The Basic Rules of …..
Basic Rule 4: What Could Go Wrong?
When we really stop and think about it, what could go wrong with our oral rehabilitations and why? The answer I break down into three main areas: diet, hygiene, and parafunction. All three of these etiologies are patient preventable only. We act as the facilitators of dental education and patient oral care. That is why excellent communication and rapport are essential before embarking on a major undertaking such as an oral rehabilitation. Let’s now take a look at these three etiologies.
Dr. John Kois has championed the concept of risk factors and assessment for restorative and prosthetic dentistry. This is a profound concept and one that must be completely assessed before treatment commences. Dr. Kois discusses risk assessment in the areas of esthetics, occlusion, and periodontics for example. I agree with his approach.1-3 When we look at risk factors especially post treatment with an eye to their effect on oral rehabilitation longevity we can readily appreciate that a non-compliant patient will doom our efforts. I can attest to this. The saying “good judgment comes from a lot of experience and a lot of experience comes from a lot of bad judgment” I am sure we have all learned the hard way. In fact, a patient that refuses to participate in effective personal and professional oral hygiene care will undoubtedly have future problems or compromises with their oral health. Root caries, periodontal issues, and esthetics (eg. staining) to mention a few. The patient has to be advised pre-treatment on a lifetime of maintenance requirements. This is documented in their file and the patient is to be reminded of this if they are found to be waning.
Diet is another source for failure. Specifically, sweet intake. The patient needs to be educated on the relationship between sweets and caries and the significance of the frequency verses the volume of consumption. The patient also needs to appreciate that sweets are more than just chocolate and candies. There are many sources of sweets that the patient might not realize that are damaging, such as fruits or sports beverages (sweet/ food breakdown product “acid” attacks or acidic substances).4,5 Age and the associated decline in salivary flow also require explanation. Strategies to offset lifestyle decisions can then be formulated. Protection with daily fluoride rinses or stimulation of salivary flow with sugarless gum or lozenges could be introduced. Once again, this is documented in the patient’s file and they are to be reminded of this if they are found to be waning.
The third and most significant reason for oral rehabilitative failure is parafunction, better described as bruxism.6 We have known for quite some time that a patient’s teeth are never to be together unless they are chewing or swallowing.7 A patient’s teeth might touch for a split second when they chew or they might touch when they swallow (my teeth do not touch when I swallow). We all have patients that ask how long their new restorations will last or what kind of guarantee I will give them. My standard response is “I will guarantee the work for the rest of their life but only on one condition - as soon as their teeth touch once, the guarantee is off.” This of course is unrealistic and somewhat of a sarcastic response but it nevertheless gets the patients attention and drives this point home. Keep your teeth apart! Isn’t this the first thing we tell TMD (temporomandibular disorder) patients to do? Oral rehabilitative patients are no different. For those patients that brux at night or who just want to protect their investment while they sleep, it is a simple task to fabricate a full coverage hard acrylic maxillary orthotic. It’s that simple.8
Diet, hygiene, and bruxism. Make the patient aware of these three vices and we are well on our way to a successful post-treatment scenario.9 Failure to properly educate and monitor these three etiologies will be your undoing.
Further Suggested Reading and References:
1. Kois Center. https://www.koiscenter.com/ firstname.lastname@example.org
2. Kois JC. The restorative-periodontal interface: biological parameters. Periodontol 2000 1996;11:29-38.
3. Malament KA, Socransky SS. Survival of Dicor glass ceramic dental restorations over 14 years: part 1. Survival of Dicor complete coverage restorations and effect of internal surface acid etching, tooth position, gender, and age. J Prosthet Dent 1999;81:23-32.
4. Coombes JS. Sports drinks and dental erosion. Am J Dent 2005;18:101-4.
5. Lussi A, Hellwig E, Zero D, Jaeggi T. Erosive tooth wear: diagnosis, risk factors and prevention. Am J Dent 2006;19:319-25.
6. The glossary of prosthodontic terms. J Prosthet Dent 2017;117 (5S):e1-e105
7. Lundeen H, Gibbs C. Jaw movements and forces during chewing and swallowing and their clinical significance. In: Advances in occlusion. Boston: John Wright PSG, 1982. p. 2-32.
8. Racich MJ. The basic rules of occlusion. Markham: Palmeri Publishing; 2012.
9. Racich MJ. The basic rules of being a dental patient. Markham: Palmeri Publishing; 2016.