TROUBLE SHOOTING IN COMPLETE DENTURE PROSTHESIS

1. It can be said that complete denture treatment is an unnatural

treatment of oral tissues left over after loss of teeth.

2. The oral tissues are exposed to the presence of a foreign body which

sandwitches the oral mucosa against the hard bone.

3. It may be understood that the oral tissues have not evolved to accept

the ravages of such large foreign bodies. It is therefore natural that

an initial copious flow of saliva is a proof of rejection of the oral

tissues of invading agency.

4. If however the tissues are compelled to accept them, rationally

speaking they have got to be formulated keeping in mind the tissue

biology and the mechanical needs of retention and stability.

5. The dentures are simply placed on tissues without anchors and the

patient is expected to acquire neuromotor skills in holding them. In

this exercise the dentures are expected to remain seated during

various functional excursions.

6. The neuromuscular attainment of skill is more easily said than done

since the learning potential of patiens vary at every age level and

hence in advanced age the patients face a situation of tight rope

walk. This itself constitutes yet another genesis for trouble shooting.

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7. It is to be reckoned that the foundations present varying degrees of

different morphology and altered physiology.

8. Infact the dentures reveal a lot of skidding effect adding to the

problem of sensitive oral mucosa.

9. Similarly food habits manifest diversity to a point that patient

needing to use the dentures successfully, has to accept the changes

in life style.

10. Emotional disturbances and more so in advancing age are yet

another manifestation that causes irritation of tissues and the

resulting tissue loss. It is for these reasons the following text is

presented to present classified information in respect of tissue

injuries and the impared functions. Therefore the purpose of this

presentation is to concentrate on tissue injuries with the intention of

knowing how to treat these conditions.

It is difficult to discuss every complaint made by a patient, but the

following are the most common and will give a comprehensive outline of

how the dentist may diagnose their cause and how they should be treated.

Grossly these problems can be grouped under these categories.

A. Tissue Injury

B. Impaired function

C. Miscellaneous

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A. Tissue Injury

a) Involving supporting and stabilizing areas

- Mucosa of the crest

- Slopes of the ridge

- Mucosa of palate

- Bone

Truamatic lesions of the stress bearing mucosa of the crest of the

residual ridge, slopes of the ridge and palate are usually the result of (i)

imperfections in or on the tissue side of the denture base (ii) Pressure areas

on the tissue side of the denture that were developed either in the

impression procedures or as a result of damage to the master cast and (iii)

disharmony in occlusion in either the centric or the eccentric jaw positions.

Lesions:

1. Punched out areas

2. Whitish areas

3. Hyperaemic and painful areas

4. Localized or generalized areas of inflammation

5. Hypertrophy

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1. Punched out lesions and the surrounding hyperaemic mucosa are

usually the result of imperfections in denture base, trauma from food

particles when the dentures were not in the mouth.

2. Lesions particularly of the crest are whitish due to the presence of

excess Keratin (whitish may also be due to ischaema improper

impression technique).

3. Lesions that are hperaemic and painful are encountered over the

mylohyoid ridges, the cuspid eminences, the alveolar tubercles and

areas of exostosis. It is usually seen when undercuts are present in

the lateral aspect of maxillary tuberosites. It is produced by the

flanges of the denture during the placement and removal of denture

from the mouth or from excessive friction when the denture moves

during function.

Hyperaemic, painful and detached areas of epthelium that develop on

the slopes of residual ridge are usually the result of disharmony of

occlusion when the teeth are making unbalanced contacts in eccentric

jaw positions.

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4. Localized or generalized areas of inflammation

Causes

Lack of Rest: Some patients do not remove

their dentures and hence do not allow rest to the tissues. The constant

pressure of the dentures retards the normal blood supply, which

oxygenates the tissue and removes waste products.

Dentures instability: It may be due to a faulty

impression technique, or when posterior teeth are placed too far

buccally or when there is inequillibrium between resilient and non

resilient areas.

Inadequate free way space: A generalized

hyperaemia of the crest and slopes of the ridges accompanied by pain in

the muscles attached to the mandible, the production of hyperKeratin

and a looseness of the dentures are often the result of insufficient

interocclusal distance.

Poor oral hygiene can result in inflammatory

reactions; e.g. in Xerostomia

A complete denture opposing natural teeth or a

partial denture may cause localized hyperaemia and edema.

