Tissue changes in cd/ dental implant courses

INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

CONTENTS
 Introduction
 Microscopic anatomy of the mucous membrane
in oral cavity
 Sequelae of wearing complete denture

Microscopic anatomy of the mucous membrane
in oral cavity
 Has thinner horny layer than skin.
 Sigmund and Weber et.al.: claimed that mucosa
has no horny layer.
 Spreng(1945) : demonstrated horny layer in
palatine mucosa and claimed that hornification
is a reaction to the wear and tear produced by
the denture.
 Orban(1953) : first to state positively that oral
mucosa has horny layer.

EPITHELIUM
 Its thickness is not
more than 0.20mm
 Consists of several
differentiated cells
covered by stratum
corneum
 Important as a
protective mechanism

Stratum corneum
 It has a mean thickness of
13.2micron
 Appears as homogenous band
stained red
 Consists of closely packed
cells which appear to have no
nuclei.
 Scrapings from palatal
mucosa shows cells appearing
as fried egg with nucleus in
centre as yolk

Stratum granulosum
 Characterized by
granulation in cytoplasm
 Kerato-hyaline granule:
located in basal
parts of the layer as
single granules
 Number of cells increase
as they approach the
surface

Stratum spinosum
 cells are polygonal/rounded
connected to each other by
protoplasm in the form of
fibrillar structure called
tonofibrils
 In the mesh b/w the fibrils,
tissue fluid facilitate the
metabolism of the cells
 Metabolism is facilitated by
extension of the papillae of
connective tissue into the
epithelium

Stratum basale
 Formed by thin layers of
amorphous materials and
of reticular fibers
 Demonstrated using PAS
 Under EM : seems to
have 1. basal lamina
2.reticular lamina

Functions
 Provide adhesion on one side to epithelial cells and
other side to connective tissue
 Act as barriers to the diffusion of molecules
 Play role in cell organization
 May influence the regeneration of peripheral nerves
after injury
 May play a role in re- establishing of neuro- muscular
junctions

Lamina propria
 Characterized by
collagenic and elastic
fibers
 Fibers run parallel to the
surface of epithelium and
extend in papillae
perpendicular to their
main course
 This wavy course
provides the tissue with
high degree of elasticity

sub mucosa
 Constitutes major bulk of
the mucous membrane
 Contains :
 Other components
(blood vessels,
lymphatic vessels and
nerves)
 Fatty tissues
 Glands
 Muscles fibers

SEQUELAE OF WEARING COMPLETE
DENTURES
 DIRECT SEQUELAE
 Denture stomatitis
 Flabby ridge
 Denture irritation hyperplasia
 Traumatic ulcers
 Oral cancer
 Burning mouth syndrome
 Gagging
 Residual ridge reduction
 Caries and periodontal disease

Indirect sequelae
 Atrophy of masticatory muscles
 Nutritional deficiencies

Denture stomatitis
 Prevalence: 50% among
the complete denture
wearers
 Synonyms : denture sore
mouth, denture-induced
stomatitis, inflammatory
hyperplasia, and chronic
atrophic candidosis
 Classification: 3 types
 By –Newton's

Newton’s classification
 Type I :
localized simple
inflammation or
pinpoint hyperemia
Cause:
trauma induced

 Type II :
 Diffuse erythema
involving a part or entire
denture covered
mucosa

 Type III :
 Granular type of
inflammatory
hyperplasia
 Cause:
 Presence of microbial
plaque ( bacteria/yeasts)

Candida associated denture
stomatitis

Colonization of the fitting denture surface by
Candida species depends on several factors
 Adherence of yeast cells
 Interaction with oral commensal bacteria
 Redox potential of the site
 Surface properties of the denture resin

Predisposing factors
 Systemic factors
 Local factors
Denture properties
Environmental factors
 Oral hygiene

Systemic factors
 Age
 Diabetes mellitus
 Nutritional deficiencies
 Malignancies
 Immune disorders

Local factors
Denture properties favoring Candida growth
 Surface irregularities
 Micro porosity
 Improper Design of prosthesis
 Mechanical irritation
 Texture

Environmental factors
 Health of adjacent mucosa
 Composition of saliva
 Salivary secretion rate
xerostomia
sjogrens syndrome
 High carbohydrate diet
 Broad spectrum antibiotics

 Smoking tobacco
 Oral hygiene maintenance
 Denture wearing habits

Associated with
 Angular chelitis
 Diffuse atrophic
glossitis

 Median rhomboid
glossitis
 Erythema of the soft
palate

Diagnosis
 Confirmed by finding of mycelia/pseudohyphae in
a direct smear or the isolation of Candida in high
numbers from the lesions.

