Management of abused tissue involves addressing factors that cause tissue damage from dental prostheses. Tissue abuse can result from ill-fitting dentures, continuous wearing, and traumatic injuries. Associated conditions include epulis fissuratum from overextended denture flanges, traumatic ulcers from minor trauma, and inflamed flabby ridges from chronic irritation. Management focuses on removing the irritant, improving denture fit, and surgically excising hyperplastic tissue when needed. Denture stomatitis, inflammation under dentures, is treated with antifungal medications and improved denture hygiene.

1. MANAGEMENT OF
ABUSED TISSUE
By
Paavana
I MDS

2. CONTENTS
• Introduction.
• Causes of tissue abuse.
• Factors responsible for tissue abuse.
• Associated tissue reaction and its management
• Conclusion
• References

3. INTRODUCTION
• ABUSE - Improper usage
• In PROSTHODONTICS-Improper usage of dental prosthesis
• Although every effort to eliminate sources of dissatisfaction in
prosthesis construction is made, it is impossible to eliminate all
possible sources.

4. COMPROMISED AND ABUSED TISSUE
Congenital or acquired
anatomic abnormalities
Systemic deficiencies
and disorders.
Detrimental
psychologic factors
Faulty prostheses.
Combination

5. Tissue
abuse
Over
extension
Ill fitting
dentures
Continuous
wearing
Traumatic
injuries
Faulty
occlusion
Bony
spicules

6. FACTORS RESPONSIBLE FOR TISSUE
ABUSE

8. EPULIS FISSURATUM
Syn-Reactive fibrous hyperplasia, Denture-induced fibrous hyperplasia
• EPULIS-Benign hyperplasia of fibrous connective tissue
• HISTOLOGICALLY
1. Epulis granulomatosa (pyogenic/telangiectatic granuloma)
2. Giant cell epulis (peripheral giant cell granuloma)
3. Epulis fissurata (denture epulis, inflammatory fibrous hyperplasia)
4. Epulis fibromatosa/ossifying fibroid epulis (focal fibrous
hyperplasia/peripheral ossifying fibroma)

9. • EPULIS FISSURATUM-
Reactive inflammatory lesion
associated with the periphery of
ill-fitting dentures
• CAUSES-Prolonged use of ill
fitting dentures
 Over extended denture flanges
 Unpolished /improperly polished
denture surface
 Broken dentures.
-Associated with Combination
syndrome
• Female predilection
• Commonly seen - Mandible.
• Varies from small single fold to
multiple folds.

10. MANAGEMENT
Surgical management-excision by scalpel or laser
Prosthodontic management-Addressing the
causative agent to prevent recurrence
>correction of over extended denture flanges
>finishing and polishing of denture borders
>Poorly fitting dentures can be relined or
new ones are constructed

11. TRAUMATIC ULCERS
A ulcer is a break in continuity of the skin and epithelium
CAUSES -Repetitive minor trauma due to
• In denture wearers-Seen in 19.5% of removable denture
wearers(complete denture wearers )
 In complete denture wearers
- Over extended denture borders
- Unpolished denture surfaces
- Due to increased vertical dimension
- Lack of retention and stability
 In partial denture wearers
- Over extended denture borders
- Unpolished denture surfaces
- Due to increased vertical dimension
- Trauma by natural teeth due to presence of sharp cusp tips
- Impinging edges of retentive clasps
- Lack of retention and stability

12. • Self inflicting injuries
- Mal positioned tooth
- Trauma due to sharp cusp tips /broken tooth.
- Supra erupted teeth
- Rough or defective restoration.
- Impinging edges of sharp submerged rootstumps

13. Traumatic ulcer on the labial mucosa Traumatic ulcer on lateral border of
tongue

14. • MANAGEMENT
• Diagnosis of ulcer- by differentiating it from other ulcers by ruling
out other causes of ulceration
-No age predilection
-commonly seen on tongue, lip and labial/ buccal mucosa.
-Shape-symmetrical
-Solitary.
-Tends to heal spontaneously once irritant has been removed.

15. • Removal of the causative factor.
• correction of denture extensions.
• -finishing and polishing of dentures.
• -correction of occlusion
• - Relining or rebasing of dentures to
improve fit/new prostheses fabrication.
• -enameloplasty / Smoothening of sharp
cusp tips of natural teeth (RPD Wearers)
In denture
wearers
• orthodontic movement of mal positioned teeth.
• -correction of occlusal plane in case of supra
erupted teeth by root canal treatment followed by
crown/extraction
• -Enameloplasty/smoothening of impinging cusp
tips.
• -Rehabilitation of retained root stumps either by
extraction/post and core and crown.
Removal of
mechano
traumatic
agents-

16. • Most ulcers will heal completely without any intervention.
• Maintaining good oral hygiene and use of an antiseptic mouthwash
or spray (e.g. chlorhexidine) can prevent secondary infection and
therefore hasten healing.

