4. 4
HYPERKERATOSIS AND ORAL CANCER
GAGGING
DENTURE BASE ALLERGY
ATROPHY OF MASTICATORY MUSCLES
NUTRITIONAL STATUS AND MASTICATORY FUNCTION
DISCUSSION
SUMMARY
REFERENCES
12. TYPE I
Localised simple
inflammation
o r p i n p o i n t
hyperaemia
TYPE II
G e n e r a l i s e d
erythematous area
involving either a
portion or the entire
surface
of the denture covered
mucosa
TYPE III
Mix of type I and type II
i n a d d i t i o n t o
granular,inflammatory
hyperplasia
u s u a l l y i n v o l v i n g
midline of hard palate
and alveolar ridges
12
13. FACTORS PREDISPOSING TO CANDIDAASSOCIATED
DENTURE STOMATITIS
SYSTEMIC FACTORS
OLD AGE
DIABETES MELLITUS
NUTRITIONAL DEFICIENCIES
MALIGNANCIES
IMMUNE DEFECTS
CORTICOSTEROIDS,
IMMUNE-SUPPRESSIVE DRUGS
13
17. 17
Kulak Y,Arikan A (1993)found that there was a statistically significant
relationship existing between denture stomatitis and denture
hygiene,smoking habits,candidal formation and colonisation.
18. Improving the denture hygiene
Adjust the denture to eliminate trauma from a poorly fitting denture base
Denture disinfection is done by soaking the denture overnight in 0.2%
chlorohexidine
Sodium hypochlorite solution can be effective, provided the denture do not
contain a resilient soft lining or metal baseplate
Tissue conditioning material (viscogel) when applied to the denture fitting
surface can improve the adaptation of the dentures to the tissues
MANAGEMENT AND PREVENTIVE MEASURES
18
19. Alternative method is to reline the upper denture fitting surface with a hard
chair side reline material (kooliner)
Laser beam, cryosurgery, electro surgery, and scalpel surgery are successfully
practised in treating infection especially in type II and type III infections.
Local therapy with Nystatin, Amphotericin B, Clotrimozole is preferred over
systematic therapy with ketoconazole or fluconazole
Treatment with anti fungal drugs should continue for 4 weeks
In type III denture stomatitis, surgical elimination of deep crypt formation
maybe necessary and could be achieved cryo surgically
19
21. CLINICAL FEATURES
⢠Ulcers are small,painful,irregularly shaped lesions usually covered by a
delicate grey necrotic membrane and surrounded by an inflammatory halo
with firm borders.
⢠Usually occurs because of over extended dentures or errors in occlusion.
21
22. TREATMENT
The lesion may be marked intra-orally with a Thomson color transfer
stick ,followed by careful insertion of the dentures so as not to smudge the
marking or to aggravate the lesion ,and then relieving the area on the denture
where the colour has been transferred.Once corrected the lesion usually heals
within a few days.
DIAGRAM
22
23. CHEEK BITING
⢠This may be due to posterior denture teeth being in violation of the neutral zone
concept.(eg, placed too far buccally).
⢠This is commonly corrected by selective recontouring of the prosthetic teeth or
even having to reset them.
23
25. Ill fitting dentures for a prolonged period
Chronic low -grade trauma,typically induced by unstable
dentures or an overextended denture flange-
as a result of which denture moves further into the vestibule-
asymptomatic ,fibrous tissue in the form of folds that proliferate
over the denture flange.
25
26. CLINICAL FEATURES
⢠Edge of the denture fits into the fissure of groove between the mucosal
folds.
⢠Single or multiple lesions are usually observed at the facial aspect of the
denture -anterior regions of the maxilla or mandible
⢠May extend along the entire length of the mandible.
26
27. TREATMENT
⢠Inflammatory fibrous hyperplasia-surgically excised.
⢠Old dentures -rebased to provide adequate retention.
Complete regression after construction of new
dentures will not occur although reduction of
inďŹammatory reaction may produce some
clinical improvement.
