Sequelae of wearing/ Labial orthodontics

Sequelae Caused
by Wearing
Complete
Dentures
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com
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THE DENTURE IN THE ORAL
ENVIRONMENT Placement of a removable
prosthesis in the oral cavity produces profound
changes of the oral environment that may have
an adverse effect on the integrity of the oral
tissues .Mucosal reactions could result from a
mechanical irritation by the dentures, an
accumulation of microbial plaque on the dentures,
or occasionally, a toxic or allergic reaction to
constituents of the denture material. The
continuous wearing of dentures may have a
negative effect on residual ridge form because of
bone resorption.

Direct Sequelae Caused by
Wearing Removable
Prostheses: Complete or
Partial Dentures
• Mucosal reactions
• Oral galvanic currents
• Altered taste perception
• Burning mouth syndrome
• Gagging
• Residual ridge reduction
• Periodontal disease (abutments)
• Caries (abutments)www.indiandentalacademy.comwww.indiandentalacademy.com

Furthermore, wearing complete dentures that
function poorly and that impair masticatory
function could be a negative factor with regard to
maintenance of adequate muscle function and
nutritional status, particularly in older
persons.There are several aspects of the
interaction between the prosthesis and the oral
environment.Surface properties of the prosthetic
material may affect plaque formation on the
prosthesis; however the original surface
chemistry of the prosthetic material is modified
by the acquired pellicle and thus is of minor
importance for the establishment of plaque .

On the contrary, surface irregularities or
microporosities greatly promote plaque
accumulation by enhancing the surface area
exposed to microbial colonization and by
enhancing the attachment of plaque.
Furthermore, plaque formation is greatly
influenced by environmental conditions such
as the design of the prosthesis, health of
adjacent
mucosa, composition of saliva, salivary
secretion rate, oral hygiene, and denture-
wearing habits of the patient.

The presence of different types of dental materials
in the oral cavity may give rise to elec
trochemical corrosion, but changes in the oral
environment due to bacterial plaque may consti
tute an important cofactor in this process.
Corrosive galvanic currents have been
implicated in the burning mouth syndrome
(BMS), oral lichen planus, and altered taste
perception. Most often it is difficult to establish a
definite causal relationship because mechanical
irritation or infection may also be involved. For
instance, local irritation of the mucosa by the
dentures may increase mucosal permeability to
allergens or microbial antigens.

This makes it difficult to distinguish between a
simple irritation and an allergic reaction against
the prosthetic material, microbial antigens, or
agents absorbed to the prosthesis capable of
eliciting an allergic response. The matter is
further complicated by the fact that certain
microorganisms (e.g., yeasts) are able to use
methylmethacrylate as a carbon source,
thereby causing a chemical degradation of the
denture resin.

DIRECT SEQUELAE CAUSED BY
WEARING DENTURES
Denture Stomatitis
The pathological reactions of the denture-bearing
palatal mucosa appear under several titles and
terms such as denture-induced stomatitis. denture
sore mouth. denture stomatitis, inflammatory
papillary hyperplasia, and chronic atrophic
candidosis. In the following sections, the term
denture stomatitis will be used with the prefix
Candida-associated if the yeast Candida is
involved. In the randomized populations, the
prevalence of denture stomatitis is about 50%
among complete denture wearer.www.indiandentalacademy.comwww.indiandentalacademy.com

Classification According to Newton's
classification, three types of denture
stomatitis can be distinguished. Type I A
localized simple inflammation or pinpoint
hyperemia .Type II An erythematous or
generalized simple type seen as more diffuse
erythema involving a part or the entire
denture-covered mucosa .Type III A
granular type (inflammatory papillary
hyperplasia) commonly involving the central
part of the hard palate and the alveolar
ridges.

Type III often is seen in
association with type I or type II
Strains of the genus Candida, in
particular Candida albicans, may
cause denture stomatitis. Still,
this condition is not a specific
disease entity because other
causal factors exist such as
bacterial infection, mechanical
irritation, or allergy. Type I most
often is trauma induced,
whereas types II andIII most
often are caused by the
presence of microbial plaque
accumulation on fitting denture
surface www.indiandentalacademy.comwww.indiandentalacademy.com

Factors Predisposing to Candida-
Associated Denture Stomatitis
Systemic Factors
Old age
Diabetes mellitus
Nutritional deficiencies (iron, folate, or
vitaminB12
Malignancies (acute leukemia,
agranulocytosis)
Immune defects
Corticosteroids, immunosuppressive drugs

Local Factors
Dentures (changes in environmental
conditions, trauma, denture usage, denture
cleanliness)
xerostomia (Sjogren's syndrome,
irradiation,drug therapy)
High-carbohydrate diet
Broad-spectrum antibiotics
Smoking tobacco

Management and Preventive Measures
Because of the diverse possible origins of denture
stomatitis, several treatment procedures could be
used, including antifungal therapy, correction of ill-
fitting dentures, and efficient plaque control.The
patient should be instructed to remove the
dentures after the meal and scrub them vigorously
with soap before reinserting them. The mucosa in
contact with the denture should be kept clean and
massaged with a soft toothbrush.

