Newsletter: November 2018

The delivery of immediate dentures is a team effort and often involves dentists, dental technicians and clinical dental technicians - it also requires good planning and communication.

Key points

• Clinical dental technicians can construct an immediate denture under prescription from a dentist, in the same way that dental technicians do.
• In any situation where a patient requests an immediate denture directly from a clinical dental technician, the clinical dental technician must refer the patient to a dentist or specialist prior to commencing the case, so a diagnosis and treatment plan can be developed.
• A dentist can only refer or return an immediate denture patient (post extraction) to a clinical dental technician once the healing of the tissue is confirmed.
• Everyone involved in managing an immediate denture patient must stay within the boundaries of their scope of practice.
• Informed consent and treatment planning is required so that the patient understands the role and responsibility of each practitioner for every aspect of the immediate denture treatment, including aftercare.
• Communication between the dentist, clinical dental technician and patient is especially important when a clinical dental technician provides clinical services to the patient, so that the patient receives timely and accurate information about the options and costs involved in their treatment.

Background

Patients can access immediate dentures in different ways. Typically a dentist will confirm the treatment plan and send impressions, bites, and other relevant information to the dental technician who constructs the immediate denture. Once the dentures are ready, the dentist extracts teeth as required and then places the denture. A healing and adaption period follows for the patient after the denture is in place.

Usually, the dentist makes the necessary adjustments to relieve sore spots and assess the condition of the extraction sites within 24 to 48 hours after surgery. Further adjustments are made as required, and a temporary reline will likely be needed to compensate for the bone resorbing over the next few months. A permanent reline or a replacement denture is made typically around six months after extraction.

What are the limits on clinical dental technicians providing immediate dentures?

As with other dental appliances, a clinical dental technician can undertake the technical work required to construct an immediate denture requested by a dentist under prescription.

When an immediate denture is prescribed by a dentist, the dentist engages the clinical dental technician in the same way as they would engage a dental technician, and responsibility for the satisfactory outcome of the immediate denture remains with the dentist.

However, where a patient requests an immediate denture directly from a clinical dental technician, limitations apply.

In this situation, the clinical dental technician must refer the patient to a dentist or specialist before starting the case for the dentist to develop a diagnosis and treatment plan. This applies even if the patient was initially referred to the clinical dental technician by a dentist, or the clinical dental technician has already taken the initial impressions and bite record from the patient.

It is not within a clinical dental technician’s scope of practice to diagnose dental decay, periodontal health or similar issues.  Accordingly, a clinical dental technician cannot advise the patient directly about immediate dentures as a treatment option. They should instead refer the patient to a dentist, and limit themselves to providing guidance about the process involved.

When can a clinical dental technician become involved?

The roles of the dentist or dental specialist and the clinical dental technician converge when the dentist extracts one or more teeth and fits the denture. At this point the dentist needs to ensure the denture fits properly and check the health and subsequent healing of tissues.

Once the soft tissues are healed, the dentist can refer a patient to a clinical dental technician to provide a soft liner or a permanent reline. As always, good communication between the dentist, clinical dental technician and patient about responsibility for ongoing treatment and costs remains important.

Problems can arise when the patient is sent to the clinical dental technician after the initial 24 to 48 hour post insertion check for ongoing care. The important information to remember at this point is that clinical dental technicians are not able to treat patients before the extraction sites are completely healed.

The scope of practice for clinical dental technicians clearly states that they are only permitted to undertake clinical procedures when there is no diseased or unhealed hard or soft tissue[1].

A clinical dental technician can help clinically post insertion with immediate dentures once the dentist has confirmed the extraction sites are healthy and healed.

During the first two weeks following surgery the tissue that surrounds the extraction sites requires a significant amount of further healing. Typically, it is considered that enough tissue healing has taken place two to three weeks after extraction but this must be confirmed by the dentist, not assumed.

The amount of healing that has taken place in the first few weeks will depend on the initial size of the wound. Sockets of smaller diameter, such as single-rooted teeth may appear mostly healed over after two weeks. Wider and deeper wounds left by comparatively larger teeth (canines, premolars) or multi-rooted molars, or wounds resulting from surgical extractions, will require a greater amount of time to heal.

Why is it important a dentist confirms the tissues are healthy and healed?

The patient may experience denture associated soreness and could develop infection in the socket post extraction. Dry socket is a painful tooth extraction complication that can occur within two to four days and manifests as a deep-seated throbbing pain, bad breath and a continuous unpleasant taste in the mouth.

Secondary infections can also occur several days after tooth extraction. The patient may have fever, abnormal swelling, pain or a salty or prolonged bad taste with or without discharge from the site. Bony sequestra can form at the extracted tooth sites and may cause soreness and interfere with the healing.

Sometimes the tissues heal without intervention. In other cases smoothing of the underlying bone will need to occur for full healing. Post extraction granuloma can happen four to five days after tooth extraction–frequently because a foreign body in the tooth socket starts an infection. This could result from amalgam remnants, bone chips, small tooth pieces, or calculus for example. The foreign bodies aggravate the area and can delay post extraction healing.  

These conditions are outside the scope of practice of a clinical dental technician and require a dentist to manage until the tissues are healed.

Who is responsible for the immediate denture?

Responsibility for the outcome of the immediate denture is initially with the dentist or dental specialist that delivered the immediate denture. It is typically the responsibility of the person who delivers the immediate denture to check the technical work is fit for purpose prior to fitting. However, this is far from predicable in the case of an immediate denture and patients should be well informed of possible issues that can occur during fitting.

The issue of responsibility becomes blurred where, for example, a clinical dental technician has a more prominent role in the initial stages. They may have been the first point of contact for the patient and done much of the pre extraction clinical and technical work, while the dentist carried out the extractions and insertion of the denture. Ultimately each practitioner needs to be responsible for their input into the case.

Issues can also arise when the immediate denture has inherent issues that a reline cannot resolve, such as aesthetic or lip support issues. This is when communication between the patient, dentist and the clinical dental technician is crucial. It is also extremely important that the dentist and clinical dental technician clearly outline their own treatment plan for the patient and obtain informed consent for their involvement from the patient prior to treatment.