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Post Insertion Problems and Management in Complete Denture Patients
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Post Insertion Instructions, Problems and
Management in Complete Denture Patients
ƌ͘DĂǇĂŶŬZ>ƵŶŝĂ ƌ͘ĞǀŝƉƌĂƐĂĚEŽŽũŝ
Post Insertion Instructions, Problems and
Management in Complete Denture Patients
Dr. Mayank R Lunia, MDS

Department of Prosthodontics,
K.V.G. Dental College and Hospital,
Sullia, D.K., Karnataka (India)

Dr. Deviprasad Nooji, MDS
Professor,
Department of Prosthodontics,
K.V.G. Dental College and Hospital,
Sullia, D.K., Karnataka (India)

TABLE OF CONTENTS
CHAPTER TITLE PAGE
1 Complete Denture Insertion
1.1 Introduction 2
1.2 Stages of Patient Education 3
1.3 Denture Insertion Procedure 6
2 Post Insertion Instructions
2.1 Introduction 15
2.2 Instructions to the Patient Before Denture 16
Insertion
2.3 Post Insertion Instructions to the Patients 19
2.4 Instructions to the Patient Regarding 23
Denture Care
2.5 Denture Cleanser 26
2.6 Denture Adhesive 32
2.7 Post Insertion Instructions to the Partial 39
Denture Wearers
2.8 Post Insertion Instructions to the Immediate 40
Denture wearers
2.9 Post Insertion Instructions to the 42
Overdenture Wearers
2.10 Future Research Needs 43
2.11 Conclusion 44
3 Post Insertion Problems and Management
3.1 Introduction 46
3.2 Common Complaints 48
3.3 Uncommon Complaints 55
3.4 Post Insertion Problems and their 59
Management
3.5 Patient Satisfaction with Complete Dentures 74
3.6 Conclusion 76
4 Bibliography 77

1. Complete Denture Insertion
Complete Denture Insertion
1.1 INTRODUCTION
The elderly population is remarkably increasing world-wide.1 The fast growing
segment of population are in increased need of special care and attention to maintain a
reasonable quality of life in the face of disability and growing frailty in this group.1 This
might result in an increased demand for health and social services over the next quarter
century.2
Tooth loss has a direct influence on reduced masticatory function and a shift
towards a poorly balanced diet.3 This in turn will result in an increase in oral diseases
due to a deficiency in various micronutrients, leading to a uncompromised immune
status.3 This may make patients more susceptible to various infections and even
malignancies.3 Ill-fitting dentures will worsen this situation and patients may avoid
certain social activities like speaking, smiling, eating etc. in the presence of other
person.3
A dental prosthesis is defined as ³an artificial replacement (prosthesis) of one or
more teeth (up to the entire dentition in either arch) and associated dental/alveolar
structures.´ Dental prostheses usually are subcategorized as either fixed dental prostheses
or removable dental prostheses. (Glossary of prosthodontics term GPT-8)
Complete denture is defined as ³removable dental prosthesis that replaces the
entire dentition and associated structures of the maxillae or mandible.´(GPT 8) It is
indicated in edentulous patients to restore the appearance and to assist in maintaining
masticatory efficiency.3
2
1.2 STAGES OF PATIENT EDUCATION
Communication (Patient-Doctor rapport):4
Establishing good communication between doctor and patient early in treatment
can prove highly supportive. Early discussion provides clues that are useful about
expectations at the time of denture insertion. A review of the patients¶ self-image is
beneficial in predicting acceptance. Good communication should continue throughout
treatment procedures and is especially important during insertion. The ability of the
doctor to listen and his skill at translating clues offered by the patient into positive
approaches are valuable at insertion time.
Patient motivation:5-7
All patients have a ³threshold of acceptability´ that determines their response to
denture insertion. This threshold is part of the motivation mechanism of the patient,
which may be identified early in treatment. Patient acceptance of treatment and reaction
to the results of treatment are measures of his motivation. The complexity of behavioral
factors involved in motivation may cause the doctor to misinterpret patient response in
any phase of the treatment procedure, especially during the initial diagnostic
procedure.5-7
General classification based on extensive clinical experience of complete denture
patients¶ mental attitudes. The House Classification, given by Dr. Milus House is as
follows:8
3
The Philosophic Patient:
(i) Accepting of dentist and oral condition.
