CARLSSON THE JOURNAL OF PROSTHETIC DENTISTRY

Clinical morbidity and sequelae of treatment with complete dentures

Gunnar E. Carlsson, DDS, Odont Dr, Dr Odont hca
Faculty of Odontology, Göteborg University, Göteborg, Sweden

Wearing complete dentures may have adverse effects on the health of both the oral and the denture-
supporting tissues. This article is a review of selected literature on the sequelae of treatment with
complete dentures in the specific areas of residual ridge resorption, mucosal reactions, burning
mouth syndrome, temporomandibular disorders, and patient satisfaction. Recent literature found
with a Medline search from 1952 to 1996 is included in this review. Residual ridge resorption is an
inevitable consequence of tooth loss and denture wearing, with no dominant causative factor
having been found. Mucosal reactions have a multifactorial cause, most of which can be easily
treated. Most patients are satisfied with their complete dentures. Correlations between anatomic
conditions and denture quality and patient satisfaction are weak. Psychologic factors seem to be
extremely important in the acceptance of and adaptation to removable dentures. There are still no
reliable methods to predict the outcome of complete denture treatment and there are many prob-
lems related to treatment with complete dentures. Although the prevalence of an edentulous
condition is decreasing, the great number of edentulous people warrants the continuing efforts of
basic and clinical research on removable partial dentures. Complete denture prosthodontics will
remain an important part of dental education and practice. In addition to clinical and technical
skills, insight into patient behavior and psychology and communication techniques are also neces-
sary. (J Prosthet Dent 1997;79:17-23.)

T he wearing of complete dentures may have ad-

verse effects on the health of both oral and denture-
be based on a difficult and subjective selection of the
abundant literature.
supporting tissues. These effects can be divided into di- This article reviews selected literature, both recent and
rect and indirect sequelae. To the first group belong re- older, on the sequelae of treatment with complete den-
sidual ridge resorption and mucosal reactions, such as tures, specifically residual ridge resorption, mucosal re-
denture stomatitis, denture irritation hyperplasia, trau- actions, burning mouth syndrome, temporomandibular
matic ulcers, and “flabby ridges.” It has also been sug- disorders, and patient satisfaction.
gested that there might be an association between oral
carcinoma and chronic denture irritation, but no indis- RESIDUAL RIDGE RESORPTION
putable evidence appears to exist. Other conditions re- Impact and etiology
lated to the wearing of complete dentures include al-
In an oft-cited article, Atwood2 called the continuous
tered taste perception, burning mouth syndrome, and
reduction of residual ridges in complete denture wear-
gagging. Indirect sequelae are related to the great
ers “a major oral disease entity.” It appears to be a pro-
changes in masticatory function in complete denture
cess encountered in all patients. Albeit, there is consid-
wearers compared with dentate subjects. Bite force is
erable interindividual variation in the rate of bone loss
reduced with risk for atrophy of the masticatory muscles.
after tooth extraction and the wearing of complete den-
The reduced masticatory ability may lead to changes in
tures, residual ridge resorption may proceed through-
dietary selection with risks for an impaired nutritional
out the lifetime of the denture wearer.2-4 It is accepted
status, especially in the elderly complete denture wearer.1
that resorption is a consequence of bone remodeling due
Today, prosthodontists’ interests are very much fo-
to the altered functional stimulus on the jaw bone. How-
cused on implant-supported prostheses, but the litera-
ever, the causes of the great individual variations are not
ture on complete dentures is still extensive. A search in
well understood.5 Two decades ago, Woelfel et al.6 listed
Medline disclosed 173 references on complete dentures
63 factors that could possibly be related to bone resorp-
from January 1996 to May 1997 and similar numbers
tion under removable dentures. In their analysis, they
for preceding years. During the same period, there were
found no single dominant factor to explain the variabil-
682 references on dental implants; 86 for dental implants
ity of bone loss. Even today, at the end of the 1990s, we
and/or prosthodontics. By necessity, this review must
must admit that little is known about which factors are
most important for the observed variations in residual
ridge resorption. Despite the large number of recent
Presented at the Academy of Prosthodontics Scientific Meeting,
studies, a single dominant factor for residual ridge re-
Halifax, Nova Scotia, Canada, May 1997. sorption has yet to be found. Factors often used in cor-
a
Professor Emeritus, Department of Prosthetic Dentistry. relation analyses are gender, age, facial structure, dura-

JANUARY 1998 THE JOURNAL OF PROSTHETIC DENTISTRY 17

THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 1. Different patterns of residual ridge resorption in maxil-
lae in relation to remaining anterior teeth in mandible during
20-year follow-up observation period. Solid line = 1 year; thin
line = 21 years after original denture treatment. Large maxil-
lary bone loss in A indicates “combination syndrome,” small
one in B does not. (Modified from reference no. 4.)
