A survey on perceptions of denture labelling and marking among dental practitioners in Australia – a pilot study

Abstract

Background

Denture labelling is an underutilised tool with many applications. Identification of patient’s denture can help to prevent loss of the appliance and be used posthumously in Forensic Odontology.

Aim

The aim of the survey was to assess the perceptions, education, and technique preferences of dental practitioners regarding denture labelling in Australia and identify any barriers. The survey also assesses the dental practitioners’ awareness of denture labelling and forensic dental identification.

Materials and methods

A questionnaire survey was conducted between “March 2023 to November 2023”. Participants consisted of general dentists, prosthodontists and dental prosthetists were surveyed across Australia. Participants who were recruited anonymously via email and information sheet through organisations including the Australian Dental Prosthetist Association (ADPA), Griffith University, the University of Sydney, and the Royal Australasian College of Dental Surgeons. The survey consists of twenty-one questions relating to the participants’ demographic background, the practice of denture labelling in their workplace, and awareness of denture labelling and forensic dental identification.

Results

Fifty-two participants completed the survey. Participants include thirty-three general dentists, sixteen dental prosthetists and three prosthodontists. 63.5% (n=51) of the participants were not taught to label dentures. The majority (67.3%; n=35) of the practitioners had never labelled a denture, whereas 15.4% (n=8) labelled dentures less than once a year, and 11.5% (n=6) monthly. Dental prosthetists and Prosthodontists are more likely to label a denture than a general dentist (p=0.003). Removable complete acrylic dentures were most commonly labelled (maxillary 94%; n=16 and mandibular 81%; n=14), with the preference for placing the label posteriorly at the palatal and lingual surfaces of the maxillary and mandibular denture (39%; n=26and 36%; n=25 respectively). The most significant barriers to denture labelling were time (mean score: 2.98 out of 5) and labour (mean score: 2.88 out of 5). The cohort was split on their exposure to forensic odontology (46%; n=24 said yes, 50%; n=26 said no);however, 71% (n=37) were aware that denture labelling could be used for forensic dental identification, and 75% (n=39) in support of mandatory denture labelling in hospitals and aged care facilities.

Conclusion

Denture labelling remains an underutilised in Australia despite widespread recognition of its value. Dental prosthetists and more experienced practitioners were more likely to implement denture labelling; however, time, labour, and cost were identified as key barriers. Although denture labelling is insufficiently covered in dental curricula, practitioners demonstrated awareness of its benefits and expressed strong support for making it mandatory in institutional settings.

INTRODUCTION

Despite the importance of denture labelling, the practice is not routine among dental practitioners. (1, 2) Across Australia, 19% of adults aged 65 and over had no natural teeth. In addition, population above 65 years old with natural teeth, 42% wore dentures. This is predicted to increase as older generations maintain more of their teeth and receive partial dentures. (3, 4) Moreover, Forensic Odontologists can utilise unique markings on dentures to create a circumstantial identification of an unidentified body. (5) Dentures can be labelled on the surface or included in the resin layering. Both methods have advantages and disadvantages; however, there is no recommended internationally recognised approach. Many governing bodies and State Health organisations recognise the importance of denture labelling and recommend its use, however, few stipulate it as a requirement. (6, 7)

Partial and complete dentures play an important role in improving the patient’s quality of life, impacting their masticatory function, nutritional intake, aesthetics, phonetics and social engagement. (8, 9) In Australian residential aged care, an estimated 41% of residents wear dentures. (10) As part of their routine hygiene practices, some care facilities collect all the residents’ dentures simultaneously and clean them in bulk before returning them, which can lead to dentures misplaced. (11) Dentures are also commonly lost in secondary care facilities such as hospitals when left on meal trays, hidden in bed linens, lost in transit between wards or expelled during an episode of vomiting or seizure. A survey of United Kingdom (UK) hospitals from 2011 to 2016 demonstrated that 695 dentures were lost while patients were receiving in-patient care. (2) A follow-up study from 2016 to 2021 reported 123 dentures were lost during that period with improvements being attributed to nursing staff awareness and denture container labelling. (8, 12)

