Spotting the at Risk Patient 

Our ability to deduce which of our patients fall into an at risk category is crucial in determining the likelihood of out restorative success. This means taking thorough histories, listen carefully and note patient behaviours. 

The BDJ released in 2018 "The Ultimate guide to restorative longevity" 10 part series. The percentages quoted in these articles will only occur if we are able to work with our patients, modify any at risk behaviours and gaining a stable oral environment. 

Important Red Flags - An Overview.

Diet:

I have put this first because it is too easy to forget and disregard. However, the frequency and acidity of the diet will have a tremendous impact on our work.(1)

Xerostomia:

A dry mouth is not only unpleasant for the patient; significantly decreasing their quality of life, without the buffering effect of saliva our restorations are vulnerable. (2)

Dry mouth can be caused by the disease its-self, e.g. Sjogrens, or it can be caused secondary by the treatment for a disease, e.g. antidepressants. (2)

Local factors may have occurred in the glands them-selves, but, if glandular fibrosis is a result of radiation therapy, we now have bone management to be aware of, due to the potential risk of necrosis. (2-3)

Disease of the Periodontium:

Without a solid foundation the tooth is deemed too fail. Remember there are 4 tissues that make up the periodontium: Bone, Cementum, PDL, Gingiva.

As students we always have the “Perio” term, which isn't the most glamorous. However, this term is essential to making both a real difference to the patients general health, and to the success of our definitive work later in the year. (4-5)

Previous and current caries:

A relevant example to use here are the patients from the "heavy metal generation" of dentistry. Amalgams which have been doing a great job for years, but have now inevitably failed with time. Once in this restorative cycle, without meticulous maintenance, patients can get secondary caries and materials can fail. We can sometimes only know the full extent of the patient's caries situation after invasive investigation.

Oral Hygiene habits:

• Is the toothpaste fluoridated?
• How stagnant is the mouth? - those who don’t brush at night?

Parafunctions and Bruxists:

Material selection alongside careful planning is critical, especially when dealing with the heavy occlusal load of a bruxist, or, areas affected by habit. 

System Disease:

A common uncontrolled disease is diabetes (type 1 and 2). Disease can influence our treatment greatly, as the impact intraorally could be significant. Disease of the periodontium can progress quicker, as well a decrease in pH of the surrounding environment. (6)

Holistic care is always fundamental, but providing more focussed support with these patient could lead to remarkable changes. Other common disease affecting dental practice; Rheumatoid Arthritis, Stroke, Sarcopenia, neuromuscular disorders and many more.   

Prosthesis:

The Prosthesis could be fixed or removable. A artificial material can be a bacterial biofilms best friend. We don’t want to provide a medical appliance for the patient which then exacerbates a non-stable mouth and impacts the surround structures (7). When providing treatment, we must consider the maintenance for treatment success e.g. denture care instructions.

TMJ:

Don’t forget to examine the TMJ. The history surrounding any previous or current TMJ problems alongside the success of the treatment provided is important to avoid introducing iatrogenic causes, that could exacerbate the patients systems e.g. placing a restoration high causing an intolerable occlusal interference. TMJ conditions may need specialist intervention, but as future GDPs we should be able to recognise them and refer appropriately. (8)

Occlusion:

Some overview questions that can help prompt further enquires as you carry our an examination of the occlusion:

• Is there an interference? Note: non-working side interference can be the most detrimental to the restoration and tooth.
• Is the occlusion mutually protective? (balanced in the edentulous pt)
• Which teeth are in guidance?
• What is the aetiology of their malocclusion if one is present?
• Does there appear to be stability and a reproducible bite?

Placing our restorations in areas of oblique force will impact the longevity of the material. Contacts on the tooth are also critical to notice when coming to placement of the restoration, avoiding shear force at the tooth-restorative interface (9).

As mentioned previously, we also don’t want to cause any iatrogenic interferences, potentially leading to patients being in pain. (8)

Lack of Space:

Some prompting questions:

• Has there been dentoalveolar compensation? (e.g. TSL with no loss to OVD)
• Has the opposing tooth over-erupted into the space?
• Have the adjacent teeth to edentulous areas rotated, drifted or tilted?

The Demanding Patient - unrealistic expectations.

Some patients will demand treatment which is not recommended or achievable, and when faced with this situation it can feel awful. If the treatment is not in their best interest, second opinions can be obtained for back-up, especially if we suspect a potential mental health aspect to the patient's actions (10). Remember when we are students the supervisors can help, but, it is important for us to try and develop our skills when confronted with this type of circumstance, and to not be afraid to say no. We have our guidelines and policies to support us, alongside any evidence supplied; we are still acting in the patient's best interest.