Sequelae Caused by Wearing Complete Dentures
SEQUELAE CAUSED BY WEARING
COMPLETE DENTURES
CONTENTS
•
INTRODUCTION
•
ETIOLOGY
•
TYPES OF SEQUELAE
•
DENTURE STOMATITIS
•
ANGULAR CHELITIS
•
FLABBY RIDGE
•
TRAUMATIC ULCERS OR SORE SPOTS
•
DENTURE IRRITATION HYPERPLASIA
•
BURNING MOUTH SYNDROME
•
GAGGING
•
RESIDUAL RIDGE REDUCTION
•
OVER DENTURE ABUTMENTS: CARIES AND
PERIODONTAL DISEASE
•
ATROPHY OF MASTICATORY MUSCLES
•
NUTRITIONAL DEFICIENCIES
•
GENERAL PRECAUTIONS TO PREVENT SEQUELAE
•
CONCLUSION
INTRODUCTION
What is Sequelae ?
•
An after effect of a disease, condition or injury.
•
It is a secondary result.
INTRODUCTION
•
Denture use is not free of trouble.
It can produce severe side effects which if left
untreated will produce:
1.Destabilization of occlusion
2.Loss of retention
3.Decresed masticatory function
4.Poor esthetics
5.Increased ridge resorption and tissue injury
INTRODUCTION
•
All these disorders produced or accelerated in
oral tissues due to presence of denture are
grouped as “SEQUELAE OF WEARING
COMPLETE DENTURE”.
•
These problems progress to stage where
patient is considered “PROSTHETICALLY
MALADAPTIVE” and hence cannot wear
dentures.
ETIOLOGY
DENTURES CAN CAUSE?
TYPES OF SEQUELAE
TYPES OF SEQUELAE
DENTURE STOMATITIS
•
The word” stomatitis”
means inflammation of
oral mucosa.
•
Denture stomatitis is a
term used to indicate an
inflammatory state of
denture bearing mucosa.
•
Other names are Denture
induced stomatitis,
Inflammatory papillary
hyperplasia and chronic
atrophic candidiasis.
CLASSIFICATION
DENTURE STOMATITIS
DENTURE STOMATITIS
CAUSES
CANDIDA
ASSOCIAED
TYPES 1,2 AND 3
CANDIDA
ASSOCIATED
DENTURE
STOMATITIS AND
ANGULAR
CHELITIS
STAINS OF GENUS
CANDIDA ,PARTICULRLY
CANDIDA ALBICANS
TRAUMA INDUCED ,
CAUSED BY MICROBIAL
PLAQUE ACCUMULATION
ANGULAR CHELITIS OR
GLOSSITIS DUE TO
INFECTIONFROM
DENTURE COVERED
MUCOSA TO ANGLES OF
MOUTH OR TONGUE.
DENTURE STOMATITIS
DIAGNOSIS
:
The diagnosis of Candida associated denture stomatitis is confirmed by
finding of mycelia or pseudohyphae in a direct smear ,or by isolation of
Candida species in high numbers from the lesion .
Yeasts are recovered in high numbers from fitting surface of dentures
than from corresponding areas of palatal mucosa which indicates that
Candida residing on fitting surface of denture is primary source of
infection.
Candidal growth has been associated with mandibular dentures relined
with soft liner.
•
The most commonly detected yeasts were strains of the genus Candida, in
paticular
C. albicans, C. glabrata and C. tropicali
MANAGEMENT
•
If fungal organism is present:
ANGULAR CHELITIS
•
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.
•
It is thought that infection may start
beneath the maxillary denture and from
that area spread to corners of mouth.
•
However this infection often results
from local or systemic predisposing
conditions such as over closure of jaws ,
general health factors such as
nutritional deficiencies and immune
dysfunction.