tion of edentulousness, denture wearing habits, number
of dentures worn, oral hygiene, oral parafunctions, oc-
clusal loading, denture quality, nutrition, general health,
medication, systemic diseases, and osteoporosis. Some
studies have reported statistically significant correlations
between residual ridge resorption and one such factor.
However, a simple, probable association between dura-
tion of edentulousness and residual ridge resorption was
not proven to be statistically significant in several cross-
sectional studies.7-16 There are also contradictory reports
on the influence of gender on residual ridge resorption:
Most state that women have more advanced bone loss
than men, but some have not found such a difference.5
One recent article found that the amount of residual
ridge resorption was significantly correlated with the
number of years women had been edentulous, but this
relationship was not found in men.15 Probable explana-
tions for these contradictions are, among other things,
the enormous individual variation in the rate of bone
loss and varying duration of the edentulous condition
in the subjects examined.
The so-called combination syndrome can be men-
tioned as another example of this lack of unequivocal
results. According to this concept, a patient who wears
a maxillary complete denture and has reduced mandibu-
18
CARLSSON
lar dentition with only anterior teeth (or a mandibular
overdenture on anterior natural teeth or implants) runs
the risk of an increased bone loss in the maxillary ante-
rior ridge, among others.17,18 Even though the combi-
nation syndrome concept has been supported over the
years by several anecdotal observations reported in the
literature and by the clinical experience of many
prosthodontists, there is a surprising lack of evidence
for this opinion in controlled studies.4,19,20 Again, an ex-
planation might be found in the fact that when results
are presented as mean values, extensive bone loss in a
few persons, due to the combination syndrome, is con-
cealed. However, one must be careful when making gen-
eral conclusions based on single observations. It is obvi-
ous that the combination syndrome does not occur in
all patients (Fig. 1). In a Belgian study,20 patients had
suffered an even greater mean bone loss in the maxilla
in the group with mandibular complete dentures than
in those with implant-supported overdentures or fixed
prostheses. The combination syndrome is also contra-
dicted by the successful long-term application of the
shortened dental arch concept.21
Multivariate analyses related to residual ridge resorp-
tion are still rare. In a recent study applying such statis-
tics, the female gender and systemic factors seemed to
be of greater importance than oral and denture factors,
especially in the mandible.22 It was also found that asthma
was a significant risk factor for severe residual ridge re-
sorption, the mechanism probably being the corticos-
teroid treatment of the asthmatic patients. On the other
hand, alcohol intake was correlated to a lesser degree of
maxillary residual ridge resorption. In a Finnish investi-
gation23 that analyzed the effects of fluoridated drink-
ing water and estrogen therapy on residual ridge resorp-
tion, it was found that persons who used fluoridated
water for long periods (> 10 years) had higher residual
ridges than those who had used fluoridated water for
shorter periods. The results from studies of patients un-
dergoing hormone replacement therapy were incon-
clusive. These researchers concluded, on the basis of this
and other studies, that systemic factors control the final
stage of residual ridge resorption, whereas local factors
(surgical method, healing capacity, bite force) dominate
the first phase after extraction.