17. INFLAMMED FLABBY RIDGE
• A fibrous or flabby ridge is a
superficial area of mobile soft
tissue affecting maxillary or
mandibular alveolar ridges.
• It develops when hyperplastic soft
tissue replaces the alveolar bone .
• Prevalence - 24% of edentulous
maxillae
5% edentulous
mandibles.
• Commonly seen - Anterior part of
maxilla and mandible.

18. • Causes
Chronic irritation due to old dentures –
1.Over extended borders.
2.Occlusal plane discrepancies
3.Changes in vertical dimension of occlusion
4.Poor adaptation of prostheses
Excessive load concentration on the anterior segment of the
ridge
Rapid ridge resorption and flabby tissue formation

19. • Combination syndrome
 The 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 tuberosities, papillary hyperplasia of the hard palatal mucosa,
extrusion of mandibular anterior teeth and loss of alveolar bone and
ridge height beneath the mandibular removable partial denture
bases, also called anterior hyperfunction syndrome.(GPT)
Described by Ellsworth kelly in 1972

20. MANAGEMENT
PROSTHODONTIC
MANAGEMENT
CONVENTIONAL
WITH SURGICAL
INTERVENTION
WITHOUT
SURGICAL
INTERVENTIION
IMPLANT
RETAINED
FIXED REMOVABLE

21. CONVENTIONAL
• Surgical management-
• Surgical excision of flabby tissue.
• RIDGE AUGMENTATION with graft material is opted
 Patient's general health and motivation level were in favor
 Sufficient bone height in posterior maxilla as a guide for grafting
 Additional surgery for graft harvesting might be required in some cases.

22. • CONVENTIONAL PROSTHODONTIC
MANAGEMENT
MODIFICATION IN THE IMPRESSION TECHNIQUE
 Primary impression is made in the conventional manner with the help
of irreversible hydrocolloidal impression material with minimum
tissue displacement.
 However various modifications have been done during secondary
impression.

23. 1. Zafrulla Khan’s Window technique:

26. 2. Palatal splinting using a two-part tray system:
Osborne in 1964

28. 3. Two part impression technique: Mucostatic and
mucodisplacive combination
• Osborne in 1964

30. 4. Modified Fluid wax impression:
• Preliminary impression made with an irreversible
hydrocolloid impression material.
• Border mold the tray with modelling plastic impression
compound in segments.
• Trim the tray over the crest of the residual ridge and create a
window opening above the displaceable ridge.
• Melt the impression wax in a water bath and apply onto the
borders of the tray with a wax spatula until a glossy surface is
visible.
• Apply adhesive on the tray surrounding the window opening
and allow it to dry.
• Place the impression tray on the ridge and inject vinyl
polysiloxane impression material over the window opening

31. • IMPLANT RETAINED PROSTHESIS
• It includes
a) Fixed prosthesis
b) Implant retained overdenture

32. • Fixed and removable implant retained prostheses offer potential
benefits to many of the problems encountered with conventional
prosthodontics.
• Attractive alternative due to the enhanced stability, retention and
oral function.
• The success rates for maxillary implants have been shown to be as
low as 78.7%.
• Other factors that must be considered include:
 surgery
 Discomfort and inconvenience
 General health of the patient
 Risk of surgical complications
 Implant failure.

33. DENTURE STOMATITIS
Syn-denture sore mouth, chronic atrophic
candidiasis, Candida-associated denture induced
stomatitis, denture-associated erythematous
stomatitis
• Inflammation and redness of
the oral mucous membrane
occurs beneath a denture.
• Female predilection
• Found in 15% to over 70% of
denture wearers.

34. • NEWTON’S CLASSIFICATION(1962)
TYPE 1 TYPE 2 TYPE 3

35. ETIOLOGICAL FACTORS
• In denture wearers
Poor denture hygiene
Continual and nighttime wearing of removable dentures
Improperly polished denture surfaces
Accumulation of denture plaque
Bacterial and yeast contamination of denture surface.

