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.