FLABBY RIDGE
Management
DENTURE IRRITATION HYPERPLASIA
OR EPULIS FISSURATUM
PROBLEMS AND SUGGESTED SOLUTION
:
:REPLACEMENT OR ADJUSTMENT OF DENTURE
TRAUMATIC ULCERS
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 lips
and lower denture bearing tissues. Oral
mucosa appears normal
•
3 types of BMS have been described by
LAMEY and LEWIS 1989
•
TYPE1: There are no symptoms on waking. A
Burning sensation then commences and
becomes worse as the day progresses. This
Pattern occurs everday.33% of patients fall
into this category and are likely to include
those haematinic deficiencies and defects in
denture designs
•
Type2: Burning is present on waking and
persists throughout the day. Occurs everyday.
About 55% of patients are placed in this
category , a high proportion of whom have
anxiety and are most difficult to treat
successfully
. Type3: Patients have symptom free days.
Burning occurs in less usual sites such as floor
of mouth , throat and buccal mucosa.
•
Type3: Main causative factors are allergy and
emotional instability. They make up for the
remaining 12% of patients.
CAUSES:
•
LOCAL FACTORS:
•
Mechanical irritation
•
Allergy due to residual monomer
•
Infection or oral habits
•
Myo facial 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.
•
Systemic Factors: Vitamin deficiency, iron
deficiency anemia, xerostomia, menopause,
diabetes.
•
MANAGEMENT:
•
Initial assessment ( history/ examination/
special test)
•
Provisional diagnosis
•
Initial treatment( elimination of local irritants
and investigating and treating haematinic
deficiencies)
•
Assessment of initial treatment
•
Definitive diagnosis
•
Definitive treatment( local/ systemic/
pyschological therapy)
•
Follow up
GAGGING
•
Stimulation of sensitive area in posterior
pharyngeal wall , soft palate ,uvula, fauces or
posterior surface of tongue results in series of
uncoordinated and spasmodic movements of
swallowing muscles. This is referred to as
gagging.
CAUSES
MANAGEMENT
Distraction techniques
Relaxation
Pharmacological techniques
- Local Anesthesia
- Conscious Sedation
Prosthodontic techniques
Impression Techniques
Marble Technique
Palate Less Denture
Altering gag reflex via palm pressure
MANAGEMENT
•
DISTRACTION TECNIQUE
:
Conversation can be useful, or the patient may be
instructed to concentrate on breathing, for example,
inhaling through the nose and exhaling through the mouth.
Distracting the patients mind by having him raise his foot
Until this tiring exercise requires more conscious effort and
a concomitant conversation
MANAGEMENT
•
PHARMACOLOGICAL TECHNIQUES
PHARMACOLOGICAL TECHNIQUES
•
Local Anaesthesia:
The deposition of local anesthetic
around the posterior palatine foramen has been used for patients
who gag when the posterior palate is touched.
•
Conscious sedation
:
Nitrous oxide alters the perception of external stimuli and it is
suggested that this altered perception depresses the gag reflex.
Combination of hyoscine, hyoscyamine and atropine with a sedative
drug can be given in initial period of denture use.
MANAGEMENT
IMPRESSION TECHNIQUE
: Borkin recommends low-fusing wax
as an impression material for gagging patients. This material can be
seated repeatedly between gagging episodes until a satisfactory
impression is obtained.
The low-fusing wax must be hardened in the mouth. This is done by
squirting ice water from a bulb syringe along the borders of the
completed impression and over as much of the impression surface
as possible.
Copious amounts of ice water should be used because the
impression must be thoroughly chilled before it is removed.
The ice water will retard the paroxisms of gagging by its cooling
effect so this chilling can be done with a minimum of difficulty.
MANAGEMENT
•
THE MARBLE TECHNIQUE
THE MARBLE TECHNIQUE
:
Five round multi-coloured, glass marbles, approximately 1/4inch in
diameter, were placed on a tray in front of the patient.
The patient was told to put the marbles in his mouth, one at a time,
at his leisure, until all five marbles were in his mouth. Since the fear
of swallowing a foreign object can induce the gag reflex, the patient
was assured that if he swallowed a marble, it could not harm him.