36. • Other factors include
1. Systemic factors
a. Physiological. (advanced age)
b. Endocrine dysfunctions.
c. Nutritional deficiencies.
d. Neoplasias.
e. Immunosuppression.
f. Ample spectrum antibiotics.
2. Local factors
a. Antimicrobials and topical or inhaled corticosteroids
b. Carbohydrate rich diet
c. Tobacco and alcohol consumption
d. Hyposalivation

37. • MANAGEMENT
• Good oral hygiene is mandatory.
• Local factors which promote growth of yeasts, such as smoking or
wearing the dentures throughout the night, must be discouraged.
• Dentures should be removed for as long as possible and definitely
overnight.
• Dentures should be brushed in warm, soapy water and soaked
overnight in an antiseptic solution.
• Denture fitting and occlusal balance should be checked to avoid
trauma.
• A new prosthesis should be made, if necessary. Dentures must be
adequately polished and glazed, as pores increase denture
contamination by oral microorganisms . Tissue conditioning agents
are generally not recommended for these patients. If there is no
other choice, an antifungal agent, like nystatin, miconazole or
ketoconazole may be incorporated to the agent.

38. • Antifungal medications
RECOMMENDED –
Yeasts have been isolated.
 When lesions do not resolve with hygiene instructions.
• FIRST CHOICE TREATMENT - Topical application of
 NYSTATIN -dry powder, lozenge (pastille), and liquid forms
MICONAZOLE - gel, varnish, lacquer and chewing gum.
• SYSTEMIC ANTIFUNGAL DRUGS
 FLUCONAZOLE -50-100 mg capsule/day
ITRACONAZOLE-100-200 mg/day
KETOCONAZOLE -200-400 mg tablets taken once or
twice daily
• Almost exclusively reserved for patients with systemic factors
that condition the development and persistence of
candidiasis, such as immunosuppression or diabetes.

39. ANGULAR CHELITIS
• Inflammation of one or both corners of the mouth.
• CAUSES-.
o Most common- Infection caused by Candida albicans,
Staphylococcus aureus, and β-hemolytic streptococci.
o Other factors-
 Use of ill fitting dentures
 Loss of vertical dimension of the mouth
 Abnormal skin folds at the corners of the mouth,
 Contact allergy
 Nutritional deficiencies
 Anemia
 Dry skin
 Hypersalivation
 Atopic or seborrheic dermatitis

40. • CLNICAL FEATURES-
 infantile thrush in denture
wearers
 In elderly patients with denture-
induced stomatitis, inflammation
frequently extends along folds of
the facial skin extending from the
angles of the mouth.

41. MANAGEMENT
• Highly dependent on the cause.
• S aureusis - topical treatment with a combination of mupirocin or
fusidic acid and 1% hydrocortisone cream (to counter inflammation)
works effectively.
• Candida - an antifungal ointment like ketoconazole should be
prescribed.
• For those with oropharyngeal candidiasis, systemic therapy need to
be prescribed.
• Patients using inhaled steroids should rinse with water after use to
minimize the amount of residual steroid left in the mouth and
reduce the chance of infection.
• For patients with underlying deficiencies, correcting nutritional
deficiencies should reverse the inflammatory process

42. FRICTIONAL KERATOSIS
• White keratinized patches
• CAUSES –Prolonged mild
abrasion of the mucous
membrane by irritants such as
a sharp tooth, cheek biting or
dentures
• At first, the patches are pale and
translucent, but later become
dense and white, sometimes
with a rough surface.

43. MANAGEMENT
• Any frictional irritant is removed.
• Biting, sucking, or improper chewing habits should be discontinued.
• Fractured or rough tooth surfaces or irregularly fitting dentures or
other appliances should be corrected.
• Observe and monitor the patient to be certain that the frictional
area is resolving in a timely fashion.
• In general, the patient should be reevaluated in 2-3 weeks for signs
of lesion regression or resolution.
• In the absence of resolution, even when the cause has been
eliminated, obtain a biopsy specimen of the tissue to confirm that no
dysplastic or neoplastic change is present.

44. ABUSE DUE TO DENTAL MATERIAL
ALLERGY
METAL ALLERGIES
• CAUSATIVE AGENT
COMMON-Nickel
RARE- Mercury, gold, platinum, palladium, silver and cobalt
• Female predilection.
• Varies from 9-24%
• ASSOCIATED REACTION- Type IV or delayed allergic reaction.

