24-Sequelae of Wearing Complete Dentures - Rajat Dang
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Transcript of 24-Sequelae of Wearing Complete Dentures - Rajat Dang
By, Dr. Rajat Dang SEQUELAE CAUSED BY WEARING COMPLETE DENTURES THE DENTURE IN THE ORAL ENVIRONMENT
Placement of a removable prosthesis in the oral cavity produces
profound changes of the oral environment that may have an adverse effect
on the integrity of the oral tissues .Mucosal reactions could result from a
mechanical irritation by the dentures, an accumulation of microbial plaque
on the dentures, or occasionally, a toxic or allergic reaction to constituents
of the denture material. The continuous wearing of dentures may have a
negative effect on residual ridge form because of bone resorption.
Direct Sequelae Caused by Wearing Removable Prostheses: Complete or Partial Dentures
• Mucosal reactions
• Oral galvanic currents
• Altered taste perception
• Burning mouth syndrome
• Gagging
• Residual ridge reduction
• Periodontal disease (abutments)
• Caries (abutments)
Furthermore, wearing complete dentures that function poorly and that
impair masticatory function could be a negative factor with regard to
maintenance of adequate muscle function and nutritional status,
particularly in older persons.There are several aspects of the interaction
between the prosthesis and the oral environment.Surface properties of the
prosthetic material may affect plaque formation on the prosthesis; however
the original surface chemistry of the prosthetic material is modified by the
acquired pellicle and thus is of minor importance for the establishment of
plaque .
On the contrary, surface irregularities or microporosities greatly promote
plaque accumulation by enhancing the surface area exposed to microbial
colonization and by enhancing the attachment of plaque. Furthermore,
plaque formation is greatly influenced by environmental conditions such as
the design of the prosthesis, health of adjacentmucosa, composition of
saliva, salivary secretion rate, oral hygiene, and denture-wearing habits of
the patient.
The presence of different types of dental materials in the oral cavity
may give rise to electrochemical corrosion, but changes in the oral
environment due to bacterial plaque may constitute an important cofactor
in this process. Corrosive galvanic currents have been implicated in the
burning mouth syndrome (BMS), oral lichen planus, and altered taste
perception. Most often it is difficult to establish a definite causal
relationship because mechanical irritation or infection may also be
involved. For instance, local irritation of the mucosa by the dentures may
increase mucosal permeability to allergens or microbial antigens.
This makes it difficult to distinguish between a simple irritation and an
allergic reaction against the prosthetic material, microbial antigens, or
agents absorbed to the prosthesis capable of eliciting an allergic response.
The matter is further complicated by the fact that certain microorganisms
(e.g., yeasts) are able to use methylmethacrylate as a carbon source,
thereby causing a chemical degradation of the denture resin.
DIRECT SEQUELAE CAUSED BY WEARING DENTURES Denture Stomatitis
The pathological reactions of the denture-bearing palatal mucosa
appear under several titles and terms such as denture-induced stomatitis.
denture sore mouth. denture stomatitis, inflammatory papillary hyperplasia,
and chronic atrophic candidosis. In the following sections, the term denture
stomatitis will be used with the prefix Candida-associated if the yeast
Candida is involved. In the randomized populations, the prevalence of
denture stomatitis is about 50% among complete denture wearer.
Classification According to Newton's classification, three types of
denture stomatitis can be distinguished.
Type I A localized simple inflammation or pinpoint hyperemia.
Type II An erythematous or generalized simple type seen as more diffuse
erythema involving a part or the entire denture-covered mucosa.
Type III A granular type (inflammatory papillary hyperplasia) commonly
involving the central part of the hard palate and the alveolar ridges.
Type III often is seen in association with Type I or Type II Strains of the
genus Candida, in particular Candida albicans, may cause denture
stomatitis. Still, this condition is not a specific disease entity because other
causal factors exist such as bacterial infection, mechanical irritation, or
allergy. Type I most often is trauma induced, whereas types II andIII most
often are caused by the presence of microbial plaque accumulation on
fitting denture surface
Factors Predisposing to Candida-Associated Denture Stomatitis
Systemic Factors Old age
Diabetes mellitus
Nutritional deficiencies (iron, folate, or vitaminB12
Malignancies (acute leukemia, agranulocytosis)
Immune defects
Corticosteroids, immunosuppressive drugs
Local Factors Dentures (changes in environmental conditions, trauma, denture usage,
denture cleanliness)
Xerostomia (Sjogren's syndrome, irradiation,drug therapy)
High-carbohydrate diet
Broad-spectrum antibiotics
Smoking tobacco
Management and Preventive Measures Because of the diverse possible origins of denture stomatitis, several
treatment procedures could be used, including antifungal therapy,
correction of ill-fitting dentures, and efficient plaque control. The patient
should be instructed to remove the dentures after the meal and scrub them
vigorously with soap before reinserting them. The mucosa in contact with
the denture should be kept clean and massaged with a soft toothbrush.