(ii)Ideal attitude for successful treatment provided the bio-mechanical factors are
reasonable.
The Indifferent Patient:
(i) Little concern about oral health and dentist.
(ii)Treatment insisted on by a significant other.
(iii) Gives up easily
The Critical Patient:
(i) Finds fault with everything.
(ii) Directs the treatment.
(iii) Usually have poor health leading to poor personality.
(iv)Medical consultation advisable before treatment.
The Skeptical Patient:
(i) Previous bad experience with dentist/dentures.
(ii) Poor health and unfavorable oral conditions for fabrication of dentures.
(iii)Often have a series of personal tragedies.
Behavioral factors affecting insertion:5-7
There are wide spectrum of behavioral problems associated with denture
insertion. The early satisfied patients do return after the insertion visit for only one or
two minor adjustments. At the other end of spectrum are patients who become an office
fixture. He or she can be found awaiting adjustments at frequent and short intervals. The
complaints are of excessive discomfort, usually of a general nature, poor function or of
nonspecific and bizarre symptoms that contribute to massive frustration for the patient
and dentist. Between these extremes are the average denture patients whose success
4
would eventual only due to the doctor who recognizes the problems at the earliest. Once
such recognition is accomplished, problem solving is an orderly procedure.
Complete denture insertion stage:9
Denture insertion represents the culmination of a series of carefully considered
and exacting procedures. It is also the moment eagerly awaited by the patient, who has
co-operated in both time and effort toward this event. Well-made dentures enable the
patient to have comfort, adequate function and an appearance that will further societal
relationships and participation. These are the goals of denture insertion that are usually
obtained. It is indicative of a satisfying experience to both dentist as well as patient,
amply repaying the skill and training of the former and the patience of latter.
5
1.3DENTURE INSERTION PROCEDURE
Denture insertion is not a separate and distinct from all other phases of denture
fabrication. It may be regarded as a pause in treatment to provide an overview that takes
account of all phases of treatment.5
Pre insertion denture evaluation:
Before the insertion appointment, dentures are inspected to determine
(i) That the polished surfaces are smooth and devoid of scratches.
(ii) That no imperfections on tissue surface remain.
(iii) That the borders are sound with no sharp angles in the border areas.
Steps in insertion procedure:
Evaluating patient¶s mouth5-7
The synergy between base adaptation and occlusion cannot be precisely
duplicated outside of the mouth, both because of minor distortions in the fabrication
process and because the oral tissues are dynamic. Casts of the edentulous arches only
represent the oral contours at the time the impressions were made. The insertion
appointment is the time to educate the patient on how to properly care for the new
dentures. Words of encouragement are very important to ensure success. Whenever
possible, the patient should be provided with printed material summarizing or
elaborating on the most important spoken instructions.
6
Evaluating tissue side5-7
Evaluation is done for undercut areas and accuracy of tissue contact. Before
inserting the denture, paint the entire tissue side of the denture base with a thin coat of
pressure disclosing paste followed by insertion and removal of the denture. When tissue
undercuts are present, the paste will be dragged from the denture base in the area of
tissue contact. When undercut area is positively established, relieve the denture by
grinding with an acrylic bur. Repeat the procedure until adequate relief is assured.
Smooth the altered surface. Areas of exostosis or areas of bone covered with tissue that
is not displaceable, such as mid-palatal suture often appear as pressure areas even when
the denture is seated with very little pressure. The altered area is not smoothened until
the denture is subjected to the pressure of occlusion and are can see that no further relief
is required.
Evaluating borders5-7
Evaluate the borders and the contour of the polished surfaces in the mouth to
determine if
(i) The border extensions and contour are compatible with the available spaces in the
vestibules.
(ii) The borders are properly relieved to accommodate the frenum attachments and
the reflection of the tissues in the hamular notch area.