The best explanation that can be offered today is that
combinations of anatomic, metabolic, psychosocial,
mechanical, and, most probably, unknown or yet-to-be-
analyzed factors are of importance for residual ridge re-
sorption. An example showing the influence of unex-
pected factors was the inclusion of smoking among con-
ventional clinical variables in a multivariate analysis of
peri-implant bone loss.24 When smoking was included
in the analyses, it was found that smoking was of greater
significance than any clinical factor in a long-term study
of peri-implant bone loss. This does not indicate that
smoking is of similar importance for residual ridge re-
VOLUME 79 NUMBER 1
CARLSSON
Fig. 2. National differences in edentulousness in various age
groups in 1980s. [Modified from Carlsson GE, Käyser A, Öwall
B. Prosthodontics: principles and management strategies. Lon-
don: Mosby-Wolfe, 1996.]
sorption, it only suggests, as do the previously mentioned
Finnish studies, that new knowledge about the cause of
residual ridge resorption may emerge when multivariate
analyses are applied to research data and previously
unanalyzed variables are included.
Epidemiology
More than 25 years after Atwood´s statement, it re-
mains that residual ridge resorption can be considered
“a major oral disease entity.” On an individual level, it is
true today, even though implant-supported prostheses
provide a favorable solution for some edentulous pa-
tients who suffer from the consequences of residual ridge
resorption. How is it on an epidemiologic level? The
prevalence of the edentulous condition is rapidly decreas-
ing in many countries, but great geographic and socio-
economic differences still exist (Fig. 2).25-27 Despite this
beneficial improvement in oral health and the decline in
the rate of the edentulous condition, there remains a
substantial number of complete denture wearers among
elderly people. A rough estimate indicates that, on a glo-
bal level, only about one in every thousand totally and
partially edentulous people have benefited from treat-
ment with implant-supported prostheses.27 The num-
ber of edentulous elderly persons may even increase be-
cause of the current expansion of the oldest segment of
the population.26 Treatment of edentulous people will
therefore continue to be a challenge for the dental pro-
JANUARY 1998
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 3. Changes in edentulousness in men and women in Swe-
den in 1975 to 2000. Y axis denotes percentage (%); x axis
represents age in years. [Modified from Österberg T, Carlsson
GE, Sundh W, Fyhrlund A. Community Dent Oral Epidemiol
1995;23:232-6.]
fession. In Sweden, where the prevalence of the edentu-
lous condition has decreased more than in many other
countries (Fig. 3), a majority of general practitioners no
longer perform complete denture treatment because they
have too little experience.28 What a few decades ago was
everyday routine treatment in general practice in Swe-
den is now considered by several colleagues to be a spe-
cialist treatment. Current demographic trends, includ-
ing the reduction of the edentulous condition, give rise
to problems in planning dental curricula; for example,
how to provide adequate education and training in com-
plete denture prosthodontics for an aging population
when so many new aspects of clinical dentistry require
attention.1,6,29
Management
The consequences of residual ridge resorption are
obvious, sometimes less so for the patient than for the
prosthodontist who encounters increasing problems in
the fabrication of well-functioning complete dentures.
Many prosthodontic and surgical treatments have been
attempted in situations of severe residual ridge resorp-
tion, but none has been completely predictable.1 The
best treatment is to avoid total tooth extraction, pre-
serve a few teeth, and make overdentures, which are as-
sociated with much lower rates of bone resorption.18,30
19
THE JOURNAL OF PROSTHETIC DENTISTRY
The placement of dental implants and the insertion of
an implant-supported prosthesis have been shown to
reduce substantially bone loss in the edentulous jaw, in-
dicating the importance of altered functional stimulus
to the bone tissue.24,31
MUCOSAL REACTIONS
Denture stomatitis
Many denture wearers develop an inflammatory reac-
tion in the denture-bearing mucosa, most frequently in
the palate. It is usually a benign disorder and most pa-
tients are unaware of their denture stomatitis. The le-
sions may be local or general in nature, and the surface
may show small or more extended areas of erythema of
a smooth or granular type. The prevalences reported for
denture stomatitis vary greatly, with up to two thirds of
the maxillary and one fifth of the mandibular mucosa
diagnosed as inflamed in complete denture wearers.16,32
This is an indication that the diagnoses used have not
been satisfactorily standardized.