With 371,000 Australians living in residential aged care and 47% of those aged over 75 years wearing dentures, labelling those dentures would benefit a large proportion of the population. (4, 13) There has already been an increase in denture wearing in older populations from 47% of those aged 65 and over in 2012 to 25% of 55-74 year-olds and 47% of those aged 75 and over in 2017-18. (3, 4) As edentulism declines, more people retain their teeth and are more likely to receive partial dentures. (14, 15) Replacing lost dentures remains complex and resource-intensive. The cost of a full set of upper and lower dentures can range from $2003 to $2504 AUD. (16) For many elderly Australians, this cost or waiting period deters them from seeking much-needed dental care. (2, 17) People with disabilities encounter additional barriers to receiving dental treatment including transportation, inaccessible facilities, time, experience of the dental professional and anxiety. (2, 17)

For forensic purposes, labelled dentures can provide a fast, inexpensive, and reliable aid in the circumstantial identification of a deceased person. (18) Alongside fingerprints and DNA, forensic odontology is recognised by INTERPOL as a primary identifier for Disaster Victim Identification (DVI). (19) Identification through dentures has been documented since 1835, when the remains of the Countess of Salisbury were identified via her gold denture. (20) Following World War II, 819 of the 3000 unidentified deceased soldiers wore dentures; however, only 1 in 9 could be identified by their dentures. (21) Forensic odontology is highly regarded when identifying bodies that are incinerated. Prosthodontic devices, particularly metal-based, can withstand higher temperatures, and when well-protected within the tissues, they can be valuable in cases of incineration. (22, 23) Despite the advantages, denture labelling is not regularly performed due to “cost, lack of awareness of standards, and a belief that marking was of little importance” cited by Alexander, Taylor (p. 337). (24)

There are two methods of denture labelling, which are inclusion and surface marking. Surface marking is done after the denture is processed by writing the identifying details on an abraded surface of the denture with an indelible pen. (25) This method is used infrequently (9%) as it creates a plaque-retentive surface that can be irritating to the tissues and removed over time with routine cleaning. (26) Inclusion remains the preferred method (89%), where either a metallic (stainless steel tape) or paper label is placed in the denture during the packing stage and covered with clear acrylic. (25, 27)

The tape or label is normally placed on the buccal flange or palatal base surface of maxillary dentures or the lingual flange of mandibular dentures. If placed on the fitting surface of the denture, it can interfere with denture relines, potentially impacting fit and comfort. When considering post-mortem identification, withstanding incineration is valuable and metallic labels are ideal for their high melting point. The metal tape material is readily available in many dental laboratories; however, it is considered less aesthetic than a transparent or onion paper label. (28) An additional benefit of metal labels is being radiopaque and therefore detectable in post-mortem computed tomography (PMCT) and radiographs if a temporary partial denture is aspirated. (26)

Regulatory requirements for denture labelling vary by jurisdiction. In the United States of America (USA), 22 states require denture labelling, with inclusion preferred for acrylic appliances and surface marking by laser etch for chrome cobalt dentures. (6) Dentists in Sweden have been mandated by the National Board of Health and Welfare since 1986 to offer denture labelling to patients and to explain its benefits. (7) There are conflicting reports in the literature regarding how many dentures receive labelling, with Swedish dentists self-reporting 81-100% uptake whilst a screening of dentures in selected nursing homes found that 35% of complete dentures were labelled. (29, 30)

In several countries, denture labelling is recommended however is not regulated. The National Health Service (NHS) Scotland has the “Caring for Smiles” program, promoting that “All dentures should be marked with the resident’s name or other form of identity”. (31) Surveys of UK prosthodontic specialists indicate that 54.9% routinely label complete dentures and 81% believe it was a worthwhile procedure. (1) Historic screening of complete dentures in the UK indicated that 47% were labelled; however, this study by Bengtsson, Olsson (32) predates the “Caring for Smiles” campaign and there may have been an uptake in denture labelling frequency since then.