Patients with recurrent infections should be
persuaded not to use their dentures at night but
rather leave them exposed to air, which seems to
be a safe and efficient means of preventing
microbial colonization.. Rough areas on the fitting
surface should be smoothed or relined with a soft
tissue conditioner. About 1 mm of the internal
surface being penetrated by microorganisms
should be removed and relined frequently. A new
denture should be provided only when the mucosa
has healed and the patient is able to achieve good
denture hygiene.

Local therapy with nystatin, amphotericin B,
miconazole, or clotrinlazole should be preferred to
systemic therapy with ketoconazole or fluconazole
because resistance of Candida species to the latter
drugs occurs regularly. For a reduction in the risk of
relapse, the following precautions should be taken
:1. Treatment with antifungals should continue for
4 weeks 2. When lozenges are prescribed,
the patient should be instructed to take out the
dentures during sucking.3. The patient should be
instructed in meticulous oral and denture hygiene;
the patient should be told to wear the dentures as
seldom as possible and to keep them dry or in a
disinfectant solution of 0.2% to 2.0% chlorhexidine
during nights

Flabby RidgeFlabby Ridge (i.e., mobile or extremely resilient
alveolar ridge) is due to replacement of bone by
fibrous tissue. It is seen most commonly in the
anterior part of the maxilla, particularly when there
are remaining anterior teeth in the mandible, and is
probably a sequela of excessive load of the
residual ridge and unstable occlusal conditions
.Results of histological and histochemical studies
have shown marked fibrosis, inflammation, and
resorption of the underlying bone.

However, in a situation with extreme atrophy of the
maxillary alveolar ridge, flabby ridges should not be
totally removed because the vestibular area would
be eliminated. Indeed the resilient ridge may
provide some retention for the denture.

REDUNDANT TISSUEREDUNDANT TISSUE. (SHELDON WRINKLER)
The forces of the mandibular teeth on the maxilla
cause an excessive resorption of the anterior
aspect of the maxilla and the mandibular teeth
supererupt. The tissue in this region becomes
hyperplastic and may form an epulis fissuratum in
the anterior maxillary fold. As the anterior aspect of
the maxilla resorbs, there is a concurrent resorption
of bone under the mandibular partial denture base.
The occlusal plane drops posteriorly and rises
anteriorly.

Denture Irritation Hyperplasia
A common sequela of wearing ill-fitting
dentures is the occurrence of tissue hyperplasia of
the mucosa in contact with the denture border. The
lesions are the result of chronic injury by unstable
dentures or by thin, overextended denture flanges.
The proliferation of tissue may take place relatively
quickly after placement of new dentures and is
normally not associated with marked symptoms.
The lesions may be single or quite numerous and
are composed of flaps of hyperplastic connective
tissue. If lymphadenopathy is present, the denture
irritation hyperplasia may simulate a neoplastic
process

Hyperplastic tissue. (SHELDON WRINKLER)
Often hyperplastic tissue is present under
an ill filling denture which may be hyperplasia or
hyper plastic folds under the denture base .
When this situation occurs the patient
should be instructed to rest the tissue by not
wearing the denture. Proper oral hygiene and
tissue massage will also improve the condition.
The existing denture should be refitted with a
tissue or temporary reline material. If marked
improvement does not occur surgical correction
will be needed.

Papillary Hyperplasia (Heart well)
Papillary hyperplasia develops in the palatal vault
as multiple papillary projections of the epithelium in
response to local irritation, poor oral hygiene, and
low-grade infections such as Monilia. The polypoid
masses are usually intensely red, soft, and freely
movable.Histologically, the surface epithelium is
hyperplastic with fibrous hyperplasia and in
flammatory cell infiltration of the underlying
connective tissue. Biopsy usually confirms papillary
hyperplasia, but some specimens show
pseudoepitheliomatous hyperplasia or dyskeratosis
of the surface epithelium.