Patients with recurrent infections should be persuaded not to use
their dentures at night but rather leave them exposed to air, which seems
to be a safe and efficient means of preventing microbial colonization..
Rough areas on the fitting surface should be smoothed or relined with a
soft tissue conditioner. About 1 mm of the internal surface being
penetrated by microorganisms should be removed and relined frequently.
A new denture should be provided only when the mucosa has healed and
the patient is able to achieve good denture hygiene.
Local therapy with nystatin, amphotericin B, miconazole, or
clotrinlazole should be preferred to systemic therapy with ketoconazole or
fluconazole because resistance of Candida species to the latter drugs
occurs regularly. For a reduction in the risk of relapse, the following
precautions should be taken
1. Treatment with antifungals should continue for 4 weeks
2. When lozenges are prescribed, the patient should be instructed to
take out the dentures during sucking.
3. The patient should be instructed in meticulous oral and denture hygiene;
the patient should be told to wear the dentures as seldom as possible and
to keep them dry or in a disinfectant solution of 0.2% to 2.0% chlorhexidine
during nights
Flabby Ridge (i.e., mobile or extremely resilient alveolar ridge) is due to
replacement of bone by fibrous tissue. It is seen most commonly in the
anterior part of the maxilla, particularly when there are remaining anterior
teeth in the mandible, and is probably a sequela of excessive load of the
residual ridge and unstable occlusal conditions .Results of histological and
histochemical studies have shown marked fibrosis, inflammation, and
resorption of the underlying bone.
However, in a situation with extreme atrophy of the maxillary alveolar
ridge, flabby ridges should not be totally removed because the vestibular
area would be eliminated. Indeed the resilient ridge may provide some
retention for the denture.
REDUNDANT TISSUE The forces of the mandibular teeth on the maxilla cause an
excessive resorption of the anterior aspect of the maxilla and the
mandibular teeth supererupt. The tissue in this region becomes
hyperplastic and may form an epulis fissuratum in the anterior maxillary
fold. As the anterior aspect of the maxilla resorbs, there is a concurrent
resorption of bone under the mandibular partial denture base. The occlusal
plane drops posteriorly and rises anteriorly.
Denture Irritation Hyperplasia
A common sequela of wearing ill-fitting dentures is the occurrence of
tissue hyperplasia of the mucosa in contact with the denture border. The
lesions are the result of chronic injury by unstable dentures or by thin,
overextended denture flanges. The proliferation of tissue may take place
relatively quickly after placement of new dentures and is normally not
associated with marked symptoms. The lesions may be single or quite
numerous and are composed of flaps of hyperplastic connective tissue.
If lymphadenopathy is present, the denture irritation hyperplasia may
simulate a neoplastic process
HYPERPLASTIC TISSUE.
Often hyperplastic tissue is present under an ill filling denture which
may be hyperplasia or hyper plastic folds under the denture base .
When this situation occurs the patient should be instructed to rest
the tissue by not wearing the denture. Proper oral hygiene and tissue
massage will also improve the condition. The existing denture should be
refitted with a tissue or temporary reline material. If marked improvement
does not occur surgical correction will be needed.
PAPILLARY HYPERPLASIA
Papillary hyperplasia develops in the palatal vault as multiple
papillary projections of the epithelium in response to local irritation, poor
oral hygiene, and low-grade infections such as Monilia. The polypoid
masses are usually intensely red, soft, and freely movable.Histologically,
the surface epithelium is hyperplastic with fibrous hyperplasia and in-
flammatory cell infiltration of the underlying connective tissue. Biopsy
usually confirms papillary hyperplasia, but some specimens show
pseudoepitheliomatous hyperplasia or dyskeratosis of the surface
epithelium.
