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INDIAN DENTAL ACADEMY
Leader in continuing dental education www.indiandentalacademy.com
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CONTENTS
Introduction
Microscopic anatomy of the mucous membrane in oral cavity
Sequelae of wearing complete denture
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Microscopic anatomy of the mucous membrane in oral cavity Has thinner horny layer than skin. Sigmund and Weber et.al.: claimed that mucosa
has no horny layer. Spreng(1945) : demonstrated horny layer in
palatine mucosa and claimed that hornification is a reaction to the wear and tear produced by the denture.
Orban(1953) : first to state positively that oral mucosa has horny layer.
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EPITHELIUM
Its thickness is not more than 0.20mm
Consists of several differentiated cells covered by stratum corneum
Important as a protective mechanism
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Stratum corneum It has a mean thickness of
13.2micron Appears as homogenous band
stained red Consists of closely packed
cells which appear to have no nuclei.
Scrapings from palatal mucosa shows cells appearing as fried egg with nucleus in centre as yolk
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Stratum granulosum Characterized by
granulation in cytoplasm
Kerato-hyaline granule: located in basal
parts of the layer as single granules
Number of cells increase as they approach the surface
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Stratum spinosum cells are polygonal/rounded
connected to each other by protoplasm in the form of fibrillar structure called tonofibrils
In the mesh b/w the fibrils, tissue fluid facilitate the metabolism of the cells
Metabolism is facilitated by extension of the papillae of connective tissue into the epithelium
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Stratum basale Formed by thin layers of
amorphous materials and of reticular fibers
Demonstrated using PAS
Under EM : seems to have 1. basal lamina
2.reticular lamina
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Functions Provide adhesion on one side to epithelial cells and
other side to connective tissue Act as barriers to the diffusion of molecules Play role in cell organization May influence the regeneration of peripheral nerves
after injury May play a role in re- establishing of neuro- muscular
junctions
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Lamina propria Characterized by
collagenic and elastic fibers
Fibers run parallel to the surface of epithelium and extend in papillae perpendicular to their main course
This wavy course provides the tissue with high degree of elasticity
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sub mucosa Constitutes major bulk of
the mucous membrane Contains :
Other components (blood vessels, lymphatic vessels and nerves)
Fatty tissues Glands Muscles fibers
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SEQUELAE OF WEARING COMPLETE DENTURES DIRECT SEQUELAE
Denture stomatitis Flabby ridge Denture irritation hyperplasia Traumatic ulcers Oral cancer Burning mouth syndrome Gagging Residual ridge reduction Caries and periodontal disease
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Indirect sequelae
Atrophy of masticatory muscles
Nutritional deficiencies
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Denture stomatitis Prevalence: 50% among
the complete denture wearers
Synonyms : denture sore mouth, denture-induced stomatitis, inflammatory hyperplasia, and chronic atrophic candidosis
Classification: 3 types By –Newton's
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Newton’s classification Type I :
localized simple inflammation or pinpoint hyperemia
Cause: trauma
induced
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Type II :
Diffuse erythema involving a part or entire denture covered mucosa
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Type III :
Granular type of inflammatory hyperplasia
Cause: Presence of microbial
plaque ( bacteria/yeasts)
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Candida associated denture stomatitis
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Colonization of the fitting denture surface by Candida species depends on several factors Adherence of yeast cells
Interaction with oral commensal bacteria
Redox potential of the site
Surface properties of the denture resin
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Predisposing factors Systemic factors Local factors Denture properties Environmental factors Oral hygiene
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Systemic factors Age Diabetes mellitus Nutritional deficiencies Malignancies Immune disorders
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Local factors Denture properties favoring Candida growth
Surface irregularities Micro porosity Improper Design of prosthesis Mechanical irritation Texture
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Environmental factors Health of adjacent mucosa Composition of saliva Salivary secretion rate xerostomia sjogrens syndrome High carbohydrate diet Broad spectrum antibiotics
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Smoking tobacco Oral hygiene maintenance Denture wearing habits
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Associated with Angular chelitis
Diffuse atrophic glossitis
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Median rhomboid glossitis
Erythema of the soft palate
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Diagnosis
Confirmed by finding of mycelia/pseudohyphae in a direct smear or the isolation of Candida in high numbers from the lesions.
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HISTOLOGICAL FINDINGS
Thinning of stratum corneum or absence of keratinization.Epithelial atrophy & hyperplasiaIntraepithelial infiltration by leucocytes.Lymphocytic infiltration in underlying connective tissue.
