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Point of Care the “Point of Care” Section Answers Everyday Clinical Questions by Providing Practical Information That Aims to Be Useful at the Point of Patient Care

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Point of Care the “Point of Care” Section Answers Everyday Clinical Questions by Providing Practical Information That Aims to Be Useful at the Point of Patient Care Point of Care The “Point of Care” section answers everyday clinical questions by providing practical information that aims to be useful at the point of patient care. The responses reflect the opinions of the contributors and do not purport to set forth standards of care or clinical practice guidelines. Readers are encouraged to do more reading on the topics covered. If you would like to contribute to this section, contact editor-in-chief Dr. John O’Keefe at [email protected]. Q U E S T I O N 1 Do missing teeth need to be replaced or is a “shortened dental arch” acceptable? Background noticed a change in chewing function when they 2 or many years, it was thought that any missing had fewer than 6 units (Figs. 1 and 2). tooth should be replaced,1 although num- The Effect of a Shortened Dental Arch on Ferous clinicians and researchers questioned Oral Function this opinion. Arnd Käyser was the first to coin the term “shortened dental arch” (SDA) to de- In general, studies comparing people with a full complement of teeth with those with SDAs scribe the concept of acceptable oral function with have not demonstrated significant differences in partial dentition.2 Through a number of clinical ability to chew.1 Among patients with the min- studies, he and his co-workers came to the conclu- imum recommended number of occlusal units, the sion that many people could function without a insertion of a removable partial denture does not full complement of teeth and that not all missing 3 2–6 significantly improve oral function. According to teeth require replacement. For many people, a some studies, the more teeth missing beyond the functional dentition consists of as little as op- minimum, the more difficulty a person will have 1 posing anterior and premolar teeth. In terms of chewing.1 a minimum number of teeth that patients need, In addition, those without molar support have Käyser and colleagues suggested that, in addition not been shown to have a higher incidence of the to anterior teeth, most people require at least 4 oc- signs and symptoms of temporomandibular disor- clusal units of posterior teeth (1 pair of opposing, ders.5 Similarly, SDA has not been associated with occluding premolars would be 1 occlusal unit, a significant discomfort, distress or occlusal wear.1 pair of occluding molars would represent 2 oc- Although it seems that most people can func- clusal units).2 People with asymmetrical tooth loss tion acceptably with an SDA, this is not true Figure 2: Here molar 16 and premolars 44 and 45 are unopposed; thus, they cannot be counted as occlusal units. Although overeruption of teeth, as seen here, can be a sequela to missing teeth, long-term Figure 1: Patients with symmetrical tooth loss (left) normally studies have tended to show that occlusal require 4 occlusal units for acceptable function, while patients changes are usually self-limiting and minor.1 with asymmetrical tooth loss normally require 6 occlusal units (right). Darkened teeth are missing. ���JCDA • www.cda-adc.ca/jcda • September 2007, Vol. 73, No. 7 • 593 ––––––– Point of Care ––––– Figure 3: This patient has 4 premolars left. Figure 4: A prosthesis for replacement of Figure 5: A maxillary complete If they are opposed by maxillary teeth, only a few missing teeth may be unneces- denture against mandibular anterior there are no other complicating factors and sary if the patient has no functional or teeth does not meet the minimum the patient has no functional or esthetic esthetic complaints and there are no other number (4) of occlusal units required complaints, then replacement of the missing reasons for replacement. for normal function. A mandibular teeth may not be necessary. prosthesis may be helpful for such patients. for everyone: 7% to 20% of people with an SDA may be no need to replace missing teeth, unless have reported that their chewing ability is hin- they are unhappy with their ability to chew or dered or that they had to change food preparation their appearance (Figs. 3 and 4). For patients with practices.1 4 or more occlusal units who do not feel they can An SDA may also be associated with greater chew as well as they wish, replacements can still be tooth migration and interdental spacing among fabricated (Fig. 5). patients younger than 40 years, although the mi- The SDA concept is based on the notion that gration was deemed small and clinically insignifi- patients have an adaptive capacity to function with cant.1 An SDA may also be associated with greater missing teeth. This capacity clearly varies, and not overeruption of teeth, although only 2% of such all patients will feel they have optimum function patients reported that it hindered their oral func- with the same