The direct sequelae of wearing complete dentures include mucosal reactions like denture stomatitis, candidiasis, angular cheilitis, traumatic ulcers, and flabby ridges. Denture stomatitis is a common inflammation under dentures caused by microbial plaque accumulation and candida species. Candidiasis includes different forms of oral candida infections associated with denture wearing. Angular cheilitis and traumatic ulcers develop from mechanical irritation or nutritional deficiencies. Flabby ridges are caused by excessive bone resorption replacing bone with fibrotic tissue under dentures, compromising denture support. Management focuses on improving denture fit, oral hygiene, and treating underlying causes.

1. SEQUELAE OF WEARING
COMPLETE DENTURE
Presented by,
Aswitha G
2nd year PG
Dept of Prosthodontics

2. CONTENTS
• Introduction
• Interaction between prosthetic materials and oral environment
• Direct sequelae
• Indirect sequelae
• Management
• Combination syndrome
• Conclusion
• References

3. INTRODUCTION
• Placement of removable prosthesis in the oral cavity produces
profound changes of the oral environment that may have an
adverse effect on the integrity of oral mucosa
• Mucosal reactions could result from a mechanical irritation by
the dentures, an accumulation of microbial plaque on dentures or
occasionally a toxic or allergic reaction to denture base material

4. • The continuous wearing of denture have a negative effect on residual ridge form
because of bone resorption
• Furthermore wearing 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

5. INTERACTION OF PROSTHETIC MATERIALS AND ORAL
ENVIRONMENT
• Surface properties of denture base – Irregularities or microporosities – Promote
plaque formation or accumulation on the prosthesis
• Different materials in oral cavity may give rise to electrochemical corrosion
• Galvanic currents is seen in Oral lichen planus & in altered taste perception

6. • Certain micro-organisms(yeast) are able to use methyl methacrylate as a carbon
source thereby causing chemical degradation of denture resin
• Local irritation of mucosa by dentures may increase mucosal permeability to
allergens or microbial antigen thereby capable of eliciting an allergic response

7. SOFT TISSUE CONSIDERATIONS
Injuries to oral tissues occur principally in 3 areas
Tissues that support
and resists stress
Tissues that act to
form a seal with
denture borders
Tissues that contact
the polished surfaces
and the teeth

8. STRESS BEARING MUCOSA
Signs and symptoms of traumatic injury to this area is as follows:
1. Lesions occurring in the mucosa that covers the palate and the crest of
the residual ridges
-Small, well circumscribed and indurated
-The presence of excessive keratin often causes the area to be white

9. 2. Lesions that appear punched out and the surrounding mucosa hyperemic
-Imperfections of denture base
-Trauma from food particles
-An injury produced when the dentures were not in mouth
3.Lesions that are hyperemic and painful to the pressure of closure – pressure
directed towards an area of exostosis – Spur of bone or a foreign body

10. 4. Hyperemic, painful and detached areas of epithelium that develop on the slope of
residual ridges – Occlusal disharmony
5. Severe irritation and detaching of overlying mucosa occurs occasionally over
mylohyoid ridge, cuspid eminences, alveolar tubercles and areas of exostosis
-Denture flanges during insertion or removal of denture or from excessive friction
during function

11. BASAL SEAT MUCOSA
2 problems associated
- Hypertrophy and inflammation
1. Continuous wear of dentures – Generalized hyperemia of crest and slopes of
the ridges accompanied by pain in the muscles attached to mandible, the
production of hyperkeratin
2. Complete denture opposite natural dentition or partial denture causes
localized hyperemia and edema

12. 3. Presence of loosely attached submucosa results in friction of
underlying bone against the undersurface of the mucosa when the
dentures glide on mucosa thereby producing inflammation
4. Poor oral hygiene
5. Allergic reactions to denture base materials

13. TRANSITIONAL MUCOSA
• Hypertrophy occur in area of transitional submucosa such as border extensions
results due to unpolished or sharp borders
• Lesions appear as slit like fissures, varying length and depth, painful and often
become ulcerated

14. Lining mucosa
Abrasions appear on mucosa of cheeks and lips are frequently the result of
1. Cheek biting
2. Rough margins on the teeth
3. Unpolished denture bases

