Denture related pathosis and its management
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Introduction
The use of complete dentures is never considered trouble
free. The dentures can produce severe side effects, which
if left unchecked will produce, destabilization of occlusion,
loss of retention, decreased masticatory efficiency, poor
esthetics, increase ridge resorption, tissue injury. These
problems when ignored, will progress to a stage where the
patient is considered maladaptive and even, cannot wear
the denture. 1 This can be totally avoided by providing
proper post insertion instructions to the patient, educating
the patient on denture care and maintenance and importance
of regular dental visits for check-up.
Denture stomatitis
Also called as denture stomatitis, inflammatory papillary
hyperplasia and chronic atrophic candidosis. 4
3.2.1. Classification according to Newton’s
1. TYPE-1: A localized simple inflammation or pinpoint
hyperemia
2. TYPE-2: An erythematous or generalized simple type
presenting a more diffused erythema involving a part
of the palate or entire denture bearing mucosa.
3. TYPE-3: A granular type (inflammatory papillary
hyperplasia) commonly involving the central part of
the palate and alveolar ridges.
Type 3 is often seen with type 1 or type 2
3.2.2. Etiology
1. Presence of dentures in the oral cavity for longer
duration (both day and night).
2. Mechanical trauma from the dentures in addition to the
plaque accumulation.
3. Candida infection.
4. Bacterial inflammation.
5. Allergic reactions.
3.2.3. Diagnosis
The presence of mycelia or psuedohyphae in the direct
smear confirms the diagnosis. Management:
3.3. Supportive measures
A. To follow effective oral and denture hygiene methods and
correction of the prevailing denture wearing habits.
B. Educating the patient on proper usage of dentures which
include:
1. Removing of the dentures during night times and
placing it in water.
2. Removing of denture after meals and to scrub it before
reinserting.
C. Smoothening the rough areas of the denture to avoid
trauma.
3.4. Drug therapy
Local therapy with antifungal mouth wash which include
nystatin, amphotericin B are preferred to systemic therapy
because resistance of candida species occur regularly when
ketoconazole is used systemically. The antifungal drugs are
continued for four weeks to avoid relapse.
3.5. Surgical management
The deep crypts in type III denture stomatitis requires
surgical intervention which is preferably done by
cryosurgery
Flabby ridge
Flabby ridge is due to replacement of bone by fibrous
tissue which is mobile and highly resilient. It is seen most
commonly in the anterior part of the maxilla with opposing
anterior teeth in the mandible. It is usually caused due to
excessive load of the residual ridge and unstable occlusal
condition. They provide poor support for the denture.
3.6.1. Management
Surgical treatment has to be considered depending on
amount of bone resorption5 because in case of complete
atrophy removal of the flabby ridge will eliminate the
vestibule.
3.7. Trauamatic ulcers (sore spots)
Overextended borders or unbalanced occlusion are the usual
causes of traumatic ulcers.
3.7.1. Clinical features
These ulcers are small, painful and usually develop within
few (1-2) days after the placement of a new denture. They
are often covered by a grey necrotic membrane surrounded
by an inflammatory halo with firm elevated borders. 6
3.7.2. Management
1. Usually the ulcer heal within few days after correcting
the dentures.
2. If no treatment is provided, it may progress into a
denture irritation hyperplasia.
3.8. Epulis fissuratum (inflammatory fibrous
hyperplasia, denture injury tumour, denture epulis)
It is a hyperplastic reaction of the oral mucosa that occuralong the borders of the dentures and usually caused due
to the trauma from the thin denture flanges of an unstable
denture.
3.8.1. Clinical features
1. Usually it appears as a single or numerous flaps of
connective tissue while some appear erythematous and
ulcerated.
2. The flange of the associated denture fits conveniently
into the fissure between the folds.
3. It usually develops on facial aspect of alveolar ridge
and the anterior regions of the jaw.
3.8.2. Management
1. Treatment consists of removing the offending denture
or shortening the flange to permit tissue rest and
healing.
2. Denture or borders are corrected with soft denture
liners or tissue conditioning agent.
3. Surgical removal is attempted only if this treatment
fails to bring about resolution.
4. Tissue rest is generally enough to cause regression of
the epuli and complete healing.
5. Suturing after surgery may decrease sulcular depth
of the vestibule once scar contracture occurs. In such
cases vestibuloplasty should be considered. 7
3.9. Oral cancer in denture wearers
An association of denture wearing and oral cancer has
been strongly claimed, but there is no definite proof to
this statement. The factors which lead to oral cancer in
denture wearing patients are heavy smoking, consumption
of alcohol, poor oral hygiene and low socio-economic
status. 8
3.9.1. Management
1. Any persistent sore spot remaining even after
the correction of dentures are often suspected for
malignancy.
2. Regular recall visits at duration of 6 months has to be
followed for comprehensive oral examination.