27
29. Longitudinal studies of the bulk and outline of edentulous residual ridges in
complete denture wearers demonstrated a continuous loss of bone tissue after
tooth extraction and placement of complete denture.
The reduction is a sequel of alveolar remodelling but to altered functional
bone stimulus.
The process of remodelling is particularly important in areas with thin cortical
bone (the buccal and labial parts of the maxilla and the lingual parts of the
mandible)
29
30. ⢠During the first year after tooth extraction the reduction of the residual ridge
height in the mid sagittal plane about 2-3 mm for the maxilla and 4-5 mm for the
mandible.
⢠In the mandible the annual rate of reduction in height is about 0.1-0.2 mm and in
general 4 times less in the edentulous maxilla.
⢠Women appear to have more residual ridge resorption, a manifestation of
osteoporosis.
30
31. 31
According to BrĂĽnemark et al in 1985, ridges were classified on the basis
of bone quantity and bone quality by radiographic means
⢠Class A: Most of the alveolar bone is present
⢠Class B: Moderate Residual Ridge Resorption occurs
⢠Class C: Advance residual ridge resorption occurs
⢠Class D: Moderate resorption of the basal bone is present
⢠Class E: Extreme resorption of the basal bone
32. They are categorised into 6 orders by Atwood
Order 1 - Pre extraction
Order II - Post extraction
Order III - high, well rounded
Order IV - Knife edged
Order V - low, well rounded
Order VI - depressed
32
33. Etiological factors
Anatomic factors
More important in the mandible versus the maxilla
Short and square face associated with elevated masticatory forces
Alveoloplasty
Prosthodontic factors
Intensive denture wearing
Unstable occlusal conditions
Immediate denture treatment
33
34. Metabolic and systemic factors
Osteoporosis
Calcium and Vit D supplements for possible bone preservation
34
35. The consequences of residual ridge reduction are
An apparent loss of sulcus width and depth with displacement of the muscle
attachment closer to the crest of the residual ridge
loss of vertical dimension at occlusion
Reduction of the lower face height
An increase in a relative prognathic appearance
Accompanying changes in alveolar bone such as sharp, shiny, uneven
residual ridges and a new location of the mental foramina close to the top of
the residual ridge are also frequently encountered.
35
36. 36
Rogers and Applebaum (1941) concluded from measurements made in cadavers
with dentulous and edentulous jaws that ,in the maxilla the vertical height of the
ridges had decreased and the crest of the edentulous ridges had shifted palatally
after tooth extraction.They felt that in the mandible the most extensive resorption
occurred on the superior surface of the ridge and the lingual surface of the
posterior part of the ridge.
38. 38
Soft liners act as a cushion between the denture base and the residual ridge. Hence, it
is important to study their effect on resorption of mandibular denture bearing area.
Therefore, the purpose of this study was to evaluate the influence of soft denture
liner on mandibular ridge resorption after 1 year in completely denture wearers.
The use of soft denture liner significantly reduces the residual ridge resorption in
complete denture wearers as compared to conventional denture wearers (without
denture liner) over a period of 1 year.
J Indian Prosthodont Soc. 2017 Jul-Sep;17(3):233-238
40. Edentulous ridges that are mobile or resistant with little evidence of underlying
supporting bone give the appearance of being flabby.
-in some denture wearers where the alveolar bone has been replaced by fibrous
tissue.
-more evident in the maxillary anterior especially when only the natural
mandibular anterior teeth remain.
-maxillary tuberosity may become hypertrophied and appear to grow downward.
40
41. -papillary hyperplasia of the hard palate,extrusions of the mandibular
anterior teeth in a labio-incisal direction and posterior bone loss in the
mandible under a Kennedy Class I removable partial denture.
-As a result there is an accompanying loss of vertical dimension of occlusion
and dramatically altered facial aesthetics ,giving rise to "witch's' chin".
41
42. TREATMENT
Surgical intervention may be required to improve the stability of the
complete upper denture and to minimise alveolar ridge resorption.
