CD

1. PRESENTED BY
DR.R.PADMINI RANI
P.G TRAINEE
DEPT.OF PROSTHODONTICS
AND CROWN AND BRIDGE

2. 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 .
 It is important to understand the nature of changes to
initiate effective treatment.
 The possible sequelae are divided as
Direct sequelae
Indirect sequelae

4. Direct Sequelae Caused by Wearing
Removable Prostheses
 Mucosal reactions
 Oral galvanic currents
 Altered taste perception
 Burning mouth syndrome
 Gagging
 Residual ridge reduction
 Periodontal disease (abutments)
 Caries (abutments)

5. Denture Stomatitis
 It is the pathological reaction of denture-bearing mucosa.
 Also known as denture induced stomatitis ,denture sore
mouth, denture stomatitis, inflammatory papillary
hyperplasia, or chronic atrophic candidosis.
 In the randomized populations, the prevalence of denture
stomatitis is about 50% among complete denture wearer.
Budtz-Jorgensen E:Oral mucosal lesions assosciated with wearing of removable dentures,J Oral Path
10:65-80,1981.

6. Classification
 According to Newton's classification,
three types of denture stomatitis can
be distinguished.
 Type I - A localized simple
inflammation or pinpoint hyperaemia
 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.

7. Aetiology
 Main cause is presence of denture in oral cavity day and night .
 Type I most often is trauma induced, whereas types II and III most
often are caused by the presence of microbial plaque accumulation on
fitting denture surface.
 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.

8. 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

9. Diagnosis of type III
 Confirmed by finding of mycelia or pseudohyphae in a
direct smear of isolation of candida species in high
numbers(>50 colonies)

10. Management and Preventive Measures
 Initiation of effective oral and denture hygiene
Scrubbing and cleaning of denture with soap after every meal.
Removal of denture at night.
 Correction of ill fitting dentures
Trimming and polishing of trauma causing areas of denture.
Relining with tissue conditioner.
 Surgical treatment
Indicated in type 3 to eliminate crypts.
Cryosurgery preferred.

11.  Antifungal therapy
Treatment with antifungal agents is used in the
following patients
1. In patients after the clinical diagnosis is confirmed by mycological
examination
2. In patients with associated burning sensation of oral mucosa
3. In patients in whom the infection has spread to other sites of oral
cavity or pharynx
4. Patients with increased risk of systemic mycotic infections due to
debilitating diseases,drugs or radiation therapy

12.  Local therapy with nystatin, amphotericin B, miconazole, or
clotrimazole 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 antifungal 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

13. Angular cheilitis
 An inflammation of the corners of the mouth is sometimes seen in
cases of denture stomatitis and then often correlated with a Candida
albicans infection.
 Earlier, it was often believed that a reduced vertical dimension of
occlusion was the most important etiologic factor for angular cheilitis,
but research has shown that general health factors such as nutritional
deficiencies and immune dysfunction seem to be of greater
importance.
 That antimicrobial treatment is often
successful.

14. Flabby ridge
 Mobile /resilient alveolar ridge,
which occurs due to replacement
of bone by fibrous tissue.
 Commonly seen in anterior part of
maxilla.
Etiology
 Excessive load on natural ridge
caused by unstable occlusal
forces from remaining natural
teeth.
Features
 H/E shows marhed fibrosis
,inflammation and resorption of
underlying bone.

15. Management
 Surgical removal is an option
but when severe resorption
exists, it is preserved to
prevent elimination of
vestibular area and thus
providing denture retention.
 Special impression
techniques are indicated
 Hobkirk technique
 Window technique

16. Flabby Ridge as a constituent of
combination syndrome (Kelly 1972)
 Aetiology
When edentulous maxilla is opposed by
natural mandibular teeth.
Due to inadequate posterior occlusion
 Clinical features
Loss of bone in anterior part of maxilla
Overgrowth of tuberosities
 Treatment
surgical excision
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.