15. Specialized mucosa
Ulcerations and other lesions appearing on the margins and apex of tongue
are results of
1. Tongue biting often caused by improper placement of teeth
2. An unpolished denture base or a too pronounced rugae area
3. Rough margins on teeth

16. SEQUELAE
Direct sequelae
Indirect sequelae

17. DIRECT SEQUELAE
1. Mucosal
reactions
Denture
stomatitis
Candidiasis
Angular
chelitis
Epulis
fissuratum
Traumatic
ulcers
Flabby ridge
Denture
irritation
hyperplasia

18. DIRECT SEQUELAE
2. Oral galvanic currents
3. Altered taste perception
4. Burning mouth syndrome
5. Gagging
6. Residual ridge resorption
7. Periodontal diseases and caries of abutments

19. INDIRECT SEQUELAE
Atrophy of masticatory muscles
Nutritional deficiencies

20. 1.DENTURE STOMATITIS
Mandana Khatibi1, Zohre Amirzadeh2, Majid Sadegh Pour Shahab3, Iraj Heidary 4, Azad Estifaee5, J. Appl. Environ. Biol. Sci., 5(12)284-287, 2015
Denture stomatitis is a generalized inflammation of the area underneath the
denture, usually the palate.
Also called as “denture sore mouth”
It is a common problem found in 30-60% of full denture wearers.
Affects women four times more than men
More likely to be found under the maxillary denture than the mandible.
It can be found under both partial and complete dentures.

21. DENTURE STOMATITIS
NEWTON’S CLASSIFICATION
Type I: Localized simple inflammation or pin point hyperemia
Type II: An erythematous or generalized simple type seen as more diffuse erythema
involving a part or entire denture covered mucosa
Type III: Granular type involving central part of hard palate and alveolar ridges
Mandana Khatibi1, Zohre Amirzadeh2, Majid Sadegh Pour Shahab3, Iraj Heidary 4, Azad Estifaee5, J. Appl. Environ. Biol. Sci., 5(12)284-287, 2015

22. etiology
• Type I – Trauma induced
• Type II & III – Presence of microbial plaque accumulation (bacteria or yeast) on
the fitting denture surface and the underlying mucosa
The direct predisposing factor for candida associated denture stomatitis is presence
of dentures in oral cavity

23. • Kulak Y, Arikan A(1993) found that there was a statistically relationship between
denture stomatitis and denture hygiene, smoking habits, candida formation and
colonization
• It is seen the major part of micro organisms of denture plaque are also involved
• In addition, trauma could stimulate turnover of palatal epithelial cells thereby
reducing the degree of keratinization and barrier function of epithelium thus the
penetration of fungal and bacterial antigens takes place more easily

24. TREATMENT
Pop the denture in a mild hypochlorite solution for up to twenty minutes. This
solution is most effective at killing plaque and cleaning your denture
Leave dentures out at night
An antifungal, such as amphotericin B, nystatin or miconazole can be useful, but it
is important that the underlying causes are treated, or when the drug therapy is
stopped, the denture stomatitis will re-occur.

25. 2.CANDIDIASIS
• 4 fungal organisms – Candida albicans, Candida stellatoidea, Candida tropicalis
and Candida pseudotropicalis
• Candida albicans – Most common
• Morphologically, presents in 3 forms: Yeast cell, hypha and mycelium

26. etiology
Adherence of yeast cells
Interaction with oral commensal bacteria
Surface properties of acrylic resins
Poor oral hygiene
High carbohydrate intake
Reduced salivary flow
Continuous denture wear
Colonization of fitting denture surface by candida species depends on

27. FACTORS INCREASES SUSCEPTIBILITY TO CANDIDA
ASSOCIATED DENTURE STOMATITIS
Aging
Malnutrition
Immunosuppression
Radiation therapy
Diabetes mellitus
Antibiotics

28. Classification of oral candidiasis
Acute pseudomembranous candidiasis (Moniliasis, Thrush)
Acute atrophic candidiasis (Antibiotic sore tongue)
Chronic atrophic candidiasis (Denture stomatitis)
Chronic hyperplastic candidiasis (Candidal leukoplakia, Median rhomboid glossitis)
Angular cheilitis
Chronic mucocutaneous candidiasis

