This document discusses the management of abused tissues in prosthodontics. It defines tissue abuse as improper usage of dental prostheses. Causes of tissue abuse include ill-fitting dentures, continuous wearing, traumatic injuries, and faulty occlusion. Associated tissue reactions include epulis fissuratum, traumatic ulcers, inflamed flabby ridges, denture stomatitis, angular chelitis, and frictional keratosis. Management involves detecting and removing irritants, improving denture fit, using soft denture liners, and following good oral hygiene. Tissue conditioners provide temporary relief while long-term soft liners help heal abused tissues by dispersing forces over wider areas.

1. BY
PAAVANA
I year MDS
MANAGEMENT OF ABUSED
TISSUE

2. CONTENTS
 Introduction.
 Causes of tissue abuse.
 Factors responsible for tissue abuse.
 Associated tissue reaction.
 Management of abused tissues.
 Review of literature
 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 TISSUES
Congenital or acquired
anatomic
abnormalities
Systemic deficiencies.
Detrimental
psychologic factors
Faulty prostheses.
Combination

5. TISSUE ABUSE IN DENTURE
WEARERS
Tissue
abuse
Over
extension
Ill fitting
dentures
Continuous
wearing
Traumatic
injuries
Faulty
occlusion
Bony
spicules

6. FACTORS RESPONSIBLE FOR
TISSUE ABUSE

7. ASSOCIATED TISSUE
REACTION
EPULIS FISSURATUM
Syn-Reactive fibrous
hyperplasia, Denture-induced
fibrous hyperplasia
 Benign hyperplasia of fibrous
connective tissue
 CAUSES-Prolonged use of ill
fitting dentures or broken
dentures.
 Female predilection
 Commonly seen - Mandible.
 Varies from small single fold to
multiple folds.

8.  TRAUMATIC ULCER
 CAUSES -Repetitive minor
trauma due to
- Ill fitting dentures.
- Self inflicting injuries with
various mechano traumatic
agents.
- Trauma caused by teeth.
 Seen in 19.5% of removable
denture wearers(complete
denture wearers )
*Jainkittivong A, Aneksuk V, Langlais RP. Oral mucosal
lesions in denture wearers. Gerodontology 2010
;27(1):26-32.

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

10.  INFLAMMED FLABBY
RIDGE
 Commonly seen - Anterior part of
maxilla and mandibular
anteriors.
 Causes
 Chronic irritation due to old
dentures.
 Load concentration on the
anterior segment of the ridge
 Rapid ridge resorption
 Combination syndrome.

11.  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.
*Gendreau, L & Loewy Z. G. Epidemiology and Etiology of
Denture Stomatitis. J Prosthodont 2011, 20(4): 251–260.

12. ETIOLOGICAL FACTORS
 Poor denture hygiene
 Continual and nighttime wearing of removable
dentures
 Accumulation of denture plaque
 Bacterial and yeast contamination of denture
surface.

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

14. ANGULAR CHELITIS
• Inflammation of one or both
corners of the mouth.
• CAUSES- Leakage of candida
infected saliva at the angles of
the mouth.
• 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.

15. FRICTIONAL KERATOSIS
 White 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.

16. ABUSE DUE TO DENTAL
MATERIAL ALLERGIES
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.

17. Allergy due to nickel crown Allergy due to nickel
crown

18. 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
*Chaturvedi TP. Allergy related to dental implant and its clinical
significance. Clin Cosmet Investig Dent 2013;5:57-61

20. 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.

21. Mucositis due to acrylic resin allergy

22. ALLERGIES CAUSED DUE
TO EUGENOL
 Eugenol is a para-
substituted phenolic
compound.
 Although eugenol allergy is
rare, it may cause type IV
allergy and in rare cases
may cause type I reactions.
 Marked erythema and
destruction of the
interdental papillae is
usually seen.
*Sarrami, N., Pemberton, M. N., Thornhill, M. H., & Theaker, E. D.
Adverse reactions associated with the use of eugenol in dentistry. Br Dent
J 2002; 193(5), 253–255.