(iii)The dentures are stable during speech and swallowing. Apply disclosing wax to
the borders of the maxillary denture in the same manner as the green stick
compound was applied during the border refining procedures. Instruct the patient
to open the jaws as in yawning, push the lower jaw forward, and move the lower
jaw from right to left. Disclosing wax is more displaceable than softened
7
compound; therefore slight overextensions that might be developed with
compound can be determined. Relieve any existing over extensions by grinding;
polish the relieved area. The same procedure is done for all areas of both
dentures.
Evaluation of denture support5-7
Denture support can be evaluated by applying disclosing paste to inner portion of
the denture and then seating it with considerable finger pressure over the posterior teeth.
When evaluating support, occlusal contact should not be used to apply force, since it
would superimpose any occlusal discrepancy that may exist. Support can also be
evaluated by seating the denture and applying finger pressure in a tissue-ward direction
alternately on one posterior occlusal section and then on the other.
Evaluation of stability5-7
It can be evaluated by grasping the denture and attempting to rotate or displace it
laterally. The amount of movement must be considered relative to the shape and
character of the supporting structures. To evaluate the stability of lower denture, apply
pressure on premolar and molar region on one side of arch, rise of denture on the other
side indicates instability.
The causes could be:
(i) Teeth set outside the ridge or lack of denture base on pressure side.
(ii) Under-extended flange on the non-pressure side.
8
Evaluation of retention5-7
Maxillary denture retention:
Retention of the maxillary denture can be assessed by two methods. When the
denture is grasped by the incisors and pulled downward between thumb and forefinger,
there should be resistance to displacement. Placing fingers on the palatal surface and
pulling forward is a second method for checking retention. Again, there should be
resistance to displacement.
Mandibular denture retention:
The retention of the mandibular denture is assessed by gently pushing posteriorly
against the facial surfaces of the mandibular incisors. The denture should not become
dislodged. Pressure indicating paste should be used to recheck the adaptation to the
bearing tissues of both upper and lower prostheses, even if retention seems acceptable.
Small areas of excess pressure can disrupt occlusal harmony or lead to ulceration that
erodes patient acceptance of the prosthesis.
Thereby, it can be summarized as follows:
(i) Retention can be evaluated for the maxillary denture by applying an upward and
anterior force on the palatal aspect of the anterior teeth to indicate the efficiency
of posterior border seal.
(ii) Buccal force on palatal aspect of the posterior teeth on one side indicates the
degree of border seal on the opposite side of mouth.
(iii) Retention in the posterior portions of the mandibular denture can be evaluated by
applying a downward and anterior force on the lingual aspect of the anterior
teeth.
(iv) Anterior retention of mandibular denture can be evaluated by applying a
superiorly directed force. Both retention and stability can be evaluated further by
9
placing a trial addition of low-fusing modeling compound on the suspected area
of deficiency. An increase in retention or stability or both after this temporary
addition confirms the location of the deficiency and indicate that improvement it
can be made.
Occlusal correction5-7
Occlusal harmony in complete denture is necessary if the dentures are to be
comfortable, to function efficiently and to preserve the supporting structures. It is
difficult to see occlusal discrepancies intraorally with complete dentures. The resiliency
of the supporting tissues and the displaceability of the tissues in varying degrees tend to
disguise premature occlusal contacts. The tissues permit the dentures to shift. As a result,
after the first interceptive occlusal contact, the remaining teeth appear to make
satisfactory contacts. At this stage minor interferences may be corrected.
Checking the occlusion with wax:
A variety of techniques can be employed for checking the dentures¶ occlusion.
Occlusal indicator wax is a soft, dark wax with an adhesive surface that is applied to the
mandibular posterior occlusal surfaces bilaterally. After the patient has been instructed to
occlude, three dimensional impressions of the cusps of the opposing tooth contacts will
be visualized as light areas in the dark wax. Isolated contacts that have penetrated the
wax represent premature contacts and should be adjusted, after which the occlusion is
checked again. This process continues until all contacts represent similar degrees of
penetration into the wax.