Etiology. The predisposing factor for denture stoma-
titis is the presence of a denture, and denture-wearing
habits are therefore correlated with denture stomatitis.
Four to five decades ago, the most important etiologic
factors were thought to be trauma from the dentures.32,33
Later, Candida albicans infections were considered to
be the most important factors. Today, the multifactorial
background of denture stomatitis is acknowledged. Poor
oral hygiene that results in microbial plaque on the fit-
ting surface of the denture and bacterial and Candida
albicans infections appear to be of great etiologic im-
portance.9,34,35 Traumatic factors such as mechanical,
thermal, and chemical irritations and allergic reactions
to components in the denture material may also be re-
sponsible for the development and maintenance of den-
ture stomatitis.9,35,36 Recently, immunologic aspects have
also been added to the multifactorial pathogenesis of
the condition.37
Management. The treatment is usually simple if the
varying etiologic factor is acknowledged. Good oral
hygiene, thorough denture cleaning, and an increased
period of rest for the denture-bearing tissues are essen-
tial and, when indicated, may be combined with anti-
fungal therapy and the correction of traumatizing fac-
tors associated with ill-fitting dentures. The use of anti-
fungal drugs as the sole method of treatment is not
recommended, because Candida albicans infections of-
ten recur if hygiene has not improved and the dentures
have not been optimized. Surgical elimination of papil-
lary hyperplasia in the granular type of denture stomati-
tis may be necessary to achieve optimal mucosal hygiene,
but in mild cases, antifungal treatment without surgery
may be an acceptable alternative.35,38
A simple treatment for reducing mucosal irritations is
the use of denture adhesives. There have been conflict-
ing opinions about this method in the prosthodontic
20
CARLSSON
literature over the years. However, negative attitudes have
been based on claims that well-constructed dentures do
not require adhesives to function properly and/or on
proposed deleterious effects of adhesives. A more posi-
tive attitude has developed lately due to controlled studies
that have demonstrated positive effects not only on
mucosal irritations but also on denture stability, reten-
tion, and comfort.39-42
The nutritional status of an individual affects the health
of the oral tissues. This implies that nutrition can influ-
ence the denture-bearing tissues and the adaptation to
complete dentures, but this area needs more basic and
clinical research. An excellent review of current knowl-
edge and relevant recommendations regarding nutri-
tional care for edentulous subjects has recently been
published.43
Angular cheilitis. An inflammation of the corners of
the mouth is sometimes seen in cases of denture stoma-
titis and then often correlated with a Candida albicans
infection. Earlier, it was often believed that a reduced
vertical dimension of occlusion was the most important
etiologic factor for angular cheilitis, but research has
shown that general health factors such as nutritional
deficiencies and immune dysfunction seem to be of
greater importance. That antimicrobial treatment is of-
ten successful indicates that an infection is frequently
present.35,44
Soft tissue hyperplasia
Flabby ridges. When hyperplastic tissue replaces the
bone, a flabby ridge develops, which is often seen in
long-term denture wearers and clearly related to the
degree of residual ridge resorption. The reported preva-
lence for this condition also varies among investigators,
but it has been observed in up to 24% of edentulous
maxillae, and in 5% of edentulous mandible, and in both
jaws most frequently in the anterior region.1,16 Even if
surgical elimination of the flabby ridge is a logical treat-
ment in many situations, care must be used when the
ridge is extremely reduced. Although the flabby ridge
may provide poor retention for the denture, it may still
be better than no ridge at all.
Denture irritation hyperplasia. The mucosal re-
sponse to chronic irritation from an overextended and/
or ill-fitting denture may be a fibrous tissue hyperplasia.
It has been reported to occur in 5% to 10% of jaws fitted
with dentures, with the higher figure for the maxillae.16
Healing is usually uneventful after reduction of the of-
fending flanges and/or minor surgery.