29. Acute pseudomembranous candidiasis (thrush)
Appearance:
 White slightly elevated plaques that can be
wiped away leaving an erythematous base
 Direct smear can be fixed and stained using
PAS reagent to reveal the candida hyphae
microscopically

30. Chronic atrophic candidiasis (denture sore mouth)
• Most common form of oral candidiasis
• Treatment should be directed towards mucosa and denture
Appearance:
 Mucosa beneath denture is erythematous with a well
demarcated border

31. Treatment for dentures
• Improve oral hygiene of appliance
• Keep denture out of mouth for extended periods and while sleeping
• Soak for 30 mins in solutions containing benzoic acid, 0.12% chlorhexidine or 1%
sodium hypochlorite and thoroughly rinse
• Apply a few drops of nystatin oral suspension or a thin film of nystatin ointment
to inner surface of denture after each meal

32. Treatment for candidiasis

33. 3.Angular cheilitis
Etiology:
• Diminished occlusal vertical dimension
• Vitamin B or iron deficiencies
• Superimposed candidiasis
• Affects approximately 6% of general population
Appearance:
Wrinkled and sagging skin at the lip commissures
Desiccation and mucosal cracking
Treatment: To construct new dentures

34. 4.Flabby ridge
• Flabby ridge (mobile or extremely resilient alveolar
ridge) is due to replacement of bone by fibrous tissue
• Seen in anterior part of maxilla, probably sequelae of
excessive load of residual ridge and unstable occlusal
conditions
• Marked fibrosis, inflammation and resorption of
underlying bone is seen
• They provide poor support for denture

35. • To improve stability of denture and minimize ridge resorption, the tissue should be
surgically removed
• In situation of extremely atrophy of maxillary alveolar ridge, flabby ridges should
not be totally removed because the vestibular area would be eliminated

36. 5.Traumatic ulcers
• Develop within 1-2 days after placement of new dentures
• Small painful lesions, covered by a gray necrotic membrane and surrounded by an
inflammatory halo with firm, elevated borders
• Caused due to overextended denture flanges or unbalanced occlusion

37. • Conditions that suppress resistance of mucosa to mechanical irritation are
predisposing factors
Eg: Diabetes mellitus, nutritional deficiency, radiation therapy, xerostomia
• In a non-compromised host, ulcers will heal after correction of dentures
• When left untreated, it subsequently develops into denture irritation hyperplasia

38. 6.Denture irritation hyperplasia
• Common sequelae of wearing ill fitting dentures is
occurrence of tissue hyperplasia of mucosa in contact
with denture border
• Lesions are a result of chronic injury by unstable
dentures or by thin, overextended denture flanges
• Lesions may be single or quite numerous and are
composed of flaps of hyperplastic connective tissue

39. treatment
• Adjustment or replacement of denture
• Surgical excision of hyperplastic tissues

40. 7.clicking
• A clicking noise when teeth contact during functional movements is a result of
insufficient interocclusal distance
• Vertical displacement of mandibular denture

41. treatment
• Correct stability and retention by rebasing or remarking the dentures
• If dentures are not loose, if sufficient interocclusal distance exists and if teeth are
porcelain, replace the porcelain teeth with acrylic resin teeth
• When interocclusal distance is not sufficient, alter the occlusal surfaces of teeth
with remount procedures to provide adequate space

42. 8.Epulis fissuratum
• The hyperplasia occur in and around the borders of a denture may be fibrous
growth referred to as epulis fissuratum
• Etiology – Chronic irritation from ill fitting or over extended denture. Since
residual ridge resorbed even best fitting denture gradually develop over extension
• Site- It occurs in free mucosa lining the sulcus or at junction of attached and free
mucosa

43. • Clinical features – Tissues are usually hyperemic and swollen with slight pain
• Treatment
1. Surgical excision is indicated but only after a period of prescribed tissue rest to
reduce edema
2. Rest to tissue and program of regular and vigorous massage of the site should be
instituted
3. The result is good in 6 weeks and eliminates the need of surgery

