaining part of their natural leg, and then they get used to that pressure.

Over time, the brain will learn to “feel” the denture by the load it puts on the gum and how the clasps exude pressure on the teeth. Wagenseil says this happens with time and repetition.

“A patient learns to adapt to a partial denture by wearing it and repeating chewing, speaking, swallowing and daily functions. It requires time to learn how to orientate with it,” he says.

Denturists hear more complaints about a lower partial than an upper. Wagenseil says it is because the tongue feels the lower more than it contacts the upper. It touches the metal and recoils from it, and that’s what causes all the problems with lowers.  

Also, the tongue’s instinctual movement affects how you chew and bite, which could be a possible choking or gagging hazard. Wagenseil says the central nervous system will need time to get used to the new material’s presence in the mouth.

“I had a patient once tell me- this was quite funny but quite brilliant-the patient said they had to physically and consciously tell themselves, ‘That is the denture. It is supposed to be there,’” Wagenseil says. “Once they started to reinforce that consciously, the adaptation process improved.”

Wagenseil says the brain requires over 90 days to adapt to the denture. He has patients stay on a soft food diet for the first few weeks, allowing the brain to learn what's in the mouth. However, even after moving from the soft food diet to a regular diet, the brain needs three months before it feels “normal” to use a denture.

In addition, Wagenseil says, the term “soft foods” can be misleading. Some soft foods can cause hard problems for keeping the partial in one piece.

For example, bread is dangerous. Wagenseil has seen more damage done on dentures with bread than chicken wings and ribs. Wheat gluten, when mixed with saliva, becomes a sticky ball in your mouth.  When chewing it, your brain is going to overexert, and the mandible and the jaw will shift. Then, the teeth will hit on the guiding planes, and they break.

“It's like chewing licorice. It's hard on your mouth, on your jaw, and on your teeth when you eat licorice because it's really rubbery. There's a lot of flexing going on,” Wagenseil says.  “That’s what it's like with gluten somewhat.”

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Additional tips and instructions for patients.

In addition to these philosophical elements, Wagenseil also has specific tips and instructions for patients with an RPD for compliance and maintenance:

• Unless instructed otherwise, do not sleep with it in. You want to release the pressures the RPD puts in your mouth.

• Always insert and remove it with your fingers using finger pressure. Never bite it into place because you will damage the denture, the clasp and your natural teeth.

• Handle with care and do not drop. Often patients think a partial should not break when it drops, but it will.  

• Clean it daily. The partial needs to be cleaned every day.

Wagenseil shares this information and then presents it in written form for the patient to signt It serves as a treatment plan with his expectations explained. He recommends dental technicians do the same and collaborate with the dentist on it.

“It's about upping your game and the value of your lab. The value of you, the owner or manager, is education. If the dentist doesn't take time to educate patients, then the lab should write it down and use it as a marketing tool to help educate the patient,” Wagenseil says.

Related reading: How to fabricate flexible removable partial dentures

Another tactic Wagenseil uses to help set patient expectations to getting used to how the partial sits in their mouth and pushes on the gums and teeth is on the sillier side-but it is effective. He compares wearing the partial to asking the patient to walk in  10-inch-high stiletto shoes. He says that man or woman, they will fall over at first, but eventually, they will train their brain and central nervous system to walk in those shoes.

“How do I know this to be true?” Wagenseil says.  “I tell them if the rock group KISS at their age can still to this day go on tour and wear those darn 10-inch platform boots, and entertain people and not die of a heart attack after or fall over, you can get used to a denture.”

Wagenseil says the patients laugh, but every patient knows who KISS is and they get it. Patients appreciate the time he takes to explain what they should expect with their partial at first.

“Then they know, ‘Oh, this is what it feels like.’ So, then their brain has to compensate,” Wagenseil says.  “When giving an explanation to someone, if you include some funny anecdotes, they get the point.”

Wagenseil is dumbfounded about the lack of proper expectation setting when it comes to a new denture. For example, he explains, when you buy a new car, the dealer tells you to take it easy and not drive it too hard. When you get surgery, they tell you to take it easy and not exercise too hard afterward.

However, when you get a new partial, dentists put it in the patient’s mouth, shake their hand, and send the patient to a steak restaurant that night. Wagenseil takes a different approach.

“You have to take it easy,” Wagenseil says. “You have to allow your central nervous system to understand and adapt to change.”

_________

References

[1] Ibid.

[2] Ibid.

[3] McCracken, William L. “Mouth preparations for partial dentures. Journal of Prosthetic Dentistry. 1956 Nov; 6 (1): 39 – 52. Accessed via web: 13 June 2019. <https://www.thejpd.org/issue/S0022-3913(56)X8003-0.>.

[4] Ibid.

[5] Mazurat NM¹, Mazurat RD. “Discuss before fabricating: communicating the realities of partial denture therapy. Part II: clinical outcomes.” J Can Dent Assoc. 2003 Feb; 69(2):96-100. Accessed via web. 13 June 2019. < https://www.ncbi.nlm.nih.gov/pubmed/12559058>.

[6] Ibid.

[7] Ibid.

[8] Alan B. Carr, David T. Brown. “CHAPTER 13 - Preparation of the Mouth for Removable Partial Dentures.” Editor(s): Alan B. Carr, David T. Brown,McCracken's Removable Partial Prosthodontics (Twelfth Edition), Mosby,2011,Pages 185-204,ISBN 9780323069908, Accessed via Web. 13 June 2019: http://www.sciencedirect.com/science/article/pii/B9780323069908000130.

[9] Ibid.

[10] Ibid.