In Australia, the Nursing Home Standards of 1987 require that residents’ dentures be “discreetly labelled”. (33) The ADA Policy Statement 6.16 on Forensics in Dentistry; states that “dentures should be marked with the patient's name and such marking noted in the dental record”. (34) The 2024 update of the Australian Government’s Aged Care Quality Standards does not specifically mention denture labelling, outlining that clear policies must be available for all carers relating to oral and dental care delivery, inventory management and equipment maintenance (34, 35). Alexander, Taylor (24) surveyed dental practitioners in South Australia; 20% of general dentists, 25% of prosthodontists and 43.5% of dental technicians self-reported to occasionally label dentures. Many of the surveyed population were unaware of the Nursing Home Standards or recommendations by the ADA. (24)

Labelling of dentures is a critical procedure for patients receiving treatment in hospitals and care facilities, where dentures are more likely to be lost. (31) In death, labelled dentures can assist forensic odontologists in the identification of unidentified remains. (22) Methods of labelling include surface marking or inclusion with the latter being preferred. Denture labelling is commonly practised in the USA, UK and Sweden. (6, 7) Australia has requirements relating to the labelling of dentures in nursing homes; however, many dental practitioners appear to be unaware of this regulation. (24) The aim of this study was to assess the perceptions, education, and technique preferences of dental practitioners regarding denture labelling in Australia and identify any barriers.

MATERIALS AND METHOD

Ethical approval for the study was granted by Griffith University Human Research Ethics Committee (GUHREC), approval number GU Ref No:2022/771.

The study involved a questionnaire survey (appendix 1), which was conducted between “March 2023 to November 2023”. Invited participants consisted of general dentists, prosthodontists and dental prosthetists. Participants were recruited via email and information sheet through organisations including the Australian Dental Prosthetist Association (ADPA), Griffith University, the University of Sydney, and the Royal Australasian College of Dental Surgeons. The survey was facilitated on the Microsoft Forms software platform (Microsoft, Washington, United States of America); no incentives were offered for survey completion, and as their participation was anonymous, no age or gender demographics data were collected.

The survey consists of three parts and twenty-one questions. Part one’s questions were related to demographic background, part two’s questions were related to denture labelling or denture marking preferences (see Figure 1, Figure 2 and Figure 3), awareness, education, and perceived barriers, while part three’s questions covered denture labelling or denture marking and forensic dental identification, record-keeping, and privacy.

Figure 1.

An illustrative example of labelling site on the buccal flange of a complete maxillary denture

Figure 2.

An illustrative example of labelling site on the palatal flange of a complete mandibular denture

Figure 3.

An illustrative example of labelling site on the lingual flange of a partial mandibular denture (metal base).

Variables analysed included participant demographics, denture labelling practices, knowledge and awareness of denture labelling techniques, its forensic Odontology applications, barriers and support. The survey data were analysed using IBM Statistical Package for Social Sciences (SPSS) (IBM, New York, United States of America) and Microsoft Office Excel (Microsoft, Washington, United States of America), focusing on descriptive statistics, cross-tabulations and inferential statistics to identify relationships between variables. Missing values were excluded from analysis on a per-variable basis. Chi-square test of independence was used to analyse the data.

RESULTS

A total of fifty-two participants completed the survey: thirty-three general dentists, sixteen dental prosthetists and three prosthodontists, represented as percentages in Figure 4.

Figure 4.

Distribution of the fifty-two surveyed dental practitioners by division.

The average years of experience amongst the participants were between three to five years for general dentists and more than ten years for both prosthodontists and dental prosthetists. There was a significant association between years of experience and frequency of labelling dentures in practice (p<0.001). Dental Prosthetists were significantly more likely to perform denture labelling compared to General Dentists (p = 0.003). Figure 5 shows the distribution of primary practice locations within Australia, noting the prominent proportion from New South Wales (NSW) and Queensland (QLD); 38.5% (n=20) and 32.7% (n=17) respectively.

Figure 5.

