Managing the retching patient/Loose dentures Flashcards
What causes retching?
Physiological mechanism
-> Involuntary contraction of the muscles of the soft palate
-> Modified by higher centres in the medulla oblongata (psychological/anxiety component)
What are the types of retching?
Psychogenic- caused by sight, smell or sound of a dental surgery or thought
Somatic
-> Touching ‘‘trigger zones’’ commonly palatoglossal and palatopharyngeal folds, base of tongue, palate, uvula, posterior pharyngeal wall
*** Often a combination
What can be done to help patient with impressions and registrations if they have retching tendency ?
Consider trimming trays and record blocks before putting in patient’s mouth
What is the ideal posterior extension of a denture? How can this be modified for patients who retch?
Vibrating line is ideal extension of the back edge of the denture
-> Perfect area to create seal, can wrap around and retain in space
Some patients will struggle with this as it will trigger retching- trimming denture further forward can help but seal is worse, and retention is compromised
How can retching be managed?
Identification of problem
Identify trigger zones
-> check areas with back of mirror (don’t tell the patient)
Anxiety reduction
Patience and empathy
Use of topical anaesthetic on vibrating line
WWhat are examples of passive relaxation techniques used to reduce anxiety?
Dim lighting
Music
Avoid sight of dental instruments
What is an example of an active relaxation technique used to reduce anxiety?
Controlled rhythmic or relaxed abdominal breathing
What are the different distraction techniques that can be used for patient’s with retching tendency?
Talk to patient
Get patient to concentrate on keeping their leg raised/wiggle toes
Get patient to press or tap their temple
Put salt on the tongue
Ask patient to close eyes
Rinse mouth with very cold water just before treatment
What can be done in order to attempt to desensitise a patient who has retching tendency?
Repeated brushing or stroking anterior palate or tongue with finger/toothbrush
Swallowing with mouth open
Which complementary treatments can help patient manage their retching?
Hypnosis
Acupressure
Cognitive Behaviour Therapy
What techniques can be used when taking impressions in patients who retch?
Modify stock trays
Lower trays in upper arch
Modify special trays (palatal reduction)
Rapid setting impression materials (eg dental composition, mix alginate with water of higher temperature)
-> reduced exposure time
Which alternative denture designs can be helpful for retching patients?
Horseshoe palate
Occasional use of buccal bar connector; use of Co/Cr rather than acrylic
Essix retainer denture/training plate (short term)
No denture- SDA
What is the SDA and extreme SDA?
SDA- ten pairs of occluding teeth- 5-5
Extreme SDA- 4-4/3-3
-> can be extended with implants and distal cantilever bridges
How can dentures be modified to be more suitable for retching patients?
Palate not too thick
Cusps posterior teeth may need rounded so do not stimulate dorsum of tongue
Consider no 2nd molars on prostheses
Having second post dam- can cut back to this if patient cannot tolerate
What are the causes of patient dissatisfaction with dentures?
Reduced self-esteem due to having to wear a denture
-> consequent negative impacts on socialisation
Aesthetic expectations unmet- try and manage this at trial stage
Facial aesthetics changed due to tooth loss
Decreased chewing efficiency
Lack of retention/stability
What is it important to remind the patient of when they are seeking dentures?
Dentures are NOT a replacement for natural teeth
-> natural teeth are the best option
Dentures are an imperfect restoration and better than having no teeth at all
-> keep expectations low
Explain this before treatment thoroughly so it doesn’t look like you are making excuses
What are the aspects that make up effective communication between dentist and denture patient?
Listen to the patient
Know your subject
Avoid healthcare speak
Be attentive
Answer questions
Respect confidentiality
Be empathetic
What questions may you ask the patient at denture assessment?
How long ago were your teeth removed?
How many dentures have you had since you lost your teeth?
How old is the last denture you had made?
Are you wearing the last denture you had made?
What features can affect denture treatment and should be looked out for on initial examination?
Severely resorbed ridges
Flabby ridges
Tori
Prominent mentalis muscles, mylohyoid ridges, genial tubercles
High muscle attachments
Pain on ridge palpation
What statements can be used by the clinical when managing a patient’s expectations regarding dentures?
I’m sorry to say that you may never be able to wear a denture that meets all your expectations to your complete satisfaction
Unfortunately, it is highly unlikely that you will ever feel that your denture is as firm as natural teeth
You are going to need much perseverance in trying to cope with your dentures and it is likely that it will be a very difficult time for you
