Chapter 35

PERSISTENT PROBLEMS

Following treatment, the patient may complain of persistent problems relating to:

• Aesthetics
• Function
• Pain/discomfort
• Paraesthesia/hyperalgesia/anaesthesia
• Fees

These problems may be real or imagined, that is, the patient considers them to exist, but there are no signs.

A correct diagnosis is vital and the history can be invaluable in this respect. Major life events, such as bereavement, redundancy, divorce, house move, job change (both promotion and redundancy), problems with children, and so on, particularly in conjunction with symptoms such as pruritus, migraine, irritable bowel syndrome, and back pain point towards the complaint being psychogenic in which case modification of the restorations will not solve the problem. Instead, counselling and/or drug therapy is required. Impending litigation, either in respect of the original treatment or following an accident can severely lessen the patient’s ability or willingness to adapt to the new restorations.

Aesthetics

An objective assessment of whether the patient’s dissatisfaction with aesthetics is justified demands a sound knowledge of normal tooth form and gingival contour. If there is doubt about the aesthetics of the restoration, a second opinion from another dentist can be valuable. If there is a possibility of litigation, guidance from the practitioner’s professional insurance company must be sought.

Function

Problems may involve:

• Speech
• Mastication
• Occupation
• Sexual activity

Speech – Real

Enlarged embrasures, excessive increase of vertical dimension, incorrect lingual contour of anterior restorations, wrongly positioned anterior teeth and osseointegrated fixtures and the space between the undersurface of a fixture supported bridge and the edentulous ridge can all give rise to speech problems. If such problems are inevitably due to the difficulties posed and the limitations of treatment, they should have been pointed out early in the treatment plan, and tests made with provisional restorations so that the patient would know the outcome. Often, with time, these problems will resolve themselves spontaneously. Enlarged embrasures may be modified by means of a removable labial veneer or a palatal removable cobalt chromium appliance. In some cases, however, refabrication will ultimately be required.

Speech – Imagined

Such problems can sometimes be resolved by making tape recordings of the patient’s speech so that they can actually hear themselves. When the patient’s initial complaint on presentation is related to speech it is advisable to make such recordings before and after treatment.

Mastication – Real

Mastication difficulties can be caused by:

• Incorrect vertical dimension.
• Unstable denture bases.
• Pain.
• Mobility.
• Inadequate number of occlusal contacts.
• Absence of cusps (although there is a lack of research to substantiate the need for cusps on fixed prostheses, subjectively, the impression is that multiple cusps with good opposing contacts cut food better than cuspless teeth).

Mastication – Imagined

The patient’s expectations may exceed what can be achieved. In such cases, wherever possible, counselling should be instituted prior to treatment. Post-treatment counselling may also be helpful. It should be explained to the patient that just as one would not expect to be able to run a race immediately after being fitted with an artificial limb, so extensive re-restoration of the dentition may require a period for adaptation.

With modern prosthodontic techniques, however, mastication should rarely be a real problem.

Occupational – Real

For example, wind instrument players may have difficulty unless due consideration has been given to the embrousure in the restorative phase. Occasionally, removable flanges may be used to alter soft tissue form and an occlusal stabilization appliance which splints mobile teeth may assist by providing better support for posteriorly directed instruments, such as trumpets. The reader is referred to a series of articles by Porter (1967).¹

Occup/>

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