History, Laboratory and Examination

Alaa Al-Otaibi

Diagnosis And Treatment In Prosthodontics, Chapter 3 By: William R.Laney

Patient Data interpretation:

History Lab test

physical

Successful treatment

A-History
Recording the history can be the first step in resolving a

patients problem.
The art of history taking lies in the ability to subtly direct

the conversation with the patient.

Universal system of checkboxes is not satisfactory to

document a patients subjective description of symptoms.

This Questionnaires may be indicated for some patients,

particularly those entering a practice for the first time.

A- History
Guideline for logical sequence of history:

1- Initial Onset 2- Anatomical location of pain 3- Characteristics of pain 4- Factors that aggravate or relieve pain

5- Previous consultation, diagnosis and treatments

II- Laboratory Data:

Although the prosthodontist may not routinely

order laboratory tests, its important that clinician have a working knowledge of laboratory data. (why?)
This information assists in disease differentiation. Determination od definitive diagnosis.

Provides parameters for treatment planning and

management.

II- Laboratory Data:

Basic tests:
Complete blood count (CBC). Hemostasis and coagulation studies

- Prothrombin time (PT) - International Normalized ratio (INR)

Comprehensive metabolic panel

II.Lab test
CBC: A CBC incudes 5 measures:

1- WBC Concentration 2- RBC concentration 3- Hematocrit

4- Platelets count
5- Hemoglobin

II. laboratory
Hemostasis and coagulation studies:

Requested for:
-

patient who have medical condition that require anticoagulant. Or medical condition that affect clotting include ( liver disease, uremia, some cancers, bone marrow disorder or vit K deficiency)

PT: measure the activity of factor II, VII,X and fibrinogen INR: (PT/PT normal)ISI

II.Labratory:
C. Comprehensive metabolic panel (CMP): Consists of 14 specific tests Provide an overview of:

- kidney function, electrolyte and acid-base balance. - blood sugar, Ca, protein level.

III- Physical
A- Extra-Oral B- Intra-Oral

III. Physical
A- Extra-Oral Examination: 1- patients relative body proportions, weight, posture, gait, degree of functional coordination, any obvious abnormalities. 2- head a neck region:

Facial composition, asymmetries, skin texture, complexion, expression in the eyes, breathing

3- perioral region:
Abnormality like swelling, deformities. Lesion, discoloration. Lips, ears, nose

4- Digital palpation to examine the( lymph nodes, salivery gland, thyroid gland and muscle of mastication).

III. Physical
B- Intra-Oral examination: 1- soft tissue ( tongue, floor of mouth, mucosa, palate)

2- Occlusal analysis and vertical dimension determine.

3- esthetic evaluation. 4- dentition:

(number, color, accretions, alignment, location in the arch, individual position mobility, migration, crown root ratio, caries incidence, morphology fracture, erosion, attrition, interproximality contact)

III. Physical
B- Intra-Oral Examination:

5- Dentition in function
-

The horizontal relationship of mandible to the maxilla and all functional occlusal conntact should be visualized. -diagnostic mounting should be made using a centric relation recording

II. Physical
6- functional analysis of mandibular movement. Classification of mandibular movement : Cyclic, vertical, bruxing Cyclic pattern Smooth surfaces on marginal ridge Inclined planes Flattened triangular ridges Widened fossae with moderate to minimal cuspal wear Vertical mastication - Relatively steep - Sharp cusp - -excessive wear on buccal or labial cuspal inclines and surface of manibular teeth - exessive wear in lingual surface of the maxillary teeth Bruxing - Flat occlusal and incisal surface. - - anti monson or reverse curve within arch. - The occlusal table generally appears widened and th incisal edges beveled

Beyron categorized mandibular movement patterns as: a- multidirectional gliding movement. b- predominantly bilateral movements. c-predominantly unilateral movements. d- predominantly unilateral movement

III. Physical
The Edentulous mouth :

The approach of examination according to the Patient experience with prostheses :-

I. with no prior experience for prosthesis look for primary reason for extraction . Periodontal cause for tooth loss : Expect reduced bone support thus reduced ability to respond to prosthesis stress. Caries as causes for tooth loss: Bone has not reduced and denture bas support expected to be optimal .

II. Patient with previous experience : -Observe tissue response to prostheses stress . - Using diagnostic cast ,Radiograph To determine appropriateness for complete denture.

The edentulous mouth:

1- Arch size and oral aperture:

Discrepancy between maxillary and mandibular arch or opening to oral cavity. These condition can be seen in patient treated surgically, burns ,traumatic injury ect. Difficulties can be encountered in impression ,maxillomandibular relation and teeth arrangement

Solution: 1- Longer appointments 3- Premedication or sedation 4- Use of topical lubricant 5- Less bulky retracting instrument 2- Staged clinical procedure

The edentulous mouth:

2- Ridge form:

Examination of the Ridge form should include :

Evaluation of ridge bony support and potential stability and

retention
Development of desirable occlusal scheme and esthetic

arrangements of tooth.