Traumatic Ulcers Traumatic ulcers or sore spots most commonly develop within 1 to 2
days after placement of new dentures. The ulcers are small and painful
lesions, covered by a gray necrotic membrane and surrounded by an
inflammatory halo with fine, elevated borders .The direct cause is usually
overextended denture flanges or unbalanced occlusion. Conditions that
suppress resistance of the mucosa to mechanical irritation are
predisposing (e.g., diabetes mellitus, nutritional deficiencies, radiation
therapy, or xerostomia). In the systemically noncompromised host, sore
spots will heal a few days after correction of the dentures.
Oral Cancer in Denture Wearers An association between oral carcinoma and chronic irritation of the
mucosa by the dentures has often been claimed, but no definite proof
seems to exist .Case reports have detailed the development of oral
carcinomas in patients who wear illfitting dentures. However, most oral
cancers do develop in partially or totally edentulous patients. The reasons
appear to include an association withmore heavy alcohol and tobacco use,
less education, and lower socioeconomic status, which predispose to oral
cancer as well as to poor dental health, including tooth extraction and
denture wearing.
This underlines the necessity of strict and regular recall visits at 6-
month to 1-year intervals for comprehensive oral examinations. The
opinion is still valid that if a sore spot does not heal after correction of the
denture, malignancy should be suspected. Patients with such cases and
clinically aberrant manifestations of denture irritation hyperplasia should be
referred immediately to a pathologist. It should be recognized that the
prognosis is poor for oral carcinoma,especially for those in the floor of the
mouth.
Guggenheimer et al (1994) studied and concluded that majority of
oral cancers are likely to develop in partially or total edentulous patient.It
has been shown that periodic oral examination can detect these tumour
earlier than when patient return only because of symptoms which will result
in unfavorable prognosis.Dentist should encourage partially and toatally
edentulous patient to return for recall visit at 6 month or 1 year. These
could reveal larger proportion of localized malignancies and premalignant
lesion as well.It is no less important to recall edentulous paatient regularly
to asses their oral tissues for the presence of disease than to recall
dentate persons for evaluation of their dentate and periodontal health.
BURNING MOUTH SYNDROME BMS could be a sequalae of denture wearing and is characterized by a
burning sensation in one or several oral structures in contact with the den-
tures. It is relevant to differentiate between burning mouth sensations and
BMS. In the former group, the patient's oral mucosae are often inflamed
because of mechanical irritation, infection, or an allergic reaction. In
patients with BMS, the oral mucosa usually appears clinically healthy. The
vast majority of those patients affected by BMS is older than 50 years of
age, is female, and wears complete dentures.
A vague burning sensation or pain under an apparently well-fitting
denture with the complete absence of any detectable lesions is a common
complaint of the geriatric patient. A burning tongue is also frequently
brought to the attention of the dentist. These symptoms may be associated
with complete or partial dentures but are sometimes experienced when no
prosthetic replacements are in use. If dentures are used, simply requesting
the patient to leave them out for a period of time to see if the sensation dis-
appears will determine whether they are at fault. Determining the exact
etiology and treatment is often difficult and may require the cooperation of
the patient's physician and possibly psychiatric.
Burning Mouth Syndrome
Local Factors Mechanical irritation
Allergy Infection
Oral habits and parafunctions
Myofascial pain
Systemic Factors Vitamin deficiency
Iron deficiency anemia Xerostomia
Menopause
Diabetes
Parkinson's disease
Medication
Psychogenic Factors Depression
Anxiety
Psychosocial stressors
Management
In denture wearers in whom no organic basis for the complaints is
identified, the approach of the prosthodontist should be very careful. The
situation may be further complicated by the fact that the patients often
claim that their psychiatric disorders are due to the poor dentures and the
inadequate prosthetic treatment they have received. The patient's
symptoms should always be taken seriously, but any comprehensive
prosthetic treatment, including treatment with implant-supported
overdentures, should be carried out only as a collaborative effort of
psychiatrist and prosthodontist.
Gagging The gag reflex is a normal, healthy defense mechanism. Its
function is to prevent foreign bodies from entering the trachea. Gagging
can be triggered by tactile stimulation of the soft palate, the posterior part
of the tongue, and the fauces. In sensitive patients, the gag reflex is easily
released after placement of new dentures, but it usually disappears in a
few days as the patient adapts to the dentures. Persistent complaints of
gagging may be due to overextended borders (especially the posterior part
of the maxillary denture and the distolingual part of the mandibular
denture) or poor retention of the maxillary denture.