Distribution of the fifty-two dental practitioners by their primary practice location.

The majority (67.3%; n=35) of the practitioners had never labelled a denture; 15.4% (n=8) labelled dentures less than once a year and 11.5% (n=6) monthly. Two of the daily denture labellers were dental prosthetist and the other a prosthodontist. Dental prosthetists and Prosthodontists were more likely to have labelled a denture than a general dentist (p=0.003). Among the 17 practitioners who had labelled dentures, removable complete acrylic dentures were the most frequently labelled (maxillary 94%; n=16; and mandibular 81%; n=14). Removable partial acrylic and metal-based dentures were labelled less often (34% (n=6) and 25% (n=4) respectively). Three respondents also reported labelling mouthguards and implant-supported dentures.

When considering the patient perspective, 61.5% (n=32) of practitioners had never been asked by a patient to label their dentures. Of the sixteen practitioners who had, complete maxillary and mandibular acrylic dentures were most frequently requested (41%; n=7). Figure 6 demonstrates different techniques of denture labelling, comparing against the practitioner's training and what technique they elect to practice presently. A large proportion were not taught to label dentures (63.5%; n=33). Of the practitioners who have labelled dentures, the inclusion technique with plastic and paper was preferred and more routinely taught during their training. The least popular was surface marking, with just three practitioners receiving training and none opting for this technique in their practice.

Figure 6.

Clusters column graph comparing denture labelling techniques practiced and taught by the fifty-two surveyed dental practitioners.

Using the patient's first and or last name on the label was the most common approach for identification (66.7%; n=24), initials or name and date of birth (11.1%; n=4 and 8.3%; n=3 respectively) were less favoured. Figure 7 shows that there was a preference for placing the label posteriorly in both the maxillary and mandibular dentures, specifically along the base of the palate and lingual surfaces (48%; n=25 and 50%; n=26 respectively) followed by the buccal flange (39%; n=20and 36%; n=19respectively). More experienced practitioners showed a significant preference for posterior palatal/lingual base areas, while less experienced practitioners preferred buccal flange areas. The majority of practitioners (63%; n=33), stated that they were not aware of the ADA item code (#777) for the ‘Marking a dental appliance with a patient’s name or other form of enduring patient identification.’

Figure 7.

Clustered column graph reviewing the preferred location of label on complete maxillary and mandibular acrylic dentures.

Practitioners reported that their perception of time (mean score: 2.98 out of 5) and labour (mean score: 2.88 out of 5) were the most significant barriers to labelling dentures. Patient privacy and cost were less of a concern. The practitioners do not doubt the usefulness of labelling, with 75% (n=39) in support of mandatory denture labelling in hospitals and aged care facilities.

The cohort was split on their exposure to forensic odontology (46%; n=24 said yes, 50%; n=26 said no and 4%; n=2 were unsure). When exploring this exposure against their division, all of the prosthodontists and half of the general dentists had been exposed during their training, compared to 30% (n=5) of dental prosthetists. Despite the partial exposure, 71% (n=37) were aware that denture labelling could be used to aid in the identification of a deceased person. There was some disagreement regarding recording the details of the label placed on the denture in the patient’s dental records with 39% (n=20) saying they do record it, 36% (n=19) are not and 25% (n=13) were unsure. Patients do not appear to consider dental labelling to be a privacy breach, with 84% (n=45) of practitioners confirming that no patient has shared this concern with them. Finally, 75% (n=39) of practitioners would be supportive of denture labelling becoming a mandatory requirement for patients with complete dentures in hospital or aged care facilities.

DISCUSSION

The study reveals that denture labelling is not a common practice among dental practitioners in Australia, with 67% reporting they never label dentures. Dental Prosthetists are significantly more likely to perform denture labelling compared to General Dentists.

When reflecting on practitioner education, 64% were never taught how to label dentures, which may explain the low adoption of denture labelling practice and highlights an opportunity for curriculum enhancement. Among those who did label dentures, inclusion techniques are preferred with plastic strips (47%) and paper (41%) being the most common methods. The majority of practitioners (67%) use the patient's name as the identification information on dentures.