45. Allergy due to nickel crown Allergy due to silver amalgam

46. ALLERGY DUE TO DENTAL
IMPLANTS
• Titanium alloys - Preferred choice for dental
implants
• However small amounts of other elements
associated with titanium alloys can initiate
allergic reactions in patients.
• ASSOCIATED REACTION-
 Type IV
 RARE- type I and III

48. • MANAGEMENT
Before treatment planning
• Proper medical/allergy history.
Unknown allergy history
Diagnosis- Various disgnostic tests
include
 Epicutaneous tests (patch
tests)-After applying different
allergens on the back of the
patient, the consequences of the
allergens are evaluated, preferably
after 48 and 72 hours for the
majority of allergens.
 Skin test (prick test) –type –I
reactions. Involves intradermal
inoculation of the allergen.
 The lymphocyte transformation
test (LTT) is applied by an in vitro
method in mucosal sensitizing
allergens.
Known allergy history
Non allergic alternatives such as
• For crowns and implants
 All ceramic restorations
 Zirconia
 Peek materials
• In orthodontic treatments
 ceramic brackets
 polycarbonate brackets
 gold brackets
• Restorations
 Composite
 glass ionomer

49. In presence of any metallic restorations
• If metal hypersensitivity is established, the following metallic
restoration/allergen should be immediately removed from the
mouth.
• Topical steroidal therapy.
• Replacement with non – allergic alternatives

50. RESIN ALLERGIES
• CAUSATIVE AGENT-
• Di- and mono-methacrylate
resins.
• Although the occurrence of
allergies to dental resins is low,
most methacrylates can
nevertheless induce a Type IV
(delayed) allergic
hypersensitivity reaction.
• Type I reactions in rare cases.

51. • MANAGEMENT

52. • ALLERGY-FREE DENTURE
• High-impact polystyrene: Elastomer graft polymer with
styrene. Similar to polystyrene and injection molded.
• Polycarbonates: Includes glass fiber-reinforced materials,
which have advantages over methylmethacrylate (MMA) because of
their high impact strength.
• Polyvinyl chloride-based acrylic: In this group of mixed
polymers consisting of vinyl chloride, vinyl acetate and MMA acid
ester are used as denture materials.

53. • Eclipse prosthetic resin system: Light cure
fabricate denture (Dentsply)
It consist of 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 for allergic patients.
• • 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 acrylic allergy.
• • Metallic denture base: Used for cast partial denture
as well as completed denture. Metals used are usually base
metal alloys, Ti alloys.

54. • LATEX GLOVES ALLERGY
• Polyether component-main causative
agent.
• Repeated exposure & duration plays
important role.
• CLINICAL FEATURES
• Dermatitis of hand (eczema) most
common adverse reaction
• Localized rashes & swelling to wheezing
& anaphylaxis
• Most serious systemic reactions occur
when gloves or rubber dam contact
mucous membrane – generalized
angioneurotic edema, chest pain, rash
on neck or chest region and respiratory
distress

55. MANAGEMENT
Use Vinyl gloves or gloves made of other synthetic polymer gloves:-
• Polythene gloves.
• Powder free gloves.
• Nitrile gloves.

56. IATROGENIC TISSUE ABUSE
• Iatrogenic trauma - Trauma
that has been induced by the
dentist’s activity, manner, or
therapy.
The four most significant factors
leading to the soft tissue injuries are:
• Visibility and access
• The presence of local
anesthesia
• The use of gloves
• Nervous patients

57. MANAGEMENT
• Tends to heal spontaneously.
• To avoid any bite injuries ,the patient should be educated about the
need the control the force during chewing during the anesthetic
period.
• In case of any burn injuries, Immediate treatment consists of
washing the area with plenty of water in order to remove the acid
and prevent further injury.
• In case of any injury due to rotary instruments, the lesion tends to
heal spontaneously. However sutures might be need in some cases.

58. RADIATION INJURIES
• Radiation therapy - Treat head
and neck cancers.
• Prolonged course of therapy
leads to-
 Sub mucosal connective tissue
 Vasculature
 Hyalinization of collagen
 Depolarization of large
molecules
 Vascular permeability
 Tissue edema

59. Signs and symptoms
• Severe radiation mucositis
• Ulceration
• Formation of pseudomembrane
• Radiation caries
The degree & extent of mucositis can become so severe that the oral
intake of solid food becomes impossible due to pain.

60. • MANAGEMENT
Radiation Prosthesis
Radiation prosthesis can be defined as any device artificially
fabricated that aids in the efficient administration of radiotherapy
to the affected areas and thereby helps in limiting the post therapy
morbidity.

61. • CLASSIFICATION
1) Positioning Stent
a) Perioral cone positioning stent
b) Tongue depressing stent
2) Shielding Stent
a) Tissue recontouring stent
b) Tissue bolus compensators
3) Radiation Carriers Incorporated With Radioisotopes
a) Preloaded carriers
b) Afterloaded carriers

62. POSITIONING STENTS:
• These devices are used to displace the positions of various
structures to assist in the efficient administration of radiotherapy.