17. Denture Irritation Hyperplasia(epulis
fissuratum)
 Aetiology
Due to chronic injury by unstable dentures or
by thin, overextended denture flanges.
 Clinical features
The proliferation of tissue may take place
quickly but symptoms are mild.
Appears as single or multiple folds of
hyperplastic tissue in alveolar vestibule.
Mild to severe ulcerations with deep fissures
Anterior >posterior
Management
Surgical removal of lesion followed by adjustment of old denture.

18. Fibro epithelial polyp
 Leaf- life denture fibroma.
 Irritation/trauma of maxillary
denture.
 Appears as flattened pink mass
attached to palate by peduncle.
 Treatment comprises of
surgical excision of lesion and
relining of ill-fitting denture.

19. Traumatic Ulcers
Sore spots are breach in surface epithelium occour
1-2 days within placement of new dentures.
 Aetiology
Due to overextended denture flanges or
unbalanced occlusion.
Conditions that suppress resistance of mucosa to
mechanical irritation are predisposing factors.
e.g,diabetes mellitus, nutritional deficiences,
radiation therapy or xerostomia.
 Clinical features
Ulcers are small, painful areas covered by gray
necrotic membrane surrounded by
inflammatory halo with firm elevated borders.
Management
Correction of denture problems and symptomatic relief by anaesthetic gels

20. Altered taste perception
 Aetiology
Covering of taste buds in the hard palate by the
dentures.
Ill-fitting dentures cause patient to choose foods which
are easier to masticate
Poor oral and denture hygiene.
Dental diseases, olfactory/neurological deficits and
other systemic disorders.
 Management
Instruction to maintain good hygiene and correction of
defects.

21. Galvanism
 Due to presence of different dental materials (mostly
metals) which cause electrochemical corrosion.
 Bacterial plaque is also a co-factor.
 May be a cause of burning mouth syndrome, lichen
planus and altered taste perception.

22. 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 tissues. Oral
mucosa appears normal.
Aravindhan, R. et al. “Burning Mouth
Syndrome: A Review on Its Diagnostic
and Therapeutic Approach.” Journal of
Pharmacy & Bioallied Sciences 6.Suppl 1
(2014): S21–S25. PMC. Web. 16 Nov. 2017

23. Lamey & Lewis 1989 C/F
Aravindhan, R. et al. “Burning Mouth Syndrome: A Review on Its Diagnostic and Therapeutic
Approach.” Journal of Pharmacy & Bioallied Sciences 6.Suppl 1 (2014): S21–S25. PMC. Web. 16 Nov. 2017.

24. Etiology
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 )

25. Diagnosis
The following steps should be performed
before arriving the diagnosis of BMS
 Taking a thorough and
comprehensive history to
quntify the sensation of pain
 Thorough clinical
examination of the oral
mucosa to rule out local and
systemic causes
 Information on previous or
current psychosocial stressors
and psychological well-being
 Objective measurements of
salivary flow rates and taste
function
 Neurological imaging and
examination to rule out any
pathology and degenerative
disorders
 Oral cultures to confirm
suspected bacterial, viral, and
fungal infections
 Patch test for allergic
individuals
 Gastric reflux studies
 Hematological test to rule out
nutritional, hormonal,
autoimmune conditions.

26. Management
 The symptoms of the patient should not be ignored and
denture should be checked thoroughly for any local causes
and corrected.
 They need to be counselled to help them understand their
problems are benign and dentures are not responsible for
their psychiatric disorders, with subsequent elimination of
fear.
 Any comprehensive treatment may need the involvement
of psychiatrist.

27. 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. This is referred to as gagging.
 Causes
1.Loose dentures
2.Poor occlusion
3.Incorrect extension or contour of dentures particularly in posterior area of
palate and retromylohyoid space.
4. Under extended denture borders.
5. Placing the maxillary teeth too far in a palatal direction and the
mandibular teeth too far in lingual direction so that the dorsum of
tongue is forced into pharynx during the act of swallowing
6.Increased vertical dimension of occlusion
7.Psychogenic factors

28.  Treatment
Determine the cause
Eliminate the biological and mechanical factors that
contribute to the problem.
Prescribe a combination of hyoscine, hyoscyamine and
atropine with a sedative during initial period of
denture use.
Conny DJ,Tedesco LA:The gagging problem in prosthodontic treatment,Part I:description & causes, J
Prosthet Dent 49:601-606,1983.