HISTOLOGICAL FINDINGS
Thinning of stratum corneum
or absence of keratinization.
Epithelial atrophy &
hyperplasia
Intraepithelial infiltration by
leucocytes.
Lymphocytic infiltration in
underlying connective
tissue.

Management and preventive measures

 Because of diverse possible origin, several
treatment procedures are used like:
 Antifungal therapy
 Correction of ill-fitting dentures
 Efficient plaque control
 Surgical care

Antifungal therapy
 Local therapy > nystatin, amphotericin B, miconazole,
clotrimazole
 Systemic therapy > ketoconazole , fluconazole
 Used mainly in following patients:
 After the clinical diagnosis has been confirmed by a mycological
examination
 Associated with burning sensation in oral mucosa
 When infection has spread to other sites of oral cavity or the
pharynx
 Patients with high risk of systemic infections

Precautions to reduce the risk of relapse
 Treatment should continue for 4 weeks

 When lozenges are prescribed > patient is instructed to
take out the denture during sucking
 Meticulous oral and denture hygiene instructions

Correction of ill-fitting dentures
 Rough surface > smoothened and polished
 Relining > soft tissue conditioner
classification:
1) short term
a) tissue conditioner
b) functional impression materials
2) long term
heat cure
silicone
cold cure

 B) acrylic based resins heat cure
cold cure
3) others:
polyvinyl chloride
polyvinyl acetate
polyurethane
hydrophilic acrylates

COMPOSITION
In general they are supplied in powder and
liquid form.
 POWDER – poly (ethyl methacrylate)
 LIQUID – A mixture of aromatic ester and
ethyl alcohol.
 The ester behaves as a plasticizer and the
alcohol is penetrated which speeds up the
process.

On mixing the two together a slurry is
formed. The liquid then penetrates between
the molecules of the powder, a process
accelerated by the ethyl alcohol present
and the whole material becomes stiffer until
a gel is formed, the setting therefore is a
physical process, there being no chemical
reaction involved.

PREFORMED SHEETS OF ACRYLIC GEL
ARE ALSO AVAILABLE WHICH CAN BE
ADAPTED TO THE SURFACES OF THE
DENTURE.

Method to condition the tissues traumatized by
ill-fitting dentures
 Ask the patient not to
wear the dentures for
days – week period
 Stimulate the diseased
tissue with a gauze
dipped in warm saline > 3
times a day
 Tissue side of the
denture should be clean

Adjust and perfect the occlusion and the vertical dimension
Adjust the periphery

Relieve the tissue side of the denture > about 11/2
mm of
relief is given
Coat the denture base with tissue conditioning material
and insert.

BEFORE CONDITIONING

AFTER CONDITIONING

Effective plaque control
 Oral hygiene instructions
 Denture and partial clasp brushes
 Denture cleansing solutions

Surgical care
 Deep crypt formations in type III :
electro surgery / cryosurgery

DETURRENCE / PREVENTION
> Educating the patient
about the oral health care.
> Instructing the patient to
take their dentures out
atleast 8hrs a day.
> Mechanical plague
control & appropriate
denture wearing habits are
important measures.

Angular chelitis
a painful inflammation
at the corners of the
mouth.
Synonyms: angular
stomatitis, perleche,
angular cheilosis

 Reduced vertical
dimension
 Secondary to denture
stomatitis
 Riboflavin and
thiamine deficiency

CLINICAL FEATURES
epithelium at the corner of
the mouth appears
wrinkled, macerated, one
or more deep fissures,
cracks which appear
ulcerated & tends to
bleed.