Traumatic UlcersTraumatic Ulcers
Traumatic ulcers or sore spots most commonly
develop within 1 to 2 days after placement of new
dentures. The ulcers are small and painful lesions,
covered by a gray necrotic membrane and sur
rounded by an inflammatory halo with fine, elevated
borders .The direct cause is usually overextended
denture flanges or unbalanced occlusion. Conditions
that suppress resistance of the mucosa to
mechanical irritation are predisposing (e.g., diabetes
mellitus, nutritional deficiencies, radiation therapy, or
xerostomia). In the systemically noncompromised
host, sore spots will heal a few days after correction
of the dentures.

Oral Cancer in Denture Wearers An
association between oral carcinoma and chronic
irritation of the mucosa by the dentures has often
been claimed, but no definite proof seems to
exist .Case reports have detailed the development
of oral carcinomas in patients who wear illfitting
dentures. However, most oral cancers do develop
in partially or totally edentulous patients. The
reasons appear to include an association withmore
heavy alcohol and tobacco use, less education,
and lower socioeconomic status, which predispose
to oral cancer as well as to poor dental health,
including tooth extraction and denture wearing.

This underlines the necessity of strict and regular
recall visits at 6-month to 1-year intervals for
comprehensive oral examinations. The opinion is
still valid that if a sore spot does not heal after
correction of the denture, malignancy should be
suspected. Patients with such cases and clinically
aberrant manifestations of denture irritation
hyperplasia should be referred immediately to a
pathologist. It should be recognized that the
prognosis is poor for oral carcinoma,especially for
those in the floor of the mouth.

Guggenheimer et al (1994) studied and
concluded that majority of oral cancers are likely
to develop in partially or total edentulous
patient.It has been shown that periodic oral
examination can detect these tumour earlier than
when patient return only because of symptoms
which will result in unfavorable prognosis.Dentist
should encourage partially and toatally
edentulous patient to return for recall visit at 6
month or 1 year. These could reveal larger
proportion of localized malignancies and
premalignant lesion as well.It is no less important
to recall edentulous paatient regularly to asses
their oral tissues for the presence of disease than
to recall dentate persons for evaluation of their
dentate and periodontal health.www.indiandentalacademy.comwww.indiandentalacademy.com

BURNING MOUTH SYNDROME
BMS could be a sequalae of denture wearing
and is characterized by a burning sensation in
one or several oral structures in contact with
the dentures. It is relevant to differentiate
between burning mouth sensations and BMS.
In the former group, the patient's oral mucosae
are often inflamed because of mechanical
irritation, infection, or an allergic reaction. In
patients with BMS, the oral mucosa usually
appears clinically healthy. The vast majority of
those patients affected by BMS is older than
50 years of age, is female, and wears
complete dentures .

(SHELDON WRINKLER)
A vague burning sensation or pain under an
apparently well-fitting denture with the complete
absence of any detectable lesions is a common
complaint of the geriatric patient. A burning
tongue is also frequently brought to the attention
of the dentist. These symptoms may be
associated with complete or partial dentures but
are sometimes experienced when no prosthetic
replacements are in use. If dentures are used,
simply requesting the patient to leave them out for
a period of time to see if the sensation dis
appears will determine whether they are at fault.
Determining the exact etiology and treatment is
often difficult and may require the cooperation of
the patient's physician and possibly psychiatric

Burning Mouth Syndrome
Local Factors
Mechanical irritation
Allergy Infection
Oral habits and parafunctions
Myofascial pain
Systemic Factors
Vitamin deficiency
Iron deficiency anemia Xerostomia
Menopause
Diabetes
Parkinson's disease
Medication
Psychogenic Factors
Depression
Anxiety
Psychosocial stressorswww.indiandentalacademy.comwww.indiandentalacademy.com

Management
In denture wearers in whom no organic basis for
the complaints is identified, the approach of the
prosthodontist should be very careful. The
situation may be further complicated by the fact
that the patients often claim that their psychiatric
disorders are due to the poor dentures and the
inadequate prosthetic treatment they have
received. The patient's symptoms should always
be taken seriously, but any comprehensive
prosthetic treatment, including treatment with
implant-supported overdentures, should be carried
out only as a collaborative effort of psychiatrist
and prosthodontist.