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An unbalanced diet and avitaminosis contribute

to inflammatory conditions in all age groups. Alcoholism and senility

may lead to malnutrition, which is reflected in the inability of the oral

mucosa to the resist the pressure of dentures.

Endocrine gland disturbances and parafunction

resulting from neurosis can cause inflammation of the oral mucosa.

Systemic debilitating diseases contribute to

poor tissue tone and poor tissue resistance of dentures. E.g.

Hypertension, diabetes.

Allergic reactions of the supporting tissues to

denture base materials.

5. Hypertrophy:

An abnormal increase in size of the stress bearing oral mucosa is

unusual. In the midpalatal suture area, particularly when a relief is placed

in the tissue side of the denture base, hypertrophy of the mucosa does

occur. Small nodules which are defined as ‘papilloma-like hypertrophy’

develop throughout the area. The incisive papilla is another area that

becomes enlarged, hyperaemic and painful if it is not relieved in the

dentures. When the cause is not removed the tissue becomes pendulous.

Problems involving bone:

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Alveolar residual ridge is the major bony support for the denture

base to resist torquing and horizontal forces.

Isolated spinous processes may develop on the surface of the bone.

The soft tissue covering is caught between the hard dentures base and the

spine of bone with resulting discomfort and pain.

Bone growth on the surface and exostosis results in a thinning of the

over lying mucosa. These areas of bony growth act as fulcrums and

pressure points.

Sharp and prominent mylohyoid ridge acts like a knife edge and also

creates an undercut area.

Bone sore mouth a rarely encountered condition in senile patients

shows no soft tissue damage but expresses a feeling of constant soreness

and desire to remove the dentures.

b) Tissue Injury in Contact with Denture Periphery:

These lesions are mostly encountered in following areas and in the

order named:

- Frenum attachments

- Retromylohyoid space

- Retromolar pad

- Masetteric notch

- Hamular notch

- Vestibular fornix

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- Floor of the mouth

- Soft palate

Lesions seen are

- Slit like fissures and

- Ulcers

- Hypertrophy

Causes i) Over extensions of dentures periphery

ii) Sharp, thin unpolished borders

Hypertrophy at the junction of tightly and loosely attached mucosa

is caused by initial trauma which may be a result of disharmony of

occlusion in the eccentric positions. This is especially true when the forces

of occlusion are directed towards the anterior residual ridges in biting. The

bone loss results in a loose denture and a loose denture produces more

trauma.

Hypertrophy in the labial flange area often occurs following the

insertion of an immediate complete denture when the occlusion and

denture base have not been altered to meet the changes taking place in the

basal seat.

c) Tissue Injury in Contact with Polished Surface of Teeth:

Areas involved are lips, cheeks and tongue.

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Lesions seen are

- Cheek biting

- Tongue bititing

- Irritation of mucosa

Causes

1. Improper placement of teeth in horizontal or vertical

direction can lead to tongue biting or cheek biting.

2. Rough margins of teeth, an unpolished denture base or

porous dentures can lead to irritation of mucosa.

Treatment procedures:

Dentures that are essentially satisfactory can be ruined by

indiscriminately altering the denture base or the teeth. To determine the

etiology, the dentist must conduct these procedures in a systemic manner.

1. Examine each denture for stability and retention with the mouth at rest

and with the mouth in function. To check functional stability and

retention instruct the patient to speak, laugh, yawn, wipe the lips with

the tip of tongue and swallow.

2. Check the dentures for indications of undercut areas. Apply pressure

disclosing paste to the tissue side of either maxillary or mandibular

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denture. Instruct the patient to place and remove the dentures from the

mouth. An undercut is detected where the paste is removed from the

denture as if it were dragged from the surface. When it has been

definitely established that an undercut exists, alter the tissue side of the

denture base with an acrylic bur. One should be careful during this

procedure since tissue contact with the denture must be maintained.

Smooth and polish all ground areas.

3. Apply pressure indicating paste to the entire tissue side of the maxillary

denture. Instruct the patient to place both the dentures and tap the teeth

together with the jaws in centric relation. An area of displaced paste in

the tissue side of the denture is a sign of pressure. The pressure area

may result from premature tooth contact or imperfection of the denture

base.

4. To determine if the pressure area is produced by faultly occlusion,

institute patient remount procedures.