Treatment
Elimination of the primary cause.
Antifungal treatment & supplement antifungal
ointment at the lesion site

FLABBY RIDGE
 It is due to the
replacement of bone
by fibrous tissue
 Common in maxillary
anterior region (when
mandibular anteriors
are remaining)
 They offer poor
support to the denture

Mechanism
Direction of applied
force of mastication
causes slight rotation of
the denture around the
anterior maxillary
alveolus.
Pressure of the distally
rotating anterior flange
against the labial plate
of bone causes
resorbtion.

The shearing force applied to the periosteum by
friction with the base during rotation results in
fibrous hyperplasia .
When the patient incises the pad, fibrous tissue
is compressed & upward movement of the
maxillary denture causes downward displacement
posteriorly ,with loss of retention in the post dam
area & development of fibrous maxillary
tuberosity.

TREATMENT
 SURGICAL:
i) surgical removal to
improve stability of denture
ii) Augment the alveolar
ridge with biocompatible bone
substitutes
iii) In extreme atrophic
condition, flabby ridges should
not be totally removed
because the vestibular area
will be limited.

 Conservative :
 judicious selection of impression materials and
technique.
 3 technique has been advocated as follow :

A
 Special tray made with a window cut in the region of
displaceable tissue

 Border molding done

 Wash impression made with ZOE paste

Tray re-inserted, impression plaster syringed
over displaceable tissue

Completed impression

Technique – B

Special tray with window cut

Medium- bodied / monophase elastomer is
loaded

 Light body material is syringed in the cut window and
then stabilized by syringing the plaster over the set
elastomer

Technique – c

Special tray with no window and border
molding done

 Impression made using ZOE / Monophase elastomer
 When set , impression material corresponding to the
displaceable tissue is removed
 Tray is perforated

 Impression plaster / light body elastomer syringed over
displaceable tissue
 Tray is reinserted and the impression is complete

Denture irritation hyperplasia

cause
 Chronic irritation by ill-
fitting dentures
 Overextended flanges

 Lesions may be single or
numerous
 Composed of flaps of
hyper plastic
connective tissue
 Severe inflammation
and ulceration in deep
fissures
 Asymptomatic

 Excessive bulk of fibrous
connective tissue
covered by a layer of
stratified squamous
epithelium
 Connective tissue shows
coarse bundle of collagen
fibers with few fibroblast
& blood vessels.

Management
 Correction of over extended flanges
 Surgical excision if its fibro tic or if the hyperplasia does not
fully subside on correction of over extended flanges.

Traumatic ulcers
 Commonly develop within
1 to 2 days after
placement 0f new
dentures
 Lesions are painful, small,
and ulcerated
 Lesion is covered by a
grey necrotic membrane ,
surrounded by
inflammatory halo with
firm and elevated borders

Direct cause
 Overextended denture flanges
 Unbalanced occlusion
 Predisposing factors
 Diabetes mellitus
 Nutritional deficiency
 Radiation therapy/xerostomia

 Loss of continuity of the
surface epithelium with the
fibrous exudates covering
exposed connective
tissue.
 Infiltration of leucocytes
into the connective tissue

Treatment
 Management includes correction of local irritant factors
in the denture.
 Not treated > subsequently may develop into denture
irritation hyperplasia

Oral cancer in denture wearers
 Associated with chronic
irritation of the mucosa
by the dentures
 Case reports > detailed
development of oral
carcinomas in patients
who wear ill-fitting
dentures

 Heavy alcohol and tobacco use
 Lower socioeconomic status
 Less education
 Prevention
regular recall visits > 6 months – 1 year
interval for comprehensive oral examinations

Burning mouth syndrome
 Characterized by a burning sensation in one or several oral
structures in contact with the dentures
 Commonly seen at the age of 50 years
 Females are affected more
 The oral mucosa appears clinically healthy
 Clinical signs: absent
 Symptoms : gradual in onset associated with pain

Characters of the pain
Gradual in onset
Often present in morning
Aggravated during the day / absent at night

Quality of pain
 Burning sensation associated dry mouth and persistent
altered taste sensation
 Associated symptoms : headache, insomnia, decreased
libido, irritability , depression
 Aggravating factors : tension, fatigue, hot or spicy food
 Reducing factors : sleeping, eating, distraction