Gagging The gag reflex is a normal,
healthy defense mechanism. Its function is to
prevent foreign bodies from entering the trachea.
Gagging can be triggered by tactile stimulation of
the soft palate, the posterior part of the tongue,
and the fauces. In sensitive patients, the gag
reflex is easily released after placement of new
dentures, but it usually disappears in a few days
as the patient adapts to the dentures. Persistent
complaints of gagging may be due to
overextended borders (especially the posterior
part of the maxillary denture and the distolingual
part of the mandibular denture) or poor retention
of the maxillary denture.www.indiandentalacademy.comwww.indiandentalacademy.com

However, the condition is often due to unstable
occlusal conditions or increased vertical
dimension of occlusion because the unbalanced or
frequent occlusal contacts may prevent adapta
tion and trigger gagging reflexes.
(Heart well)
Patients who develop a gagging or vomiting
problem with dentures are frequently difficult to
treat, and the difficulty is primarily one of
determining the cause. Some patients have a
hypersensitive gagging reflex evident prior to and
during the denture construction. The insertion or
removal of complete dentures may elicit gagging.
However, occasionally a patient develops a
gagging problem after denture insertion.www.indiandentalacademy.comwww.indiandentalacademy.com

Residual Ridge Reduction Longitudinal studies
of the form and weight of the edentulous residual
ridge in wearers of complete dentures have
demonstrated a continuous loss of bone tissue
after tooth extraction and placement of complete
dentures. The reduction is a sequel of alveolar
remodeling due to altered functional stimulus of
the bone tissue. The process of remodeling is
particularly important in areas with thin cortical
bone (e.g., the buccal and labial parts of the
maxilla and the lingual parts of the mandible).
During the first year after tooth extraction, the
reduction of the residual ridge height in the
midsagittal plane is about 2 to 3 mm for the maxilla
and 4 to 5 mm for the mandible.

Jahangiri et al (1998) describes the clinical feature
of residual ridges.
• definition- continuous size reduction of the
residual ridge ,largely due to bone loss after tooth
extraction.
• General feature: RRR is chronic progressive
,and irreversible.
•The rate is fastest in first six month of extraction.
•Rate is variable between different persons ,within
the same person at different times, within same
person at different sites.
•Has a multifactorial cause
• anatomoc factor,prosthetic factor,metabolic and
systemic factor,fundamental factor.

Some Proposed Etiological Factors of
Reduction of Residual Ridges
Anatomical Factors
1 More important in the mandible versus the
maxilla
2 Short and square face associated with
elevated masticatory forces
3 Alveoloplasty
Prosthodontic Factors
Intensive denture wearing
Unstable occlusal conditions
Immediate denture treatment
Metabolic and Systemic Factors
Osteoporosis .
Calcium and vitamin D supplements for possi
ble bone preservationwww.indiandentalacademy.comwww.indiandentalacademy.com

Overdenture Abutments: Caries and Periodontal
Disease The retention of selected teeth to serve
as abutments under complete dentures is an
excellent prosthodontic technique. In this simple
method, a few teeth in a strategically good
position are preserved and are treated
endodontically before the crown is modified. The
exposed root surface and canal are filled with
amalgam or a composite restoration. In this way,
even periodontally affected teeth can be
maintained for several years in a relatively simple
way.Overdenture treatment does not necessarily
increase the risk of technical failures such as den
ture fractures or loss of denture teeth.

However, the wearing of overdentures is often
associated with a high risk of caries and
progression of periodontal disease of the
abutment teeth. One of the reasons for this is
that the bacterial colonization beneath a close-
fitting denture is enhanced, and good plaque
control of the fitting denture surface is generally
difficult to obtain. One reason is that the species
of Streptococcus and Actinomyces
predominating in denture plaque are well known
for their major contributions to dental plaque on
smooth enamel surfaces, as well as on root
cementum.. This could explain why it is difficult
to maintain healthy periodontal conditions
adjacent to overdenture abutments.

Use of the fluoride-chlorhexidine gel controlled
caries development and maintained healthy
periodontal conditions.The introduction of adequate
denture-wearing habits (e.g., to abstain from
wearing the denture during the night) is another
efficient way to control caries and development of
periodontal disease in overdenture
wearers.Treatment of superficial caries of the
overdenture abutments includes application of
fluoridechlorhexidine gel and polishing, and not
exclusive placement of fillings, which could result in
recurrent caries.

INDIRECT SEQUELAE
Atrophy of Masticatory Muscles
It is essential that the oral function in complete
denture wearers is maintained throughout life.
The masticatory function depends on the skeletal
muscular force and the facility with which the
patient is able to coordinate oral functional
movements during mastication. Maximal bite
forces tend to decrease in older patients.
Furthermore, computed tomography studies of
the masseter and the medial pterygoid muscles
have demonstrated a greater atrophy in
complete-denture wearers, particularly in women.