Steps:

Make a face bow record

Remount the dentures on an adjustable articulator

Adjust protrusive condylar and incisal guidance

Correct the occlusion

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5. The steps mentioned are done after tissue conditioning. Patient is

advocated only with soft food during the entire course of treatment.

When problem arises from loose and illfitting dentures, either remake

or rebase the dentures. It is possible that both the occlusion and denture

base may need correction.

6. When a generalized inflammatory condition exists or hyperkeratosis

is present in the stress bearing mucosa, evaluate interocclusal distance.

If the interocclusal distance is not adequate, alter the teeth to provide

space or remake the prosthesis.

7. When traumatic lesions are present in relation to the denture border,

apply disclosing wax to the borders of one denture at a time. Instruct

the patient to speak, swallow, laugh, yawn, wipe the lips with the tip of

the tongue in the buccal and labial vestibular spaces. If the wax is

moved from the border of the denture, overextention is indicated.

Remove the overextended area by grinding with an acrylic bur.

Smoothen the ground surface with wet pumice on a wet rag wheel.

8. Hypertrophy of the mucosa which does not include fibrous

hyperplasia is usually reversible and will resolve when the source of

trauma is removed.

9. When abrasions and ulcerations of the tongue and cheek occur, the

vertical and horizontal positions of the teeth must be evaluated. A loss

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of muscle tonus allow the cheek to sag and the result may be cheek

biting.

Tongue biting can occur in patients who have disease of the nervous

system such as epilepsy.

10. Xerostomia or Asialorrhoea

Results from regressive changes in salivary glands particularly of the

cells lining the intermediate ducts causing decreased flow of saliva.

Causes: Diabetes, Nephritis, Pernicious anaemia, Menopausal women,

Vitamin deficiency, X-ray irradiations, Medications.

Treatment for xerostomia:

- Frequent lubrication with petroleum jelly, silicone fluid and

improving hydration of the patient.

- If glandular function is present administration of sialogogues –

pylocarpine hydrochloride or pylocarpine nitrate 5 mg dose before

meals.

- Therapeutic dose of nicotinamide (250-400) mg TDS for 2 weeks.

Dentures are to be used minimally as tissues are fragile. These

patients are prone to conditions and chlorhexidine is the treatment of

choice.

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11. Surgical procedures or systemic theraphy usually resolve problems

involving bone.

B. Impaired Function

Esthetics:

Mental and emotional responses to the appearance of dentures vary.

What is acceptable to one person may be unacceptable to another.

Regardless of age or sex, esthetics is an important factor in denture

acceptance.

Common problems

1. Dissatisfaction with appearance

2. Dissatisfaction with teeth colour

3. Dissatisfaction with teeth position

1. Dissatisfaction with appearance: The number of patients who are

dissatisfied with their appearance with final dentures can be much

reduced if the dentist insists on a relation or a candid friend being

present at the trail stage, although it has to be stressed that the

appearance cannot be fully assessed until four to six weeks after

placement of finished dentures. This is because, the lip and muscles

have to adapt to the dentures.

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2. Dissatisfaction with teeth colour: The complaint is almost

invariably that the teeth are too dark or too yellow, but before

changing them it must be explained to the patient that natural teeth

darken with age and that very light shaded teeth look more artificial

than darker ones.

Treatment: Comply if possible with the patients request for lighter

teeth, usually by a compromise between the shade chosen by the

operator and that chosen by the patient.

3. Dissatisfaction with teeth position: The complaint may be that the

upper incisal edges are too low and therefore too much tooth is

showing. If there is a fault in the orientation of the occlusal plane,

the anterior teeth may be removed and replaced at a higher level but

usually this is unsatisfactory as it spoils the acrylic matrix and ruins

the protrusive tooth contacts. The best solution in such cases is to

remake the dentures.

The complaint may also be that the teeth are too far back in the

mouth or too far forward. A fear is sometimes expressed that moving the

teeth anterior to the ridge in the position the natural teeth occupied, will

affect the stability of the denture. But it is not so. Stability will be

jeoparadised much more by encroaching on the tongue.

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Phonetics:

When complete dentures are first worn, there is always some

temporary alteration in speech owing to the thickness of the denture

covering the palate, necessitating slightly altered positions of the tongue.

Commonly this is only a temporary inconvenience, most rapidly overcome

by the patient reading aloud. However, some knowledge of phonetics in

relation to dentures is necessary, inorder to correct speech defects that may

occur in denture wearers, and also to act as a guide for the more accurate

design of complete dentures.