42
44. GPT definition-characteristic features that occur when an edentulous maxilla is
opposed by natural mandibular anterior teeth including loss of bone from the anterior
portion of the maxillary ridge,overgrowth of the tuberosity,papillary hyperplasia of the
hard palate mucosa,extrusion of the lower anterior truth and loss of alveolar bone and
ridge height beneath the mandibular removable partial denture base -also called-
anterior hyper function syndrome.
Kelly-1972 modified by Saunders et al 1979
44
46. CLINICAL FEATURES
LOSS OF BONE IN THE ANTERIOR REGION OF MAXILLARY ALVEOLAR RIDGE
⢠This part of alveolar ridge consists exclusively of soft tissue (fibrous alveolar ridge)
with sometimes marked mobility.
⢠Loss of bone in the anterior region of edentulous maxilla-overloading of this part of
dental arch opposite the mandibular anterior teeth.
⢠Hence complete maxillary denture loses its stability -known as combination
syndrome.
46
47. OVERGROWTH OF THE TUBEROSITY
⢠Caused by increased vacuum -region of maxillary tuberosity-mobility of the denture
during its contact with opposing mandibular anterior teeth.
⢠Fibrous hypertrophy of maxillary tuberosity is often observed.
⢠Occlusal plane is located at a lower level close to mandibular alveolar ridge
47
48. Extrusion of the mandibular anterior teeth.
⢠This is the result of the lack of sufficient stimulation required by the
periodontium of the anterior mandibular teeth.
⢠Extrusion of the mandibular teeth exerts increased pressure on the anterior part
of the edentulous ridge in the maxilla and can overload the residual ridge
causing atrophy of the bone.
48
49. PAPILLARY HYPERPLASIA ON THE HARD PALATE
⢠Slight or bright reddening covering the total area of the prosthesis adhering
on the hard palate.
⢠Occurs as a result of incorrect relief made on the area of soft tissues (non-
resilient should be relieved)
⢠In 1979 Saunders,Gillis and Desjardins suggested range of symptoms that
characterise this syndrome by adding the following features.
â Loss of correct vertical dimension of occlusion
â Patients poor adaptation to dentures
â Occurrence of granuloma fissuratum
â Changes in the periodontium of the existing natural teeth.
49
50. TREATMENT
⢠Denture bases that fit well and offer maximal extension and border seal.
⢠Occlusal scheme developed at the correct vertical dimension and centric
relation.
⢠Balanced occlusion to ensure load distribution is spreader the dentures.
⢠No anterior teeth contact in maximum occlusion.
⢠Retention in maxillary over denture abutments ,this stabilises the maxillary
denture and resisted strong anterior forces.
⢠Placement of implants in the anterior maxillary region.
50
51. 51
Thirteen patients who had worn a maxillary conventional denture and mandibular
osseointegrated implant-supported overdenture for at least 3 years were evaluated
for subjective assessment of fit of the maxillary denture, occlusal integrity, and the
status of the anterior maxillary residual ridge. The findings of this study support the
view that this combination of prostheses can result in perceived loosening of the
maxillary denture, loss of posterior occlusion, increased anterior occlusal pressure,
and anterior maxillary bone loss, similar to the effects seen in Combination
Syndrome. It is therefore important to ensure that where an implant-supported
mandibular overdenture is planned for the edentulous patient, some form of
stabilisation of the maxillary arch is also considered.
Int J Prosthodont. 1996 Jan-Feb;9(1):58-64.
Lechner SK1, Mammen A
53. ⢠No evidence that oral cancer and denture related mucosal irritation are related.
⢠Excessive use of tobacco or alcohol,frequent exposure to UV radiation , low
socioeconomic status and poor dental health-oral cancer.
⢠The persistent appearance of an oral lesion even after appropriate denture
adjustment-strong indication for intervention by pathologist.
53
54. 54
A control group ,and the cancer patient group, total of 140 new cancer cases and
140 subjects were included. Out of 140 patients in the cancer group, 16 were
nonsmokers, while 110 smoked cigarette in the cancer patient group. As far as
alcohol consumption is concerned, 42 patients in the control group and 102
patients in the oral cancer group were chronic heavy drinkers. Fried food intake
was high in both the groups. Significant correlation was obtained while comparing
the heavy smokers, heavy alcohol consumers, and oral health status in both the
study groups.
