How the hygienist can bridge the communication gap between chairside dental staff and the lab to complete the ultimate patient experience
Carly Scala, RDH, and A. Chase Ellis, CDT
Before graduation, I was not familiar with what a lab technician even does. The office I began working in had an on-site lab that fabricates dentures, and I was amazed. There was so much to learn, from types of prosthesis impressions to denture steps, even to the infinitesimal details. Of course, I was familiar with a full maxillary denture and mandibular cast partial (as the last patient of the day), but I was completely unaware of the journey it took to get there. Since then, I’ve learned that, in most offices, the journey begins in the dental hygiene chair.
I sat down with a former colleague, A. Chase Ellis, CDT, and we deconstructed the fabrication process of a prosthesis from start to finish. In our home state of West Virginia, 36% of adults are edentulous compared to the national average of 17%. If one-third of the adults I see are edentulous, shouldn’t I have a complete understanding of how each prosthesis functions to replace teeth? Shouldn’t I be able to communicate my patient’s concerns to the doctor and the dental technician with a relative knowledge of how to achieve a successful resolution?
A hygienist’s ear
The first step of the prosthetic journey begins with the new-patient exam. I actively listen to each patient’s concerns regarding pain, esthetics, and a general concern for his or her oral health. The doctor works in conjunction with the hygienist’s assessment to diagnose a comprehensive treatment plan for the patient. The variables of concern are usually dental history, health, cost, and the patient’s expressed desires. The treatment plan must incorporate all of these variables and communicate how they will impact the patient before the patient consents to treatment.
Patient desires and esthetics are first on the treatment plan, as they are the patient’s chief concerns. In most cases, a patient’s desires will determine the type of restoration the doctor chooses. While fixed prostheses are generally viewed as ideal restorations, a patient’s dental history and budget often prevent that. For example, a periodontally involved diabetic smoker would not be an ideal candidate for implants, so we should examine all risk factors prior to any full-mouth reconstruction procedures. Based on the hygienist’s and doctor’s findings, the technician and doctor must work together to come up with a beneficial treatment plan.
Ellis explains that it is the responsibility of the technician to create a prosthesis that provides adequate esthetics, phonetics, and function. If cost is not an issue, implant overdentures may be an ideal choice. If, on the other hand, the patient has budget constraints, we can examine other options.
In many states, hygienists are able to make adjustments to temporary/immediate dentures while the patient is in the healing process. Hygienists should assess the abutment teeth or surrounding bone for any areas of discomfort.
We must evaluate the patient’s maxillary and mandibular bony ridges to determine whether a regular denture is possible. If the bone is adequate, then most labs can provide more denture options for the doctor to choose from. The details and the way these dentures are fabricated are what differentiates them. If patients are only partially edentulous, they have different options for partial dentures as well.
Historically, cast partials have been the popular choice among doctors due to strength, but thermoplastic (or a combination of metal and flexible material) partials are becoming increasingly fabricated. This benefits patients esthetically, with pink or clear flexible clasps versus metal clasps. It is important to evaluate abutment teeth to make sure they are free of decay and periodontal disease prior to denture fabrication. If patients have a history of periodontal issues and yet are stable at the time, cast partials are ideal options as additional teeth can be added if necessary. A Cu-Sil (Present Investment Corp.) denture could also be made for patients who have a few healthy teeth remaining. These gasket-type dentures can possibly create a better fit than cast or thermoplastic partials.
All pieces of the puzzle
Once the doctor, patient, and technician decide on the type of prosthesis to fabricate, it is important to obtain a variety of patient information materials to deliver to the technician so that an acceptable prosthetic can be made. According to Ellis, a technician can never have too much information. Just like hygienists and doctors, technicians need every piece of the “patient puzzle” to deliver a quality experience. General patient information—such as age, height, and weight—are available on the health history and should be shared with the technician.
Patient race, face shape, tooth shape and shade, occlusion, bite record, and marked midline are important for creating a customized prosthesis. Obtaining where the high lip line or smile line is is also critical so patients do not show “too much teeth” or have a “gummy smile.” If possible, a “before” photo of the patient with full dentition should be acquired. Quality impressions need to be free of voids and drags/pulls; be sure to capture adequate anatomy on the retromolar pad, maxillary tuberosity, and the gingival margin into the mucobuccal fold and include frenum attachments.