44. 9.gagging
• Stimulation of sensitive areas in posterior pharyngeal
wall, soft palate, uvula, fauces or the posterior surface of
tongue results in series of uncoordinated and spasmodic
movements of swallowing muscles
• Treatment
1. Determine the cause
2. Eliminate the biological and mechanical factors that
contribute to the problem
3. Prescribe a combination of hyoscine, hyoscyamine and
atropine with a sedative during initial period of
denture use

45. 10.Burning mouth syndrome
• Characterized by a burning sensation in one or several oral
structures in contact with dentures
• Symptoms often appear for first time in association with
placement of new dentures
• Common sites are tongue and upper denture bearing tissues
• Less common sites are the lips and lower denture bearing
tisssues
• Oral mucosa appears normal

46. causes
• Local factors: Mechanical irritation, allergy due to residual monomer, infection,
oral habits, parafunction and myofascial pain
• Errors in denture design which cause a denture to move excessively over the
mucosa which increase the functional stress on the mucosa or which interfere with
the freedom of movement of the surrounding muscles may initiate a complaint of
burning rather than soreness
• Seen in 50% of BMS patients
Classification
 Type 1 – Symptoms not present upon waking, and then increases throughout the day
 Type 2 – Symptoms upon waking and throughout the day
 Type 3 – No regular pattern of symptoms

47. Systemic
factors
Vitamin
deficiency
Iron
deficiency
anemia
Xerostomia
Menopause
Diabetes
Parkinson’s
disease
Medication
Psychogeni
c factors
Depression
Anxiety
Psychosocial
stressors

48. management
 Management is usually palliative not curative
 Patient education and encouragement, best
approach to improve quality of life
 Adjusting or replacing poorly fitting dentures
 Taking nutritional supplements
 Avoiding tobacco and alcohol
 The drug therapies that have been found to be
the most helpful are low doses of TCAS, such
as Amitriptyline and Doxepin or Clonazepam

49. 11.Residual ridge reSORPtion
• RRR - A term used for the diminishing quantity and quality of the residual ridge after
teeth are removed
• Continuous bone loss after tooth extraction and placement of complete denture is seen
• Reduction is a sequel of alveolar remodeling due to altered function stimulus of bone
tissue
• It is a progressive and irreversible course that results in impairment of prosthesis and oral
function

50. • The process of resorption is important in areas with thin cortical bone (eg. Buccal
and labial plates of maxilla and lingual plate of mandible)
• The annual rate of reduction in height in mandible is about 0.1 – 0.2 and in general
4 times less in edentulous maxilla

51. Classification of residual ridge resorption
According to Branemark et al in 1985, ridges were classified on
the basis of bone quantity and bone quality by radiographic
means
BONE QUANTITY(Branemark)
• Class A: Most of the alveolar bone is present
• Class B: Moderate residual ridge resorption occurs
• Class C: Advance residual resorption occurs
• Class D: Moderate resorption of the basal bone is present
• Class E: Extreme resorption of the basal bone

52. Atwood’s classification
• Order I – Pre-extraction
• Order II – Post-extraction
• Order III – High, well rounded
• Order IV – Knife edged
• Order V – Low, well rounded
• Order VI – Depressed

53. Etiological factors of residual ridge reduction
Prosthodontic factors
• Intensive denture wearing
• Unstable occlusal conditions
• Immediate denture treatment

54. Metabolic and systemic factors
• Osteoporosis
Mechanical factors
• Transmitted by dentures or tongue to the residual ridges results in remodeling
process

55. Consequences of residual ridge reduction
Apparent loss
of sulcus
width and
depth
Displacement
of muscle
attachment
closer to the
crest of
residual ridge
Loss of
vertical
dimension of
occlusion
Reduction of
lower face
height
Anterior
rotation of
mandible

56. treatment
Pre-prosthetic surgery includes the following:
1. Ridge preservation procedure as a preventive measure
2. Corrective or recontouring procedures of the defects and abnormalities
3. Ridge extension procedures
Relative methods Eg. Sulcus extension (vestibuloplasty)
Absolute methods Eg. Ridge augmentation methods