Site of occurrence
 Anterior two third of the tongue
 Anterior hard palate
 Mucosa of the lower lip

Etiology

Management
Systematic approach is necessary to identify the
possible causes. symptomatic treatment should
be given.
- Mucosal disease -diagnosis & treat the
mucosal condition.
-Dry mouth - high fluid intake & sialagogue
Any systemic disease present should be identified
& treated.
-Menopause-hormonal replacement
-Nutritional deficiency -oral supplementation.

if no organic basis is found, proper
counseling of the patient, help the patient to
understand the benign nature of the
problem & with subsequent elimination of
fears.
comprehensive prosthetic treatment should
be carried out as collaborative effort of
psychiatrist & prosthodontist

Gagging
 Normal , healthy defense mechanism
 Functions to prevent the entry of foreign bodies in to the
trachea

Gagging problem in prosthodontic treatment.
Part I : Description and causes, JPD ; 1983:49
 FAIGENBLUM’S CLASSIFICATION
 Mild :
 Experiences nausea with mild stimulus
 Will be able to control the stimulus
 Severe :
> responds in an exaggerated
manner to physical or psychological stimuli

Five trigger zones identified producing gag
reflex
 Fauces ( tonsils )
 Base of the tongue
 Palate
 Uvula
 Posterior pharyngeal wall

Clinical behavior ( by khan ) - Intraoral
 Puckering of the lips or attempting to close the jaws
 Elevating and furrowing the tongue
 Elevation of the soft palate and hyoid bone
 Fixation of the hyoid bone
 Contraction of anterior and posterior pillars of the fauces (tonsils)
 Elevation, contraction and retraction of larynx and closure of the
glottis
 Simultaneous and uncoordinated respiratory muscle spasm
 vomiting

Extra oral
 Excessive salivation
 Lacrimation
 Coughing
 sweating

Causes of gagging
 SYSTEMIC FACTORS
 Psychological FACTORS
 PHYSIOLOGIC FACTORS
 IATROGENIC FACTORS

SYSTEMIC FACTORS
 Deviated septum
 Nasal polyps or sinusitis
 Inflammation of pharynx
 Chronic gastritis
 Carcinoma of stomach
 Peptic ulcer
 Psychological FACTORS
 Active
 passive

PHYSIOLOGIC FACTORS
 Extra oral stimuli
 Visual
 Auditory
 Olfactory
 Intraoral stimuli
 Inadequate post-dam
 Over-extended posterior borders
 Disharmonious occlusion
 Poor retention
 Surface finish of acrylic resin
 Inadequate free-way space

Management – Daniel J. conny and Lisa A.
1983; 49
 Clinical techniques
 Prosthodontic management
 Pharmacologic measures
 Psycho logic intervention

Clinical techniques
 Surgical ( Leslie ):
 Removal of uvula
 Shortening of soft palate
 Prosthodontic
 Impression technique > BORKIN
 Provides greater control of setting time
 Discrepancies can be easily corrected

Technique
 Primary impression > stock tray and red modeling
compound
 Secondary impression > by pouring “Kerr impression
wax”
 Flexible nature of the wax allows reseating
of the tray and border molding until
desirable results are obtained

Marble technique > SINGER
 First visit :
 Patient asked to place 5 marbles in his/her mouth > 1 at
time at leisure
 Further instructed to keep the marbles continuously for
1 week, except while sleeping and eating
 Second visit :
 Patients ability to tolerate the marbles was evaluated
 Reassured that patient would be able to tolerate the
denture

 Third visit :
 Primary impression made
 Special tray fabricated
 Fourth visit :
 Lower tray was inserted with 3 marbles in the
mouth
 Training bead placed on the lingual aspect of the
tray to maintain proper tongue position
 Fifth visit :
 Use of marbles discontinued

 Sixth visit :
 Fabrication of bite rims
 Jaw relation
 Seventh visit :
 Wax – try in made
 Eighth visit :
 Final denture insertion
 This technique admits patient motivation
 Has definite risk in aspiration of marbles by the
patient during the procedure

