Identificando Pacientes en Protesis

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Complete dentures

DiRcult denture birds

Alex Koper, B.S., D.D.S.*

Inglewood, Calif.

D

nture patients are “special” people because they have the problem of adapting

to a prosthesis which affects one of the most sensitive and emotionally charged re-

gions of the body. This must take place in full view of their friends, who, like base-

ball fans, are often opinionated and voluble “experts,” The problem is compounded

by the fact that in our North American culture, with its emphasis on youth, vir ili ty

or femininity, and apparent immortality, the individual who lacks a normal and

attractive dentition is disadvantaged. Therefore, it takes an uncommonly secure

individual to accept dentures with equanimity.

During the time their dentures are being made, and later while they are learn-

ing to use them, our patients are dependent, frightened, “less than whole” people.

and in many instances, regress to infantile behavior. There are individuals who have

so much diff icu lty with their dentures that they never make an acceptable adjust-

ment to them. Some wander from dentist to dentist in search of a solution to their

dental needs, while others isolate themselves from society. These people are called

problem denture patients or dificult denture patients.

Because American standards of function and appearance are so high, people

whose physical or emotional limitations prevent adequate achievement with den-

tures suffer much and seek help from dentists. In other parts o f the world where

teeth are not looked upon as such a necessary and positive asset, these individuals

might suf fer little as a result of this deficiency. The diff icult denture patient is,

therefore, a more common problem to American dentistry, and is a product of ours

higher living conditions.

IDENTIFICATION OF TtlE PROBLEM DENTWtE PATIENT

Dif ficult denture patients have been described by Schultz’ as “Individuals who

present abnormal and uncommon denture problems. Because of the extreme com-

Read before the American Prosthodon tic Society in Chicago, Feb. 3, 1967.

This article is being published simultaneously in the JOURNAL OF PROSTHETIC DENTISTRY

and the Journal of the Southern California Dental Ass ociation by spe cial arrangements be-

tween the editors.

Co-director of The Odontic Seminar, Los Angeles.

532


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Difficult denture birds 533

plexities of their symptoms and their physical and emotional handicaps, these are

difficult denture patients.”

It is conceded that what may be an abnormal and uncommon denture problem

for one dentist may be fairly routine to a more experienced practitioner. Also, the

evaluation of the physical and emotional limitations a patient presents varies with

the perception, observation, and experience of the dentist who treats him. It is also

true that there are individuals who present severe challenges to all dentists who

a:te npt to treat them. This poses the questions: “What makes a problem denture

patient? Are there any criteria by which one may measure an edentulous patient

in order to determine whether or not he is or will be ‘difficult’?”

SOME CHARACTERISTICS OF PROBLEM DENTURE PATIENTS

1. They complain.

2. They have pain.

3. They are hostile.

4. They exhibit regressive behavior.

5. They are tense, anxious, and appear unhappy.

6. They often have systemic illnesses.

7. They are inordinately preoccupied and conscious of their mouth and their

dental problem.

8. They have an unrealistic fantasy regarding dentures.

9. They are often devious, deceptive, and disarming.

10. They are indefatigable and persevering in their effor ts to obtain satisfaction.

While it may be true that some of these signs appear in patients needing types

of treatment other than dentures, difficult denture patients exhibit all or most of

these limitations, and often have additional handicaps which aggravate and intensify

their symptoms.

Many edentulous patients become problem patients because they lack the physi-

cal apparatus to wear dentures successfully. Some are frustrated in their attempts to

adapt themselves to a mechanical appliance which requires a rather high degree of

neuromuscular skill and coordination. This most often comes at a time in their lives

when they yearn for the comfort of familiar things and do not have the energy for

this difficult task.

FROM WHISTLER’S MOTHER TO THE KARATE HAWK

Prosthodontic literature is replete with many analyses of these problems. There

are certain individuals who cannot wear dentures successfully. Most writers on this

subject attribute the causes for this lack of success to personality or emotional prob-

lems, physical problems, or failure of the dentist to provide the proper treatment for

his patient. Whatever the cause of their lack of success with dentures, these people

do not become problem denture patients unless they have had considerable experi-

ence as recipients of various kinds of dental therapy, and have thereby developed a

particularly colorful and effective modus operandi which continuously and success-

fully thwarts efforts to construct workable oral prosthetic devices for them.

Only occasionally does one come upon discussions of denture failures in the

literature.2 Brewer3 writes that he has no failures, just varying degrees of success.