For full upper dentures, the posterior palatal base area (44%) and posterior buccal flange area (42%) are the preferred locations for marking. For full lower dentures, the posterior lingual base area (48%) and posterior buccal flange area (40%) are most commonly selected. It's noteworthy that some respondents mentioned labelling mouthguards and implant-supported dentures, indicating a broader potential application for denture labelling.

Despite low implementation rates, 67% of practitioners are aware of the forensic applications of denture labelling, and 75% would support mandatory denture labelling in hospitals and aged care facilities. This suggests that practitioners recognise the value of denture labelling even if they don't regularly practice it. This might be explained through the identified primary barriers to denture labelling which included time constraints and labour requirements. Patient privacy concerns were rated lower (mean score: 2.65), and the perception that denture labelling is not useful received the lowest barrier score. (2, 33)

Comparative investigations were completed by Alexander, Taylor (24) in South Australia (SA) looking at general dentists. That study documented that 19.9% of participants reported labelling dentures on some occasions and 50% said that denture labelling was not useful. Cost was cited as a barrier by 25% of participants. A high proportion of participants were aware of denture labelling techniques, with only 12% reporting they did not, compared to 63.5% who were not taught in the present study. This comparison indicates that denture labelling techniques were taught more previously but due to the perceived lack of relevance, the education practice has diminished.

Many practitioners may be unaware of the existing Australian Nursing Home Standards of 1987 for “discreet labelling” of residents’ dentures. Additionally, 63% of practitioners were not aware of the ADA code #777 for marking dental appliances with patient identification. Both of these areas indicate a potential area for improvement in dental education and awareness of existing guidelines and standards related to denture labelling.

Practitioners exposed to forensic odontology during their education showed significantly stronger support for mandatory labelling in institutional settings. The majority (67%) were aware that denture labelling could aid in the identification of deceased individuals. There was some variation in recording denture label details in patient dental records, with 39% of practitioners doing so, 36% not doing it, and 25% being unsure. This inconsistency in record-keeping practices may have implications for the forensic utility of denture labelling. This is highlighted in the ADA Policy Statement 6.16 on Forensics in Dentistry: “dentures should be marked with the patient's name and such marking noted in the dental record”. (34) The lack of information, such as denture label details in the patient dental records, may result forensic dental identification may not be suitable for use, and instead different forensic identification modalities might be required.

Based on the educational gaps identified in this survey, it is recommended that denture labelling is incorporated into dental and prosthodontic curricula. It is recommended that standardised guidelines be developed to promote consistent practises and mandatory policies for aged care facilities and hospitals where higher levels of practitioner support are available. This can be advocated through various health associations such as ADA, nursing associations, etc. There is a need to increase awareness among practitioners about the benefits of denture labelling would be required, particularly its forensic application, and recording the information in patient dental records as stated in the ADA Policy Statement on Forensics in Dentistry. Comprehensive and accurate dental record is not only important for forensic purposes, it is also required for medico-legal purposes. The importance and raising awareness of dental record keeping and the ADA Policy Statement 6.16 can be conducted through regular ADA CPD activities including collaboration with Australian dental schools. Lastly additional research should be conducted on patient attitudes and experiences with denture labelling to gain a more comprehensive understanding of the issue.

The sample size of practitioners limits the generalizability of findings. The sampled population was one of convenience and does not necessarily represent all dental practitioners in Australia; however, the sample size was still able to identify clear trends. There was sampling bias amongst the locations (Queensland and New South Wales) and types of practitioners. Being a survey, the data is self-reported and subject to inaccuracies.

CONCLUSION

Denture labelling remains an underutilised practice in Australia, even though surveyed practitioners show recognition of its value. This study has identified significant gaps in dental education regarding denture labelling techniques. Dental Prosthetists and more experienced practitioners are more likely to implement denture labelling. There is substantial support for mandatory denture labelling in institutional settings despite the primary barriers of time, labour and cost.