29. Residual Ridge Resorption
 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.
(GPT 9)
 Resorption is a sequel of alveolar remodeling due to altered functional
stimulus of bone tissue. It is a progressive and irreversible course that
results in impairment of prosthesis and oral function
 The process of resorption is important in areas with thin cortical
bone(e.g 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 four times less in edentulous maxilla.
Tallegren A:The continuing reduction of the residual alveolar ridges in complete denture wearers:mixed longitudinal
study covering 25 yrs,J Prosthet Dent 27:120-132,1972.

30. Etiological Factors of Residual
Ridge resorption
Anatomical Factors
 mandible > maxilla
 Short and square face associated with elevated masticatory forces
 Alveoloplasty
Prosthodontic Factors
 Intensive denture wearing
 Unstable occlusal conditions
 Immediate denture treatment
Metabolic and Systemic Factors
 Osteoporosis
 Calcium and vitamin D supplements for possible bone preservation

31. Classification
According to Atwood’s :
(JPD 1971 Vol.26)
 Order 1 : Pre-extraction
 Order 2 : Post- extraction
 Order 3 : High, well
rounded
 Order 4 : Knife-edge
 Order 5 : Low, well
rounded
 Order 6 : Depressed

32. Consequence of residual ridge resorption
 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
 Increase in relative prognathia.
 Changes in interalveolar ridge relationship after progression of residual
ridge reduction
 Morphological changes of alveolar bone such as sharp,spiny, uneven
residual ridges and location of mental foramen to the top of residual ridge

33. Treatment and prevention
 “Treatment of RRR is ideally by preventing it.” Prevention of loss
of natural teeth
 Proper design of dentures and maintaining it Optimal tissue
health prior to making impression.
 Impression procedures
Selective pressure impression technique: places stress on those areas
that best resist functional forces
Adequate relief of non stress bearing areas eg. Crest of mandibular ridge.
Broad area of coverage helps in reducing the force /unit area (Snow Shoe
Effect)

34.  Avoidance of inclined planes to minimize dislodgment of dentures
and shear forces.
 Centralization of occlusal contacts to increase stability and maximize
compressive forces.
 Provision of adequate tongue room to improve stability of denture in
speech and mastication.
 Adequate interocclusal distance during jaw rest to decrease the
frequency and duration of tooth contact.
 Occlusal table should be narrow.
 The concept and arrangement of teeth in neutral zone helps the teeth
to occupy a space determined by the functional balance of the oro-
facial and tongue musculature.

35.  Nutrition
Diet counseling for prosthodontic patients is necessary to correct
imbalances in nutrient intake.
 Pre prosthetic surgery
Inferior Border Augmentation , Superior Border Augmentation ,
Interpositional Grafts.
 Immediate denture
Extraction followed by immediate dentures reduces the ridge resorption.

36.  Osseointegration and implant supported overdenture or tooth
supported overdenture
Over dentures help in improved stress distribution there by maintaining
the integrity of residual ridge.
The occlusal and parafunctional stresses are distributed through the
abutment teeth/implant .

37. Overdenture abutments:caries and
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 and
predominant micro organisms are streptococcus,lactobacilli and
actinomyces.

38. Management
 Abstain from wearing dentures in the night.
 Application of flouride-chlorhexidine gel and polishing, mechanical &
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

40. Atrophy of Masticatory Muscles
 Masticatory function depends on skeletal muscle force and
coordination of oral functional movements by patients.
 Bite force decreases with age especially in women.
 CD patients require seven times more chewing strokes than persons
with natural dentition to achieve similar reduction in particle size

41. 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.
 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.