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It might be erroneously surmised that the problem denture patient, the D~Ju~u~u\

Calamitous Amrricanus,

likr the dodo bird and the silver dollar. is brcornit~~

extinct. Nothing could be farther from the truth. As vet. no statistics on the rlrm~t)~XI

and varieties of these birds are available. but informed observers rstimatc. thrir

number to be as hiah as 5 per cent of the denture-wearimg population. Ijentists wlrc;

have encountered them are happy to disengage themselves from the clutchry (Ii

these predatory creatures, and forget their experiences as quickly as possible.

Problem denture patients do not wear wrist bands that would identify them.

and even well-trained veteran observers often fail to spot them. There simply is no

ty$cal problem denture patient. They come younp and old, male and female. rich

and poor. They may be as gentle and kind as Whistler‘s mother. or as aggrrssi\,t: a<

. . . . .

a pohtlclan a week before pollmg time. Generally. the female of the specit~ is man‘

colorful than the male.

Just as there is no stereotype of the problem denture patient, neither is the1.c.

a uniform pattern to his behavior.

Some of them will become unhappy and un,-

manageable at the first appointment; for others, the difficulties begin at the try-in

appointment; while the majority wait until the dentures are completed before the\

begin their perverse maneuvers. Most of them need this time to measure their prrs\

and plan their tactics.

I have been in a particula,rly strategic position to observe many exotic species

of these denture birds. My experiences with grievance committees of the Los Angrles

County Dental Society for the past fifteen years, plus a practice which is yuitt’

heavily populated with many varieties of these creatures, has made an avid and

wary denture bird watcher of me. Although I have never seen such rare specitnenh

as the l’awkorchoo Gobblrr (Fig. 1)

who uses two separate lower dentures-- -on


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Vcllume 17

Number fi

Dificult denture birds 535

Fig. I

Fig. 2

wears an upper denture made by one dentist and a lower denture made elsewhere.

In her purse she carries other trophies of previous kills. Another revealing clue is

her handshake. This hawk, tiny and thin as she may be, can crush the hand of the

average greeter. This is an important identifying sign, which I shall soon ex-

Pl

ain.

Generally this species is very cooperative at the beginning of treatment, and

will so lull the dentist that he will wonder why anyone with such excellent coordina-

tion and healthy ridges should ever have difficulty with artificial teeth. Only after

the dentures are placed does the trouble begin. This patient has so much hostility,

and is so strong, that she fractures porcelain denture teeth as though they were

peanuts. After three days, all semblance of balance of the posterior teeth is destroyed,

and the anterior teeth begin to crack away. If gold occlusal surfaces are used, the

upper denture base soon splits under the stress of the extraordinary strength of this

sweet, quiet-spoken, but deadly creature.

GOING MY WAY?

The Myway Mug@ (Fig. 3)) also known as the Hertz Bird, wears the feathers

of a hard working solid citizen whose occupation, if a male, might be an examiner

for the Internal Revenue Service; the female is generally the president of the local

chapter of the League of Women Voters.

The Myway Magpie generally appears with dentures worn in the pocket or

purse. One hand holds a suitcase which contains a complete set of instruments for

setting up teeth and waxing a denture base, in the other hand is a 25-year-old copy

of Swenson’s Complete Dentures (in a plain wrapper, of course), and coiled over

one shoulder at a jaunty angle is a large whip of the type used by lion tamers.

At first an amiable creature, the Hertz Bird readily agrees to the fee, and can

hardly wait to get started. This is because having dentures made is an engrossing


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Fig.

3

avocation for this bird, and the fee is rarely paid because the dentist seldom com-

pletes his treatment.

As its name implies, this bird must be “in the driver’s seat.” It should be pointed

out that, at all times, this creature maintains a sporting attitude. In his conversa-

tions with the dentist, he will occasionally use phrases like “balanced occlusion” or

“incisal clearance,” and no’w and then he will chirp out the word “centric.” If he

does not feel he has given the dentist enough warning, he may casually mention

the fact that he was a navy dental corpsman for three weeks during World War II.

The preliminaries are over when the try-in begins. Now the Myway Magpie

takes charge of all aspects of the construction. No set-up is satisfactory. The teeth

must be changed. Their color is wrong, They are too long or short, or they just do

not feel right. Months may go by, and spouses or other supporting relatives may be

called in to support the contention that a marriage is being ruined by the dentist’s

inability to achieve the proper esthetics for this person. Often, if the dentist lasts

long enough, the patient will take over completely. The following is an excerpt from

a grievance committee case; the dentist’s reply to a patient’s complaint. IIere, in

part, is the chronicle of his experiences with a Myway Magpie:

She threw her hands up in despair and said: “You just won’t set them the way I tell

you. If you will just give me an instrument 1’11 show you how I want them.” I thought-“What

have I to lose in humoring her? I’ve tried everything else without being able to satisfy her.”

So I lit the fire in the lab, set out a wax spatula and wax, and invited her to be my guest. I

thought she meant to shift a tooth or two. That was where I was mistaken.

