Clinical Maxillofacial Prosthetics

Thomas D. Taylor

• Publisher: Quintessence Publishing Co, Inc
• Year: 2000
• ISBN:
  9780867156959
• Edition: 1
• Topic: Medicina
• Subtopic: Odontotecnica

Within the growing body of literature dedicated to the subspecialty of maxillofacial prosthetics, this book fills a genuine need for a hands-on clinical guide to performing the challenging prosthodontic procedures required by this patient population. Based on careful discussion of both general and specific prosthodontic principles and techniques rather than on numerous case reports, and minimizing surgical and medical considerations that are more adequately addressed elsewhere, this user's guide will be a valuable addition to the libraries of practicing prosthodontists, general and hospital dentists, and others not formally trained in the subspecialty of maxillofacial prosthetics.

In the process of recording a patient’s chief complaint, present and past illness, medical and dental history, diagnostic records and tests, examination, and adjunctive consultations, the health care provider mentally assesses the patient’s demeanor. Such assessment is necessary to ascertain whether the proposed prosthodontic treatment may be performed efficaciously or understood and appreciated by the patient once it is completed. The prognosis for a successful treatment outcome is dependent upon the prosthodontist making a correct diagnosis and anticipating issues beyond the realm of dentistry alone.

The health care provider in the process of patient evaluation assesses the attitude, demeanor, and/or behavior of the patient and attempts to classify his or her mental status. Patient classifications in and of themselves may offer the clinician a rubric that is critical to patient management and treatment planning. However, it is more important to understand the etiology of behaviors and its potential impact upon the treatment process in order to implement the appropriate care.

Psychological Classification and Interpretation

Prosthodontists often use House’s (1978) classifications of philosophical, exacting, indifferent, and hysterical to categorize the mental status of patients. This approach may be meaningful for the typical prosthodontic patient, but it may fall short in classifying those patients with life-threatening diseases or who have suffered recent traumatic events. Additionally, those patients in whom the face is disfigured and/or those who have lost an important biological function such as speech or swallowing will experience changes in social acceptance that impact the psyche and sense of well-being. The “philosophical” patient, the one who cognitively understands and is rational or who appreciates the prosthodontic treatment being attempted, may abruptly change demeanor upon the challenge of ablation of an extensive facial cancer or a surgical/prosthetic reconstructive outcome that is less than desirable.

As the maxillofacial patient’s quality of life is altered and social integration becomes difficult, the patient’s expectations to return to “normalcy” often collapse. Underlying emotional issues that were subconsciously buried may come to the surface, or unachievable expectations and unreasonable demands may arise that hinder the prosthodontist’s ability to provide adequate treatment. Further, in such a case it is critical for the prosthodontist to assess whether treatment should be performed at all, delayed until the patient’s demeanor is more conducive to treatment, and/or coordinated with services of supportive professionals such as social workers or psychologists (Gillis, 1979).

The prosthodontist’s goal is a successful treatment outcome, but not at the expense of one’s emotional and mental well-being or that of staff. A health care provider is not required to “heal” every patient who walks through the front door. This principle applies to all patients, whether a traditional prosthodontic patient, a temporomandibular disorder patient, or a maxillofacial prosthetic patient. In practice, this principle means that if at the examination level one recognizes a patient with underlying psychological conditions or confounding emotional factors, it may be best to not treat until these are addressed. If treatment commences without the fundamental controls or sufficient rapport in place, the clinician is likely to wonder in the middle of treatment how things ever went awry and regret that treatment ever began. There must be an unconditional commitment to the same treatment goals by both doctor and patient. Therefore, it becomes paramount that the prosthodontist understand the various psychological diagnoses, ranging from subtle emotional nuances to overt psychological disorders, that potentially undermine successful prosthodontic treatment.

The types of psychological impairments that may be anticipated are outlined below. While these summaries are not exhaustive, they can add to any prosthodontist’s knowledge base. The ability of the practitioner to recognize these impairments will facilitate total patient care. Psychological changes that can occur in maxillofacial patients follow with directives presented on the various methods of referral to improve the patient’s mental status prior to treatment.

General Psychological Impairments

The purpose of this section is to provide the prosthodontist with a general understanding of the range of psychological disorders that may be experienced by patients. This section is not intended to be a detailed explanation of all of the disorders described by the American Psychiatric Association. Psychological impairments are characterized by disturbances in a person’s thoughts, emotions, or behavior. These impairments can range from those that cause mild distress to those that severely impair a person’s ability to function individually, in a family, or in a community. Some individuals with acute impairments require hospitalization because they become unable to care for themselves or because they are at risk of harming others or themselves. Most people, however, can recover from mental illness and return to normal lives with appropriate referral and treatment.