Factors in denture design affecting speech

The vowel sounds:

These sounds are produced by a continuous air stream passing

through the oral cavity which is in the form of a single chamber. All vowel

sounds involve the tongue which has a convex configuration. The tip of the

tongue, in all the vowel sounds, lies on the floor of the mouth either in

contact with or close to the lingual surfaces of the lower anterior teeth and

gums. The application of this in denture construction is that the lower

anterior teeth should be set so that they do not impede the tongue

positioning for these sounds.

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Consonant sounds:

- Labial sounds – They are b, p and m formed mainly by the lips

- Labiodental sounds – They are f and v made between the upper

incisors when they contact the posterior 1/3 of the lower lip. Most

important information to be sought while the patient makes these

sounds is the relation ship of incisal edges to lower lip.

Dental and alveolar sounds:

Dental sounds such as ‘th’ are made with the tip of the tongue

extending slightly between the upper and lower anterior teeth. This sound

is closer to the alveolar than the tip of the teeth. Careful observation of the

amount of tongue that can be seen can provide information regarding

labiodental position of anterior teeth.

The sibilants s, z, sh, ch and j are alveolar sounds because the

tongue and alveolus form the controlling valve. When these sounds are

made, the upper and lower incisors should approach each other end to end,

but they should not touch.

The ‘S’ sound can be considered dental and alveolar speech sounds

because they are produced equally well with two different tongue

positions. Most people make the ‘S’ sound with the tip of the tongue

against alveolus in the area of rugae with small space for escape of air

between tongue and alveolus. Size and shape of this small space will

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determine the quality of the sound. If the opening is too small, a whistle

will result. If the opening is too broad, the ‘S’ sound will be developed as

an ‘Sh’. Frequent cause of undersired whistles with denture is a posterior

dental arch form that is too narrow.

A cramped tongue space, especially in the premolar region forces

the dorsal surface of the tongue to form too small an opening for the escape

of air. The procedure for correction is to thicken the center of the palate so

that the tongue does not have to extend up so far into the narrow palatal

vault.

Posterior palatal seal area: Errors of construction in this region

involves the vowels ‘u’ and ‘o’ and the consonants ‘k’, ‘g’. A denture

which has a thick base in the posterior seal area or a posterior edge finished

square instead of chamfered, will probably irritate the dorsum of the

tongue, impeding speech and possibly producing a feeling of nausea.

Mastication

Inability to eat:

This complaint is mainly confined to patients who are wearing

complete dentures for the first time, and are impatient at the time spent in

acquiring new habits of eating. Careful attention by the operator to the

psychological approach to denture wearing, will eliminate his complaint

except in rare cases.

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Difficulty may be encountered with certain fibrous foods and this is

likely to be due to low-cusp or zero cusp posterior teeth or lack of

interdigitation of posterior teeth.

An overextended periphery may cause a denture to dislodge. (This is

because movements during eating are more extensive than those employed

when moulding the periphery of the impression. Intelligent observation by

the patient of the exact movements which cause the instability will

eventually enable the operator to locate the overextention).

Retention and Stability

Patients more often complain that the lower denture lifts than that

the upper one drops.

Causes

Over extension, Tight lips, Under extension, Lack of saliva, when

coughing or sneezing, Upper denture drops when patient yawns, Lower

denture raises when mouth is partly open, Lower denture unseats with

various tongue movements, Upper denture drops while patient is talking,

Dislodgement of dentures on taking fluids.

Overextention :

It is due to incorrect moulding of the impression or incorrect

outlining of the denture on the cast and is visible in the mouth as an area of

hyperaemia or an ulcer.

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With the help of pressure indicating paste the overextention can be

detected and corrected.

Tight lips:

It can be the most difficult problem if the mandibular ridge is flat

and atrophic. The inward pressure from the lips will push the lower denture

backwards up the ascending ramus.

Treatment: Remake the lower denture with the lower anterior teeth set

more lingually, with a labial concavity an the denture. Surgical

vestibuloplasty must be considered.

Tongue space

It the lower posterior teeth are tilted or set lingually they produce an

undercut area into which the wide middle third of the tongue will get

locked. Movements of the tongue then lift the denture.

Treatment: Reduce the width of the lower posterior teeth by grinding off

the lingual cusps.