10
Checking the Occlusion with Articulating Paper and Paper holder:
Two pieces of occlusal marking paper or a single ³horseshoe´ articulating paper
is inserted intraorally, placed over the mandibular teeth and the patient is instructed to
gently bite together once and release. Ideally, the desired inter-occlusal scheme will be
represented by the contact marks. However, owing to subtle changes in the denture bases
and intrinsically unavoidable distortions occurring during processing, only a small
number of contacts will appear. These should be recognized as pre-maturities, adjusted
and the occlusion checked again. This process continues until the desired pattern is
achieved. After one or two passes, if contacts still only appear unilaterally or bilaterally
but exclusively anteriorly or exclusively posteriorly, a laboratory remount will be
required for proper adjustment of both centric and eccentric contacts.
Complete denture insertion (Denture fit-in)9
The following critical requirements shall be met:
(i) Esthetic requirements are met.
(ii) Predetermined occlusal vertical dimension is maintained.
(iii)Predetermined freeway space is evident.
(iv) Centric occlusion demonstrates repeatable maximum inter-cuspation of maxillary
and mandibular teeth.
(v) All eccentric relations demonstrate bilateral balance occlusion. (Optional)
(vi) Denture is retentive and stable.
(vii) Patient has relative phonetic freedom.
11
Patient education regarding complete dentures10,11
Some people experience difficulties with their natural teeth and believe that
having them extracted and getting dentures will solve all their problems. For some
patients with dentures that fit perfectly and they won't have to worry about their teeth
again. However, some have lifelong problems with their dentures. The following
information, concerning some of the challenges a person might face with the placement
of dentures, may be helpful:
(i) Some of the difficulties and problems associated with wearing dentures include:
difficulties with speaking and eating, food under dentures, function, loose
dentures, lack of retention, need for adhesives, feeling of fullness, poor ridge
relationship (i.e. Class II) as well as the probable need for future relines and
remakes.
(ii) It is necessary for immediate dentures to be relined or remade, usually within six
months.
(iii) Dentures fabricated within six to eight weeks after tooth removal frequently need
to be relined or remade before one year, due to continued bone resorption. This is
especially true for patients with a history of periodontal disease or extensive ridge
surgery. As shrinkage from bone loss is unpredictable and varies for individuals,
patients are usually charged for any laboratory relines or remakes.
(iv) The average denture usually requires a laboratory reline or remake at least once
in every four years, due to functional wear and/or continued bone resorption. This
bone resorption will continue throughout the patient's lifetime, making
subsequent denture construction more difficult, less satisfying and less
comfortable for the patient than their previous denture experience.
12
(v)Dentures should not be considered a replacement for teeth. They are a
replacement for no teeth. Dentures are prosthetic appliances, not real teeth, made
to imitate the function of teeth as closely as possible. However, most people end
up with about 20% efficiency of their natural teeth.
13
2. Post Insertion Instructions
Post Insertion Instructions
2.1 INTRODUCTION
Patient education is the prosthodontic service that refers to giving complete
information and instructions to a complete denture patient in the use, care and
maintenance of the prosthesis.5
Communication is the basic medium of education and can be encouraged by
establishing a feeling of trust between the doctor and his patients. By careful listening
and observing, the dentist learns about the patient¶s problems and expectations regarding
denture, his emotional and physical conditions, the health and adequacy of his oral
tissues and associated structures and whether the present dentures are fulfilling the needs
of this patient.
A willingness to instruct the patient in the care and use of his dentures and an
understanding of his desires are essential to assure a successful prognosis. An informed
patient will realize when his dentures require attention and will seek treatment before an
ill-fitting denture damages the oral tissues. Therefore, a patient should be educated to
understand his responsibility in denture service5-7
15
2.2 INSTRUCTIONS TO THE PATIENT BEFORE DENTURE
INSERTION
Oral and general conditions complicating use of complete denture
Educating a prospective denture patient about his/her oral status and systemic
conditions as they apply to his/ him is absolutely necessary.