Continual assurance that he would be able to wear dentures was
given to the patient at each weekly visit.
He was urged to keep the five marbles in his mouth continuously for
one week, except when eating and sleeping.
MANAGEMENT
•
PLATE LESS DENTURES
PLATE LESS DENTURES
:
:
A cast metal denture base of aluminum or chrome nickel alloy is
recommended.
The primary advantage is the achievement of intimate contact
between the denture base and the underlying tissue, which
markedly increases the retention of the prosthesis.
The metal base also provides rigidity to resist breakage, uniform
thickness of material, a beaded metal finish line on the palatal
surface, and a stable substructure for recording jaw relations. The
metal base extends from the palatal bead line to cover the crest of
the ridge.
MANAGEMENT
•
ALTERING GAG REFLEX VIA PALM PRESSURE POINT
ALTERING GAG REFLEX VIA PALM PRESSURE POINT
The pressure point used is located in the middle of the palm
at the angle of intersection of the thumb and the third digit
marking.
The patients hands at his intersection is marked with a
marker.
With the help of hand pressure device ,pressure is applied
at this point and patient is asked not to resist to the
pressure while the force is increased manually of the
actuator to two pounds and
gag trigger point (Hegupoint) is
gag trigger point (Hegupoint) is
described.
ALTERING GAG REFLEX VIA PALM AND
PRESSURE POINTS.
RESIDUAL RIDGE REDUCTION
Residual ridge resorption: This is the most common and
important sequel of wearing complete denture which is
chronic, progressive, irreversible & cumulative.
Definition: RRR is a multi factorial, biomechanical disease
that results from a combination of anatomic, metabolic, and
mechanical determinants.
The basic structural change in RRR is a reduction in the size
of the bony ridge under the mucoperiosteum. It is primarily
a localized loss of bone structure.
•
The process of resorption important in areas with
thick cortical bone(e.g buccal and labial plates of
maxilla and lingual plates 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.
ATWOOD CLASSIFICATION
ATWOOD CLASSIFICATION
for categorizing most
common mandibular residual ridge configurations: -
•
Order 1 – pre extraction.
•
Order II – post extraction
•
Order III – high,well rounded.
•
Order IV – knife edge
•
Order V - low, well rounded.
•
Order VI - depressed
ACCORDING TO FALLUSCHUSSEL
Six orders of maxillary ridge resorption:
1.Fully preserved
2. Moderately wide and high
3. Narrow and high
4. Sharp and high
5. Wide and reduced in height
6. Severly atrophic
ETIOLOGICAL FACTORS
•
Intensive denture wearing
•
Unstable occlusal conditions.
•
Immediate denture treatment
•
Metabolic and systemic factors like
osteoporosis
•
Mechanical factors transmitted by dentures or
tongue to residual ridges results in
remodelling process
CONSEQUENCES OF RESIDUAL RIDGE
RESORPTION
•
Apparent loss of sulcus width and depth
•
Displacement of muscle attachment closer to
crest of residual ridge
•
Loss of vertical dimension of occlusion
•
Reduction of lower face height
•
Anterior rotation of mandible
•
Changes in interalveolar ridge relationship
after progression of residual ridge reduction.
TREATMENT
Pre – prosthetic surgery includes the following:
•
Ridge preservation procedure as a preventive
measure
•
Corrective or recon touring procedures of defects
and abnormalities
•
Ridge extension procedures: Relative methods:
sulcus extension( vestibuloplasty)
•
Absolute methods :
Ridge augmentation methods
PROSTHETIC FACTORS CONSIDERED TO
REDUCE RESIDUAL RIDGE RESORPTION
•
Broad area coverage
•
Decreased bucco lingual width of teeth
•
Improved tooth form
•
Avoidance of inclined planes
•
Centralization of occlusal contacts
•
Provision of adequate tongue room
•
Adequate inter-occlusal distance during rest
jaw relation.