In my office, if a set of impressions is deemed inadequate by the technician, only 10 to 15 minutes of working time is lost and the patient will still get to the next denture step around the same time. If this happens often in an office, this can accumulate to several hours over the course of a week. If this happens when an office is using an off-site (or even offshore!) lab, the next denture step can be pushed out weeks due to the turnover. This creates an unhappy patient, wasted time, and decreased revenue due to shipping costs, extra materials, and the loss of a productive appointment.
All subsequent appointments—such as a framework try-in and wax try-in—must be evaluated similarly. Are the midlines accurate? Is the patient in proper occlusion? Does the framework rock or seat? Are the mold and shade of tooth esthetically pleasing to the patient? Are the clasps esthetically placed? If you can answer all of these questions with a “yes,” then congratulations! You have yourself a denture.
Final comfort level
Once the patient receives the prosthesis that fits securely, seats without rocking, with a centered midline, and that is properly occluded, the hygienist should be prepared to assess common abnormalities within a patient’s mouth and help determine the steps to take to resolve the issue. Ellis recommends creating realistic expectations for patients with prostheses from the very beginning. In many states, hygienists are able to make adjustments to temporary/immediate dentures while the patient is in the healing process. Hygienists should assess the abutment teeth or surrounding bone for any areas of discomfort. Does the denture rub, pinch, or poke? Is it causing numbness, cheek biting, or rocking? Grab the articulating paper, and let’s figure it out.
If patients are concerned about the lingual flange digging in too deep when they chew, that doesn’t necessarily mean the flange is too long. They could possibly be hitting harder on the lingual cusps than anywhere else, which can be determined by heavier markings on the cusp tips and fissures. As a general rule, relief would ideally be found by adjusting the buccal of the upper and lingual of the lower. Flanges are necessary to hold onto the patient’s ridges during speaking, mastication, and smiling. If your patient has a denture that pops out or rocks, the issue could also be posterior cusp height, not just an ill-fitting denture.
If your patient presents with a burning, tingling, or numbness on the roof of the mouth, a well-trained doctor or technician would be led to believe that there is too much pressure on the papilla and some material needs to be removed. After 15 to 20 minutes, check back with the patient and possibly repeat. If your patient presents with sores, some adjustments could be necessary. Use articulating paper or pressure-indicating paste to identify any additional adjustments that need to be made.
Your patient could be allergic to the methyl methacrylate commonly used in denture fabrication. This can cause blisters as well as swelling. The allergic reaction can be identified by taping a 1 x 1 inch piece of processed acrylic from the technician’s “denture graveyard” to the patient’s arm for the duration of the hygiene appointment. If there is a redness and irritation localized in that area, the patient is likely allergic to the material. The denture can be remade using hypoallergenic materials.
It’s OK if the patient needs to return for a follow-up visit, as not all problems will be immediately resolved. The important thing to know is what steps need to be taken to rectify the situation. It’s true that these issues will generally fall upon the doctor and technician. They will have to work with the patient, rather than the hygienist. Part of a well-working team is being able to swiftly assist with duties that might be out of your usual expertise and being cross-trained (while still working within your scope of practice, of course). Understanding why these adjustments are being made or knowing about each type of prosthesis helps you understand your patient even more.
The biggest struggle among labs is the disconnect in communication between chairside dental staff and the lab. Hygienists are not commonly educated about prosthetic fabrication and why these steps are performed.
When a team is fluid, the process is flawless. A team consisting of the dental hygienist, lab technician, and doctor results in a synchronized standard of comprehensive care. A streamlined approach between the hygiene assessment, doctor diagnosis, and lab technician’s expertise creates the ultimate patient experience. It’s a great opportunity to learn something new, create additional dialogues with your team, and build a bridge to bridge the gap.
Carly Scala, RDH, has been practicing for more than four years. Currently, she works full-time clinical hygiene in Parkersburg, WV, within a corporate setting as well as part-time in dental product sales and print/online publications nationally. Carly has been an ADHA member since graduating in 2014 and currently serves on the WVDHA Board. She can be contacted at [email protected].
A. Chase Ellis, CDT, is a certified dental technician, practicing for over nine years. He is currently enrolled in the MDT program through NYU. Although his certification is in removables, he is trained in all aspects of dentistry including, but not limited to, crown and bridge, orthodontics, CAD/CAM, and implant case planning. Currently, Chase serves as the director of laboratory operations at Liberty Dental Centers in Beckley, WV. He can be reached at [email protected].