Traumatic ulcers. Sore spots and ulcers are frequent
findings the first few days after placement of new den-
tures. They are usually caused by overextended flanges
and occlusal disturbances and can be expected to heal
rapidly after the dentures have been modified. In cross-
sectional studies of long-term denture wearers, traumatic
ulcers in the mandible have been observed in up to 7%
VOLUME 79 NUMBER 1
CARLSSON
of the patients and in the maxillae in up to 1%.16 Dis-
eases that impair the resistance of the mucosa to me-
chanical irritation are predisposing to such lesions and
make healing more difficult and recurrences more fre-
quent. It is a well-established opinion that if a sore spot
does not heal after correction of the denture, malignancy
should be suspected and the patient should be immedi-
ately referred to a surgical specialist. However, there
appears to be a lack of evidence that chronic irritation
by dentures can cause oral carcinoma, although some
anecdotal observations have been presented.35
Burning mouth syndrome
In contrast to denture stomatitis, which is often not
painful, burning mouth syndrome (BMS) is a condition
characterized by burning and painful sensations in a
mouth with normal mucosa.45 It may occur in subjects
with all types of dental status and is thus not limited to
denture wearers. The tongue is reported to be the most
frequent site of BMS, denture-bearing mucosa being
another frequent location. It is most prevalent in middle-
aged people and more frequent in women (4%) than in
men (1%).
BMS has a multifactorial cause comprising local, sys-
temic, and psychogenic factors. There are conflicting
opinions about the importance of denture factors in
BMS. Some investigators consider the causative factors
such as local denture pressure, Candida albicans and
bacterial infections, and allergic reactions to be the same
for both denture stomatitis and BMS. In a recent study,
it was observed that the dentures of patients with BMS
revealed reduced tongue space, incorrect placement of
the occlusal table, and increased vertical dimension of
occlusion in comparison with control subjects.46 Others
have not been able to corroborate these opinions and
maintain therefore that dentures are an uncertain etio-
logic factor.47 In xerostomia, burning sensations in the
oral mucosa may occur, but direct evidence of the rela-
tionship with BMS is lacking.
Among systemic factors of etiologic influence, hor-
monal, vitamin, and iron deficiencies have frequently
been suggested, but the evidences of associations be-
tween such factors and BMS is not strong.35
Currently, great emphasis has been placed on psycho-
logic factors. It has been found that anxiety and depres-
sion are frequent among patients with BMS, and their
personality characteristics indicate that they are more
concerned with their health and more socially isolated,
depressed, anxious, distrustful, and easily fatigued than
control subjects. Such findings have led some authors
to suggest that the burning sensations are psychosomatic
symptoms.48 Other authors warn against the conclusion
that BMS is primarily a psychogenic disorder and main-
tain that changes noted in the psychologic profile may
simply be a reaction to chronic pain conditions and not
necessarily its cause.46,49
JANUARY 1998
THE JOURNAL OF PROSTHETIC DENTISTRY
Optimizing deficient dentures is a natural first step in
the management of BMS in complete denture wearers.
However, if there are no obvious denture deficiencies,
the prosthodontist should be careful and not escalate
the prosthetic treatment until a psychologic evaluation
has been performed and psychogenic causes have been
ruled out. If psychologic and/or psychosocial distur-
bances are diagnosed, adequate treatment should be of-
fered. Any extensive prosthodontic treatment, such as
an implant-supported prosthesis, should be carried out
as a collaborative effort between the psychologist/psy-
chiatrist and the prosthodontist.35,48
TEMPOROMANDIBULAR DISORDERS
Complete denture wearers and people with other types
of dentition can both be afflicted by temporomandibu-
lar disorders (TMD) in a similar way. However, it seems
that severe signs and symptoms are rare, even in sub-
jects with old dentures of poor quality. This can perhaps
explain why in general there have been relatively few
complete denture wearers in samples of patients with
TMD.50 That differences in the prevalence of TMD, with
respect to dental state, has not been well-established and
the role of dental occlusion in the cause of TMD is still
controversial.51 Some investigators have found correla-
tions between signs and symptoms of TMD on one side,
and the wearing of dentures, the quality of the dentures,
and denture-wearing habits on the other,52-54 and others
have not.55
Even if the multifactorial character of TMDs is ac-
knowledged and the importance of occlusal factors is
questioned by many experts, it appears sensible to com-
bine the counseling, so essential in all management of
TMDs,56 with correction of poor dentures when treat-
ing denture-wearing patients who have TMD. Positive
effects on signs and symptoms of TMD have been shown
in several studies by fitting new complete dentures.53,57
SATISFACTION WITH COMPLETE DEN-
TURES
Prosthodontists have rightly maintained that they have
been able to successfully rehabilitate edentulous subjects
with an artificial dentition, such as complete dentures.
