Mohamed Hania

Introduction

Oral & Dental Complications of RPDs

Literature Review

Discussion

Conclusions

Definition :- Removable partial dentures (RPDs) are dental prostheses that replace one or more missing teeth but not all They receive support and retention from underlying tissues and from some, if not all, of the remaining teeth They can be removed by the patient from the oral cavity Must have adequate support, retention, and

stability Used to restore function, occlusion, aesthetics and

phonetics

RPDs are classified according to the material which they are made

The types of RPD include Acrylic resin and Chrome-Cobalt

Chrome-Cobalt Acrylic Advantages Disadvantages Advantages Disadvantages

Smaller design , less

bulky Expensive

Cheaper than

chrome-cobalt Least comfortable

Good retention

Difficulty in altering

denture after made –

cannot be relined

Easy to make Require more muscle

control

Better masticatory

performance ,

Tooth preparation

needed

Can alter denture

design after made

Tend to break more

easily

More hygienic Metal components

may be visible

Can be used for

immediate dentures Least comfortable

Better conduction of

temperature

Fractured

restorations will

effect fit of denture

Can be transitional

denture Less hygienic

More comfortable for

patient

More difficulty in

making denture

Can be relined for

better fit Less stable

Zitzmann 2007

The use of RPDs in Europe varies between 13% and 29.3%

Whealton 2007

More teeth are retained in elderly population due changes in attitudes and advancements in preventative dentistry

In the Republic of Ireland the rate of edentulism of 65+ year olds has decreased from 72% in 1968 to 40.9% in 2007

Age Groups Average number Of Teeth Present In

2007

16 – 24 year olds 28.2

25 – 54 year olds 25.5

64 + year olds 14.3

Given the high percentage of RPD use, it is important to note that the use of this prosthesis is associated with several dental and oral complications.

Decrease in the level of edentulism

Increasing elderly population

Results in an increasing number of partially edentulous

patients seeking RPDs

1. Deterioration in oral hygiene 2. Increased levels of plaque and gingivitis 3. Increased risk of caries in abutment and non-abutment teeth 4. Clinical attachment loss in abutment and non-abutment teeth 5. The risk of teeth overeruption in the opposing arch 6. Changes in oral microflora 7. Denture stomatitis 8. Traumatic ulceration 9. Denture granuloma These complications depend on the type of RPD used, the number

and position of missing teeth These complications are a result of poor design and/or

maintenance of RPD itself

Carlsson 1976 Good oral hygiene is directly related to positive treatment outcomes Chandler 1984 No direct evidence between RPD wearing and oral and dental breakdown Wagner 2000 et al: Most common complication – Poor Oral hygiene 64% of dentures had poor hygiene Considerable difference between the levels of calculus on acrylic surfaces

and metal surfaces, 36% vs 14% respectively De Souza 2009 – Cochrane Review Failed to identify the most effective method of maintaining denture

hygiene

Author(S) , Year Design of Study Sample Size Control Results

Carlsson, GE, 1976 13 year retrospective study 58 patients No control

Majority of patients need

treatment for caries,

periodontitis and other

prosthodontic treatment

Good oral hygiene is directly

related to positive treatment

outcomes

Chandler, JA, 1984 8- to 9-year retrospective

study 38 patients Non-RPD 9wearers

RPD wearing resulted in no

difference in the levels of caries,

probing depths, tooth mobility

and bone loss when compared

to non RPD wearers.

RPDs caused increased levels of

gingival inflammation in areas

that were covered and in the

gingivae apical to clasp arms.

No direct evidence between RPD

wearing and oral and dental

breakdown.

Wagner B, 2000

Retrospective study

10 years after provision of

RPDs

74 patients No control

Several abutment teeth

supporting an RPD had better

success rate

Non – Clasp retained RPDs had a

higher failure rate (66.7%) than

Clasp Retained Partial Denture

(44.8%)

De Souza, RF et al, 2009

Cochrane review

Randomized controlled trials

(RCTs)

N/A N/A

Six RCTs could not be compared

due to wide range of variables

and different interventions.