At 5 P.M., Mrs. B. was still setting teeth. Words cannot describe the results “This,” she

said, “is the way I want them.” I asked her repeatedly,

“Mrs. B, are you sure that is what


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Dificult denture birds 537

you want

?” I asked her to assure me that she would be satisfied if we completed the case thus.

She said that she would. That wax was a mess, to put it mildly. I assured her that we would

not shift a tooth.

The completed denture was to be delivered on Monday. . . etc., etc.

It goes without saying that this patient won again, and was soon released by

this dentist to fly to the next encounter.

MAKE ME LIKE I NEVER WAS

The Minewere Mallard (Fig. 4)) also known as the ‘I Usta” Duck, or the

“Younger Than Springtime” Buflehead, is one of the most frequently encountered

species of the Denturus Calamitous Americanus family. This feather-brained creature

is generally a female who achieves full maturity during, or shortly after her meno-

pause. Flush with insurance money gained from a recently buried husband, or full

of the freedom and lust for further adventure that a substantial divorce settlement

affords, this bird descends upon the prosthodontist full o f heady visions of herself

with new dentures.

The Minewere Mallard may be identified by her habit of flying backward-so

that she can always see where she has been. Her mode of dress may be described as

“teen twentyish” or more accurately, “nineteen twentyish.” Positive identification is

achieved when this beauty emits the shrill raucous call characteristic of the species.

This is the “Minewere” or “I Usta” sound, as in ‘


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538 Koper

.I. Pros. Dent.

.Junr. 1967

Identification of the Forever Flicker can be made early if the dentist can hear

this bird sing. If she is left alone in the chair for a while, one may hear a continuous,

clear, double-noted warble that sounds unmistakably like “Till the End of Time.”

Without this clue, it is only possible to identify the bird after it is too late to matter.

This species is strictly a low pressure operator. There are no heartrending ex-

clamations, no threats of legal action, and no comparisons with previous dentures.

Ill will has no place in this lifetime liaison. Instead, there is an endless series of

gentle complaints (say one per week) forever. The dentures always need adjusting.

cleaning, sharpening, repairing, refitting, relieving, lightening, or tightening.

Specific instructions not to return, or extra charges fomr additional services are

accepted with sweet tolerance and a patient smile by this persevering bird, because

she knows something the dentist does not: only death will sever their relationship.

It is simply a matter of who goes first.

THE GUMMY RUMMIES

The next group of difficult denture birds is an often-encountered species. Be-

cause they vary so much in behavior and appearance, they are known by many

names. Some of the more familiar are. the Tipsy Pipit, the Hollow-Legged Tanager,

the Rummy Robin, and the Martini Meadowlark (Fig. 6). These feathered chas-

acters, together with their cousins (the Heroin, Marijuana, or LSD Juncos [Fig. 71)

form a colorful group whose numbers appear to be growing.

These playboys and girls display a wide variety of bizarre songs and markings.

A common identifying characteristic, noted in all but the J~ncos, is an affinity for

spiritous liquids to the exclusion of other forms of nourishment. The odor of alcohol

accompanies every exhalation,

and makes identification easy. Occasionally, these

birds will reek of cologne or Bay Rum. One does not need to look hard for these

free spirits, because they are found everywhere.

They fly about on unsteady wings

in search of a dentist who will make dentures which can float on their booze-ridden.

fragile, and undernourished oral tissues.

FolQVETL FtiCK=

Fig. 5

LSD JUWO

Fig. 6

Fig. 7


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Difficult denture birds 539

Unfortunately, these pathetic creatures cannot tolerate dentures without the

constant support of their dentist, so that, unwittingly, he also becomes a part of their

pattern of addiction.

THE WOODS ARE FULL OF THEM

These descriptions of a few species of the Denturus Calamitous Americanus are

intended to sharpen the eyes of difficult denture bird watchers everywhere. There

are many varieties yet to be described. The Gagging Grackle or the Bruxing Booby

are often sighted. The Ridgeless Firemouth Raven is not an uncommon sight, and

the Whittling Denture Dove has always been with us.

The woods are full of these unfortunate suffering individuals. They confound,

frustrate, and antagonize us, but their needs are so varied, and their problems so

intense, that they stimulate and challenge us to seek new ways to help them.

References

1. Schultz, A. W.: Management of Difficult Denture Patients, J.

PROS. DENT.

11: 4-8, 1961.

2. Koper, A.: Why Dentures Fail, D. Clin. N. America 721-734, 1964.

3. Brewer, A. A.: Treating Complete Denture Patients, J. PROS. DENT. 14: 1015-1030, 1964.

645 E. AERICK STREET

INOLEW~~D, CALIF. 90301

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