Prosthodontics

Dominic P Laverty

A Damien Walmsley

Training Plates: A Solution for

Patients Unable to Tolerate a
Removable Prosthesis
Abstract: Dealing with patients who are unable to tolerate dentures can present a challenge to the general dental practitioner (GDP).
Careful assessment of patients and their dentures will identify any causes of the intolerance to dentures. Training plates are a useful
technique that can be used to allow patients to become accustomed to removable prosthesis but will inevitably lengthen the treatment
process.
CPD/Clinical Relevance: Training plates offer a possible solution to general dental practitioners who treat patients who are struggling to
tolerate dentures.
Dent Update 2015; 43: 159-166

There are a number of treatment options
available to replace missing teeth. This can
include implant-retained prostheses, fixed
prostheses and removable prostheses.
One of the most straightforward is the
removable option, providing either
complete or partial dentures. The majority
of patients that are provided with a
removable prosthesis cope well but there
are some patients that struggle to tolerate
them.
The demographics of the UK
adult population is changing. People
are living longer, with the population of
Dominic P Laverty, BDS(Hons), MFDS
RCS(Ed), ACF/StR in Restorative Dentistry,
Birmingham Dental Hospital and A
Damien Walmsley, PhD, MSc, BDS,
FDS RCPS, Professor of Restorative
Dentistry, School of Dentistry, University
of Birmingham, St Chad’s Queensway,
Birmingham B4 6NN, UK.
March 2016 DentalUpdate 159
over 65-year-olds estimated at 17%,1 but
predicted to increase by approximately
30% over the next 25 years, and it is also
predicted that the number of patients in
the over 85 years age group will rise even
more dramatically.2 The Adult Dental Health
Survey in 2009 showed that 19% of adults
wore dentures, of these 13% wore partial
dentures and 6% complete dentures.3 The
Adult Dental Health Surveys also show that
the incidence of edentulism in England and
Wales has decreased from 37% in 1968 to
6% in 2009 and that elderly patients are
retaining their natural teeth into their older
age and fewer are becoming edentate.3 It
is often stated that the need for complete
denture treatment will decline as the
elderly retain teeth for longer, but many
elderly patients still require prosthodontic
replacement.2,4,5
It has been shown that
elderly patients find it more difficult to
accommodate dentures, particularly
patients that are being provided with
complete dentures for the first time.4,6 It has
also been stated that successful provision
of dentures in the elderly individual is
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arguably more of a challenge now than it
was a few decades ago.2,5 It has also been
shown that there is a link between denture
provision and gagging in some patients. 7-21
The aim of this article is to
provide the clinician with an understanding
of training plates, the clinical process
involved in their fabrication and delivery to
a patient and the subsequent management.
Training plates
Training plates are
prosthodontic appliances that are used
to prepare the patient for prosthodontic
treatment. This appliance has the effect
of acclimatizing the patient to the feel
of the denture in the mouth prior to
definitive denture construction.4 There
are many descriptors, including training
bases, training plates, training dentures,
treatment dentures, conditioning appliance,
rehabilitation devices and transitional
prostheses.6,7,15-17 The British Society of
Prosthodontics (BSSPD) have defined
‘training bases’ as ‘A denture base, usually
made of heat-cured acrylic resin, provided
 Prosthodontics
for a patient who has difficulty in tolerating
the bulk of a denture, with the intention of
promoting its acceptance. Once the base
is tolerated additions to it can be made to
facilitate progression to a denture.’22
These appliances have
predominantly been used in patients that
suffer from a prominent gag reflex. They
can also be used in patients acclimatizing
to dentures. Training plates can be used in
partially dentate or edentate patients and
can be made of a variety of materials and
be in a number of designs.16,23
The gagging patient
Training plates have a role
in the management of the gagging
patient. Treating patients who gag may
be unpleasant and dealing with such a
situation is something all dentists have
experienced at some point. Gagging can
hinder and often prevent procedures being
performed, and may also lead patients to
being unable to tolerate appliances within
the mouth. The majority of patients cope
well with appliances within the mouth and
are able to adapt, but some do not and it
can be difficult to identify the cause of such
reactions in patients.
The gag reflex is a normal,
defence mechanism controlled by the
parasympathetic division of the autonomic
system. Its function is to prevent foreign
bodies from entering the trachea.17
The prevalence of gagging within the
general population is unknown, but is not
uncommon.20 Patients who suffer from
these problems can be divided into two
groups:
 The somatogenic group − those in
whom physical stimulation produces the
gagging reflex;20
 The psychogenic group − those in
whom the stimulation appears to be
primarily by psychological stimuli, and
may be induced by fear, anxiety and
apprehension.20
Dickinson and Fiske20 devised a
gagging severity index to define a patient’s
level of gagging (Table 1). The majority
of gaggers will be mild/moderate and
the most amenable group to treat. The
severe/very severe category of gaggers
are a difficult group to treat and, in some
cases, a solution may not be possible. Also
note from Table 1 how reassurance and
160 DentalUpdate March 2016
good communication forms part of the to stop him/her gagging and assist in
management in these patients and is an toleration of the denture. Instructions are
important adjunct to treatment in ‘gaggers’. given to the patient about how this will take
This reflex disappears in most cases as the time and will inevitably slow the process of
patient adapts to the dentures. However, denture delivery.
some patients may not be able to tolerate The process is known as
the denture. systematic desensitization, a technique
When examining a patient, that consists of incremental exposure of
a detailed assessment of the patient’s the patient to the feared stimulus. The
dentures, in order to identify any faults maladaptive thoughts and expectations
that could be causing or exacerbating a of patients can be altered by positive
patient to gag, is required (Table 2). If no experience and this forms the basis of
clinical faults can be identified, it may be re-education techniques. Behaviour that
a consideration to provide the patient has been classically conditioned can be
with a training plate, and this needs to reversed essentially by reversing the
be discussed with the patient.4,7,21 Once process.13 This entails exposing the patient
constructed, it is advised that it be worn gradually to the stimulus by increasing the
at home to help desensitize the patient intensity, duration and frequency of the
Normal gagging Very mild, occasional and controlled by the patient
Mild gagging Control is required by the patient with reassurance from the
dental team
Moderate gagging Consistent and limits treatment options. Gagging prevention
measures are usually required
Severe gagging Gagging occurs with all forms of treatment including simple
visual examination. Treatment is limited
Very severe gagging Affecting patient behaviour and dental attendance and making
treatment impossible without specific treatment for control of
gagging
Table 1. Gagging Scores: Dickinson and Fiske gagging severity index (GSI).20
Poor retention/Rocking of the denture4,8-10,20,21
Excessive thickness of the posterior border of the upper denture (particularly when it is
placed forward of the vibrating line)10,15,20,21
Over extension of posterior border of upper denture (placed beyond the vibrating
line)15,20
Reduced posterior extension of upper denture4
Narrow arch form that forces the lingual cusps of the upper posterior teeth to impinge on
the dorsum of the tongue21
Inadequate peripheral seal8,10,15,20
Incorrect occlusal planes20
Reduced or excessive freeway space9,10,20
Incorrect denture tooth positions15,20
Malocclusion10
Restricted tongue space10,20
Table 2. Various denture design faults and characteristics have been suggested to explain retching/
gagging in the denture wearer.
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 Prosthodontics