However, the condition is often due to unstable occlusal conditions
or increased vertical dimension of occlusion because the unbalanced or
frequent occlusal contacts may prevent adaptation and trigger gagging
reflexes.
Patients who develop a gagging or vomiting problem with dentures
are frequently difficult to treat, and the difficulty is primarily one of
determining the cause. Some patients have a hypersensitive gagging
reflex evident prior to and during the denture construction. The insertion or
removal of complete dentures may elicit gagging. However, occasionally a
patient develops a gagging problem after denture insertion.
Residual Ridge Reduction
Longitudinal studies of the form and weight of the edentulous
residual ridge in wearers of complete dentures have demonstrated a
continuous loss of bone tissue after tooth extraction and placement of
complete dentures. The reduction is a sequel of alveolar remodeling due to
altered functional stimulus of the bone tissue. The process of remodeling is
particularly important in areas with thin cortical bone (e.g., the buccal and
labial parts of the maxilla and the lingual parts of the mandible). During the
first year after tooth extraction, the reduction of the residual ridge height in
the midsagittal plane is about 2 to 3 mm for the maxilla and 4 to 5 mm for
the mandible.
Jahangiri et al (1998) describes the clinical feature of residual ridges.
• Continuous size reduction of the residual ridge, largely due to bone loss
after tooth extraction.
• General feature: RRR is chronic progressive ,and irreversible.
• The rate is fastest in first six month of extraction.
• Rate is variable between different persons ,within the same person at
different times, within same person at different sites.
• Has a multifactorial cause
• Anatomic factor, prosthetic factor, metabolic and systemic factor,
fundamental factor.
Some Proposed Etiological Factors of Reduction of Residual Ridges Anatomical Factors 1. More important in the mandible versus the maxilla
2. Short and square face associated with elevated masticatory forces
3. Alveoloplasty
Prosthodontic Factors Intensive denture wearing
Unstable occlusal conditions
Immediate denture treatment
Metabolic and Systemic Factors Osteoporosis .
Calcium and vitamin D supplements for possible bone preservation
Overdenture Abutments: Caries and Periodontal Disease
The retention of selected teeth to serve as abutments under
complete dentures is an excellent prosthodontic technique. In this simple
method, a few teeth in a strategically good position are preserved and are
treated endodontically before the crown is modified. The exposed root
surface and canal are filled with amalgam or a composite restoration. In
this way, even periodontally affected teeth can be maintained for several
years in a relatively simple way.Overdenture treatment does not
necessarily increase the risk of technical failures such as denture fractures
or loss of denture teeth.
However, the wearing of overdentures is often associated with a
high risk of caries and progression of periodontal disease of the abutment
teeth. One of the reasons for this is that the bacterial colonization beneath
a close-fitting denture is enhanced, and good plaque control of the fitting
denture surface is generally difficult to obtain. One reason is that the
species of Streptococcus and Actinomyces predominating in denture
plaque are well known for their major contributions to dental plaque on
smooth enamel surfaces, as well as on root cementum.. This could explain
why it is difficult to maintain healthy periodontal conditions adjacent to
overdenture abutments.
Use of the fluoride-chlorhexidine gel controlled caries development
and maintained healthy periodontal conditions.The introduction of
adequate denture-wearing habits (e.g., to abstain from wearing the denture
during the night) is another efficient way to control caries and development
of periodontal disease in overdenture wearers.Treatment of superficial
caries of the overdenture abutments includes application of fluoride-
chlorhexidine gel and polishing, and not exclusive placement of fillings,
which could result in recurrent caries.
INDIRECT SEQUELAE Atrophy of Masticatory Muscles
It is essential that the oral function in complete denture wearers is
maintained throughout life. The masticatory function depends on the
skeletal muscular force and the facility with which the patient is able to
coordinate oral functional movements during mastication. Maximal bite
forces tend to decrease in older patients. Furthermore, computed
tomography studies of the masseter and the medial pterygoid muscles
have demonstrated a greater atrophy in complete-denture wearers,
particularly in women.