Diabetes mellitus. Diabetic patients show an abnormally high rate of bone resorption
with decreased tissue tolerance and delayed wound healing. Such patients should be
informed about frequent oral examinations, denture adjustments and relines along with
effective oral hygiene.12
Arthritis. These patients should be made aware that occlusal relationship may change as
a result of their disease and that limited jaw function may follow.13
Anemias. Mucositis, glossitis and angular cheilitis decrease the tolerance to a foreign
body in the mouth. Patients should be counseled about the diet and pharmacotherapy.13
Neuromuscular disorders. Lack of neuro-motor skill and control can result in
instability of the denture base. The use of a denture adhesive may be advised in this type
of patients.13
Menopause. Post-menopausal osteoporosis results in excessive alveolar bone resorption
and chronic tenderness of oral tissues. This condition requires diet modification,
pharmacotherapy and use of soft liner.14
Other conditions.14
i. Patients who have problems where surgery is either contraindicated or surgery
cannot be performed can complicate the use of dentures.
ii. Patients who cannot control tongue and jaw movements due to wasting or
muscular incoordination.
16
iii. Macroglossia or microglossia can result in loss of peripheral seal and loss of
retention and stability.
iv. Patients who do not accept their responsibility in spite of excellent prosthodontic
treatment.
v. Patients with adverse mental attitude and lack of mental capacity to adjust to the
treatment.
Patient education impression and jaw relation recording procedures15-16
Considerable instruction may accompany impression making and brief concise
explanation of the impression technique should be given with proper emphasis on the
role of the patient in that procedure. Dental education should include a discussion on the
harmony and beauty of the human face. Diagnostic casts, facial measurements, old and
recent photographs, profile records and the patients old dentures if available can be
employed to illustrate the discussion.
Patient education at the try-in15-16
At the try-in stage, the dentist should instruct the patient carefully that denture
teeth should be shaded and have embrasures and diastemas to simulate natural
appearance. Dentist should explain that the denture will seem to be bulky at the try-in
stage. The patient should be given a mirror and instructed to speak and count. Each
patient should be accompanied by a close friend or relative at the try in. It is absolutely
necessary to obtain the complete consent and satisfaction of the patient before
proceeding with the construction of the dentures.
17
Patient education at the denture insertion stage15-16
The denture insertion appointment represents a marked transition in complete
denture treatment. From this point forward, the here to fore dentist-directed care
becomes patient-directed as the patient experiences new sensations and reports those that
are unexpected or intolerable to the dentist for remedy. For this reason, at the insertion
appointment, the dentist must employ both technical and interpersonal skills in order to
place the patient on a trajectory toward success. The technical quality of the prosthesis
must be of the highest possible caliber and the patient must be prepared psychologically
for what will accompany insertion.
18
2.3 POST INSERTION INSTRUCTIONS TO THE PATIENTS
Adjustment period17-18
Following the insertion of new dentures there is a variable period (generally 2-6
weeks) during which patients must adjust and accommodate. New dentures often feel
bulky and awkward at first. Soft tissues of the mouth, now covered, may have been open
or left uncovered by a previous denture. This strangeness, although bothersome, is a
temporary problem that is usually resolved during the adjustment period.
Appearance19
Nervous patient at the time of insertion has a strained facial expression because
he has not been prepared psychologically for the denture. The facial expression may
seem slightly altered and it takes time for the muscles and lips to relax and assume their
natural position around the dentures.
Speech7,20
At first, there is a feeling of full mouth and a crowding of the tongue as the
dentures have altered the shape of the mouth. Patient will be conscious of something in
the mouth that was not there before and he/she will have to learn to speak. Because the
new artificial teeth may be placed in slightly different relationships and the plastic
denture base may feel bulky, speech patterns are often temporarily interrupted.
However, as soon as the lips, tongue and cheeks have been accustomed to the
dentures (as the muscles of the tongue, lips and cheek must learn to coordinate
movement to allow normal speech) and new muscle habits are formed, this difficulty is
overcome easily. A good way to learn to speak is by reading aloud before a mirror since
19
it is a way to minimize the time required to recover normal speech patterns and carefully
enunciating each syllable. The learning process can be enhanced by practice. Practice
and patience resolves all difficulties. Continued difficulty should be brought to the
clinician¶s attention.
Dentures wearing at night21
There is no question that the healthiest policy is to remove the dentures for at
least six hours daily to allow the soft tissues to breathe and recover. For most patients,
the most convenient way to accomplish this is to remove the dentures during sleep.
While out of the mouth, the dentures should be soaked in water or a denture cleaning
solution. Such a practice will maintain much healthier oral tissues, preserve the ridges
and the underlying bone, and allow the dentures to fit properly for a longer period of
time. Those patients who suffer discomfort and loss of sleep after removal of dentures,
may provide short periods of rest to oral tissues during the day.