Indeed, elderly denture wearers often find that
their chewing ability is insufficient and that they are
obliged to eat soft foods.
Diagnosis 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 subjects
wearing complete dentures. 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 an equivalent reduction
in particle size. As a consequence,
completedenture wearers prefer food that is easy
to chew, or they swallow large food particles.www.indiandentalacademy.comwww.indiandentalacademy.com

Preventive Measures and Management To
some extent, the retention of a small number of
teeth used as overdenture abutments seems to
play an important role in the maintenance of oral
function in elderly denture wearers. Therefore
treatment with overdentures has particular
relevance in view of the increasing numbers of
older people who are retaining a part of their
natural dentition later in life.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. There is is no evidence of a
similar benefit after a preprosthetic surgical
intervention to improve the anatomical conditions
for wearing complete dentures.

Nutritional DefiNutritional Deficienciesciencies
Epidemiology
Aging is often associated with a significant
decrease in energy needs as a consequence of a
decline in muscle mass and decreased physical
activity. Thus a 30% reduction in energy needs
should be and usually is accompanied by a 30%
reduction of food intake. However, with the
exception of carbohydrates, the requirement for
virtually all other nutrients does not decline
significantly with age. As a consequence, the
dietary intake by elderly individuals frequently
reveals evidence of deficiencies, which is clearly
related to the dental or prosthetic status.www.indiandentalacademy.comwww.indiandentalacademy.com

Masticatory Ability and Performance
One of the strong indications for prosthodontic
treatment is to improve masticatory function. In
this context, the term masticatory ability is used
for an individual's own assessment of his or her
masticatory function, whereas efficiency is to be
understood as the capacity to reduce food during
mastication. There is no striking evidence that
malnutrition could be a direct sequelae of wearing
dentures. However, edentulous women have a
higher intake of fat and a higher consumption of
coffee and a lower intake of ascorbic acid
compared with dentate subjects within the same
age group.

Nutritional Status and Masticatory
Function Four factors are related to dietary
selection and the nutritional status of wearers of
complete dentures: masticatory function and oral
health, general health, socioeconomic status,
and dietary habits. In healthy individuals there is
no evidence that the nutritional intake is impaired
in wearers of complete dentures or that
replacement of ill-fitting dentures with well-fitting
new dentures will causea major improvement .
Also, reduced salivary secretion rate during
mastication has a negative effect on masticatory
ability and efficiency

CONTROL OF SEQUELAE WITH THE USE
OF COMPLETE DENTURES
The essential consequences of wearing
complete dentures are reduction of the
residual ridges and pathological changes of
the oral mucosa. This often results in poor
patient comfort, destabilization of the
occlusion, insufficient masticatory function,
and esthetic problems. Ultimately, the patient
may not be able to wear dentures and will
receive a diagnosis of prosthetically
maladaptive. For the adverse sequelae of
residual ridge resorption to be reduced, the
following should be considered:www.indiandentalacademy.comwww.indiandentalacademy.com

1.Restoration of the partially edentulous patient
with complete dentures should be considered if
this is the only alternative as a result of poor
periodontal health, unfavorable location of the
remaining teeth, and economic limitations. In
this situation, every effort should be made to
retain some teeth in strategically good
positions to serve as overdenture abutments.
The maintenance of tooth roots in the mandible
is particularly important.
2. The patient with complete dentures should
follow a regular control schedule at yearly
intervals so that an acceptable fit and stable
occlusal condition can be maintained.www.indiandentalacademy.comwww.indiandentalacademy.com

3. Edentulous patients should be aware of the
benefits of an implant-supported prosthesis In
young patients, the primary advantage would
be reduced residual ridge reduction. In elderly
patients, the main advantages are improved
comfort and maintenance of masticatory
function.
The following precautions should be taken to
preclude development of soft tissue disease:1.
Patients wearing overdentures supported by
natural roots or implants should follow a
program of recall and maintenance for
continuous monitoring of the denture and the
oral tissues. www.indiandentalacademy.comwww.indiandentalacademy.com

If patient compliance is difficult to obtain, this
might indicate that it is necessary to see the
patient every 3 to 4 months.
2. The patient should be motivated to practice
proper denturewearing habits such as not
wearing dentures during the night.Finally, it is
important to remind and to explain to our patients
that treatment with complete dentures is not a
"definitive" treatment and that their collaboration
is important to prevent the long-term risks
associated with the consequences of wearing
comlete dentures.

Thank you
For more details please visit
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Sequelae of wearing/ Labial orthodontics

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Sequelae of wearing/ Labial orthodontics