“Over the years, dentists have demonstrated consider-
able skill at replacing depleted dentitions and in com-
pensating for the resultant deficit in periodontal sup-
port. Prosthetic care has…evolved into an applied clini-
cal skill of variations on a theme of ingenious salvage.”58
The great majority (70% to 85%) of edentulous patients
has also acknowledged the benefit of complete denture
treatment and declared themselves satisfied with their
dentures.59,60 Older patients have been found to be more
satisfied with poorly fitting dentures and less prepared
to seek denture improvement.61
Measurements of masticatory function, such as bite
force and the ability to comminute a test food, are sub-
21
THE JOURNAL OF PROSTHETIC DENTISTRY
stantially reduced in complete denture wearers in com-
parison with people with natural dentitions, as well as
with implant-supported prostheses.62 Nevertheless, stud-
ies have shown that only a small proportion of denture
wearers (8%) consider their chewing ability to be poor63
or express a subjective need for dental implants. In a
Swedish epidemiologic study, only 8% of the totally eden-
tulous subjects would accept dental implants if avail-
able. The most important reason for declining implant
treatment (83%) was that they were satisfied with their
present dentures.59
Even if most edentulous people are satisfied with their
complete dentures, there are some who have complaints
that need to be addressed. The diagnosis is usually simple
and the problems can, in most situations, be eliminated
by counseling and either correction of the dentures or
fabrication of new ones, provided that treatment is car-
ried out on an individual basis.1,64 However, all who have
worked with complete dentures know that patient satis-
faction is not based solely on the technical quality of the
dentures. Psychologic and emotional factors may be of
great importance in maladaptive patients, even though
they seek technical advice. To help such patients, the
dentist must be able to listen and communicate effec-
tively. The “iatrosedative interview” has been suggested
to be an effective method of communication for help-
ing patients who are unable to adapt to dentures for
various reasons.65 Although this method has not been
systematically evaluated, several studies have demon-
strated the great impact of the dentist-patient relation-
ship and psychologic factors on patient acceptance of
new dentures.
The correlations between patients’ satisfaction with
their dentures and “objective” measurements of ana-
tomic conditions, denture quality such as retention and
stability, and masticatory performance are in general
surprisingly weak and often statistically nonsignifi-
cant.15,66 Results from the evaluations of maxillary and
mandibular dentures often differ, making “a total as-
sessment” problematic. Improving denture quality has
been shown to increase patient satisfaction but not to
substantially alter the chewing ability of denture wear-
ers.62,67,68
A number of assessment methods for measuring pa-
tient satisfaction with their complete dentures has been
presented over the years. However, there does not seem
to be any reliable means for predicting a patient’s ac-
ceptance of new dentures. Work has been in progress to
find better methods for studying these relationships.69-72
The complex nature of adaptation to and satisfaction
with complete dentures must be acknowledged in the
construction of such assessment methods.
CONCLUSIONS
There are many problems related to complete den-
ture treatment. Several of them can be easily solved ac-
22
CARLSSON
cording to research and clinical experience; for others,
there is a lack of evidence-based knowledge, making the
prosthodontic service unpredictable. The prevalence of
the edentulous condition is decreasing but there will
remain a great number of edentulous people, a situation
that will continue in the foreseeable future. Therefore
continuing investments in basic and clinical research on
removable dentures are warranted.
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Reprint requests to:
DR. GUNNAR E CARLSSON
DEPARTMENT OF PROSTHETIC DENTISTRY
FACULTY OF ODONTOLOGY
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SWEDEN
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