23. 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
Iatrogenic tissue injury during tooth prepara

24. Allergic reaction due to local anesthesia
 CAUSATIVE AGENT-
 Preservatives (e.g. Methyl-p-hydroxybenzoate)
 Antioxidants (e.g. Bisulphate)
 Antiseptics (e.g. Chlorhexidine)
 Other antigens such as latex, as well as local
anesthetic drugs.
 ALLERGIC REACTION-type IV reaction.
 OCCURANCE RATE- 80 and 90%.
* Tomoyasu Y, Mukae K, Suda M, Hayashi T, Ishii M, Sakaguchi M, Watanabe Y, Jinzenji A, Arai Y, Higuchi H,
Maeda S and Miyawaki T. Allergic Reactions to Local Anesthetics in Dental Patients: Analysis of Intracutaneous and
Challenge Tests Open Dent J. 2011; 5: 146–149.

25. REACTIONS DUE INTERDENTAL
CEMENT RETENTION
 Rare .
 GICs contain a polyalkenoic acid such as
polyacrylic acid and fluoride-containing silicate
glass (fluoroaluminosilicate) powder do
occasionally cause reactions.
 CLINICAL INTRA-ORAL FINDINGS
 Swelling
 soreness or necrosis of the oral mucosa .
 Burning mouth syndrome has also been
observed in some cases.

26. 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

27.  It leads to the
 Severe radiation mucositis
 Ulceration
 Formation of
pseudomembrane
The degree & extent of
mucositis can become so
severe that the oral intake of
solid food becomes impossible
due to pain.

28. 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.
 Clinical signs-According to Box
and Stillman
 Traumatic crescent
 Asymmetrical gingival
recession.
 Stillman's clefts
 McCall's festoons

29. TISSUE INJURIES DUE TO
MALOCCLUSION
 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

30. MANAGEMENT OF
ABUSED TISSUE

31. DETECTION AND REMOVAL OF
THE IRRITANT
For any tissue undercut or any
inaccuracies in tissue contact
Areas of exostosis
Midpalatine raphae
• Evaluation of tissue side

32. • Evaluation of tissue borders
For compatible
extensions and contour
Frenum attachments
and hamular notch areas
Stability during speech
and swallowing

33. Checking for any occlusal errors
Articulating
paper
• Used to check for occlusal interferences, and the
occlusion be adjusted if necessary.
Central bearing
device
• Aids to record maxillomandibular relationships and
to refine the occlusion in complete dentures
Occlusal wax
• Excellent method of correcting occlusal in centric
position only
Abrasive paste
• Detects shifting of denture bases

34. MOUNTING OF INTEROCCLUSAL
RECORDS
 Easy to visualise ,locate and correct
 Helps to stabilise denture bases.
 Articulating marks can be easily made on dry
teeth.

35.  Denture hygiene maintenance

36. DIET AND NUTRITION
 Tissue abuse- complicated by weakened host
response or repair
 Poor nutrition-reduced tissue recovery
- increase in rate of deterioration of
supporting tissues

37. DRUG AND MEDICATION
Local management
 Topical local anesthetic with emolient base.
 Tincture of benzoin-ulcerated area.
 30% trichloro acetic acid- granulation tissue
 Topical steroids-generalized inflammatory
response.
 Warm saline rinse- therapeutic and cost effective

38. PROSTHETIC
MANAGEMENT
PREPROSTHETIC
SURGICAL
MANAGEMENT
PROSTHODONTIC
MANAGEMENT

39. PRE PROSTHETIC SURGICAL
MANAGEMENT
SURGICAL EXCISION/ALTERATION
 Hyperplastic, hypertrophoid and pendulous
tissue.
 Alteration of bony support
 Repositioning of sulci.

40. PROSTHODONTIC
MANAGEMENT
Denture lining materials
 Materials used to refit the surfaces of complete
dentures and help to condition
traumatized/abused tissues, and even provide a
time dependent, simulated cushion like effect.
 The earliest resilient liners were made from
natural rubber
 The first synthetic resin used as a liner is poly
vinyl resin developed in 1945.
 Silicone based resins were introduced in 1958.

41. CLASSIFICATION
DENTURELINING
MATERIALS
SHORT TERM
SOFT
LINERS/TISSUE
CONDITIONERS
LONG TERM
SOFT LINERS

42. Tissue conditioners/Short term
soft liners
 They are soft, resilient, plasticized methacrylate resins
commonly used as temporary liners.
 Tissue conditioners were first described by C.C.
Smith.