57. 12.Overdenture abutments: caries & periodontal disease
• Wearing of overdentures is often associated with a high risk of caries and
progression of periodontal disease of abutment teeth
• This is due to bacterial colonization, beneath a close fitting denture is enhanced,
and good plaque control of fitting denture surface is difficult to obtain
• Predominant micro organisms are streptococcus, lactobacilli and actinomyces

58. • These species initiate gingivitis after 1-3 days of plaque accumulation when oral
hygiene is discontinued
• Presence of streptococcus mutans and lactobacilli in dental plaque flora in high
proportions results in caries

59. management
• Abstain from wearing dentures in the night
• Application of fluoride- chlorhexidine gel and polishing, mechanical and chemical
plaque control
• Placement of copings that cover the exposed dentin and root surface is indicated
where caries is more deeply penetrating. This is to reduce risk of new or recurrent
caries
• Periodontal pockets greater than 4-5 mm should be surgically eliminated

60. Indirect sequelae:
1.atrophy of masticatory muscles
• Masticatory function depends on the skeletal muscular force and the facility with
which the patient is able to coordinate oral functional movements during
mastication
• In complete denture wearers, particularly in women atrophy of masseter and
medial pterygoid muscle is seen
• The decrease in bite force and chewing efficiency results in impaired masticatory
function

61. Preventive measures & management
• Retention of a small number of teeth used as overdenture abutments helps in
maintenance of oral functions
• In completely edentulous patients, placement of implants is usually followed by an
improvement of masticatory function and an increase of maximal occlusal forces

62. 2.Nutritional status and masticatory functions
4 factors are related to dietary selection and nutritional status of wearers of complete
dentures
1. Masticatory function and oral health
2. General health
3. Socio-economic status
4. Dietary habits

63. management
• Re-education of elderly denture wearers regarding dietary habits
• Replacement of ill fitting dentures
• Mechanical preparation of food before eating will help mastication and reduce its
influence on food selection

64. KELLY’S COMBINATION SYNDROME
• A series of destructive changes occurring in the jaws of the patients wearing a
complete maxillary denture opposed by a mandibular distal extension partial
denture has been described as “Combination Syndrome” by Kelly

65. FEATURES
Loss of bone in anterior maxilla and
subsequent replacement with flabby
fibrous tissue
Down growth of the tuberosities
Papillary hyperplasia of the palate
Lower incisors supra eruption
Bone loss under the removable
prosthesis

66. Saunders et al (1978) added 6 more additional features
Loss of vertical dimension
Occlusal plane discrepancy
Anterior spatial repositioning of
the mandible
Loss of stability and refabrication
of the existing dentures
Epulis fissuratum
Periodontal problems of the
remaining teeth

67. Prevention of combination syndrome
• Avoid combination of complete maxillary dentres opposing class I mandibular
RPD
• Retaining weak posterior teeth as abutments by means of endodontic and
periodontic techniques
• An overdenture on the lower teeth

68. conclusion
• The essential consequences of wearing complete dentures are reduction of residual
ridges and pathological changes of oral mucosa. This results in poor patient
comfort, destabilization of occlusion, insufficient masticatory function and esthetic
problems
• The patient should follow a regular follow-up schedule at yearly interval so that an
acceptable fit and stable occlusion can be maintained

69. references
• Zarb – Bolender: Prosthodontic treatment for edentulous patients, 12th edition
• Arthur.Rahn.O, Charles.Heartwell.M,Jr: Textbook of complete dentures, 5th
edition
• Sheldon Winkler: Essentials of complete denture prosthodontics, 2nd edition
• Basker RM & Davenport JC: Prosthetic treatment of edentulous patients, 4th
edition

70. • Tallegren A: The continuous reduction of the residual alveolar ridges in complete
denture wearers: mixed longitudinal study covering 25yrs, J Prosthet Dent 27:120-
132,1972
• Budtz-Jorgensen E: Oral mucosal lesions associated with wearing of removable
dentures, J Oral Path 10:65-80,1981
• Conny DJ, Tedesco LA: The gagging problem in prosthodontic treatment, Part I:
description & causes, J Prosthet Dent 49:601-606,1983
• Hillerup S: Preprosthetic surgery in the elderly, J prosthet Dent 72:551-558,1994