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Management and preventive measures
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Because of diverse possible origin, several treatment procedures are used like:
Antifungal therapy
Correction of ill-fitting dentures
Efficient plaque control
Surgical care
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Antifungal therapy Local therapy > nystatin, amphotericin B, miconazole,
clotrimazole Systemic therapy > ketoconazole , fluconazole
Used mainly in following patients: After the clinical diagnosis has been confirmed by a mycological
examination Associated with burning sensation in oral mucosa When infection has spread to other sites of oral cavity or the
pharynx Patients with high risk of systemic infections
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Precautions to reduce the risk of relapse
Treatment should continue for 4 weeks
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When lozenges are prescribed > patient is instructed to take out the denture during sucking
Meticulous oral and denture hygiene instructions
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Correction of ill-fitting dentures
Rough surface > smoothened and polished
Relining > soft tissue conditionerclassification:1) short term a) tissue conditioner
b) functional impression materials 2) long term heat cure silicone cold cure
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B) acrylic based resins heat cure cold cure 3) others: polyvinyl chloride polyvinyl acetate polyurethane hydrophilic acrylates
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COMPOSITION
In general they are supplied in powder and liquid form.
POWDER – poly (ethyl methacrylate) LIQUID – A mixture of aromatic ester and
ethyl alcohol. The ester behaves as a plasticizer and the
alcohol is penetrated which speeds up the process.
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On mixing the two together a slurry is formed. The liquid then penetrates between the molecules of the powder, a process accelerated by the ethyl alcohol present and the whole material becomes stiffer until a gel is formed, the setting therefore is a physical process, there being no chemical reaction involved.
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PREFORMED SHEETS OF ACRYLIC GEL ARE ALSO AVAILABLE WHICH CAN BE ADAPTED TO THE SURFACES OF THE DENTURE.
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Method to condition the tissues traumatized by ill-fitting dentures Ask the patient not to
wear the dentures for days – week period
Stimulate the diseased tissue with a gauze dipped in warm saline > 3 times a day
Tissue side of the denture should be clean
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Adjust and perfect the occlusion and the vertical dimension
Adjust the periphery
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Relieve the tissue side of the denture > about 11/2 mm of relief is given
Coat the denture base with tissue conditioning material and insert.
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BEFORE CONDITIONING
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AFTER CONDITIONING
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Effective plaque control
Oral hygiene instructions
Denture and partial clasp brushes
Denture cleansing solutions
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Surgical care Deep crypt formations in type III :
electro surgery / cryosurgery
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DETURRENCE / PREVENTION
> Educating the patient about the oral health care.
> Instructing the patient to take their dentures out atleast 8hrs a day.
> Mechanical plague control & appropriate denture wearing habits are important measures.
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Angular chelitisa painful inflammation at the corners of the mouth.
Synonyms: angular stomatitis, perleche, angular cheilosis
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Predisposing factors Reduced vertical
dimension
Secondary to denture stomatitis
Riboflavin and thiamine deficiency
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CLINICAL FEATURES
epithelium at the corner of the mouth appears wrinkled, macerated, one or more deep fissures, cracks which appear ulcerated & tends to bleed.
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Treatment
Elimination of the primary cause.
Antifungal treatment & supplement antifungal ointment at the lesion site
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FLABBY RIDGE It is due to the
replacement of bone by fibrous tissue
Common in maxillary anterior region (when mandibular anteriors are remaining)
They offer poor support to the denture
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Mechanism
Direction of applied force of mastication causes slight rotation of the denture around the anterior maxillary alveolus.Pressure of the distally rotating anterior flange against the labial plate of bone causes resorbtion.
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The shearing force applied to the periosteum by friction with the base during rotation results in fibrous hyperplasia .When the patient incises the pad, fibrous tissue is compressed & upward movement of the maxillary denture causes downward displacement posteriorly ,with loss of retention in the post dam area & development of fibrous maxillary tuberosity.
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TREATMENT SURGICAL:
i) surgical removal to improve stability of denture
ii) Augment the alveolar ridge with biocompatible bone substitutes
iii) In extreme atrophic condition, flabby ridges should not be totally removed because the vestibular area will be limited.
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Conservative :
judicious selection of impression materials and technique.
