MUCOSAL RESPONSE TO ORAL PROSTHESESSOME PATHOLOGICAL CONSIDERATIONS -Aaron Sarwal
WHAT IS ORAL PROSTHESES?• “Oral Prostheses” also known as “Dental Prostheses” is a specialist area of medicine which is concerned with the recreation of the dentition when there are missing or badly damaged teeth.• It is covered under the „Prosthodontics‟ branch of Dentistry according to the ADA.• Prosthodontics is the dental specialty pertaining to the diagnosis, rehabilitation Oral Prostheses and maintenance of the oral function, comfort, appearance and health of patients with missing or deficient teeth and/or oral and maxillofacial tissues.
WHY AND HOW DOES ORAL PROSTHESES CAUSE MUCOSAL PATHOLOGIES? “ …the treatment modalities • Appliance put in oral cavity which deal with1 the replacement of • Appliance surrounded by mucous missing teeth2 membrane and contiguous structures with a • Disrupts normal oral conditions or suitable3 oral environment prostheses can be broadly • Initiates response (pathological classified as4 condition) removable and fixed… ”
TYPES OF ORAL PROSTHESESRemovable Prostheses Fixed Prostheses (Denture) (Implant)
WHAT MUCOSAL PATHOLOGIES DOES ORAL PROSTHESES CAUSE? Mucosal Pathologies of Oral Prostheses • Prostheses are designed to conserve the remainingDue to Removable Due to Fixed structures and maintain them. Mucosal Lesions Secondary Caries • Prostheses act as etiologicalBurning Mouth Syndrome Pulpal and Periodontal Inflammation factors either due to error from Allergic response Allergic Reactions operator, inadeq uate Fungal Infection maintenance or Occlusion Related Disorders the properties of the materialTrauma (metallic clasps) Periimplantitis itself.
DENTURE IN THE ORAL ENVIRONMENT „Placement of Mechanical irritation removable Mucosal Accumulation ofprostheses in the reactions microbial plaque oral cavity Allergic reactions produces Negative effect Poor profound function on muscle function changes of the Denture inoral environment the Oral Surface Cavity Irregularities Plaque formation that may have and Microporosities an adverse Local Increased effect on the Irritation permeability to allergens integrity of the Bacteria use Accumulate, form oral tissues.‟ PMMA as Bacterial plaque Carbon source
INTERACTION OF PROSTHETIC MATERIAL WITH THE ORAL ENVIRONMENT AND ITS CONSEQUENCES• There are two types of consequences of prosthetic material in the oral cavity: 1. Direct 2. Indirect• These are results of interaction of prosthetic material with the oral mucosa, and are influenced by:a. Surface Properties: Chemical stability, Adhesiveness, Texture, Microporosities, Hardnessb. Chemical properties: Corrosion, Toxic Reactions, Allergic Reactionsc. Physical properties: Mechanical irritation, Plaque accumulationd. Changes of environmental conditions: Plaque Microbiology
DIRECT CONSEQUENCES OF WEARING DENTURES PATHOLOGICAL CONSIDERATIONS
DENTURE STOMATITIS Candida – associated if yeast is involved. Type I Localized simple inflammation Types and ClinicalDenture Stomatitis Presentations Type II Generalized diffuse erythema in part or entire denture-covered area. Granular type involves central hard palate Type III and the alveolar ridges. Seen in association with type I or type II. Strains of genus Candida, in Candida – particular Candida associated Albicans , cause denture stomatitis. trauma induced, caused by microbial Causes Type I, II and III plaque accumulation (bacteria or yeast) on denture surface. Candida associated Angular chelitis or glossitis due to infection denture stomatitis from denture covered mucosa to angles of and angular chelitis the mouth or tongue.
FLABBY RIDGEClinical Presentations:•Alveolar ridge mobile, extremely resilient.•anterior part of maxilla, when remaining anterior teeth in mandible.Histology:•Marked fibrosis and inflammation, and resorption of the underlying bone.Causes:•Replacement of bone by fibrous tissue.•Excessive load of the residual ridge•Unstable occlusal conditions.Problems and Suggested Solutions:•Provides poor support of the dentures.•removed surgically to provide the stability required by dentures.•extreme cases, total removal not done, leads to elimination of vestibular sulcus.•Resilient ridges provide some support for retention.