Underextention:

Maximum retention cannot be obtained without covering the

greatest possible denture bearing area.

It can be corrected by proper border moulding procedures with low

fusing compound and a conventional reline can then be carried out.

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Lack of saliva: already discussed under xerostomia. Serous salva produces

better cohesive force than mucous saliva.

When coughing or sneezing: occasionally a new denture wearer will

complain that his upper denture falls and his lower denture lifts whenever

he coughs or sneezes.

Treatment: It must be explained to the patient that when coughing or

sneezing the soft palate rises suddenly and the air pressure is considerable

so that the peripheral seal of the upper denture is broken and it is liable to

fall; the usual muscular movement will cause the lower denture to lift.

There is no way of preventing these movements of the dentures, but

covering the mouth with a hand or handkerchief is an obvious suggestion.

Upper denture drops when patient yawns:

During the act of yawning the mouth is opened

to its fullest extent, and the border tissues pull down against the

borders of the denture. If there is an area of irritation, the borders are

overextended and should be reduced. If there is no evidence of

overextention, the patient should be cautioned to refram from

opening the mouth too wide.

Distobuccal flange of the denture may be too

thick so that they interface with the action of ramus. A side to side

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movement of the jaw will loosen the denture. If this occurs, reduce

the thickness of the distal ends of the buccal flanges.

Denture is inadequate in posterior palatal seal.

This leads to a poor palatal seal and air is permitted to enter under

the posterior border of the denture.

Buccal surfaces of the teeth are placed too far

towards the cheek. When this occurs, and the mouth is opened the

muscles of the cheek pull against the buccal surfaces of teeth and

tend to unseat the denture.

Denture is overextended in the pteregomixillary

notch. When this occurs, the functional activity of the

pteregomandibular raphae is interfered with and during jaw

movements the denture is unseated.

Lower denture rises when the mouth is partly

open

Lingual flanges are over extended in the mylohyoid

region.

Lower posterior teeth are too far to the buccal.

Overextention of the buccal flangs.

Upper denture drops while patient is talking

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Poor border seal

Improper frenum relief in the denture.

Dislodgement of dentures on taking fluids

The patient should be told that when the dentures are delivered it is

possible for him or her to experience a loosening of dentures while

drinking. During swallowing, the soft palate rises and the posterior palatal

seal may be lost. The tongue and floor of the mouth are raised by the

tongue muscles. The mandible is prevented from moving downwards by

the suprahyoid muscles. So the mandibular denture rises during

swallowing.

However, this will not persist when the tongue, lips and cheeks learn

to manipulate the dentures.

Gagging:

One of the most bewildering problems encountered in complete

denture prosthodontics is that presented by the patient referred to as

“gagger”.

“Gagging is an involuntary retching reflex that may be stimulated

by something touching the posterior palatal region”. The retching may lead

to actual vomiting and is accompanied by lacrimation, salivation and

flushing. These symptoms are usually triggered by tactile stimulation of the

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soft palate by the maxillary denture, but may also be caused by virtually

any intraoral procedure.

The maxillary denture of the gagging patient usually has either of

the two characteristic contours. It may have a posterior palatal margin that

is so concave that it almost terminates on the hard palate, or it may have a

palate which has a marked downward slope away from the soft palate. In

either case the dentures can exert only minimal pressure against the soft

palate.

The most paradoxical feature found in almost every gagging patient

is although the soft palate is extremely sensitive to the contact of the

denture or any instrument, the patient seldom gags on foods and liquids of

his diet which contact this same area during swallowing.

It can thus be seen that the picture presented by the average gagger

can be separated into –

i) Acute

ii) Chronic

Shortening of palatal margin does not decrease the tendency to gag

but may actually increase it. Even in a non gagger light touch or pressure

against the soft palate can cause tickling sensation, whereas firm pressure

is much less apt to do so. A similar experiment can be performed by

touching the back of one’s hand with the lightest possible pressure; this

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will usually cause a tickling sensation. However if the pressure on the same

area is firm, no tickling is felt. And so, too, with the maxillary denture; it is

much more apt to cause a tickling sensation if it exerts too little pressure

against the soft palate than if it exerts too much.

So the consistent feature of the acute phase is a maxillary denture

which feels “too long” and causes gagging which is not relieved by palate

shortening.