3 technique has been advocated as follow :
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A
Special tray made with a window cut in the region of displaceable tissue
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Border molding done
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Wash impression made with ZOE paste
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Tray re-inserted, impression plaster syringed over displaceable tissue
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Completed impression
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Technique – B
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Special tray with window cut
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Medium- bodied / monophase elastomer is loaded
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Light body material is syringed in the cut window and then stabilized by syringing the plaster over the set elastomer
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Technique – c
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Special tray with no window and border molding done
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Impression made using ZOE / Monophase elastomer When set , impression material corresponding to the
displaceable tissue is removed Tray is perforated
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Impression plaster / light body elastomer syringed over displaceable tissue
Tray is reinserted and the impression is complete
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Denture irritation hyperplasia
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cause Chronic irritation by ill-
fitting dentures
Overextended flanges
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Lesions may be single or numerous
Composed of flaps of hyper plastic connective tissue
Severe inflammation and ulceration in deep fissures
Asymptomatic
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HISTOLOGICAL FINDINGS Excessive bulk of fibrous
connective tissue covered by a layer of stratified squamous epithelium
Connective tissue shows coarse bundle of collagen fibers with few fibroblast & blood vessels.
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Management Correction of over extended flanges
Surgical excision if its fibro tic or if the hyperplasia does not fully subside on correction of over extended flanges.
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Traumatic ulcers Commonly develop within
1 to 2 days after placement 0f new dentures
Lesions are painful, small, and ulcerated
Lesion is covered by a grey necrotic membrane , surrounded by inflammatory halo with firm and elevated borders
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Direct cause
Overextended denture flanges Unbalanced occlusion
Predisposing factors Diabetes mellitus Nutritional deficiency Radiation therapy/xerostomia
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HISTOLOGICAL FINDINGS Loss of continuity of the
surface epithelium with the fibrous exudates covering exposed connective tissue.
Infiltration of leucocytes into the connective tissue
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Treatment Management includes correction of local irritant factors
in the denture.
Not treated > subsequently may develop into denture irritation hyperplasia
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Oral cancer in denture wearers Associated with chronic
irritation of the mucosa by the dentures
Case reports > detailed development of oral carcinomas in patients who wear ill-fitting dentures
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Predisposing factors Heavy alcohol and tobacco use Lower socioeconomic status Less education
Prevention
regular recall visits > 6 months – 1 year interval for comprehensive oral examinations
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Burning mouth syndrome Characterized by a burning sensation in one or several oral
structures in contact with the dentures
Commonly seen at the age of 50 years
Females are affected more
The oral mucosa appears clinically healthy
Clinical signs: absent
Symptoms : gradual in onset associated with pain
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Characters of the painGradual in onset
Often present in morning
Aggravated during the day / absent at night
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Quality of pain Burning sensation associated dry mouth and persistent
altered taste sensation
Associated symptoms : headache, insomnia, decreased libido, irritability , depression
Aggravating factors : tension, fatigue, hot or spicy food
Reducing factors : sleeping, eating, distraction
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Site of occurrence Anterior two third of the tongue
Anterior hard palate
Mucosa of the lower lip
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Etiology
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Management Systematic approach is necessary to identify the possible causes. symptomatic treatment should be given.
- Mucosal disease -diagnosis & treat the mucosal condition.
-Dry mouth - high fluid intake & sialagogueAny systemic disease present should be identified & treated.
-Menopause-hormonal replacement -Nutritional deficiency -oral supplementation.
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if no organic basis is found, proper counseling of the patient, help the patient to understand the benign nature of the problem & with subsequent elimination of fears.comprehensive prosthetic treatment should be carried out as collaborative effort of psychiatrist & prosthodontist
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Gagging
Normal , healthy defense mechanism
Functions to prevent the entry of foreign bodies in to the trachea
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Gagging problem in prosthodontic treatment. Part I : Description and causes, JPD ; 1983:49 FAIGENBLUM’S CLASSIFICATION
Mild : Experiences nausea with mild stimulus Will be able to control the stimulus
Severe : > responds in an exaggerated
manner to physical or psychological stimuli
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Five trigger zones identified producing gag reflex Fauces ( tonsils )
Base of the tongue
Palate
Uvula
Posterior pharyngeal wall