63. Types of radiation stents include
• Tongue Depressing Stents-
A tongue depressing stent is a custom made device which positions the
mandible and depresses the tongue during radiotherapy .

64. • Peri oral Cone Positioning Stents-
A peri oral cone positioning stent positions a peri oral cone during
radiotherapy for head and neck tumors. This type of stent is commonly
used when boosting the dose to the tumor site

65. • SHIELDING STENT
They are used to shield the vital structures which are adjacent to
radiation therapy sites from excess dosage of radiation.
TYPES
> Tissue recontouring stent
> Tissue bolus compensators

66. Tissue re contouring stent:
 These stents are effective when treating skin lesions which are
associated with lips when the beam is adjusted for midlines.
 Low doses are delivered at the corners of the mouth because of the
curvature of the lips.
 A stent can be made to flatten the lip and the corner of the mouth,
thereby placing the entire lip in the same plane.

67. • Tissue bolus compensators
 These prostheses help in the treatment of superficial lesions of the
face with irregular contours.
 BOLUS is a tissue equivalent material which is placed directly onto
or into the irregularities, that helps in converting irregular tissue
contours into flat surfaces which are perpendicular to the central
axis of the ionizing beam, to thereby more accurately aid in the
homogenous distribution of the radiation.

68. Radiation carriers incorporated with radioisotopes
 This type of prostheses is needed when radiation therapy is to be
administered to confined areas by means of capsules, beads, tubes
or needles of radiation emitting materials.
 They are used to carry the radiation sources close to the site of
treatment (intracavitary) or directly into the tumour
(interstitial).They are of two types:
a) Preloaded carriers
b) After loaded carriers

69. TISSUE INJURIES DUE TO MALOCCLUSION
Causes
• Size mismatch between jaw
and teeth
• Certain oral habits (eg, thumb-
sucking, tongue thrusting)
• Missing teeth
• Certain congenital defects
• Lacerations of the soft tissue
can be seen
• Gingival erythema along with
signs of injury can be seen on
the palate or cheeks due to the
impingement of incisal
/occlusal edges of
corresponding teeth

70. MANAGEMENT
• DENTAL MODIFICATION- Occlusion can be improved by
aligning teeth properly, by selectively grinding teeth and correcting
restorations that contact prematurely, and by inserting crowns or
onlays to build up tooth surfaces that are below the plane of
occlusion.
• ORTHODONTIC APPLIANCES (BRACES)-Orthodontic
appliances (braces) apply a continuous mild force to teeth to
gradually remodel the surrounding alveolar bone.
• SURGERY-When orthodontic treatment alone is insufficient,
surgical correction of jaw abnormalities contributing to
malocclusion (orthognathic surgery) may be indicated.

71. INJURIES DUE TO TRAUMA FROM OCCLUSION
• TFO -Pathologic alterations or adaptive changes which develop in
the periodontium as a result of undue force produced by the
masticatory muscles.
• CLASSIFICATION
1. ACUTE TFO
• Results from an abrupt occlusal impact, such as that produced by
biting on a hard object (e.g., an olive pit).
• In addition, restorations or prosthetic appliances that interfere with
the direction of occlusal forces on the teeth may induce acute
trauma
2.CHRONIC TFO
• Develops from gradual changes in
a) occlusion produced by tooth wear,
b) drifting movement,
c) extrusion of teeth,
d) combined with parafunctional habits such as bruxism and clenching

72. • Clinical signs-According to
Box and Stillman
 Traumatic crest
 Asymmetrical gingival
recession.
 Stillman's clefts
 McCall's festoons
 Absence of stippling

73. • MANAGEMENT
• Orthodontic correction is usually restricted to cases where tooth
malpositions are the prime cause of trauma.
• Before orthodontic appliances are removed, the clinician should
ensure that occlusal interferences are eliminated.
• This assessment should be made in both static and functional
excursion.
• Investigations that may aid this decision may include visual
inspection using articulating paper, occlusion, mobility assessment,
radiographs and the use of the lately developed computer-aided
occlusal evaluation systems.
• Retention should be custom-designed for each patient taking into
account the nature of the initial malocclusion and periodontal status
of the patient.

74. CONCLUSION
• Any faulty prostheses can alter the character, condition and form of
the underlying oral tissues. The pathological changes must be
carefully examined and resolved. It is essential for the patient to
develop good oral and denture hygiene habits in order to achieve
oral tissue health, esthetics, control of oral odor and affirmation of
patient’s sense of well being.

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