OVER DENTURE ABUTMENTS:CARIES
AND PERIODONTAL DISEASE
•
Wearing of over denture 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 microorganisms are
streptococcus, lactobacilli and actinomyces.
•
These species initiate
gingivitis after 1-3 days of
plaque accumulation when
oral hygiene is discontinued.
•
Presence of streptococcus
mutans and lactobacillli in
dental plaque flora in high
proportions results in caries.
ATROPHY OF MASTICATORY MUSCLES
ESSENTIAL THAT MASTICATORY FUNCTION BE
MAINTAINED THROUGH OUT LIFE
MASTICATORY FUNCTION DEPENDS ON THE SKELETAL
MUSCULAR FORCE AND THE ABILITY TO COORDINATE
ORAL FUNCTIONAL MOVEMENTS DURING
MASTICATION
MAXIMAL BITE FORCES DECREASE IN OLDER PATIENTS
•
Wearing dentures does compromise masticatory
performance greatly as compared to a natural set
of teeth. Common muscle that undergo disuse
atrophy are masseter and medial pterygoid.
GREATER ATROPHY OCCCURS IN COMPLETE
DENTURE WEARERS ESPECIALLY WOMEN
LITTLE EVIDENCE THAT NEW DENTURES REDUCE THE
ATROPHY
•
Preventive measures and Management:
•
Overdentures prevent disuse atrophy.
•
In absence of overdenture abutments
implants can be inserted and an implant
supported complete denture can be
fabricated.
Nutritional deficiencies
•
Masticatory ability:
It is an individual’s own assessment of his
masticatory function.
•
Masticatory efficiency:
It is the capacity of a person to reduce food
during mastication.
•
Aging is often associated with decrease in energy
needs. All these factors make patient weak and
show symptoms of malnourishment.
GENERAL PRECAUTIONS TO PREVENT
SEQUELAE
•
Modified dietary habits wherein balanced diet
is administered.
•
Food particles can be mechanically broken
down before eating to reduce burden on the
oral musculature.
•
Dentist should try to preserve remaining teeth
as much as possible and fabricate an
overdenture in order to reduce sequelae.
•
In absence of overdenture abutments., the
dentist should try an implant supported denture.
•
Regular followup should be conducted so that
stable occlusion can be maintained.
•
Overdenture patients should be frequently
recalled to examine the status of the abutment.
•
Patient should be motivated to follow optimum
denture wearing and maintaining habits.
CONCLUSION
Several problems regarding complete denture treatment can be easily
solved according to research and clinical experience.
•
The prevalence of the edentulous condition is decreasing but there
will remain a great number of edentulous people, a situation that
will continue in the foreseeable future.
•
Therefore continuing investments in basic and clinical research on
removable dentures are warranted. Routine follow-up visits to
assess that the prostheses maintain proper fit and function, and
that users are maintaining denture hygiene is of extreme
importance in reducing risk of sequelae of denture wearing.
REFRENCES
Rahn & Heartwell,Textbook of complete dentures, fifth
edition
Bolender zarb,prosthodontic treatment for edentulous
patients.,twelfth edition
Shafers,textbook of oral pathology,fiftn edition.
Bassi GS,Humphris GM,MClin Psychol C Psychol,and Longman
LP, The etiology and management of gagging: A review of the
literature;J Prosthet den;5:91,459-467,2004.
THANK YOU
Denture use can lead to various sequelae, including denture stomatitis, angular cheilitis, flabby ridge, traumatic ulcers, and more. These issues can cause discomfort, destabilization of occlusion, loss of retention, decreased masticatory function, poor aesthetics, and increased ridge resorption. Factors contributing to these sequelae include inadequate maintenance, material properties, operator errors, allergic reactions, and microporosities. Understanding these effects is crucial to prevent prosthetically maladaptive conditions.