3.9.2. Burning mouth syndrome
It is characterised by the burning sensation in the oral tissues
which are in contact with the dentures without any visible
changes. Most commonly seen in women denture wearers
above the age of 50 (post-menopausal). 9,10
3.9.3. Clinical features
The pain usually starts in the morning and aggravates
during the day and the burning sensation is often associated
with dry mouth and persistent alteration in the taste
.Other associated symptoms include headache, insomnia,
decreased libido, irritability fatigue.
3.9.4. Etiological factors
1. Local factors.
2. Systemic factors.
3. Psychogenic factors.
Local factors: Irritation caused by ill-fitting dentures,
constant parafunctional movements of tongue, prolonged
masticatory activity and constant excessive friction on the
mucosa.
Systemic factors: vitamin B-12 deficiency or iron
deficiency, xerostomia which is caused by radiation
therapy, systemic disease or drugs.
Psychogenic factors: patients with anxiety and depression
are more associated with BMS.
3.9.5. Management
Identifying the causative factor is important and it should be
removed. Vitamin therapy is provided when associated with
its deficiency. If psychogenic / psychosocial disturbance are
diagnosed, adequate treatment should be offered through
counselling and use of tranquilizers if required.
3.9.6. Gagging
Gag reflex is considered a normal. It is a healthy defence
mechanism that prevents the foreign bodies from entering
into the trachea.
3.9.7. Causes
It can be triggered by tactile stimulation of the posterior
portion of the tongue, soft palate and faucial pillars. Other
stimuli include taste, sight, noise or psychological factors
can also stimulate gagging. The placement of new dentures
can stimulate gag reflex in sensitive patients. Overextended
denture borders in posterior part of maxillary or the
distolingual part of the mandibular denture often result in
a persistent gagging. 11,12
3.9.8. Management
1. It reduces gradually within few days as patient adapts
to the new denture.
2. Correction of the posterior extensions of the denture.
3.9.9. Residual ridge resorptionIt is the most common sequelae of wearing complete denture
in which there is a continuous loss of bone not only after the
extraction of teeth but also after the placement of dentures.
Residual ridge resorption is a normal physiologic process
wide variation in the rate of resorption. 13,14
3.9.10. Management
1. Prosthodontic
2. Surgical
3.9.10.1. Prosthodontic management.
1. Mouth preparation
2. Modification of the fitting surfaces
3. Occlusion adjustment
4. Impression making
3.9.10.2. Surgical management.
1. Vestibuloplasty
a. Labial
b. Lingual
2. Ridge augmentation with
a. Hydroxyapatite
b. Alloplastic materials
c. Implants
3.9.11. Caries and periodontal disease (in case of over
denture abutments)
In case of over denture abutments, the risk of caries
and periodontal disease is very high because of bacteriacolonization (mostly streptococcus and actinomyces) and
plaque formation at the sites where the access for cleansing
and maintenance is very limited. 15,16
3.9.12. Preventive measures and Management
1. Dental Caries can be prevented by fluoride application
and also by avoiding the use of dentures during night
time (where the flow of saliva help in cleansing and
protecting the abutments from caries).
2. Patient education and motivation to maintain good oral
hygiene along with regular follow up is required.
3. Chlorohexidine mouth wash can be used to prevent
periodontal problems.
4. Periodontal therapy can be done for pocket
elimination.
3.10. Indirect sequelae of denture wearing
3.10.1. Atrophy of masticatory muscles
Maximal bite force tends to decrease in old persons. CT
studies of muscles show greater atrophy of muscles in
denture wearer especially in women. Masticatory muscles
impairment is often caused due to reduced bite force and
chewing efficiency.
3.10.2. Diagnosis
1. Measurement of capacity to reduce test foods into
small particles verified the chewing efficiency.
2. In order to achieve equivalent reduction of food the
number of chewing strokes required by a denture
wearer is more than the person with natural dentition.
3.10.3. Preventive measurement and Management
1. Retention of teeth and using as over denture abutment
will improve masticatory performance of individual.
2. Implant supported over denture is usually followed by
improved masticatory efficiency.
3.10.4. Nutritional Deficiency
Nutritional deficiencies seen in older patients is often
due to decreased food intake which can be due to
reduced masticatory function or even due to reduced taste
perception. However, some individuals even with poor
masticatory function, rarely show nutritional deficiencies.
Prosthodontic therapy should be indicated to improve the
masticatory function. Other factors that effect nutrition
include General health, socioeconomic status and dietary
habits. 17
3.10.5. Management
1. Restoring the masticatory function by providing a
prosthesis or by preventing the sequelae of complete
denture.
2. Modification of the dietary habits.
4. Conclusion
There are many problems related to complete denture
treatment. Several can be easily solved according to research
and clinical experience. For others lack of evidence based
knowledge making treatment unpredictable. Therefore
continuing investment in clinical research and follow up on
denture wearing patients are required.
5. Source of Funding
None.
6. Conflict of Interest
1
Dentistry 4 lovers
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