Bergman et al 1977,1982 RPDs that are carefully designed and accompanied with good oral hygiene and regular

follow ups, caused little deterioration in periodontal health Issues with occlusion, mastication, stability and clasp retention

Yusuf 1989 The frequency and severity of the complications tended to increase with increasing age

of the RPDs Kearn 2001 Disproportionately more number of abutment teeth being lost compared to non-

abutment teeth (26.4% vs 14.2% respectively) Recommended Maintenance regime Zlataric et al 2002 Natural abutment teeth had the highest levels of plaque(PI) and gingivitis(GI) similar

levels to surveyed crowns on abutments Mobility(TM) of abutment teeth was grade one in 50% of cases. Non abutment performed better for levels of PI, GI and TM but had significantly more

gingival recession Recommended Maintenance regime

Author, Year Design of Study Sample size Control Results

Bergman , 1977 6-year retrospective study 28 patients No control

RPDs did not result in the deterioration of the

periodontal status of the remaining teeth.

Low number of new caries lesion was

observed.

Deterioration was found of occlusion,

articulation, stability and clasp retention of

RPDs in the long term.

Bergman, 1982 10-year longitudinal study 27 patients No control

RPDs did not result in the deterioration of the

periodontal status of the remaining teeth.

Low increase in the number of decayed and

filled tooth surfaces was found.

Deterioration of the RPD required corrective

prosthetic procedures.

Yusuf, Z, 1989 Retrospective study 18 patients

Teeth in the opposing

arch not opposed to any

prosthesis

The wearing of RPDs resulted in higher levels

Plaque, Gingivitis compared to the controls.

Older dentures caused more plaque retention

and gingivitis.

Poor Hygiene while wearing dentures

resulted in a negative impact on the

periodontium.

Kern, M, 2001 Retrospective study

10 year study 74 patients No control

RPDs caused an increase in probing depths

and tooth mobility.

The abutment teeth of the non-clasp retained

RPDs suffered more deterioration than the

abutment teeth of the clasp retained RPDs.

Lack of maintenance regime may have

caused these complications.

Zlatarić, DK, 2002 Retrospective study 205 patients No control

RPDs caused an increase in probing depths

and tooth mobility.

There was substantial difference in the levels

Plaque, Gingivitis, Calculus, Tooth mobility,

Probing Depths and Gingival recession

between abutment and non-abutment teeth.

Good design and oral hygiene are needed to

minimise the negative impact of RPD on the

periodontium.

Budtz-Jorgensen 1990 Caries detected at six times the frequency in RPD

wearing than patients who were provided with cantilever resin bonded bridges

Jepson (RCT) 2001 RPD wearers had nearly five times more caries

lesions when compared to those with fixed prostheses

Steele 1997 & Nevalainen 2004 Increased susceptibility to root caries

Author, Year Design of Study Sample Size Control Results

Jepson, NJ, 2001 Randomised control trial

2 years 60 patients

Cantilever resin bonded

bridges (RBBs)

Bigger increase in the levels of

new and recurrent caries lesions

in patients wearing RPDs than

patients provided with cantilever

RBBs.

Budtz-jorgensen, 1990 A 5 year longitudinal study 53 patients Fixed partial denture opposing

complete upper denture

Caries was 6 times more likely in

patients with RPD than patients

with FPD.

Occlusion and function

deteriorated in the RPD patients

only.

RPD patients needed more

follow-upprosthodontic

treatment than FPD patients.

Nevalainen, MJ, 2004 5 year follow-up study 113 patients No control

RPD patients had higher levels of

salivary microbes and higher

root caries incidence than those

with natural teeth.

Steele J.G 1997 Cross sectional study 1228 patients Control is previous disease

history

RPDs increased the risk of having

root caries.

RPDs use should precipitate

additional steps to prevent root

caries.

Kiliardis 2000 & Craddock 2004 Overeruption of molars with no opposing dentition

occurred in 82% to 83% of cases

Matsuda 2014 Overeruption can occur in 38.1% of cases in patients

provided with RPDs, 57.1% in unopposed teeth, and 4.1% in teeth opposed by natural dentition

This may be due to wearing of the artificial teeth and/or the displacement of denture by residual ridge resorption

Which can be minimized by having regular relining and/or replacement of artificial teeth i.e. maintenance regimes