Distribution

Mental illness affects people of all ages, races, cultures, and socioeconomic classes. In the United States, researchers estimate that about 24% of people 18 or older, or about 44 million adults, experience a mental illness or substance-related disorder during the course of any given year. The most common of these disorders are depression, alcohol dependence, and various phobias (irrational fears of things or situations). In any given year an estimated 2.6% of adults in the United States, or about 4.8 million people, suffer from a severe and persistent mental illness such as schizophrenia, bipolar disorder, or a severe form of depression or panic disorder. An additional 2.8% of adults, or about 5.2 million people, experience a mental illness that seriously interferes with one or more aspects of daily life, such as the ability to work or to relate to other people. Please note that all of these figures exclude people who are homeless and those living in prisons, nursing homes, or other institutions—populations that have high rates of mental illness. International surveys have demonstrated that from 30% to 40% of people in a given population experience a mental illness during their lives. These surveys have also revealed that anxiety disorders are usually more common than depression.

In children and the elderly, rates and forms of mental illness change with age and gender. For example, depression and anxiety disorders occur at the same rate among girls and boys until midadolescence, when girls account for more of the case histories. Among prosthodontic patients, children most often present with congenital defects or alterations in growth and development, whereas adolescents and young adults often present with developmental defects or trauma. Mental illness among the elderly has grown significantly as a greater percentage of people live beyond the age of 65, both in the industrialized nations of the West and in the developing countries of Asia, Africa, and Latin America. Dementia, characterized by impaired intellectual functioning and memory loss, occurs mostly among the elderly and may overlap with the ablative cancer patient groups.

Like physical diseases, the highest rates of mental illness occur among people in the lower socioeconomic classes, especially those living in severe poverty. Rates of almost all mental illnesses decline as levels of income and education increase. The hardships associated with poverty seem to contribute to the development of some mental illnesses, particularly anxiety disorders and depression. In addition, debilitating mental illnesses, such as schizophrenia, may cause individuals to shift to lower socioeconomic classes. The ability of maxillofacial patients to integrate into society and to be employable will be critical to their mental status. The overall prevalence rates of mental illnesses among men and women are similar. However, men have much higher rates of antisocial personality disorder and substance abuse. The acquired maxillofacial cancer/defect population may correlate with substance abuse. In the United States, women suffer from depression and anxiety disorders at about twice the rate of men. The gender gap is even wider in some countries. For example, women in China suffer from depression at nine times the rate of men.

Anxiety Disorders

Anxiety disorders involve excessive apprehension, worry, and fear. More than 16 million adults ages 18 to 54 in the United States suffer from anxiety disorders, which include panic disorder, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), social phobia, and generalized anxiety disorder. People with generalized anxiety disorder experience constant anxiety about routine events in their lives. Phobias are fears of specific objects, situations, or activities. Panic disorder is an anxiety disorder in which people experience sudden, intense terror and physical symptoms such as rapid heartbeat and shortness of breath.

Panic disorder affects about 1.7% of the US adult population ages 18 to 54, or 2.4 million people, in a given year. Panic disorder typically strikes in young adulthood. Roughly half of all people who have panic disorder develop the condition before age 24. Women are twice as likely as men to develop panic disorder. People with panic disorder may also suffer from depression and substance abuse. About 30% of people with panic disorder abuse alcohol and 17% abuse drugs such as cocaine and marijuana. About one third of all people with panic disorder develop agoraphobia, an illness in which they become afraid of being in any place or situation where escape might be difficult or help is unavailable in the event of a panic attack.

Patients with obsessive-compulsive disorder experience intrusive thoughts or images (obsessions) or feel compelled to perform certain behaviors (compulsions). About 2.3% of the US adult population ages 18 to 54, approximately 3.3 million Americans, have OCD in any given year. OCD affects men and women with equal frequency.

Patients with posttraumatic stress disorder relive traumatic events from their past and feel extreme anxiety and distress about the event. In the United States, about 3.6% of adults ages 18 to 54, or 5.2 million people, have PTSD during the course of a given year. PTSD can develop at any age, including childhood. PTSD is more likely to occur in women than in men. About 30% of men and women who have spent time in war zones experience PTSD. The disorder also frequently occurs after violent personal assaults, such as rape, mugging, or domestic violence; terrorism; natural or human-caused disasters; and accidents. Depression, alcohol or other substance abuse, or another anxiety disorder often accompanies PTSD.

About 3.7% of American adults ages 18 to 54, or 5.3 million people, have social phobia in any given year. Social phobia occurs in women twice as often as men, although a higher proportion of men seek help for this disorder. The disorder typically begins in childhood or early adolescence and rarely develops after age 25. Social phobia is often accompanied by depression and may lead to alcohol or other drug abuse.

Mood Disorders: Depression and Mania

Mood disorders, also called affective disorders, create disturbances in a person’s emotional life. Depression, mania, and bipolar disorder are examples of mood disorders. More than 19 million adult Americans will suffer from a depressive illness—major depression, bipolar disorder, or dysthymia—each year. Many of them will be incapacitated for weeks or months because their illness is left untreated.