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Presentation Transcript
SEQUELAE CAUSED BY WEARING SEQUELAE CAUSED BY WEARING COMPLETE DENTURES COMPLETE DENTURES
CONTENTS INTRODUCTION ETIOLOGY TYPES OF SEQUELAE DENTURE STOMATITIS ANGULAR CHELITIS FLABBY RIDGE TRAUMATIC ULCERS OR SORE SPOTS DENTURE IRRITATION HYPERPLASIA
BURNING MOUTH SYNDROME GAGGING RESIDUAL RIDGE REDUCTION OVER DENTURE ABUTMENTS: CARIES AND PERIODONTAL DISEASE ATROPHY OF MASTICATORY MUSCLES NUTRITIONAL DEFICIENCIES GENERAL PRECAUTIONS TO PREVENT SEQUELAE CONCLUSION
INTRODUCTION What is Sequelae ? An after effect of a disease, condition or injury. It is a secondary result.
INTRODUCTION Denture use is not free of trouble. It can produce severe side effects which if left untreated will produce: 1.Destabilization of occlusion 2.Loss of retention 3.Decresed masticatory function 4.Poor esthetics 5.Increased ridge resorption and tissue injury
INTRODUCTION All these disorders produced or accelerated in oral tissues due to presence of denture are grouped as SEQUELAE OF WEARING COMPLETE DENTURE . These problems progress to stage where patient is considered PROSTHETICALLY MALADAPTIVE and hence cannot wear dentures.
ETIOLOGY Inadequate maintenance by patient Properties of material Error from operator Allergic reactions Microporosities leading to plaque accumulation Continuous wear of denture Overextension Flange width inadequate Inaccurate fit Occlusal plane too high Inadequate freeway space Cuspal interference.
DENTURES CAN CAUSE? SURFACE MUCOSAL REACTIONS POOR FUNCTION IRREGULARITIES AND MICROPOROSITIES MECHANICAL IRRITATION AND PLAQUE ACCUMULATION PLAQUE FORMATION NEGATIVE EFEECT ON MUSCLE FUCTION BACTERIA USE PMMA AS CARBON SOURCE. ALLERGIC REACTIONS
TYPES OF SEQUELAE DIRECT SEQUELAE INDIRECT SEQUELAE DENTURE STOMATITIS ATROPHY OF MASTICATORY MUSCLES FLABBY RIDGE NUTRITIONAL DEFICIENCY DENTURE IRRITATION HYPERPLASIA OR EPULIS FISSURATUM ALLERGIC REACTION TRAUMATIC ULCERS BURNING MOUTH SYNDROME GAGGING OVER DENTURE ABUTMENTS:CARIES AND PERIODONTAL DISEASE
TYPES OF SEQUELAE IMMEDIATE SEQUELAE DELAYED SEQUELAE BURNING MOUTH SYNDROME DENTURE STOMATITIS GAGGING DENTURE IRRITATION HYPERPLASIA TRAUMATIC ULCERS OR SORE SPOTS FLABBY RIDGE RESIDUAL RIDGE REDUCTION OVER DENTURE ABUTMENT CARIES
DENTURE STOMATITIS The word stomatitis means inflammation of oral mucosa. Denture stomatitis is a term used to indicate an inflammatory state of denture bearing mucosa. Other names are Denture induced stomatitis, Inflammatory papillary hyperplasia and chronic atrophic candidiasis.