John MT 2004 Provision of fixed partial dentures, RPDs, and

complete dentures He found there was an improvement in quality of

life in all patients The provision of fixed partial dentures resulted in

the greatest improvement in the patient’s quality of life

Aleem 2009 & Jepson 1995 Observed that just replacing RPDs will have a

positive effect on patient’s quality of life Patient acceptance and satisfaction with RPDs was

still poor

Baxter 1984 & Krall 1998

Found that there was either little or no relationship between fully dentate patients and patients with RPDs on nutrition

Factors such as financial and socioeconomic status were more likely to be a significant factor on nutrition

Shinkai 2001

RPDs had poorer masticatory performance, compared with fully dentate patients

Nutritional intake did not differ

Nordlund 2009 Streptococcus Mutans and Lactobacilli are the microorganisms

responsible for the caries process Beighton 1990 & Tanka 2009 They are found in higher levels in patients wearing RPDs

than in patients with fixed prostheses & natural dentition Candida Albican was detected to be three times higher in

RPD wearers Mihalow 1998 Levels of Strep Mutans increased within 4-6 months of RPD

wearing Preshaw 2011 Periodontal disease-causing pathogens were found to be in

insignificant levels in RPD wearing patients compared to non-RPD wearing patients

Author, Year Design of Study Sample

Size

Control

Results

Krall 1998 Prospective

observational study

1,231

patients No control

Missing teeth and the presence of RPDs are predictors of

nutrition.

Preventative measures and Replacement of missing

teeth help people maintain a healthy diet and reduce risk

of diet related chronic disease.

Shinkai, RS, 2001 Cross-sectional study 731 patients No control Masticatory factors are not indicative of diet quality

across all socio-demographic groups.

Kiliardis 2005 Retrospective study of

10 years 53 patients No control

18% of molars did not overerupt.

Less than 2mm of overeruption in molars occurred in

58% of cases.

24% of molars showed signs of moderate to severe

overeruption.

Molars are less likely to overerupt in older age of

patients when their antagonist is lost.

Maxillary molars are more likely to rotate.

Mandibular molars are more likely to tip.

Tanaka, J, 2009 Longitudinal 3-year. 22 patients No control

RPD increase Lactobacillus numbers and more

cariogenic than FPD.

RPD may cause increased risk of caries when compared

to FPD.

Matsuda, 2014. Retrospective study 33 patients Control is unrestored

opposing dentition

Overeruption was observed in 38.1% of teeth opposed

by RPDs.

Overeruption was observed in 4.1% of teeth opposed by

natural teeth.

Overeruption was observed 57.1% of teeth that were

unopposed.

Definition :-

Denture stomatitis is defined as an inflammation of the denture bearing mucosa caused by microbial plaque composed of bacteria and/or candida species

Candida involvement in 90% of cases

It is caused by night-time denture wearing and poor denture hygiene

It affects older dentures more

Traumatic ulcers which are a break in the lining of epithelium caused by mechanical injury to the mucosa by RPDs

Chronic irritation by a denture can result in a condition called denture granuloma

benign hyperplasia of fibrous connective tissue and is most commonly found in the sulci where the denture is overextended

It is clear from the research of the literature that well-designed, randomised controlled studies with large sample size is lacking

It is difficult to extrapolate valuable conclusions regarding RPD complications, as the baselines of the patient’s oral health have not been established and poor level of evidence in the literature

It can be reasonable to assume that some oral and dental complications can be a result of certain risk factors (poor oral hygiene and diet, untreated periodontal disease etc) of patients remaining following prosthodontic treatment

RPDs alone is not a major risk factor

Nonetheless complications of RPDs are extensive and real. The design of the RPD is very critical in maintaining periodontal health

and a need for a maintenance regime Kratochvil, 1963 In distal extensions RPDs – RPI system Kapur (RCT) 1994 I Bars vs Occlusally approaching clasps McHenry 1992 Lingual bars causes significantly less gingival inflammation than lingual

plates Zlataric 2002 RPDs should be located as far away from the gingival margin as possible

to prevent gingival trauma and inflammation. Every effort should be made to retain posterior teeth for the distal extensions The options of implant supported dentures or the use of attachments should be explored

The oral and dental complications of RPDs are extensive and can be severe but that should NOT preclude them as a treatment modality

The complications that are widely known can be minimised if not eliminated with careful design, beginning at mounted study cast stage and a regular maintenance regime following delivery of prosthesis

RPDs are still an effective treatment modality , have a major role in replacing missing teeth which can restore function, occlusion, aesthetics and phonetics