43. COMPOSITION
• Polyethyl methacrylate or
related co polymers of ethyl with
methyl and / or isobutyl
methacrylate.
• Pigments
POWDER
• 10 %Ethanol
• 90%Aromatic Pthalate ester -
Plasticizer
• flavoring agents
LIQUID

44. IDEAL REQUIREMENTS
 Flow under constant force
 Resilient at high rates of deformation
 Remain viscous for several days
 Have a high adhesion to aid retention to denture
base.
 Permanent resiliency
 Dimensional stability
 Adherence to denture base
 Color stability
 Biocompatibility

45.  Absence of odor, taste, irritation, toxicity.
 Ease of processing and repair
 Wettability
 Slow fluid absorption
 Abrasion resistance
 Long shelf life
 Economical

46. INDICATIONS
Ridge atrophy/ resorption
Bruxers
Surgery
CONTRAINDICATIONS
Relief areas
Xerostomia
Obturators to enhance retention
Denture opposing natural
dentition

47. USES
 Tissue treatment
 Temporary obturator
 Baseplate stabilization
 To diagnose the outcome of resilient liners
 Liners in surgical splints
 Trial denture base
 Functional impression material

48. PREREQUISITES FOR USE OF
TISSUE CONDITIONERS
 Dentures should have adequate coverage of the
bearing area.
 A good centric relation.
 Adequate occlusal vertical dimension.
 No gross interferences in eccentric jaw positions.

49. TRIMMING
PREPARATION OF DENTURE

50. SUFFICIENT REMOVAL

51. PREPATION OF TISSUE
CONDITIONER
• The Polymer (powder)
• The monomer (liquid)
• A liquid plasticizer (“flow
control”)
-Plastic cup / glass jar
-Steel Spatula
• For conditioning tissues, a
ratio of 1.25 parts of
polymer to 1 part of
monomer with the addition
of approximately ½ cc of
the plasticizer is

54. PLACEMENT OF THE TISSUE
CONDITIONER IN THE MOUTH
Hold in light contact with Even

55. The excess material removed or trimmed away
with a sharp knife, scalpel or scissors.

56. Resultant denture

57. SPECIFIC PATIENT
INSTRUCTIONS
 Patient should be told to return the following day for
inspection and correction of pressure areas.
 This procedure will have to be repeated every 3-4
days until the traumatized and irritated tissues have
fully recovered (as the material will harden with time)
 No hard foods should be consumed the 1st eight
hours following the application of the material.

58. USE AND MISUSE
 As they provide immediate relief and comfort to
the patient, there is a danger that the patient will
wear them too long and so cause trauma to the
supporting tissue thereby producing the very
situation which their use is intended to prevent
or correct

59. ADVANTAGES
 Low solubility in the oral environment.
 No adverse effects on the denture base.
 Relative persistence of softness and resiliency.
 Bonding to the denture base.
 Laboratory and clinical data showing safety and
biologic acceptability.
 Adequate evidence of effectiveness of material as
a resilient reliner.
 Freedom of hazards when material is used
according to the manufacturer’s instructions.

60. DISADVANTAGES
 Low cohesive strength .
 Affected by cleaners.
 Alcohol can sting inflamed mucosa.
 Replacement should occur at frequent intervals.
 High standards of oral hygiene have to be
maintained.
 Antimicrobial medication should be avoided
unless specifically indicated.

61. LONG TERM SOFT LINERS
 They are mostly used as a therapeutic measure
for patients who cannot tolerate the stresses
induced by dentures.
 They usually permit wider dispersion of forces
and impact forces that are involved in both
functional and parafunctional movements.
 This consequently allows the abused denture
bearing tissues to heal completely, increasing
patient comfort and tolerance to prostheses.

62. IDEAL REQUIREMENTS
 Biocompatible.
 Low degradation.
 Good dimensional stability.
 Low water sorption and water solubility.
 Good wettability by saliva.
 Permanent softness/compliance/viscoelasticity.
 Adequate abrasion resistance and tear resistance.
 Good bond to denture base.
 Unaffected to aqueous environment and cleansers.
 Simple to manipulate.
 Color stable and good esthetics.
 Inhibits colonization of fungi and other
microorganisms.