 Radiographic > RICHARD’S
 use of high – speed film
 Preset the timer
 Moisten the film pack
 Ask the patient to rinse in cool water
 Psycho logic > LANDA
 Engage the patient in conversation
 Make the patient count rapidly from 50 – 100
 Have the patient to read aloud

Prosthodontic management
 Obtaining proper post – dam
 Correcting over – extended borders
 Correcting the occlusion
 Proper retention
 Mattel surface finish
 Increasing the free – way space

Pharmacologic measures
 Approached when clinical and prosthodontic measures
are ineffective
 Their efficacy, however is not universally accepted
 Classification
peripherally acting drugs centrally acting

 peripherally acting drugs
 Topical and local anesthetics
 Centrally acting drugs
 Antihistamines
 Sedatives and tranquilizers
 Parasympathocytics
 Central nervous system depressants
Psycho logic intervention
• Hypnosis
• Behavioral therapy

RESIDUAL RIDGE REDUCTION
 A term used for the
diminished quality &
quantity of the residual
ridge after the teeth are
removed.(GPT-7)
 A continuous loss of the
bone tissue after tooth
extraction & placement of
the complete denture
 the reduction is the
sequelae of alveolar
remodeling due to altered
functional stimulus of the
bone tissue.

 Follows a chronic progressive & irreversible course that
often results in severe impairment of prosthetic
restoration & oral function.
 First year after tooth extraction ,the reduction of the
residual ridge in the midsagittal plane
maxilla:2-3mm
mandible:4-5mm
 After healing remodeling takes place in decreased
intensity

Etiological factors of reduction of residual
ridges
 Anatomical factors :
 Short and square face associated with elevated
masticatory forces
 Alveoloplasty
 Prosthodontic factors :
 Intensive denture wearing
 Unstable occlusal conditions
 Metabolic and systemic factors :
 Osteoporosis
 Calcium and vitamin D deficiency

CONSEQUENCE OF RR REDUCTION
 Apparent loss of sulcus width
& depth
 Displacement of muscle
attachment
 closer to the crest of the ridge
 Loss of vertical dimension of
occlusion

 reduction of lower facial
height
 Anterior rotation of
mandible & increase in
relative prognathism
 Sharp, spiny, uneven
residual ridge & location
of mental foramina closer
to the ridge

Treatment
 Preprosthetic surgical initiation such as vestibuloplasties
 Severe situations > ridge augmentation procedures

PREVENTVE MEASURES
 Dietary / nutrition intervention, estrogen therapy when
indicated, maintenance of teeth & placements of implants.
 Supplement of calcium & vit D to reduce the rate of post
extraction remodeling of RR in immediate denture wearers
(Wical & Bruser 1979)
 Retaining the tooth as for the over denture abutments.RRR
was found to be 0.6mm in over denture wearers compared
with 5mm in complete denture wearers( Crum &
looney,1978).
 Osseo integrated implants as abutment, reduces rate of
resoption of RR than conventional complete
denture( Sennerby et al 1988)

OVERDENTURE ABUTMENTS:
CARIES & PERIODONTAL
DISEASE
 Wearing of over denture
are often associated with
high risk of caries &
periodontal disease of
the abutments when oral
hygiene measures are
not adequate.

Etiology
 Bacterial colonization beneath the close fitting denture
due to poor oral hygiene
 Streptococcus and actinomyces > gingivitis and
periodontitis
 streptococcus mutans and lactobacilli > caries

Treatment
 Maintain good oral hygiene
 Motivate the patient with
regular recall visits at 3 – 6
months intervals
 Superficial caries > application
of fluoride- chlorhexidine gel
and polishing
 Deep caries > placement of
copings
 Periodontal pockets greater
than 4 to 5 mm > surgically
eliminated

Indirect sequelae

Atrophy of masticatory muscles
 Computed tomography study > masseter and medial
pterygoid muscle demonstrated greater atrophy in
complete denture wearers
 Maximal bite forces tend to decrease in the old age.
 Chewing efficiency decreases as the number of natural
teeth is reduced.
 Reduced bite force & chewing efficiency are sequelae
caused by wearing the complete denture , resulting in
impaired masticatory function