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Clinical behavior ( by khan ) - Intraoral Puckering of the lips or attempting to close the jaws Elevating and furrowing the tongue Elevation of the soft palate and hyoid bone Fixation of the hyoid bone Contraction of anterior and posterior pillars of the fauces (tonsils) Elevation, contraction and retraction of larynx and closure of the
glottis Simultaneous and uncoordinated respiratory muscle spasm vomiting
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Extra oral Excessive salivation
Lacrimation
Coughing
sweating
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Causes of gagging SYSTEMIC FACTORS
Psychological FACTORS
PHYSIOLOGIC FACTORS
IATROGENIC FACTORS
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SYSTEMIC FACTORS Deviated septum Nasal polyps or sinusitis Inflammation of pharynx Chronic gastritis Carcinoma of stomach Peptic ulcer
Psychological FACTORS Active passive
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PHYSIOLOGIC FACTORS Extra oral stimuli
Visual Auditory Olfactory
Intraoral stimuli Inadequate post-dam Over-extended posterior borders Disharmonious occlusion Poor retention Surface finish of acrylic resin Inadequate free-way space
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Management – Daniel J. conny and Lisa A. 1983; 49
Clinical techniques
Prosthodontic management
Pharmacologic measures
Psycho logic intervention
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Clinical techniques Surgical ( Leslie ):
Removal of uvula Shortening of soft palate
Prosthodontic Impression technique > BORKIN
Provides greater control of setting time
Discrepancies can be easily corrected
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Technique Primary impression > stock tray and red modeling
compound
Secondary impression > by pouring “Kerr impression wax”
Flexible nature of the wax allows reseating of the tray and border molding until desirable results are obtained
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Marble technique > SINGER First visit :
Patient asked to place 5 marbles in his/her mouth > 1 at time at leisure
Further instructed to keep the marbles continuously for 1 week, except while sleeping and eating
Second visit : Patients ability to tolerate the marbles was evaluated Reassured that patient would be able to tolerate the
denture
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Third visit : Primary impression made Special tray fabricated
Fourth visit : Lower tray was inserted with 3 marbles in the
mouth Training bead placed on the lingual aspect of the
tray to maintain proper tongue position Fifth visit :
Use of marbles discontinued
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Sixth visit : Fabrication of bite rims Jaw relation
Seventh visit : Wax – try in made
Eighth visit : Final denture insertion
This technique admits patient motivation Has definite risk in aspiration of marbles by the
patient during the procedure
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Radiographic > RICHARD’S use of high – speed film Preset the timer Moisten the film pack Ask the patient to rinse in cool water
Psycho logic > LANDA Engage the patient in conversation Make the patient count rapidly from 50 – 100 Have the patient to read aloud
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Prosthodontic management Obtaining proper post – dam Correcting over – extended borders Correcting the occlusion Proper retention Mattel surface finish Increasing the free – way space
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Pharmacologic measures Approached when clinical and prosthodontic measures
are ineffective Their efficacy, however is not universally accepted
Classification
peripherally acting drugs centrally acting
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peripherally acting drugs Topical and local anesthetics
Centrally acting drugs Antihistamines Sedatives and tranquilizers Parasympathocytics Central nervous system depressants
Psycho logic intervention• Hypnosis• Behavioral therapy
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RESIDUAL RIDGE REDUCTION A term used for the
diminished quality & quantity of the residual ridge after the teeth are removed.(GPT-7)
A continuous loss of the bone tissue after tooth extraction & placement of the complete denture
the reduction is the sequelae of alveolar remodeling due to altered functional stimulus of the bone tissue.
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Follows a chronic progressive & irreversible course that often results in severe impairment of prosthetic restoration & oral function.
First year after tooth extraction ,the reduction of the residual ridge in the midsagittal plane
maxilla:2-3mm mandible:4-5mm
After healing remodeling takes place in decreased intensity
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Etiological factors of reduction of residual ridges Anatomical factors :
Short and square face associated with elevated masticatory forces
Alveoloplasty Prosthodontic factors :
Intensive denture wearing Unstable occlusal conditions
Metabolic and systemic factors : Osteoporosis Calcium and vitamin D deficiency
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CONSEQUENCE OF RR REDUCTION Apparent loss of sulcus width
& depth
Displacement of muscle attachment
closer to the crest of the ridge
Loss of vertical dimension of occlusion
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reduction of lower facial height
Anterior rotation of mandible & increase in relative prognathism
Sharp, spiny, uneven residual ridge & location of mental foramina closer to the ridge
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Treatment
Preprosthetic surgical initiation such as vestibuloplasties
Severe situations > ridge augmentation procedures
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PREVENTVE MEASURES Dietary / nutrition intervention, estrogen therapy when
indicated, maintenance of teeth & placements of implants. Supplement of calcium & vit D to reduce the rate of post
extraction remodeling of RR in immediate denture wearers (Wical & Bruser 1979)
Retaining the tooth as for the over denture abutments.RRR was found to be 0.6mm in over denture wearers compared with 5mm in complete denture wearers( Crum & looney,1978).
Osseo integrated implants as abutment, reduces rate of resoption of RR than conventional complete denture( Sennerby et al 1988)
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OVERDENTURE ABUTMENTS: CARIES & PERIODONTAL DISEASE
Wearing of over denture are often associated with high risk of caries & periodontal disease of the abutments when oral hygiene measures are not adequate.