42. Nutritional status and masticatory
function
Four 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

43. Management
1. Re-education of elderly denture wearers regarding
dietary habits.
2. Replacement of ill-fitting dentures.
3. Mechanical preparation of food before eating will
help mastication and reduce its influence on food
selection

44. Role of nutrition in healthy ageing
 The goal of healthy aging is not only to increase years of life but
also, and importantly, to extend healthy active years.
 Older adults have unique nutrient needs. This was reflected in
the most recent revision of the recommended dietary allowances
(RDA), now termed dietary reference intakes (DRI)
 For the first time, the “greater than age 50 y” category was
subdivided into , 51–70, and >70 years
 Nonetheless, vitamin and mineral needs either remain constant
or increase
 The 2015 Dietary Guidelines Advisory Committee Scientific Report: Development and Major
Conclusions. Millen BE, Abrams S, Adams-Campbell L, Anderson CA, Brenna JT, Campbell WW, Clinton S,
Hu F, Nelson M, Neuhouser ML, Perez-Escamilla R, Siega-Riz AM, Story M, Lichtenstein AH. Adv Nutr. 2016
May 16

45. Changing family dynamics means that older adults have less support,
while facing substantial challenges in obtaining recommended
nutrient-dense diets, because many experience
1. changes in taste and smell ,
2. loss of appetite,
3. dental and chewing problems
4. limitations in mobility and access to high-quality fresh food .
 The >70-y-old group can be vulnerable to compromised nutrient
status. Food intake tends to decrease with advancing age to
compensate for the diminished energy needs associated with lower
energy expended in physical activity and basal metabolic rate
 Aging-related inefficiencies in absorption and utilization mean that
the requirement for some essential nutrients increases, despite lower
energy needs .

46.  “Shortfall nutrients” as per 2015 Dietary Guidelines report include
calcium, vitamin D, dietary fiber, and potassium, with protein noted as
a nutrients of concern.
 Commonly used medications for chronic conditions can alter nutrient
requirements by interacting in ways that may affect absorption or
metabolism.
 For example, long-term use of acid-blocking medications may
contribute to the development of vitamin B-12 deficiency
 Tucker KL. High risk nutrients in the aging population. In: Bales C, Locher J, Saltzman, editors. Handbook of clinical
nutrition and aging. 3rd ed. New York: Springer; 2015. p. 335–53.
 Millen BE, Abrams S, Adams-Campbell L, Anderson CA, Brenna JT, Campbell WW, Clinton S, Hu F, Nelson M,
Neuhouser ML, et al. The 2015 Dietary Guidelines Advisory Committee scientific report: development and major
conclusions. Adv Nutr 2016;7:438–44.
 Chan L-N. Drug-nutrient interactions. JPEN J Parenter Enteral Nutr 2013;37:450–9.

47.  Although supplements are useful in the face of inadequate intakes of
some nutrients, the promotion of food-based approaches to meeting
nutrient requirements is needed as a first approach.
 A Mediterranean style diet that is high in fruit and vegetables and
adequate dietary protein, also may support lean body mass
maintenance.
 More than 8 glasses of water prevents constipation and dehydration.
 Intakes of specific micronutrients is required for optimal immune
function and resistance to infection

48. Alice H. Lichtenstein et al. J. Nutr. 2008;138:5-11
©2008 by American Society for Nutrition

51.  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.

52.  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 implant-
supported prosthesis .In young patients, the primary advantage would
be reduced residual ridge reduction.

53. The following precautions should be taken to preclude
development of soft tissue disease:
 Patients should follow program of recall and maintenance for
continuous monitoring of the denture and the oral tissues.
 If patient compliance is difficult it is necessary to see the patient every
3 to 4 months.
 The patient should be motivated to practice proper denture wearing
habits such as not wearing dentures during the night.

54. Summary
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 complete dentures

55. 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
patient, 4th edition.
 Tallegren A:The continuing reduction of the residual alveolar ridges in
complete denture wearers:mixed longitudinal study covering 25 yrs,J
Prosthet Dent 27:120-132,1972
 Budtz-Jorgensen E:Oral mucosal lesions assosciated 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.
 Aravindhan, R. et al. “Burning Mouth Syndrome: A Review on Its
Diagnostic and Therapeutic Approach.” Journal of Pharmacy &
Bioallied Sciences 6.Suppl 1 (2014): S21–S25. PMC. Web. 16 Nov. 2017.