Diagnosis
 Capacity to reduce the test food particles
 It has been verified > chewing efficiency
as the number of natural teeth is reduced
 Worse for subjects wearing complete
denture
 Complete denture wearers need
approximately 7 times more chewing
strokes than subjects with natural dentition

Management
 Retention of small number of teeth used as over denture
abutments > role in maintaining the oral function
 Completely edentulous patients > placement of implants

Nutritional deficiencies
 Nutrition the science of how the body utilizes food to
meet requirements for development, growth, repair and
maintenance
 Essential nutrients to maintain good health are
 Carbohydrates
 Fat
 Protein
 Vitamins
 Minerals
 Water

Nutritional deficiencies
 Primary > faulty selection of food
 Lack of knowledge what to eat
 Fat diets
 Poor food habits
 Food like n dislikes
 Poverty
 Physical incapacities
 Emotional prejudices

 Secondary> systemic disorders
 Factors that interfere with food intake
 Conditions that interfere with digestion
 conditions that interfere with absorption
 Factors that interfere with metabolism
 Conditions that interfere with utilization
 Factors that increases nutrition requirements
 Factors that cause excessive excretion

Risk factors for malnutrition in
patients with dentures
 Eating less than two meals/day.
 Difficult chewing and swallowing
 Unplanned weight gain or loss of more than 10lb
in the last 6 months.
 Undergoing chemotherapy or radiation therapy.
 Loose denture or sore spots under denture
 Oral lesions(glossitis,cheliosis,or burning tongue)
 Severely resorbed mandible
 Alcohol or drug abuse

NUTRITION & THE DENTURE
BEARING TISSUE
Nutritional deficiency
(Proteins, vitamin C & D, Ca)
Alveolar ridge resorption Thin friable mucosa
ILL-Fitting denture Poor force tolerances

ALCOHOLISM, SMOKING &
DENTURE
Decrease in food intake
Multiple nutrient def Dehydration
(Vit B & C)
Thinning of oral mucosa Friable oral mucosa
Abrasion of the denture bearing mucosa

NUTRITION & OVER DENTURE
Cariogenic diet Ca++ deficiency Vit A & C def
Caries of abutment Ridge resorption Poor periodontal
health
Failure of abutment
FAILURE OF OVER DENTURE

Providing nutrition care for
denture wearing patients
 Obtain a nutrition history and an accurate record of food intake over
a 3-5 day period or complete a food frequency form
 Evaluate the diet: assess nutritional risk
 Teach about the components of a diet that will support the oral
musosa,bone health, and total body health
 Help patient establish goals to improve the diet
 Follow-up to support patient in efforts to change food behaviors.

Dietary counseling for Denture wearers
 Diet for the first day after denture insertion :
 liquid diet

 Diet for the 2nd and 3rd day after denture insertion:
Pureed diet to soft diet
 Diet for the fourth day and later:
Soft diet to regular diet as tolerated

CONTROL OF SEQUELAE WITH USE
OF COMPLETE DENTURES
 Every effort should be made to retain some teeth in good positions
to serve as over denture abutments.
 Proper patient education & good oral hygiene practices.
 Patient should be motivated to practice proper denture wearing
habits.
 Patients wearing complete dentures should follow a regular control
schedule at yearly intervals so that acceptable fit & stable occlusal
condition to be maintained.
 Patients wearing over dentures should follow a program of recall &
maintenance for continuous monitoring of the denture and the oral
tissues

REFERENCE
 Prosthodontic treatment for edentulous patients-BOUCHER.
 Essentials of complete denture prosthodontics-WINKLER.
 Textbook of complete denture-HEARTWELL.
 Complete denture-sharry.
 Problems & solution in complete denture prosthodontics-DAVID J.LAMB.
 Clinical dental prosthetics-FENN.
 Principles & practise of complete denture-IWAO.
 Prosthodontics for elderly-BUDTZ-JORGENSEN.
 Txtbook of oral pathology-SHAFER.
 Oral lesions of interest to prosthodontics JPD1961.
 Oral conditions associated with dentures JPD 1958.
 Trouble shooting in CD prosthesis JPD 1960.
 Candida associated denture stomatitis Aus DJ 1998.

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