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 take out the dentures during sucking. should be instructed to

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 inflammatory 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 6month 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 dentures. 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 disappears 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 fluoridechlorhexidine 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 implantsupported 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.