⢠The results favoured the hypothesis that positive correlation exists between oral
cancer risk and recurrent denture sores.
⢠People wearing denture prosthesis should be periodically visualized for
identification of any mucosal alteration or changes at the earliest.
J Contemp Dent Pract. 2016 Nov 1;17(11):930-933
56. ⢠Burning sensation in one or several oral structures in contact with the dentures.
⢠In BMS patients ,oral mucosa usually appears clinically healthy.
⢠Affected patients-older than 50 years,mostly females.
⢠The pain is often present in the morning and tends to aggravate in the daytime.
⢠Generally burning sensation with a feeling of dry mouth and persistent altered
taste sensation.
56
57. Associated symptoms may include
Headache
Insomnia
Decreased libido
Irritability or depression
Aggravating factors
Tension
Fatigue
Hot or spicy food
Sleeping,eating and distraction reduce pain intensity.
57
62. MANAGEMENT
⢠Proper counselling should be given for the elimination of fear.
⢠Any comprehensive prosthetic treatment ,including treatment with implant
supported over dentures should be carried out as a collaborative effort of
psychiatrist and prosthodontist.
62
64. ⢠Gagging reflex is a normal healthy defence mechanism.
⢠Its function is to prevent foreign bodies from entering the trachea.
⢠It can be triggered by tactile stimulation of soft palate ,the posterior part of the
tongue.
⢠In sensitive patients,the gag reflex is easily released after placement of new
dentures,but usually disappears in a few days as the patient adapts to the
denture.
64
65. ⢠Persistent complaints of gagging may be due to over extended borders
(posterior part of the maxillary dentures ) or poor retention of the maxillary
denture.
⢠In wearers of old dentures gagging may be a symptom of diseases or
disorders of the gastrointestinal tract adenoids or catarrh in the upper
respiratory passages,alcoholism or severe smoking.
65
67. ⢠Case reports and studies suggested that these were due to sensitivity of monomer.
⢠Methyl methacrylate can produce a reaction in susceptible persons.
⢠Clinically-simple generalised inflammation or denture sore mouth.
⢠Cobalt-chromium alloy base materials in dentures on very rare occasions cannot
be tolerated by patients.
⢠Some patients are sensitive to nickel alloy.
67
68. 68
In 13 patients with a maxillary complete denture with a titanium base (group I)
and in 12 patients with a maxillary complete denture with a resin base (group II),
the (a) patient's adaptation to the denture, (b) denture retention and (c) appearance
of the mucosa under the denture were evaluated. In all cases, the adaptation was
assessed with a questionnaire, while the retention and the appearance of the
mucosa were assessed by clinical examination. None of the three measures
considered (adaptation, retention and mucosa appearance) differed significantly
between patients with titanium-base dentures and patients with resin-base dentures.
Titanium bases are suitable for dentures likely to be subject to severe
mechanical stresses (as in the case of maxillary complete dentures opposing
natural teeth), and in patients who show hypersensitivity responses to other
materials.
J Oral Rehabil. 2000 Feb;27(2):131-5
69. 69
Intolerance to dentures as a result of allergy is very rare. In such cases, the
allergy is triggered not by the acrylic but mostly due to the unpolymerized
precursors. Epicutaneous test reveals the allergy is due to the presence of
benzoyl peroxide initiatorand hydroquinone inhibitor.Researchpaperswere
reviewedâmanypaperswerestudiesfortheircytotoxicityeffectsofMethylMethacrylate
⢠Contact Allergy to Denture Resins and Its Alternative Options.Int J Oral
Implantol Clin Res 2016;7(2):40-44.
