SEQUELAE CAUSED BY

WEARING COMPLETE
DENTURES
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)
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.
Classifications
• 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.
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 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 TISSUE 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.
• 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 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 inflammatory 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 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 surrounded 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.
• 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. 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 disappears 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 stressors
• 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. 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 adaptation and trigger gagging reflexes. 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.
• 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.
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.
• 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 Deficiencies 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.
• 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: 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. Edentulous patients
should be aware of the benefits of an implantsupported 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. If patient compliance is difficult to obtain, this might indicate
that it is necessary to see the patient every3to4months. 2. The
patient should be motivated to practice proper denture wearing
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.