Indeed, elderly denture wearers often find that their chewing ability is
insufficient and that they are obliged to eat soft foods.
Diagnosis : Direct measurement of the capacity to reduce test food to small
particles has verified that chewing efficiency decreases as the number of
natural teeth is reduced and is worse for subjects wearing complete
dentures. One of the consequences is that wearers of conventional
complete dentures need approximately seven times more chewing strokes
than subjects with a natural dentition to achieve an equivalent reduction in
particle size. As a consequence, completedenture wearers prefer food that
is easy to chew, or they swallow large food particles.
Preventive Measures and Management To some extent, the retention of a small number of teeth used as
overdenture abutments seems to play an important role in the
maintenance of oral function in elderly denture wearers. Therefore
treatment with overdentures has particular relevance in view of the
increasing numbers of older people who are retaining a part of their natural
dentition later in life.In the completely edentulous patients, placement of
implants is usually followed by an improvement of the masticatory function
and an increase of maximal occlusal forces. There is is no evidence of a
similar benefit after a preprosthetic surgical intervention to improve the
anatomical conditions for wearing complete dentures.
Nutritional Deficiencies Epidemiology
Aging is often associated with a significant decrease in energy
needs as a consequence of a decline in muscle mass and decreased
physical activity. Thus a 30% reduction in energy needs should be and
usually is accompanied by a 30% reduction of food intake. However, with
the exception of carbohydrates, the requirement for virtually all other
nutrients does not decline significantly with age. As a consequence, the
dietary intake by elderly individuals frequently reveals evidence of
deficiencies, which is clearly related to the dental or prosthetic status.
Masticatory Ability and Performance One of the strong indications for prosthodontic treatment is to
improve masticatory function. In this context, the term masticatory ability is
used for an individual's own assessment of his or her masticatory function,
whereas efficiency is to be understood as the capacity to reduce food
during mastication. There is no striking evidence that malnutrition could be
a direct sequelae of wearing dentures. However, edentulous women have
a higher intake of fat and a higher consumption of coffee and a lower
intake of ascorbic acid compared with dentate subjects within the same
age group.
Nutritional Status and Masticatory Function
Four factors are related to dietary selection and the nutritional status
of wearers of complete dentures: masticatory function and oral health,
general health, socioeconomic status, and dietary habits. In healthy
individuals there is no evidence that the nutritional intake is impaired in
wearers of complete dentures or that replacement of ill-fitting dentures with
well-fitting new dentures will causea major improvement . Also, reduced
salivary secretion rate during mastication has a negative effect on
masticatory ability and efficiency
CONTROL OF SEQUELAE WITH THE USE OF COMPLETE DENTURES
The essential consequences of wearing complete dentures are
reduction of the residual ridges and pathological changes of the oral
mucosa. This often results in poor patient comfort, destabilization of the
occlusion, insufficient masticatory function, and esthetic problems.
Ultimately, the patient may not be able to wear dentures and will receive a
diagnosis of prosthetically maladaptive.
For the adverse sequelae of residual ridge resorption to be reduced, the
following should be considered:
1. Restoration of the partially edentulous patient with complete dentures
should be considered if this is the only alternative as a result of poor
periodontal health, unfavorable location of the remaining teeth, and
economic limitations. In this situation, every effort should be made to
retain some teeth in strategically good positions to serve as
overdenture abutments. The maintenance of tooth roots in the mandible
is particularly important.
2. The patient with complete dentures should follow a regular control
schedule at yearly intervals so that an acceptable fit and stable occlusal
condition can be maintained.
Edentulous patients should be aware of the benefits of an implant-
supported prosthesis in young patients; the primary advantage would be
reduced residual ridge reduction. In elderly patients, the main advantages
are improved comfort and maintenance of masticatory function.
The following precautions should be taken to preclude development of
soft tissue disease:
1. Patients wearing overdentures supported by natural roots or implants
should follow a program of recall and maintenance for continuous
monitoring of the denture and the oral tissues. If patient compliance is
difficult to obtain, this might indicate that it is necessary to see the
patient every3to4months.
2. The patient should be motivated to practice proper denture wearing
habits such as not wearing dentures during the night. Finally, it is
important to remind and to explain to our patients that treatment with
complete dentures is not a "definitive" treatment and that their collaboration
is important to prevent the long-term risks associated with the
consequences of wearing comlete dentures.