70. 70
Compound Use Molecular structure Possible adverse
effect
Methyl Methacrylate Acrylate monomer,
common in
orthodontic
bansplates and
dentures
Allergy Toxic
2-hydroxyethyl-
methacrylate
cements Allergy
Ethyleneglycol
dimethacrylate
Common monomer in
composite and
bonding
Allergy Cytotoxic
Urethane dimethacrylate Monomer used in
composites Allergy Genotoxicity
Triethylene- glycol
dimetha- crylate
Common monomer
in composites and
fissure sealants
Allergy Genotoxicity
71. 71
⢠A method was suggested by Jorge et al,which evaluated the effect of two
postpolymerization treatment and different cycles of polymerization on cytotoxicity
of two denture base resins, Lucitone 550 and QC
⢠They mentioned that after polymerization, water bath at 55°C for 1 hour reduced the
cytotoxicity of Lucitone 550.
⢠Another method suggested by Sheridan et al reported that cytotoxic effect of acrylic
resins was greater in the first 24 hours after polymerization
⢠The authors concluded that longer the resins were soaked, lesser its cytotoxic effect.
⢠Patients having allergic reactions to temporary restorations made with
autopolymerizing resins should be provided with prefabricated temporary crowns,
which eliminate the potential of residual monomerallergy
72. 72
ÂĽHigh-impact polystyrene: Elastomer graft polymer with styrene. Similar to
polystyrene and injection molded.
ÂĽPolycarbonates: Includes glass fiber-reinforced materials, which have advantages
over methylmethacrylate (MMA) because of their high impact strength. They do not
contain MMAmonomer, so can be used in allergic patients.
ÂĽPolyvinyl chloride-based acrylic: In this group of mixed polymers consisting of vinyl
chloride, vinyl acetate and MMA acid ester are used as denture materials. This
denture acrylic group includes luxene, virlene which show good dimensional
consistency, low water absorption, and high breaking strength. They require a complex
special apparatus for processing using the melt-press process, which means these
materials are less used.
ALLERGY FREE MATERIALS
73. 73
⢠Eclipse prosthetic resin system: Light cure fabricate denture (Dentsply), indirect buildup
method for fabricating dentures, i.e., monomer free and flask free; does not contain
any ethyl, methyl, butyl, or propyl methacrylates; and can be used forallergic patients.
ÂĽ Valplast: Flexible denture base material, i.e., ideal for partial denture but very rarely
used for complete dentures. It is a nylon thermoplastic material which eliminates the
concern about acrylicallergy.
ÂĽ Metallic denture base: Used for cast partial denture as well as completed denture.
Metals used are usually base metal alloys, TiSAl4V. The advantages are
biocompatibility, hypoallergenicity, dimensional stability, and good proprioception.
⢠Contact Allergy to Denture Resins and Its Alternative Options.Int J Oral
Implantol Clin Res 2016;7(2):40-44.
75. ⢠Overdentures-high risk of caries and progression of periodontal disease of the
abutments.
⢠Bacterial colonisation-beneath a close fitting denture is enhanced,good plaque control
of the fitting denture surface is difficult to obtain.
⢠Mainly -streptococcus and actinomyces-caries rate is 30% after 1 year in denture
wearing patients.
⢠Aim of preventive measures-to control accumulation of plaque on the exposed dentin
of the abutment teeth as well as the root surface.
75
76. ⢠The effect of daily application of gels containing fluoride or fluoride plus
chlorhexidine has been assessed.
⢠The placement of copings that cover the exposed dentin and root surfaces is indicated
only when caries is more deeply penetrating.
⢠Periodontal pocket greater than 4-5 mm should be eliminated surgically.
76
77. 77
Tymstra et al (2011) compared the effect of the mandibular implant retained
over denture using 2 or 4 implants over conventional complete denture on
resorption of the residual ridge of the maxillary and mandibular posterior areas
over a period 10 years.
It was concluded that patients rehabilitated with implant retained mandibular
over dentures are not subjected to more residual ridge resorption in the anterior
maxilla when compared to patients wearing a conventional full denture.
⢠Regarding the mandibular posterior residual ridge ,resorption was irrespective of
wearing an implant-retained mandibular over denture or a conventional
mandibular denture.