CLASSIFICATION LOCALIZED SIMPLE INFLAMMATION TYPE 1,2,3 GENERALIZED DIFFUSE ERYTHMATUS DENTURE STOMATITIS CANDIDA ASSOCIATED IF YEAST IS INVOLVED
DENTURE STOMATITIS STAINS OF GENUS CANDIDA ,PARTICULRLY CANDIDA ALBICANS CANDIDA ASSOCIAED CAUSES TRAUMA INDUCED , CAUSED BY MICROBIAL PLAQUE ACCUMULATION TYPES 1,2 AND 3 ANGULAR CHELITIS OR GLOSSITIS DUE TO INFECTIONFROM DENTURE COVERED MUCOSA TO ANGLES OF MOUTH OR TONGUE. CANDIDA ASSOCIATED DENTURE STOMATITIS AND ANGULAR CHELITIS
DENTURE STOMATITIS DIAGNOSIS: The diagnosis of Candida associated denture stomatitis is confirmed by finding of mycelia or pseudohyphae in a direct smear ,or by isolation of Candida species in high numbers from the lesion . Yeasts are recovered in high numbers from fitting surface of dentures than from corresponding areas of palatal mucosa which indicates that Candida residing on fitting surface of denture is primary source of infection. Candidal growth has been associated with mandibular dentures relined with soft liner. The most commonly detected yeasts were strains of the genus Candida, in paticular C. albicans, C. glabrata and C. tropicali
MANAGEMENT APPROPIATE DENTURE WEARING HABITS DENTURE SANITIZATION. MECHANICAL PLAQUE CONTROL. Denture soaked overnight in an antiseptic solution such as chlorhexidine or dilute sodium hypochlorite. Patient instructed to remove dentures after meal and scrub them vigorously before reinserting them. Mucosa in contact with denture should be kept clean and massaged with a soft tooth brush.
If fungal organism is present: TOPICAL ANTIFUNGAL THERAPY SYSTEMIC ANTIFUNGAL THERAPY Seen in Type2 diabetes mellitus patients. Clotrimazole(1%) cream Ketoconazole or fluconazole.(200- 400)mg Nystatin lozenges
ANGULAR CHELITIS 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. It is thought that infection may start beneath the maxillary denture and from that area spread to corners of mouth. However this infection often results from local or systemic predisposing conditions such as over closure of jaws , general health factors such as nutritional deficiencies and immune dysfunction.
FLABBY RIDGE CLINICAL PRESENTATION M MANDIBULAR TEETH ALVEOLAR RIDGE MOBILE AND EXTREMELY RESILIENT SEEN IN ANTERIOR PART OF MAXILLA OPPOSING NATURAL HISTOPATHOLOGY MARKED FIBROSIS ,INFLAMMATION AND RESORPTION OF THE UNDERLYING BONE CAUSES UNSTABLE OCCLUSAL CONDITIONS EXCESSIVE LOAD ON RESIDUAL RIDGE
Management CONVENTIOAL PROSTHODONTICS WITHOUT SURGICAL INTERVENTION IMPLANT RETAINED PROSTHESIS SURGICAL REMOVAL Various impression techniques are LIMITATION : DECREASE IN VESTIBULAR HEIGHT Economic concerns 1. Two tray technique 2. Window impression technique REQUIRING VESTIBULOPLASTY
DENTURE IRRITATION HYPERPLASIA OR EPULIS FISSURATUM CLINICAL PRESENTATION HYPERPLASIA OF MUCOSA OCCURS ALONG BORDERS OF DENTURE SINGLE OR NUMEROUS LESIONS FLAPS OF HYPERPLASTIC CONNECTIVE TISSUE PRESENT HISTOLOGY CELLS RESEMBLE NORMAL CELLS BUT ARE GREATLY INCREASED IN NUMBER CAUSES ILLFITTING DENTURE INJURY DUE TO THIN OVEREXTENDED DENTURE FLANGE PROBLEMS AND SUGGESTED SOLUTION: :REPLACEMENT OR ADJUSTMENT OF DENTURE
TRAUMATIC ULCERS CLINICAL PRESENTATION Small painful lesions,covered by a gray necrotic membrane and surrounded by an inflammatory halo with firm ,elevated borders Develop within 1-2 days after placement of new dentures CAUSES Caused due to overextended denture flanges or unbalanced occlusion. TREATMENT In a non compromised host ulcers will heal after correction of dentures.When left untreated it subsequently develops into denture irritation hyperplasia.