63. INDICATIONS
 Patients with sharp, thin ridges.
 Highly resorbed ridges.
 Patients with sensitivity due to sub mucosal
exposure of inferior alveolar nerve.
 Severe bony undercuts.
 Congenital or acquired defects of the palate.

64. TYPES
LONG TERM
SOFT LINERS
METHACRYLATE
RESINS
HEAT
ACTIVATED
CHEMICALLY
ACTIVATED
SILICONE
RESINS
HEAT
ACTIVATED
CHEMICALLY
ACTIVATED

65. OTHER LESS COMMONLY USED
 Plasticized vinyl polymers and co polymers.
 Hydrophilic polymers.
 Polyphosphazene fluoropolymers.
 Fluoro ethylene.
 Polyvinyl siloxane addition silicones.

66. METHACRYLATE RESIN
HEAT ACTIVATED METHACRYLATE RESIN
 Laboratory processed usually at the time of denture
processing.
 Supplied as preformed sheets or in powder/liquid
form.
 COMPOSITION
 POWDER-poly/ethyl methacrylate
-benzoyl peroxide(initiator)
 LIQUID-Methcrylate monomer (ethyl, n-butyl or 2-
ethoxyetyl methacrylate)
-Phthalate ester (plasticizer)

67.  ADVANTAGES-Exhibits good durable bond
strength .
-good tear strength and abrasion
resistance.
 DISADVANTAGES-Biodegradation in the oral
environment.
-promotes calculus deposition
and food accumulation and undergoes fouling with
micro-organisms.

68. CHEMICALLY ACTIVATED METHACRYLATE
RESIN
 They are chair side liners.
 Chemical composition similar to heat activated.
 Polymerization is initiated by peroxide-tertiary
amine system.

69.  DRAWBACKS-They can be used as only
temporay liners because of their tendency to foul
and de bond from the denture base within a few
weeks.
-Presence of free monomer also
results in inferior mechanical properties and
reduced biocompatibility.

70. SILICON BASED SOFT LINERS
 These materials have gained considerable
success over methacrylate liners mainly because
of their superior resilience and ability to retain
elasticity for longer periods.

71. HEAT ACTIVATED SILICONE LINERS
 Supplied as a single paste system
 COMPOSITION-Dimethyl siloxane(liquid)
-silica(filler)
-benzoyl peroxide(initiator)
 SETTING REACTION-By cross linking reaction
catalysed by heat and peroxide initiator.
 -Usually processed against the methacryate
dough of the new denture.

72. CHEMICALLY ACTIVATED SILICONE
LINERS/ROOM TEMPERATURE VULCANIZED
SILICONES
 Supplied as two component systems, a paste and
liquid.
 Laboratory processed to the fitting surface of the
denture base.
 SETTING REACTION-condensation cross linking
process catalysed by organotin compound.

73.  ADVANTAGES-High resilience and elasticity
-superior flexibility and shock
absorption properties.
 DISADVANTAGES-Intrinsic tendency to lose
adhesion to methacrylate resin base
-Tend to swell or peel off the denture base.
-Tendency to support growth of candida albicans.
-Tendency to reduce the strength of denture base.

74. PROSTHODONTIC MANAGEMENT
IN PATIENTS TO
PREVENTRADIATION INJURIES
Positioning Stents:
 A radiation stent designed to position/shield
tissues during radiotherapy of the head and neck
regions

75. 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 .
 Parotid Stents
A parotid stent contains an alloy that shields
contralateral tissues during unilateral radiotherapy of
the parotid gland or buccal mucosa.

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

77. REVIEW OF LITERATURE
 Correlation between age and gender in
Candida species infections of complete
denture wearers: a retrospective analysis.
Loster JE, Wieczorek A, Loster BW. Clin Interv Aging 2016. 21;11:1707-
1714
AIM:
To evaluate the intensity, genera, and frequency of
yeasts in the oral cavity of complete denture wearers in
terms of subject gender and age.