stimuli.11,12
There are a number of
re-education techniques that have been
described in which the patient is given an
object to place in the mouth for a period
of time.14 The size of the object and length
of time for which it is held in the mouth is
progressively increased until the patient is
able to acclimatize.14,16,18 With reassurance
and conditions of relaxation the patient is
exposed to an aversive stimulus and learns
to cope with this.14 The approach is to
develop the necessary confidence to feel
motivated to overcome the problem.7
A review of the literature on
successful denture provision has suggested
that a good relationship with the patient
seems more important than technically
perfect denture construction for achieving
patient satisfaction, and is therefore a
consideration in treatment delivery.24
Construction of training plates
at the posterior border with a correctly
formed post dam. Therefore a good
knowledge of dental anatomy is needed.
There are some design features that can
be incorporated, such as a finger grip, that
may be provided so that the patient can
control insertion and removal of the device.
The baseplates can also be constructed
with a small acrylic bead attached to the
lingual polished surface. This is a further
distraction ‘device’ to focus the attention.
It also ‘trains’ the tongue to adopt a more
favourable position and discourage it
from taking up a ‘pharyngeal guarding’
posture.16,23 The surface finish of the training
bases can form part of the technique and
sandblasting the acrylic to create a dull,
matte surface texture can be used.16,23 This
was suggested by Jordan in 1954 with the
reasoning behind it being that a smooth,
highly polished surface which is coated
with saliva may produce a slimy sensation,
which is sufficient to cause gagging in some
patients; a matte finish has been suggested
as more acceptable.19 However, this may
vary from patient to patient. A training plate
is usually constructed without teeth and the
patient is asked to wear it at home.11,15,16,21,23
The above features are more a personal
preference of the clinician and patient
rather than based on evidence.
Impression-taking needs to

Training plate clinical technique (Table 3)

Training plates usually consist Figure 3. Training plate used for an upper
of a thin acrylic base (Figure 1) and can be complete denture with anterior teeth set-up.
fully extended and appropriately thinned

Figure 4. Training plate used to produce an upper Figure 5. Training plate used to produce an upper
complete denture. complete denture.

1. 1st impression in stock tray

Figure 1. Training plate for an upper complete
denture.
2. 2nd impression with appropriate special tray
3. Fit of training baseplate
4. Regular review and adjustment where needed
5. Once patient accustomed to training plate. Option of:
 Setting anterior teeth onto training plate then the posterior teeth as the patient gets
accustomed
 Set all teeth onto the training plate
6. Once patient happy with the constructed denture can either be the final prosthesis or
can be used via a copying technique to provide the definitive prosthesis

Figure 2. Training plate used for an upper 7. Regular review post insertion of prosthesis
complete denture with anterior teeth set-up. Table 3. The clinical stages in the fabrication of a training plate to the definitive dentures.