Nearly twice as many women (12%) as men (7%) are affected by a depressive illness each year. Depression is a frequent and serious complication that follows heart attack, stroke, diabetes, and cancer, but it is very treatable. Further, depression increases the risk of having a heart attack. According to one recent study that covered a 13-year period, individuals with a history of major depression were four times as likely to suffer a heart attack compared with people without such a history. Symptoms of depression may include feelings of sadness, hopelessness, and worthlessness, as well as complaints of physical pain and changes in appetite, sleep patterns, and energy level. In mania, on the other hand, an individual experiences an abnormally elevated mood, often marked by exaggerated self-importance, irritability, agitation, and a decreased need for sleep. In bipolar disorder, also called manic-depressive illness, a person’s mood alternates between extremes of mania and depression. More than 2.3 million Americans ages 18 and over, about 1% of the population, suffer from manic-depressive illness. As many as 20% of people with manic-depressive illness die by suicide. Men and women are equally likely to develop manic-depressive illness.

Schizophrenia and Other Psychotic Disorders

People with schizophrenia and other psychotic disorders lose contact with reality. Symptoms may include delusions and hallucinations, disorganized thinking and speech, bizarre behavior, a diminished range of emotional responsiveness, and social withdrawal. In addition, people who suffer from these illnesses experience an inability to function in one or more important areas of life, such as social relations, work, or school. More than 2 million adult Americans are affected by schizophrenia. In men, schizophrenia usually appears in the late teens or early twenties. Onset of the disorder in women is usually in their twenties to early thirties. Schizophrenia affects men and women with equal frequency. Most people with schizophrenia suffer chronically throughout their lives. One of every 10 people with schizophrenia eventually commits suicide.

Personality Disorders

Personality disorders are mental illnesses in which one’s personality results in personal distress or a significant impairment in social or work functioning. In general, people with personality disorders have poor perceptions of themselves or others. They may have low self-esteem or overwhelming narcissism, poor impulse control, troubled social relationships, and inappropriate emotional responses. Considerable controversy exists over where to draw the distinction between a normal personality and a personality disorder. In addition, treatment for this disorder is typically long term, though success is not extremely difficult to achieve.

Cognitive and Dissociative Disorders

Cognitive disorders, such as delirium and dementia, involve a significant loss of mental functioning. Dementia, for example, is characterized by impaired memory and difficulties in such functions as speaking, abstract thinking, and the ability to identify familiar objects. The conditions in this category usually result from a medical condition, substance abuse, or adverse reactions to medication or poisonous substances.

Dissociative disorders involve disturbances in a person’s consciousness, memories, identity, and perception of the environment. Dissociative disorders include amnesia that has no physical cause; dissociative identity disorder, in which a person has two or more distinct personalities that alternate in their control of the person’s behavior; depersonalization disorder, characterized by a chronic feeling of being detached from one’s body or mental processes; and dissociative fugue, an episode of sudden departure from home or...

Table of contents

• Cover
• Half Title Page
• Title Page
• Copyright Page
• Contents
• Foreword
• Preface
• Contributors
• Chapter 1 Psychological Management of the Maxillofacial Prosthetic Patient
• Chapter 2 Reimbursement Considerations for the Maxillofacial Prosthetic Practice
• Chapter 3 The Radiation Therapy Patient: Treatment Planning and Posttreatment Care
• Chapter 4 Resin Bonding for Maxillofacial Prostheses
• Chapter 5 Nasoalveolar Molding in Early Management of Cleft Lip and Palate
• Chapter 6 Clinical Management of the Edentulous Maxillectomy Patient
• Chapter 7 Clinical Management of the Dentate Maxillectomy Patient
• Chapter 8 Clinical Management of the Soft Palate Defect
• Chapter 9 Clinical Application of the Palatal Lift
• Chapter 10 The Impact of Endosseous Implants on Maxillofacial Prosthetics
• Chapter 11 Diagnostic Considerations for Prosthodontic Rehabilitation of the Mandibulectomy Patient
• Chapter 12 Prosthodontic Rehabilitation of the Mandibulectomy Patient
• Chapter 13 Implant Rehabilitation of the Mandible Compromised by Radiotherapy
• Chapter 14 Prosthodontic Rehabilitation Following Total and Partial Glossectomy
• Chapter 15 Treatment of Upper Airway Sleep Disorder Patients with Dental Devices
• Chapter 16 Facial Prosthesis Fabrication: Technical Aspects
• Chapter 17 Facial Prosthesis Fabrication: Coloration Techniques
• Chapter 18 Fabrication of Custom Ocular Prostheses
• Chapter 19 Craniofacial Osseointegration: Prosthodontic Treatment
• Index