DENTURE IRRITATION HYPERPLASIA •Hyperplasia of mucosa •Lesions single/ numerous/ consist of flaps of connective tissue. Clinical •Development of elongated rolls ofPresentations tissue in mucofacial folds. •Inflammation is variable, deeper fissures severe with ulceration. •Cells resemble normal cells, great Histology increase in number. •Main cause ill-fitting denture Causes •Lesions result of chronic injury by thin, over extended denture flanges. •Replacement or adjustment of theProblems and denture, produces some clinical improvement Suggested •Post surgical excision of the Solutions tissue, replacement of denture, lesions are unlikely to reoccur. Histology
TRAUMATIC ULCERSClinical Presentations:• „Sore spots in one to three days after new dentures.• Ulcers small, painful, covered gray necrotic membrane, surrounded by inflammatory halo with firm, elevated borders. Histology:• Patient adapts to the condition, may develop into denture irritation hyperplasia. Causes:• Result of overextended denture flanges or unbalanced occlusion. Notes:• Suppression of mucosal resistance to mechanical irritation is predisposing e.g., diabetes mellitus and vitamin deficiency.• Normally, the sore spots heal in a few days.
ANGULAR CHEILITIS •Multifactorial disease, seen in denture wearers, adults and children. •Feeling of dryness and burning sensation at the ends of the mouth Clinical •Skin at the commissure appears wrinkled and macerated, evenPresentations: ulcerated, never bleeds, crust may form. •Lesions stop at the mucocutaneous junction. Histology: •Majority are Candida associated. •A result overextended denture flanges or unbalanced occlusion. Causes: •In patients with loss of vertical dimension, deep folds of skin are produced at the corners of the mouth. Saliva collects in this area, the skin becomes cracked, macerated. •Variable due to varied etiology, any infection present is secondary for Treatment: permanent cure, the primary cause must be corrected. •The lesions rarely completely disappear, usually reoccur in minor form. •A clinical diagnosis should only be arrived at after other lesions like due to known trauma, syphilis etc. are ruled out. Notes: •Often associated with many other factors like infection and vitamin deficiency( esp Vit B) and loss of vertical dimension
ORAL CANCER IN DENTURE WEARERS An association between the chronic irritation of the oral mucosa by dentures and oral cancer has been claimed, however, no definite proof exists. Reports have detailed the development of oral carcinomas in patients who wear ill-fitting dentures. The opinion is still valid that if a sore spot does not heal for long, malignancy may be suspected. Patients with such lesions should be immediately referred to a pathologist. Prognosis is poor for oral cancers, especially the ones in the floor of the mouth.
BURNING MOUTH SYNDROME (BMS)Clinical Presentations: Causes: Moderate to severe burning in the mouth is Damage to nerves that control the main symptom of BMS and can persist for pain and taste months or years. Hormonal changes For many people, the burning sensation begins in late morning, builds to a peak by evening, and Dry mouth, which can be caused by often subsides at night. Some feel constant pain; for many medicines and disorders such as others, pain comes and goes. diabetes, nutritional deficiencies Oral candidiasis, a fungal Oral mucosa appears healthy clinically. infection in the mouth Other symptoms of BMS include: Acid reflux •Tingling or numbness on the tip of the tongue or in the mouth •Bitter or metallic changes in taste Poorly-fitting dentures or allergies •Dry or sore mouth. to denture materials
BURNING MOUTH SYNDROME (BMS) •Adjusting/replacing irritating dentures •Treat existing disorders e.g. diabetes, supplements for nutritional deficienciesTreatment: •Switching medicine, if a drug is causing BMS •prescribing medications to •Relieve dry mouth •Treat oral candidiasis •Help control pain from nerve damage •Relieve anxiety and depression. •Anxiety and depression result from chronic pain. •May have more than one cause. •Mostly, the exact cause of symptoms cannot be found. Notes: •Treatment tailored to ones individual needs. •If no cause can be found, aim is to try to reduce the pain associated with burning mouth syndrome.
GAGGING AND RESIDUAL RIDGE REDUCTION GAGGING: RESIDUAL RIDGE REDUCTION •Normal, healthy defense •Studies have established a continuous loss mechanism, prevents foreign bodies from of the bone tissue after teeth extraction entering trachea and the placement of complete dentures. •Many stimuli cause gagging, such as •The resorption rate varies by individual. irritation of the posterior part of the •Some say that RRR is physiological process tongue, soft palate, even sights, tastes etc. that occurs because the use of the alveolar can cause gagging bone is lost after tooth extraction, however, •Due to dentures, patient may gag initially RRR can proceed to the basal bone and but gets accustomed. hence is believed to be a pathological •Gaging may also be a symptom of process and not a physiological one. disorders and diseases of the GIT, adenoids or catarrh in the upper respiratory passage.
OVERDENTURE ABUTMENTS : CARIES AND PERIODONTAL DISEASE The retention of selected teeth to serve as abutments under complete dentures is an excellent prosthodontic technique. However, bacterial colonization beneath a close fitting denture is enhances and leads to caries, due to microbial plaque of Streptomyces and Actinomyces (predominantly). If the plaque is left undisturbed, it initiates gingivitis in one to three days. Patients with overdentures demonstrate up to 30% increase in caries within one year. Preventive measures should be aimed at preventing the accumulation of plaque near the roots.