Hypersalivation22
Soon after the insertion of dentures, salivary flow is stimulated which declines
after 2-3days unless something is physically wrong with the dentures which can cause
irritation. The glands try to wash out the strange ³foreign body´. Simply swallowing the
saliva more often is the best remedy and in a few days, the salivary glands will adjust
themselves to the presence of dentures and resume normal function.
20
Chewing with dentures17,18,23-25
Again, it will take practice to learn to eat a fairly normal diet with the
introduction of new dentures. During the first several days, soft diet are recommended.
Avoid having tough, hard and sticky food initially.
Some points to remember regarding chewing habits:
i. Eat slowly and cut food into small pieces.
ii. Although the normal tendency is to chew on one side or the other, denture
wearers may function better by chewing food on both sides over the back teeth at
the same time. This helps to balance the forces on the denture.
iii. Avoid bringing the lower front teeth forward and against the upper front teeth to
cut or incise foods. This protects the delicate upper front ridge and prevents
tipping of the denture.
iv. If it is necessary to bite using the front teeth, try spreading the tongue against the
back of the maxillary denture to keep it in place.
v. Try to chew vertically (up and down) rather than horizontally (side to side).
vi. Learning to eat with dentures takes time and requires positive effort from the
patient side.
Maxillary versus mandibular dentures5
Patient¶s should be advised that his/her maxillary denture will rest comfortably in
place with moderate-to-strong ³suction´. Although mandibular denture will have good
stability, it is infrequent that ³suction´ can be expected on a mandibular denture.
Tenderness17
The patient will experience some tenderness and discomfort from the dentures
during the first
21
few weeks. The reason is that the mucous membrane of the mouth is vulnerable and not
evolve to bear stresses placed upon them by the dentures. New dentures will require
some adjustment. The patient should be told to wear the denture continuously for the first
24 hours and then immediately report to the dentist. Any irritations or impingements can
be detected easily and corrected. Later he should be instructed to only wear the dentures
at daytime without using them for eating. After 1-2 weeks he can start with soft chewy
foods and then as the ridges get accustomed to pressures, he can resume his daily diet.
Parafunctional habits such as clenching and grinding should be avoided.
Denture soreness5,7
New dentures almost always cause some sore spots. These will be relieved during
the first few post-insertion appointments. Clinicians recommend soft foods during the
first few days. The best home treatment between appointments for sore spots is to rinse
with warm salt water.
Denture life-span5,6
Ideally 5-7 years is the average life span of a well-made denture. As time passes,
the tissues and bone that support the denture will resorb. Generally, the denture will
require reline every couple of years to maintain an ideal fit. Every patient is unique and
as result, every denture case is particular to that patient. It is important to keep in mind
that not everyone can wear a denture successfully. Variable factors include anatomical
shape of mouth, strength of muscles and presence/absence of saliva, quality of mucosa,
psychological tolerance.
22
2.4 INSTRUCTIONS TO THE PATIENT REGARDING DENTURE CARE
How to insert denture26
Denture insertion is a topic requiring patient instruction at the insertion
appointment.
However, there are three possible exceptions to this rule:
i. First time denture wearers may want to know if it matters which prosthesis is
inserted first. A patient asking about this should be reassured that the order of
insertion does not matter, unless there is virtually no retention to the maxillary
denture. In this case the mandibular denture should be inserted first.
ii. If the patient has significant undercuts in the retro-mylohyoid space, instruction
should clarify the mandibular denture needs to be positioned posterior to its
ultimate position to seat the posterior segment and then the prosthesis brought
anteriorly and then fully seated.
iii. If the patient suffers from cognitive dysfunction due to stroke or Alzheimer¶s
disease (or other types of dementia), it may be impossible for him/her to initially
distinguish maxillary and mandibular denture and/or to position a prosthesis over
the ridge. In such an event, the dentist needs to work with both the patient and the
caregiver who will be able to reinforce the information away from the office. It
should be stressed that for some patients, use of a mirror will actually make the
process more difficult, whereas it may ease matters for others.