Shinkai, RS, 2001. Oral function and diet quality in a community based sample, Journal of Dental Research 80:1625-1630

Nordlund, A, 2009. Improved ability of biological and previous caries multimarkers to predict caries disease as revealed by multivariate PLS modelling , Biomed Central Oral Health 9,28

Tanaka, J, 2009. Longitudinal research on the oral cavity of elderly wearing fixed or removable prostheses , Journal of Prosthodontic Research 53:83-8

Beighton, D, 1990. Associations between salivary levels of mutans streptococci ,lactobacilli , yeasts and black pigmented bacteroids spp and dental variables in elderly patients, Archives of Oral Biology 35, 173s-175s

Milhalow, DM, 1988. The influence of removable partial dentures on the level of strep mutans in saliva, Journal of Prosthetic Dentistry, 59, 49-51.

Preshaw, P.M, 2011. Association of removable partial denture use with oral and systemic health, Journal of Dentistry, 08, 18

Tanaka, J, 2009. Longitudinal research on the oral cavity of elderly wearing fixed or removable prostheses, Journal of Prosthodontic Research 53:83-8

Jean B, 2003. Reassessing the presence of Candida albicans in denture related stomatitis . Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics 95: 1

Scully, C, 2008. Oral and maxillofacial medicine: the basis of diagnosis and treatment. 2nd ed. Edinburgh: Churchill Livingstone.

Tyldesley, AF, 2003. Tyldesleys's Oral Medicine. 5th ed. Oxford: Oxford University Press. Newton, A.V 1962. Denture sore mouth. British Dental Journal 112:357-60, Neville, BW, 2002. Oral &Maxillofacial pathology. 2nd ed. Philadelphia: W.B. Saunders.

Chandler, JA, 1984. Clinical evaluation of patients 8 to 9 years after placement of removable partial denture Journal of Prosthetic Dentistry 51;736-43

Zlatarić, DK, 2002. The effect of removable partial dentures on periodontal health of abutment and non-abutment teeth Journal of Periodontology 73(2): 137-144

Yusuf, Z, 1989. Periodontal status of teeth in contact with denture in removable partial denture wearers Journal of Oral Rehabilitation 16:119-26

Kern, M, 2001. Periodontal findings in patients 10 years after insertion of removable partial dentures Journal of Oral Rehabilitation 28:991-997

Kratochvil, f, 1963. Influence of occlusal rest position and clasp design on movement of abutment teeth Journal of Prosthetic Dentistry 13,114-124

Kratochvil, f, 1963. Influence of occlusal rest position and clasp design on movement of abutment teeth Journal of Prosthetic Dentistry 13,114-124

Kapur, KK, 1994. A randomized clinical trial of two basic removable partial denture designs Part 1 comparisons of five-year success rates and periodontal health Journal of Prosthetic Dentistry 72:268-282

McHenry, 1992. The effect of removable partial denture framework design on gingival inflammation a clinical model Journal of Prosthetic Dentistry 68:799-803

Zlatarić, DK, 2002.The effect of removable partial dentures on periodontal health of abutment and non-abutment teeth Journal of Periodontology 73(2): 137-144

Dinh X. Bui. Removable Partial Denture and its Effects on Periodontal Health. [ONLINE] Available at: http://www.drbui.com/artrpd.html.

Budtz-jorgensen, 1998. Alternate frame work designs for removable partial dentures , Journal of Prosthetic Dentistry 80:58-66

Jepson, NJ, 2001. Caries incidence following restoration of shortened lower dental arch in randomised controlled trial British Dental Journal 191:140-144

Budtz-jorgensen, 1990. A 5 year longitudinal study of cantilevered fixed partial dentures compared with removable partial dentures in a geriatric population, Journal of Prosthetic Dentistry 64:42-47

Nevalainen, MJ, 2004. A 5 year follow-up study on the prosthetic rehabilitation of the elderly in Finland, Journal of Oral Rehabilitation 31;647-653

Steele, JG, 1997. Partial denture as an independent indicator of root caries risk in group of older adults ,Gerodontology 14:67-74

Carlsson, GE, 2005. Tooth movement, British Dental Journal 198:420-421 ,

Kiliaridis, 2000. Vertical position , rotation and tipping of molars without antagonists, International Journal of Prosthodontics 13:480-486