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 lips and lower denture bearing tissues. Oral mucosa appears normal
3 types of BMS have been described by LAMEY and LEWIS 1989 TYPE1: There are no symptoms on waking. A Burning sensation then commences and becomes worse as the day progresses. This Pattern occurs everday.33% of patients fall into this category and are likely to include those haematinic deficiencies and defects in denture designs
Type2: Burning is present on waking and persists throughout the day. Occurs everyday. About 55% of patients are placed in this category , a high proportion of whom have anxiety and are most difficult to treat successfully . Type3: Patients have symptom free days. Burning occurs in less usual sites such as floor of mouth , throat and buccal mucosa.
Type3: Main causative factors are allergy and emotional instability. They make up for the remaining 12% of patients. CAUSES: LOCAL FACTORS: Mechanical irritation Allergy due to residual monomer Infection or oral habits Myo facial 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. Systemic Factors: Vitamin deficiency, iron deficiency anemia, xerostomia, menopause, diabetes.
MANAGEMENT: Initial assessment ( history/ examination/ special test) Provisional diagnosis Initial treatment( elimination of local irritants and investigating and treating haematinic deficiencies) Assessment of initial treatment
Definitive diagnosis Definitive treatment( local/ systemic/ pyschological therapy) Follow up
GAGGING Stimulation of sensitive area in posterior pharyngeal wall , soft palate ,uvula, fauces or posterior surface of tongue results in series of uncoordinated and spasmodic movements of swallowing muscles. This is referred to as gagging.
CAUSES Loose dentures Poor occlusion Incorrect extension or contour of dentures particularly in posterior area of palate and retromylohyoid space Under extended denture borders. Placing the maxillary teeth too far in a palatal direction and , mandibular teeth too far in lingual direction Increased vertical dimension of occlusion. Psychogenic factors
MANAGEMENT Distraction techniques Relaxation Pharmacological techniques - Local Anesthesia - Conscious Sedation Prosthodontic techniques Impression Techniques Marble Technique Palate Less Denture Altering gag reflex via palm pressure
MANAGEMENT DISTRACTION TECNIQUE: Conversation can be useful, or the patient may be instructed to concentrate on breathing, for example, inhaling through the nose and exhaling through the mouth. Distracting the patients mind by having him raise his foot Until this tiring exercise requires more conscious effort and a concomitant conversation
MANAGEMENT PHARMACOLOGICAL TECHNIQUES Local Anaesthesia: The deposition of local anesthetic around the posterior palatine foramen has been used for patients who gag when the posterior palate is touched. Conscious sedation : Nitrous oxide alters the perception of external stimuli and it is suggested that this altered perception depresses the gag reflex. Combination of hyoscine, hyoscyamine and atropine with a sedative drug can be given in initial period of denture use.
MANAGEMENT IMPRESSION TECHNIQUE: Borkin recommends low-fusing wax as an impression material for gagging patients. This material can be seated repeatedly between gagging episodes until a satisfactory impression is obtained. The low-fusing wax must be hardened in the mouth. This is done by squirting ice water from a bulb syringe along the borders of the completed impression and over as much of the impression surface as possible. Copious amounts of ice water should be used because the impression must be thoroughly chilled before it is removed. The ice water will retard the paroxisms of gagging by its cooling effect so this chilling can be done with a minimum of difficulty.
MANAGEMENT THE MARBLE TECHNIQUE: Five round multi-coloured, glass marbles, approximately 1/4inch in diameter, were placed on a tray in front of the patient. The patient was told to put the marbles in his mouth, one at a time, at his leisure, until all five marbles were in his mouth. Since the fear of swallowing a foreign object can induce the gag reflex, the patient was assured that if he swallowed a marble, it could not harm him. Continual assurance that he would be able to wear dentures was given to the patient at each weekly visit. He was urged to keep the five marbles in his mouth continuously for one week, except when eating and sleeping.