The edentulous mouth:

2- Ridge form:
Ridge form is the cross sectional contour specially the maxillary form and its relation to palate is very critical

U shape: The most favorable arch form is the provide broad base to support the occlusal stresses and parallel sides enhance adhesion and resistance to displacement

V shape ridge: Has narrow crest that cannot absort masticatory stress without irritation or discomfort .

Flat ridge: most frequently seen and most difficult to restore .

The edentulous mouth:

2- Ridge form:
Ridge resorption ranges from minimal to extreme, the pattern

of resoroption vary depends on the local influences .

Parasthesia and ridge soreness is common complaint when

the Ridge are resorbed .

Variation within typical ridge forms can occur, exostoses ,

lingual tori, irregular bony resorption , sharp spicules ,bulky or flared ridge , undercut complicate insertion and removal of prosthesis .

The edentulous mouth:

3- Palate:
Palatal configuration is interrelated to maxillary ridge form to the

extent .

When the hamulus is prominent , the mucosal covering can be

easily irritated by over extension of the denture.

Soft palate:
The form of soft palate can be classified into Class I,II,III According

the slop of the palate , which can be covered by the denture base. Soreness and loss of border seal can be seen in class III palate which drop abruptly from the hard palate.

4- Lateral throat form: - This observation is important ascertain the opportunity for denture base extension area
70% class I 25% class II 5% class III

- The recommendation is to use implant depth gauge to determine length of lateral throat form and aid in custom impression tray fabrication .

The edentulous mouth:

5- Maxilla mandibular relashionship:
A critical evolution of arch alignment and the

interarch ridge relationship is necessary to formulate a treatment approach that enhances the strength and minimize the weaknesses of the structure .
Factor such as tray selection , impression technique

, tooth forms and position , division of interarch space , occlusal scheme and base material

The edentulous mouth:

6- Tongue: I. Morphology
long narrow and tapered
Not problematic in taking impression

short broad and thick

Provide positive contact surface for the lingual denture flange and better border seal - Complicate impression procedure. - More susceptible to irritation and occlusal trauma from teeth

Less effective in providing lingual seal

Smith E,1951

The edentulous mouth:

Tongue position: - According to Wright et al :

75% normal position 25% retracted position classified class I ,II normal tongue position enhance retention and stability of maxillary and mandibular denture

retracted tongue result in looseness of the denture

Tongue must be respected and accommodated adequately in the prostheses design . Poor tongue habits usually result in unsuccessful denture experience

The edentulous mouth:

7- Mucosa:

Divided into masticatory , lining and specialized mucosa

Masticatory mucosa: Examination of masticatory mucosa allows determination the degree of stability of the prostheses that might be expected

Lining mucosa : The vestibule Mucobuccal fold Floor of the mouth When functional space and appearance permit, increased width of the denture flanges enhance the border seal.

Specialized mucosa: Covering the dorsal and lateral surface of the tongue

III.Physical
Implant therapy: Examination of patient needing implant therapy ,particular attention :
Ridge morphology , Interocclusal relationship , Parafunction occlusal habits ,location of available bone ,

Esthetic consideration that needs gingival recontouring,

and psychological profile of the patient

III. Physical
Taste: alterations in taste sensation is a complaint for denture wearers

Henkin and chrestenson found that person wearing complete maxillary denture had significant elevation of taste for bitter and sour . Which is similar phenomenon happened for anesthetized palate region. In contrast ,other study found the taste perception was slightly enhanced. Other investigation suggested that neither the contour nor the denture base material affected the ability to perceive taste of a solution at room temperature. Hyposmia : decreased sensitivity to odor. But patient demonstrate high threshold for bitter and sour taste s and have high arched palate . Patient with surgical defects reported to have loss of taste sensation. However, this found to be enhanced when prostheses in place.

III. Physical
Malignant lesions - 25 % of oral cancer occur in patient without known risk factors
-

Early lesion and premalignant lesion are difficult to detect due to subtle changes to mucosa. Lesions present initially as either leukoplakia or erythroplakia and pregress non healing ulceration. In advance stage, other manifestation such as bleeding, lossening of teeth, dysphagia, dysarthria, development of neck masses

- The use of oral cancer diagnostic tools as an alternative to biopsy:

Oral cytology light detection of mucosal abnormality

IV. Informed Concent

Is thought appropriate for all non reversible procedures and those involve risk of the patient

Proper informed consent should contain the key principles:

Informed consent is not substitute for patient education . Clinician should have open discussion with patient to ensure the communication is clear . The forms should be written in language that average person would understand. Patient should actively participate in discussion .and provide the opportunity to discuss the concerns Verbal provision of information to patient about the risks , benefits and alternative to treatment and subsequent documentation of the dcussion in the medical records may be an acceptable substitute for a formal signed consent form Brenner etal,2009