number of teeth. Future research tion.1 People with SDA have been found to have will most likely improve our understanding of this more mobile teeth and lower alveolar bone levels. clinically relevant subject. a The combination of increased occlusal loading and existing periodontal disease probably repre- THE AUTHOR sents a risk factor for further loss of teeth in these people. Patients with SDA probably also represent a high-risk group in terms of periodontal disease. Dr. Robert Loney is professor and head, division Additional longitudinal studies have been recom- of removable prosthodontics, faculty of dentistry, 1 Dalhousie University, Halifax, Nova Scotia. ������Email: mended to study this relationship. [email protected]. Shortened Dental Arch Options in Dental References Practice 1. Kanno T, Carlsson GE. �������������������������������������A review of the shortened dental arch The SDA concept is increasingly accepted, al- concept focusing on the work by the Kayser/Nijmegen group. J Oral Rehabil 2006; 33(11):850–62. though in some areas, it is not widely put into 2. Kayser AF. Shortened dental arches and oral function. J Oral 1 practice. For dentists who provide services to pa- Rehabil 1981; 8(5):457–62. tients with limited financial resources or patients 3. Witter DJ, van Elteren P, Kayser AF, van Rossum MJ. The effect of removable partial dentures on the oral function in shortened dental who do not wish to acquire a prosthesis, the evi- arches. J Oral Rehabil 1989; 16(1):27–33. dence provides a measure of reassurance that “no 4. Witter DJ, de Haan AF, Kayser AF, van Rossum GM. A 6-year treatment” can be a sound option. Considering the follow-up study of oral function in shortened dental arches. Part I: implications of informed consent and the evidence Occlusal stability. J Oral Rehabil 1994; 21(2):113–25. 5. Witter DJ, De Haan AF, Kayser AF, Van Rossum GM. A 6- collected by Käyser and others, it is prudent to year follow-up study of oral function in shortened dental arches. ensure that treatment planning for all partially Part II: Craniomandibular dysfunction and oral comfort. J Oral edentulous patients includes a discussion of the Rehabil 1994; 21(4):353–66. 6. Witter DJ, van Palenstein Helderman WH, Creugers NH, Kayser option of not replacing missing teeth and the pros AF. The shortened dental arch concept and its implications for oral and cons of this choice. For many patients, there health care. Community Dent Oral Epidemiol 1999; 27(4):249–58. 594 JCDA • www.cda-adc.ca/jcda • September 2007, Vol. 73, No. 7 • ––––––– Point of Care ––––– Q U E S T I O N 2 A patient new to my practice had a heart transplant a few years ago. What are the chief considerations in the management of this patient? Background prudent to monitor blood pressure throughout the ince the pioneering surgery of Dr. Christian dental appointment. Furthermore, stress manage- Barnard and his team in the 1960s, human ment measures, such as oral sedation, inhalation Sheart transplantation has evolved into a sur- or sedation, may be indicated. The lack of sensory gical procedure with a reasonably predictable out- innervation of the transplanted heart also implies come. Many heart transplant recipients now have that, in the event of angina or myocardial infarc- a greatly increased life expectancy and are able to tion, the patient would not experience the retro- sternal pain associated with both emergencies.2 return to normal daily life. Although medically The transplanted heart is nevertheless acutely compromised, they are typically more stable from sensitive to circulating catecholamines and is con- a cardiovascular perspective than patients with sequently affected by epinephrine-containing solu- a history of severe cardiac disease.1 With special tions.3 Among transplant recipients surviving for care, routine dental or minor oral surgical proced- 5 years or longer, about 40% will have accelerated ures may be undertaken within the dental practice graft atherosclerosis. The cardiac complications setting. However, for more invasive procedures, that may arise include myocardial infarction, con- referral may be appropriate. There is no general gestive heart failure, ventricular arrhythmias and systematic approach to dental treatment for these sudden death.2 It is good clinical practice to limit patients, making close liaison with the primary the amount of epinephrine necessary to maintain care physician and cardiologist essential. local anesthesia among these patients to 0.04 mg A medical letter sent to the cardiologist and for dental procedures.4 physician will help to confirm the patient’s medical The 2007 American Heart Association guide- history and current medications. The letter should lines on antibiotic prophylaxis to prevent infective include proposed dental surgical treatment, along endocarditis do not advise blanket coverage for with the concentration and dose of drugs that will cardiac transplant patients.5 Unless a patient de- be used (e.g., local anesthetics, antibiotics and an- velops cardiac valvulopathy, is immunosuppressed algesics).
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