MANAGEMENT PLATE LESS DENTURES: A cast metal denture base of aluminum or chrome nickel alloy is recommended. The primary advantage is the achievement of intimate contact between the denture base and the underlying tissue, which markedly increases the retention of the prosthesis. The metal base also provides rigidity to resist breakage, uniform thickness of material, a beaded metal finish line on the palatal surface, and a stable substructure for recording jaw relations. The metal base extends from the palatal bead line to cover the crest of the ridge.
MANAGEMENT ALTERING GAG REFLEX VIA PALM PRESSURE POINT The pressure point used is located in the middle of the palm at the angle of intersection of the thumb and the third digit marking. The patients hands at his intersection is marked with a marker. With the help of hand pressure device ,pressure is applied at this point and patient is asked not to resist to the pressure while the force is increased manually of the actuator to two pounds and gag trigger point (Hegupoint) is described.
ALTERING GAG REFLEX VIA PALM AND PRESSURE POINTS.
RESIDUAL RIDGE REDUCTION Residual ridge resorption: This is the most common and important sequel of wearing complete denture which is chronic, progressive, irreversible & cumulative. Definition: RRR is a multi factorial, biomechanical disease that results from a combination of anatomic, metabolic, and mechanical determinants. The basic structural change in RRR is a reduction in the size of the bony ridge under the mucoperiosteum. It is primarily a localized loss of bone structure.
The process of resorption important in areas with thick cortical bone(e.g buccal and labial plates of maxilla and lingual plates 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.
ATWOOD CLASSIFICATION for categorizing most common mandibular residual ridge configurations: - Order 1 pre extraction. Order II post extraction Order III high,well rounded. Order IV knife edge Order V - low, well rounded. Order VI - depressed
ACCORDING TO FALLUSCHUSSEL Six orders of maxillary ridge resorption: 1.Fully preserved 2. Moderately wide and high 3. Narrow and high 4. Sharp and high 5. Wide and reduced in height 6. Severly atrophic
ETIOLOGICAL FACTORS Intensive denture wearing Unstable occlusal conditions. Immediate denture treatment Metabolic and systemic factors like osteoporosis Mechanical factors transmitted by dentures or tongue to residual ridges results in remodelling process
CONSEQUENCES OF RESIDUAL RIDGE RESORPTION Apparent loss of sulcus width and depth Displacement of muscle attachment closer to crest of residual ridge Loss of vertical dimension of occlusion Reduction of lower face height Anterior rotation of mandible Changes in interalveolar ridge relationship after progression of residual ridge reduction.
TREATMENT Pre prosthetic surgery includes the following: Ridge preservation procedure as a preventive measure Corrective or recon touring procedures of defects and abnormalities Ridge extension procedures: Relative methods: sulcus extension( vestibuloplasty) Absolute methods : Ridge augmentation methods
PROSTHETIC FACTORS CONSIDERED TO REDUCE RESIDUAL RIDGE RESORPTION Broad area coverage Decreased bucco lingual width of teeth Improved tooth form Avoidance of inclined planes Centralization of occlusal contacts Provision of adequate tongue room Adequate inter-occlusal distance during rest jaw relation.
OVER DENTURE ABUTMENTS:CARIES AND PERIODONTAL DISEASE Wearing of over denture 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 microorganisms are streptococcus, lactobacilli and actinomyces.
These species initiate gingivitis after 1-3 days of plaque accumulation when oral hygiene is discontinued. Presence of streptococcus mutans and lactobacillli in dental plaque flora in high proportions results in caries.
ATROPHY OF MASTICATORY MUSCLES ESSENTIAL THAT MASTICATORY FUNCTION BE MAINTAINED THROUGH OUT LIFE MASTICATORY FUNCTION DEPENDS ON THE SKELETAL MUSCULAR FORCE AND THE ABILITY TO COORDINATE ORAL FUNCTIONAL MOVEMENTS DURING MASTICATION MAXIMAL BITE FORCES DECREASE IN OLDER PATIENTS