March 2016 DentalUpdate 163

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 Prosthodontics
maximize the area from which a denture
can gain support. An adequate impression
needs to record the full denture-bearing
area with close tissue adaptation and
functional border moulding, which is
important for both edentulous and
partially dentate patients.25
The patient is given tailor-
made instructions and asked to practise
progressively increasing the length of
time the training plate is worn. A suitable
regimen may be 15 minutes once each
day, then twice each day; after one week
the patient is asked to increase this to
15 minutes 3 times each day, then 30
minutes and 1 hour, until the patient
is happy to wear it for long periods of
time. It is often best for patients to wear
it when doing something distracting,
such as watching television, or even
wearing it at night so that they are not
concentrating on what is in their mouth.11
Eventually the patient will
be able to tolerate the training base for
most of the day.18 The timing and rate
of progress will vary between patients
and the patient needs to be pre-warned
of this.11 The patient is reviewed on a
regular basis as problems may occur
Figure 6. Case 1: Upper edentulous ridge.
Figure 7. Case 1: Training plate.
164 DentalUpdate March 2016
and encouragement and advice needed. Clinical cases
It may be necessary to reduce the
Case 1
posterior border of the training plate.
An 84-year-old male patient
One approach is to place two post dams,
was referred by his GDP for provision of
one slightly more anterior, to allow some
complete dentures. The GDP had made a
adjustment of the posterior edge, where
number of sets but the patient complained
necessary.4,11This will all take time, which
of being unable to wear the upper set due
can be difficult in a busy practice, and
to gagging. On examination, it was noted
will also delay the provision of the final
that the patient was completely edentulous
prosthesis, which the patient needs to
and had resorbed firm residual ridges with
understand.
reasonable height and width (Figure 6). The
Once tolerated, the bases can
current dentures had correct peripheral
be used to fabricate the final dentures.12
extension and the patient had a prominent
The teeth can be set up gradually by
gag reflex on palpation around the
placing anterior teeth (Figures 2, 3) and
vibrating line. It was planned for the patient
then posterior teeth (Figure 4, 5) as the
to be provided with an upper training
patient gets accustomed to the denture or
plate (Figures 7, 8) with regular review and
all the teeth placed at once. This can then
adjustments. Once the patient was able to
be the patient’s definitive denture or, via a
tolerate the training plate, it was copied
copying technique, be used to achieve the
and used to construct his upper complete
final denture.21
denture (Figure 9). This was carried out over
Good denture construction is
a 5-month period and the patient is now
needed to optimize retention and stability
able to tolerate and wear dentures (Figure
of the prosthesis and this process is not an
10). He was discharged back to his GDP.
excuse for poor denture fabrication.11
Case 2
A 75-year-old female patient was
referred by her GDP who was struggling
to provide an upper partial denture with
which the patient could cope. This was
Figure 8. Case 1: Training plate in situ.
Figure 10. Case 1: Complete upper and lower
dentures in situ.
Figure 9. Case 1: Upper complete denture
produced via copying training plate. Figure 11. Case 2: Partial dentate upper arch.
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Figure 12. Case 2: Upper partial training plate
(Cunliffe design).
Figure 13. Case 2: Upper partial denture produced
via copying training plate.
Figure 14. Case 2: Partial upper denture in situ.
due to the patient’s medical condition of
having a blepharospasm (facial muscle
disorder) of the left side of the face which
caused the denture to be readily dislodged.
Examination revealed a partially dentate
patient with severely resorbed residual
ridges (Figure 11). It was planned for the
patient to have an upper training plate of a
Cunliffe design to assess tolerance (Figure
12). The patient was able to tolerate the
training plate quickly and provided with an
March 2016 DentalUpdate 165
Figure 15. Case 3: Upper partial training plate.
Figure 16. Case 3: Upper partial denture produced
via copying training plate.
Figure 17. Case 3: Upper partial denture in situ.
upper partial denture, and the patient has
been subsequently discharged back to her
GDP (Figures 13, 14).
Case 3
A 67-year-old male patient had
been referred by his GDP to provide an
upper denture due to the patient being
unable to tolerate a removable prosthesis.
The patient had recently been provided
with his first removable prosthesis and
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Prosthodontics
was unable to cope as it felt like it was
‘too bulky’ and ‘went too far back’. On
examination, it was noted that the patient
was partially dentate with firm residual
ridges of reasonable height and width;
it was also noted that the patient had a
very prominent gag reflex. A training plate
(Figure 15) was provided and extensively
adjusted until the patient was able to
tolerate it. The training plate was then
copied to provide the definitive prosthesis
(Figure 16). The patient was able to
tolerate the dentures (Figure 17) and was
discharged back to his GDP.
Conclusion
Patients are retaining teeth
for longer and requiring prosthetic
replacement later in life. Within this group
there will be some people who are unable
to tolerate dentures and will include
‘gaggers’. Training plates are a useful
technique that can be used on edentulous
and partially dentate patients to allow them
to become accustomed to dentures. This
technique is a useful tool but will inevitably
slow the process of denture delivery.
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