How to remove denture or break the peripheral seal26
Patients with no prior familiarity to remove a denture should be instructed to
break the seal by running one or both fingers along the full length of the flanges or by
puffing out the cheeks.
23
Guidelines for the care and maintenance of complete dentures27
In 2009, the American College of Prosthodontists (ACP) formed a task force to
establish evidence based guidelines for the care and maintenance of complete dentures.
i. Careful daily removal of the bacterial biofilm present in the oral cavity and on
complete dentures is of paramount importance to minimize denture stomatitis and
to help contribute to good oral and general health.
ii. To reduce levels of biofilm and potentially harmful bacteria and fungi, patients
who wear dentures should do the following:
a. Dentures should be cleaned daily by soaking and brushing with an effective,
nonabrasive denture cleanser.
b. Denture cleansers should only be used to clean dentures outside of the mouth.
c. Dentures should always be thoroughly rinsed after soaking and brushing with
denture cleansing solutions prior to reinsertion into the oral cavity. Always
follow the product usage instructions.
iii. Dentures should be cleaned annually by a dentist or dental professional using
ultrasonic cleansers to minimize biofilm accumulation over time.
iv. Dentures should never be placed in boiling water.
v. Dentures should not be soaked in sodium hypochlorite bleach, or in products
containing sodium hypochlorite for more than 10 minutes.
vi. Dentures should be stored immersed in water after cleaning to avoid warping.
vii. Denture adhesives can improve the retention and stability of dentures and help
seal out the accumulation of food particles beneath the dentures, even in well-
fitting dentures.
24
viii. Improper use of zinc-containing denture adhesives may have adverse systemic
effects. Therefore, as a precautionary measure, zinc-containing denture adhesives
should be avoided.
ix. Denture adhesives should be completely removed from the prosthesis and the
oral cavity on a daily basis.
x. If increasing amounts of adhesives are required to achieve the same level of
denture retention, the patient should see a dentist or dental professional to
evaluate the fit and stability of the dentures.
xi. It is recommended that dentures should not be worn continuously (24 hours per
day) in an effort to reduce or minimize denture stomatitis.
xii. Patients who wear dentures should be checked annually by the dentist for
maintenance of optimum denture fit and function, for evaluation for oral lesions
and bone loss and for assessment of oral health status.
Recall appointments28
Patients with complete dentures have lower awareness of preventive dental behaviors.
A deliberate and proactive effort must be made to bring them back to the practice
annually for a recall. This is important to re-evaluate and revise the prostheses and to
assess the health of the oral cavity. Patients must be educated that annual recall
appointments are important to ensure the sustained optimal fit and function of their new
prosthesis as well as for the maintenance of mucosal health. These considerations are
particularly important for patients employing denture adhesive because the use of such
product can modify or eliminate customary cues for returning to the dental office.
25
2.5 DENTURE CLEANSERS
Ideal denture cleanser29
i. It should demonstrate anti biofilm activity and should be anti-bacterial as well as
anti-fungal.
ii. It should be non-toxic.
iii. It should be compatible with denture materials and should not modify (roughen)
or degrade the surface of the acrylic resin denture base or prosthetic teeth.
iv. It should be short acting (8 hours).
v. It should be easy to use for the patient or caregiver.
vi. It should have an acceptable (or no) taste.
vii. It should be cost effective.
Three literature reviews on denture cleansers were identified by the task force.
Abelson¶s review focused on the literature published between 1936 and 1983.29This
review described the nature of denture plaque and its role in oral disease. Additionally,
he reviewed the development of denture cleansers, their mechanism of cleansing and
their efficacy. The review suggested that the use of abrasive pastes may be the most
efficacious method of denture cleansing. He also suggested hypochlorite solutions were
highly effective but potentially damaging to prostheses and that new standards for
evaluating denture cleansers were needed.
A second review by Nikawa et al30 focused on the literature published between
1979 and 1995. This review covered more than 20 articles that evaluated the efficacy of
denture cleansers and determined that the results obtained were highly dependent on the
methods used to evaluate the selected cleansing methods. Nikawa et al30, like Abelson29,
called for the development of a standardized method for evaluation of denture cleansers.