Chronic phase:

In this phase the gaggers history resembles a simple conditioned

reflex in that the gagging becomes so intimately associated with the

denture that ultimately any procedure involving the denture, or the oral

cavity, can set off the reflex. Even the thought of such contact may cause

gagging.

Kovats and Krol mentioned that the gag reflex can be markedly

diminished if the patient’s complete attention is diverted by having him

maintain a leg in an elevated position.

Treatment:

There are a number of methods of dealing with the problem. It is

important to give the patient a feeling of confidence of on the part of the

dentist.

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Prior to the impression making, the patient should be instructed to

breathe through the nose slowly and audibly and at the same time to

rhythmically tap his right leg on the floor. By doing so the patients

attention would be diverted enough to allow the making of mandibular

impression without incident.

The palate may be sprayed with surface anesthetic or ethylchloride

prior to recording the impression. Posterior third of the tongue which is

often implicated in the retching reflex can also do anesthetized.

It is wise to have the patients head upright and to record the lower

preliminary impression first an impression compound with minimal

flow is recommended eg. Medium fusing compound. Either silicone or

heavy bodied polysulphide is suitable for final impression.

For registration of centric relation, virtually the entire palate of the

maxillary occlusal rim was removed in order to reduce to an absolute

minimum the area of contact between rim and palatal tissue. In addition, a

thin film of adhesive was sprinkled onto the record base for retention, and

an anesthetic was sprayed onto the palate. Patient followed instructions

regarding breathing and foot tapping.

Prior to actual placing of new dentures, the patient was prepared for

a temporary period of discomfort, but was assured that although initially

uncomfortable, it would be short lived.

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Lower denture should be placed first. The maxillary denture should

then be placed and the patient is requested to close into centric occlusion in

centric relation. The patient should be made to nose-breathe in a deep slow

fashion. Although initially very severe, the gagging will subside over a

period of (4-5) minutes.

Hypnotheraphy is also used as are various types of behaviour

therapy. Barbiturates may be used to depress the CNS, antihistamines to

lower the feeling of sickness or pararymphathetic depressants to reduce the

salivary flow which increases at the outset of retching.

Miscellaneous:

1. Burning tongue (glossopyrosis) and burning mouth (stomatipyrosis)

these symptoms are frequently seen in complete denture patients.

However complete dentures are not always the etiologic factor.

It is almost impossible to make a clear cut diagnosis of the cause of

stomatopyrosis. Severe burning mouth is most frequently found in

menopausal women between 40 and 60 yrs of age.

Other causes:

Deficiency : Vit B12, Folate, Iron

Infections : Staphylococcal, Candidiasis

Psychogenic : Cancerophobia, depression

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Prosthetic : Occlusal faults, bony irregularities, allergy to denture base

material.

Treatment:

- Occlusion should be balanced in all positions

- Check for roughness on the tissue and polished surface of the

denture.

- Treat the causative systemic diseases.

- Reconstruct the dentures, if porous and unhygienic

- Change denture base material if necessary

- A balanced diet rich in vitamins and essential minerals should be

prescribed.

- Whenever indicated, hormones should be administered

- Psychotherapy can be instituted.

2. Food under the denture

This compliant is usually made by patients wearing dentures for the

first time and who have not yet leant how best to control the food. A

perfect peripheral seal will prevent the ingress of food beneath the denture,

but perfection is not always attained and owing to alveolar resorption,

never maintained.

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Treatment: Covering maximum possible area of the edentulous foundation

and obtaining an adequate peripheral seal

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3. Clicking of teeth

The main causes are:

- Excessive vertical dimension of occlusion causes the denture to

contact during speech, particularly the sibilant sounds, as the

mandible moves vertically through the speaking space.

- Movement of the lower denture from whatever cause is very liable

to lead to clicking of teeth.

- Excessive incisive guidance angle usually means that the horizontal

overjet is inadequate in relation to the vertical overlap. This means

that during speech, in which there is often a pronounced horizontal

movement of mandible the incisors contact each other and cause

clicking.

- Porcelain teeth by nature of the material creates more impact noise

than acrylic.

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TROUBLE SHOOTING IN COMPLETE DENTURE PROSTHESIS

- INTRODUCTION

- CLASSIFICATION OF PROBLEMS

- DESCRIPTION OF THE PROBLEMS WITH THEIR ETIOLOGY

- MANAGEMENT OF THE PROBLEMS

- SUMMARY AND CONCLUSION

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