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Etiology Bacterial colonization beneath the close fitting denture
due to poor oral hygiene
Streptococcus and actinomyces > gingivitis and periodontitis
streptococcus mutans and lactobacilli > caries
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Treatment Maintain good oral hygiene Motivate the patient with
regular recall visits at 3 – 6 months intervals
Superficial caries > application of fluoride- chlorhexidine gel and polishing
Deep caries > placement of copings
Periodontal pockets greater than 4 to 5 mm > surgically eliminated
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Indirect sequelae
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Atrophy of masticatory muscles Computed tomography study > masseter and medial
pterygoid muscle demonstrated greater atrophy in complete denture wearers
Maximal bite forces tend to decrease in the old age.
Chewing efficiency decreases as the number of natural teeth is reduced.
Reduced bite force & chewing efficiency are sequelae caused by wearing the complete denture , resulting in impaired masticatory function
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Diagnosis Capacity to reduce the test food particles
It has been verified > chewing efficiency as the number of natural teeth is reduced
Worse for subjects wearing complete denture
Complete denture wearers need approximately 7 times more chewing strokes than subjects with natural dentition
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Management Retention of small number of teeth used as over denture
abutments > role in maintaining the oral function
Completely edentulous patients > placement of implants
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Nutritional deficiencies Nutrition the science of how the body utilizes food to
meet requirements for development, growth, repair and maintenance
Essential nutrients to maintain good health are
Carbohydrates Fat Protein Vitamins Minerals Water
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Nutritional deficiencies
Primary > faulty selection of food Lack of knowledge what to eat Fat diets Poor food habits Food like n dislikes Poverty Physical incapacities Emotional prejudices
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Secondary > systemic disorders
Factors that interfere with food intake
Conditions that interfere with digestion
conditions that interfere with absorption
Factors that interfere with metabolism
Conditions that interfere with utilization
Factors that increases nutrition requirements
Factors that cause excessive excretion
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Risk factors for malnutrition in patients with dentures Eating less than two meals/day. Difficult chewing and swallowing Unplanned weight gain or loss of more than 10lb
in the last 6 months. Undergoing chemotherapy or radiation therapy. Loose denture or sore spots under denture Oral lesions(glossitis,cheliosis,or burning tongue) Severely resorbed mandible Alcohol or drug abuse
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NUTRITION & THE DENTURE BEARING TISSUE
Nutritional deficiency (Proteins, vitamin C & D, Ca)
Alveolar ridge resorption Thin friable mucosa
ILL-Fitting denture Poor force tolerances
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ALCOHOLISM, SMOKING & DENTURE
Decrease in food intake
Multiple nutrient def Dehydration (Vit B & C)
Thinning of oral mucosa Friable oral mucosa
Abrasion of the denture bearing mucosa
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NUTRITION & OVER DENTURE
Cariogenic diet Ca++ deficiency Vit A & C def
Caries of abutment Ridge resorption Poor periodontal health Failure of abutment FAILURE OF OVER DENTURE
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Providing nutrition care for denture wearing patients Obtain a nutrition history and an accurate record of food intake over
a 3-5 day period or complete a food frequency form
Evaluate the diet: assess nutritional risk
Teach about the components of a diet that will support the oral musosa,bone health, and total body health
Help patient establish goals to improve the diet
Follow-up to support patient in efforts to change food behaviors.
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Dietary counseling for Denture wearers
Diet for the first day after denture insertion :
liquid diet
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Diet for the 2nd and 3rd day after denture insertion:
Pureed diet to soft diet
Diet for the fourth day and later:
Soft diet to regular diet as tolerated
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CONTROL OF SEQUELAE WITH USE OF COMPLETE DENTURES Every effort should be made to retain some teeth in good positions
to serve as over denture abutments. Proper patient education & good oral hygiene practices. Patient should be motivated to practice proper denture wearing
habits. Patients wearing complete dentures should follow a regular control
schedule at yearly intervals so that acceptable fit & stable occlusal condition to be maintained.
Patients wearing over dentures should follow a program of recall & maintenance for continuous monitoring of the denture and the oral tissues
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REFERENCE Prosthodontic treatment for edentulous patients-BOUCHER. Essentials of complete denture prosthodontics-WINKLER. Textbook of complete denture-HEARTWELL. Complete denture-sharry. Problems & solution in complete denture prosthodontics-DAVID J.LAMB. Clinical dental prosthetics-FENN. Principles & practise of complete denture-IWAO. Prosthodontics for elderly-BUDTZ-JORGENSEN. Txtbook of oral pathology-SHAFER. Oral lesions of interest to prosthodontics JPD1961. Oral conditions associated with dentures JPD 1958. Trouble shooting in CD prosthesis JPD 1960. Candida associated denture stomatitis Aus DJ 1998.
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