78.  MATERIALS AND METHODS:
 SAMPLE SIZE-920 patients (307 males and 613 females)
with complete upper dentures
 Divided into four age groups: ≤50 years, 51-60, 61-70, and
>70 years.
 Smears from the palate.
 CONCLUSION:
The genera of Candida species and the frequency of yeast
infection in denture wearers appear to be influenced by both
age and gender. The complete denture wearers ≤50 years of
age appeared to have the greatest proclivity to
oral Candida infections

79.  Prevalence of denture-related oral lesions
among patients attending College of
Dentistry, University of Dammam: A clinico-
pathological study.
Mubarak S, Hmud A, Chandrasekharan S, Ali AA. J Int Soc Prev Community
Dent 2015;5(6):506-12.
 AIM
To determine the exact prevalence of oral lesions among
denture wearers attending the clinics of the College of
Dentistry, University of Dammam.

80.  MATERIALS AND METHODS:
 SAMPLE SIZE- 210 patients, 166 (79%) were males and
44 (21%) were females.
 Comprehensive oral examination was performed for all
patients.
 Any denture-induced lesion was biopsied.
 Data collected were analyzed using SPSS program.
 CONCLUSION:
The prevalence of denture-induced oral lesions was found
to differ significantly from that reported in other studies. The
diversity of these lesions among different studies depends
on the quality and materials of dentures delivered, the
techniques used, and the methods of patients' instructions
adopted.

81.  Effects of a Hydrogel Patch on
Denture‐Related Traumatic Ulcers; an
Exploratory Study
Jivanescu A, Borgnakke WS, Goguta L, Erimescu R, Shapira L, Bratu E. J
Prosthodont 2015 ;24(2):109-14.
 AIM
To evaluate the effects of hydrogel patch wound
dressing on healing time and pain level of
denture‐related lesions of the oral mucosa in
edentulous individuals.

82.  MATERIALS AND METHODS
 23 adults with newly fabricated complete sets of dentures with at
least two ulcerative lesions related to their complete dentures
 Smaller lesion (control lesion) - Usual care, that is(adjustment of
the denture's margins)
 Larger lesion (test lesion) - Usual care plus application of a
hydrogel patch.
 HYDROGEL PATCH-First 24hours-3 times
next 3 days- additional 3 patches
 RESULTS
The participants reported significant improvement in pain level 1
day following treatment initiation for 30% of the control lesions,
compared to 65% of the lesions treated with the hydrogel patch.

83.  Allergic Reactions to Dental Materials-A
Systematic Review
Syed M, Chopra R and Sachdev V. J Clin Diagn Res. 2015 ; 9(10):
ZE04–ZE09.
 AIM
 Develop a systematic approach for the evaluation and monitoring
of the severity of adverse reactions to dental materials available
in the market,
 Give an insight into the diagnosis and management of allergy to
dental materials
 To help dentists become aware of incidence of allergy; thereby
preventing the progression of these allergies by early recognition
and preventive strategies

84.  CONCLUSION
 The most common allergic reactions in dental
staff are allergies to latex, acrylates and
formaldehyde.
 While polymethylmethacrylates and latex trigger
delayed hypersensitivity reactions, sodium
metabisulphite and nickel cause immediate
reactions.
 Over the last few years, due to the rise in number
of patients with allergies from different materials,
the practicing dentists should have knowledge
about documented allergies to known materials
and thus avoid such allergic manifestations in the
dental clinic.

85. 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.

86. REFERENCES
 Zarb G, Hobkirk JA, Eckert SE, Jacob RF.Prosthodontic
treatment for Edentulous patients.13th Edition.
 Winkler S.Essentials of complete denture
prosthodontics.2nd Edition.
 Jainkittivong A, Aneksuk V, Langlais RP. Oral mucosal
lesions in denture wearers. Gerodontology 2010 ;27(1):26-
32.
 Gendreau, L & Loewy Z. G. Epidemiology and Etiology of
Denture Stomatitis. J Prosthodont 2011, 20(4): 251–260.
 Chaturvedi TP. Allergy related to dental implant and its
clinical significance. Clin Cosmet Investig Dent 2013;5:57-
61
 Sarrami, N., Pemberton, M. N., Thornhill, M. H., & Theaker,
E. D. Adverse reactions associated with the use of eugenol
in dentistry. Br Dent J 2002; 193(5), 253–255
 Tomoyasu Y, Mukae K, Suda M, Hayashi T, Ishii M,
Sakaguchi M, Watanabe Y, Jinzenji A, Arai Y, Higuchi H, Maeda
S and Miyawaki T. Allergic Reactions to Local Anesthetics in