INDIRECT CONSEQUENCES OF WEARING DENTURES PATHOLOGICAL CONSIDERATIONS
ATROPHY OF MASTICATORY MUSCLES AND MASTICATORY ABILITY AND PERFORMANCE Essential that masticatory function (in complete denture wearers) be maintained through out life. Masticatory function depends on the skeletal muscular force and the ability to co-ordinate oral functional movements during mastication. Maximal bite forces decrease in older patients. Greater atrophy occurs in complete denture wearers especially women. Little evidence that new dentures reduce this atrophy.Wearing dentures does compromise masticatory performance greatlyas compared to a natural set of teeth Masticatory ability: • it is an individual‟s own assessment of his/her masticatory function Masticatory efficiency: • it is the capacity to grind the food during mastication.
NUTRITIONAL DEFICIENCIES• Aging is often associated with a significant decrease in energy needs as a consequence of decline in muscle mass and decreased physical activity.• There is a 30% fall in the energy however, with the exception of carbs, the nutritional requirement doesnt decrease with age.• As a result dietary intake of elder individuals often reveals evidence of deficiencies clearly related to dental/ prosthetic status.• Severe nutritional deficiencies are rare in the healthy, even with impaired masticatory functions, it is only in hospitalized/ chronically ill patients that inability to chew and altered taste perception lead to negative dietary habits and nutritional status.
ALLERGIC REACTIONS: INTRAORAL CONTACT ALLERGY REACTIONS•Poorly understood , not very commonly dealt with in specialized literature.•No single or specific clinical picture of IOCA, lichenoid reactions common.•Metals used in dental practice – e.g. amalgams ,Ni base metal alloys- cause IOCA reactions, hypersensitivity consequence of increasingly widespread use.•Common allergens: 2-HEMA (hydoxyethyl methacrylate) and triethylene glycol dimethacrylate.•Methacrylates have rarely cause oral lichenoid reactions.•Dental amalgams are the most common cause of IOCA.•No single or pathognomic IOCA lesion exists.•Replacement of restorations containing materials that give a positive epicutaneous test is not warranted.•Allergy due to many nonspecific or unclear intraoral clinical disorders. Generalized gingivitis as a symptom of IOCA to othodontic metals
PERIIMPLANTITIS• Soft and hard tissues surrounding osseointegrated implant show similarities with periodontium.• Big difference in the collagen fibers being non-attached and parallel to implant surface instead of being perpendicular and in functional arrangement from bone to cementum.• Periodontitis like process- periimplantitis affects implants and leads to loss osseointegrated implant.• Bacteria play significant role in this, similar to periodontitis, failing implants include gingival inflammation, deep pockets and bone loss.• Bacterial flora is gram negative rods e.g. Bacteroides and Fusobacterium sps.• Probing depths > 6mm and periimplant radiolucency.
PERIIMPLANTITIS• Etiology is either infection with periodontal pathogens of increased trauma (retrograde periimplantitis).• Implants have less effective soft tissue barrier around their necks than natural teeth, less resistant to infection.• The micro flora associated with failing implants is similar to that of periodontally affected teeth.• Treatment involves determination of the etiology, it‟s control along with hygiene techniques, instrumentation and use of antimicrobials.
CONCLUSION• „Placement of removable prostheses in the oral cavity produces profound changes of the oral environment that may have an adverse effect on the integrity of the oral tissues.‟ (Mahesh Verma, Shafers‟s)• Mucosal reactions occur from the mechanical irritation, accumulation of microbial plaque and occasionally due to allergic reactions.• Dentures that function poorly may act as negative factors in muscle function• Surface irregularities and micro porosities can greatly encourage plaque formation.• At times, the local irritation may end up increasing the permeability of the mucosa to allergens, hence making it difficult to distinguish between simple irritation and an allergic response.• Some bacteria can use the PMMA as a carbon source and hence the accumulation of bacterial plaque at the interface of the denture and mucosa causes several negative effects.
RESOURCES• Appendix II, Shafer‟s Textbook of Oral Pathology.(“Mucosal Response To Oral Prostheses: Some Pathologicalconsiderations” - Dr. Mahesh Verma)• Image credits: Internet (http://www.google.co.in/imghp?hl=en&tab=wi)• General research on the web was also done in making this presentation just to confirm the information and update it where required.• Burning Mouth Syndrome slide source: http://www.nidcr.nih.gov/OralHealth/Topics/Burning/BurningMou thSyndrome.htm
Special thanks to : Dr. Rupinder Kaur (Ex-Lecturer,Department of Dental Anatomy and OralPathology, Gian Sagar Dental College and Hospital)