79. ATROPHY OF MASTICATORY MUSCLE
⢠Maximal bite forces tend to decrease in older patients.
⢠Computed tomography studies of the masseter and the medial pterygoid muscles
have demonstrated a greater atrophy on complete dentures esp in women.
⢠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 complete denture wearers.
79
80. ⢠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 equivalent reduction in particle size.
⢠As a result they prefer food that is easy to chew,or they swallow large food
particles.
80
81. Preventive measures and management
⢠The retention of a small number of teeth used as over denture abutments seem to
play an important role in the maintenance of oral function in elderly denture
wearers.
⢠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.
81
82. NUTRITIONAL STATUS AND MASTICATORY FUNCTION
4 widely cited factors related to dietary status and nutrition of
complete denture wearers
ORAL HEALTH AND MASTICATORY FUNCTION
SYSTEMIC HEALTH
SOCIO-ECONOMIC STATUS
DIETARY HABITS
82
83. Reduced salivary secretion can also affect the masticatory ability and
efficiency.
It is associated with
⢠Complaints of xerostomia
⢠Chewing diďŹculties
⢠Complaints related to complete dentures
⢠Increased number of chewing cycles before swallowing
⢠Loss of appetite
⢠Reduced serum albumin level
⢠Reduced body mass index
83
88. ⢠The major time dependent consequences of wearing complete dentures are
pathological changes of the oral mucosa and residual ridge reduction.
⢠They often compromise patient comfort,masticatory function and appearance
and de-stabilize the occlusion.
88
89. The adverse sequelae can be partially managed by the following
Restoration of partially edentulous patients with complete denture should only be
considered if this is the only option because of poor periodontal
health,unfavorable location of the remaining teeth.
Patients should follow a regular ,controlled maintenance schedule at yearly
intervals (acceptable fit and stable occlusal condition can be maintained)
Inform edentulous patients about the benefit of prosthesis.
89
90. 90
⢠Zarb âBolender : Prosthodontic treatment for edentulous patients, 12th edition .
⢠Zarb,Hobrick:Prosthodontic treatment for edentulous patients 13th edition
⢠Arthur.Rahn.O,Charles.Heartwell.M,Jr: Textbook of complete dentures, 5th
edition.
⢠Sheldon Winkler:Essentials of complete denture prosthodontics, 2nd edition .
⢠Hugh Delvin-Complete denture,A clinical manual for the general dental
practitioner
⢠Burket's Oral Medicine,11th edition
⢠Bhalajhi:Textbook of Orthodontics.5th edition
TEXTBOOK REFERENCES
91. 91
⢠Tymstra N, Raghoebar GM Maxillary anterior and mandibular posterior residual
ridge resorption in patients wearing a mandibular implant-retained overdenture.J
Oral Rehabil. 2011 Jul;38(7):509-16.
⢠Jain P, Jain M .A Case-control Study for the Assessment of Correlation of
Denture-related Sores and Oral Cancer Risk.J Contemp Dent Pract. 2016 Nov
1;17(11):930-933.
⢠Rilo B, Santana U.Titanium for removable denture bases.J Oral Rehabil. 2000 Feb;
27(2) 131-5
⢠Lechner SK, Mammen.ACombination syndrome in relation to osseointegrated
implant-supported overdentures: a survey.Int J Prosthodont. 1996 Jan-Feb;9(1):
58-64
92. 92
⢠Mangtani N, Pillai RS.Effect of denture soft liner on mandibular ridge resorption
in complete denture wearers after 6 and 12 months of denture insertion: A
prospective randomized clinical study.J Indian Prosthodont Soc. 2017 Jul-Sep;
17(3):233-238.
⢠Kelly E. Changes caused by a mandibular removable partial denture opposing a
maxillary complete denture.J Prosthet Dent. 2003 Sep;90(3):213-9
⢠Kulak Y, Arikan A. Aetiology of denture stomatitis.J Marmara Univ Dent Fac. 1993
Sep;1(4):307-14.
⢠Ashish Choudhary, Ashwin S Devanarayanan .Contact Allergy to Denture Resins
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