Craddock, HL, A study of the incidence of over eruption and occlusal interferences in unopposed posterior teeth British Dental journal 196:341-348

Matsuda, 2014. Over eruption of teeth opposing removable partial denture : a preliminary study, International Journal of Prosthodontics 27:475-476

John, MT, Oral health-related quality of life in patients treated with fixed , removable and complete dentures , International Journal of Prosthodontics 17:503-511

John, MT, Oral health-related quality of life in patients treated with fixed , removable and complete dentures , International Journal of Prosthodontics 17:503-511

Aleen, PF, 2009. Determining the minimally important difference for the oral health impact profile, European Journal of Oral Science 117:129-34

Jepson, NJ, 1995.The influence of denture design on patient acceptance of partial dentures, British dental journal 178:296-300

Makila, 1969. Effects of complete dentures on dietary intake and serum levels of pantothenic acid , folic acid and iron in edentulous person, Suomen Hammaslaakariseuran Toimitukisia 65:299-311

Baxter, JC, 1984. The nutritional intake of geriatric patients with varied dentitions , Journal of Prosthetic Dentistry 51:164-168

Krall, E, 1998. How dentition status and masticatory function affect nutrient intake , Journal of the American Dental Association 129:1261-1269

Carr, AC, 2005. McCracken’s Removable Partial Prosthodontics. 5th ed. St. Louis, Missouri: Elsevier Mosby

Carr, AC, 2005. McCracken’s Removable Partial Prosthodontics. 5th ed. St. Louis, Missouri: Elsevier Mosby

Zitzmann, NU, 2007. What is the prevalence of various types of prosthetic dental restorations in Europe?, Clinical Oral Implants Research 18:20-33

Preshaw, P.M, 2011. Association of removable partial denture use with oral and systemic health. Journal of Dentistry, 08, 18

Whelton, H. A Ten year longitudinal study: Oral health of Irish adults 2000-02. Department of Health and Children. Brinswick Press LTD. Final report ,April 2007

Whelton, H. A Ten year longitudinal study: Oral health of Irish adults 2000-02. Department of Health and Children. Brinswick Press LTD. Final report ,April 2007

Whelton, H. A Ten year longitudinal study: Oral health of Irish adults 2000-02. Department of Health and Children. Brinswick Press LTD. Final report ,April 2007

Vaupel, JW, 2010. Bio demography of human ageing. Nature, 464

Douglas, CW, 1988. Need and effective demand for prosthodontic treatment. Journal of Prosthetic Dentistry, 59, 94-104

Carr, AC, 2005. McCracken’s Removable Partial Prosthodontics. 5th ed. St. Louis, Missouri: Elsevier Mosby

Carr, AC, 2005. McCracken’s Removable Partial Prosthodontics. 5th ed. St. Louis, Missouri: Elsevier Mosby

Preshaw, P.M, 2011. Association of removable partial denture use with oral and systemic health. Journal of Dentistry, 08, 18

Wagner B, 2000. Clinical evaluation of Removable partial denture 10 years after insertion Clinical Oral Investigations 4:74-80

Wagner B, 2000. Clinical evaluation of Removable partial denture 10 years after insertion Clinical Oral Investigations 4:74-80

De Souza, RF et al, 2009. Intervention for cleaning dentures for adults (Cochrane review) CD007395

Carlsson, GE, 1976. Late results of treatment with removable partial denture Journal of Oral Rehabilitation 3,267-272

Wagner, B, 2000. Clinical evaluation of Removable partial denture 10 years after insertion, Clinical Oral Investigations 4:74-80

Kratochvil, f, 1963. Influence of occlusal rest position and clasp design on movement of abutment teeth, Journal of Prosthetic Dentistry 13,114-124

Chandler, JA, 1984. Clinical evaluation of patients 8 to 9 years after placement of removable partial denture , Journal of Prosthetic Dentistry 51;736-43

Bergman,B ,1982.Caries, periodontal and prosthetic findings in patients with removable partial dentures , Journal of Prosthetic Dentistry 48,506-514

Bergman B, 1977.Caries and periodontal status in patients fitted with removable partial dentures. 4,132-146

Bergman,B ,1982.Caries, periodontal and prosthetic findings in patients with removable partial dentures: a ten-year longitudinal study, Journal of Prosthetic Dentistry 48,506-51