26
Third, a Cochrane Review on interventions for cleaning dentures was recently published
by D¶Souza et al31. After careful comparison of the six clinical trials in this cochrane
review the authors suggested that there was no evidence that any denture-cleaning
method is more beneficial than others for the health of the denture-bearing tissues or has
a higher level of patient satisfaction or preference than that of others.
Brushing with denture creams and pastes
Three in vivo studies considered the efficacy of denture paste in biofilm removal.
Dills et al32 suggested that brushing with a denture paste was inferior to use of an
effervescent cleaner or to use of the same cleaner followed by paste brushing. Panzeri et
al33 demonstrated that brushing with two types of pastes (one antibacterial and one with a
fluoro surfactant) reduced the biofilm mass when compared with brushing with water;
however, brushing with either paste had no impact on Candida species colonization.
Barnab´e et al34 compared brushing the dentures with coconut soap followed by soaking
it in sodium hypochlorite solution for 10 minutes to brushing with soap and soaking in
water. This cross-sectional study indicated that both treatments reduced the levels of
denture stomatitis. but neither treatment reduced the levels of Candida species cultured
from the prostheses. Thus, Candida species appears to be resistant to mechanical
debridement from the denture base.
Soaking and brushing with commercially available denture cleansers (effervescent
tablets)29
Commercially available denture cleansers use various active agents including
hypochlorite, peroxides, enzymes, acids and oral mouth rinses to remove biofilm from
dentures. Each of these immersion cleansers has a different mode of action and they
27
differentiate in efficacy for removal of adherent denture biofilms. While the denture
cleaning methods tested were capable of reducing the biomass present on dentures over
the various time courses evaluated, none of the in vivo trials reviewed demonstrated that
any of the methods used was bactericidal.
Ultrasonic cleaning35,36
Ultrasonic cleaning of dentures occurs frequently in both the dental office and the
dental laboratory. The mode of action of ultrasonic devices is unique in that they produce
ultrasonic sound waves (20 to 120 kHz), which create microscopic cavities (bubbles) that
grow and implode. This implosion creates voids that result in localized areas of suction.
Materials adhering to the denture are loosened and removed by this action. This action is
commonly known as ³cavitation.´ Two representative types of solutions that are
commercially available for use in the ultrasonic cleaner are Bio-Sonic Enzymatic
(Coltene-whaledent) which contains non-ionic detergents, protease enzymes and 400
parts per million isopropyl alcohol and Ultra-Kleen (Sterilex) which requires the mixing
of two solutions that results in the formation of an alkaline-peroxide cleanser.
Interestingly, the ultrasonic cleaning demonstrated remarkably improved kill
rates of bacteria but none of these two solutions tested were completely bactericidal. The
literature review indicated that the use of other commercially available denture cleansers
in conjunction with ultrasonic cleaning in the dental office has not been investigated.
Precautions associated with use of denture cleansers36
In 2008, the U.S. Food and Drug Administration (FDA) issued a requirement for
manufacturers of denture cleansers to revise their labeling regarding contents and to
consider alternatives to the types of ingredients present in this class of products. This
28
action was in response to 73 severe reactions including at least one death linked to
denture cleansers. The specifically identified ingredient persulfate is known to cause
allergic reactions. Persulfates are used in denture cleansers as part of the cleaning and
bleaching process.
Symptoms due to hypersensitivity to persulfates include:
i. Irritation of the tissues
ii. Tissue damage
iii. Rash
iv. Hives
v. Gum tenderness
vi. Breathing problems
vii. Low blood pressure
The Food and Drug Administration (FDA) noted that other reactions may be the
result of misuse of the product by patients. The requirement specifically involves
labeling revisions to ensure denture wearers understand that these products are for use
only when the dentures are outside the mouth.
Symptoms due to to misuse of the denture cleansers include:
i. Damage to the esophagus
ii. Abdominal pain
iii. Burns
iv. Low blood pressure
v. Seizures
vi. Bleaching of tissues
29
vii. Internal bleed
viii. Nausea and vomiting
Alternative denture cleansing methods36
Microwave irradiation of dentures immersed in sterile water at 650 Watts for
three minutes sterilizes dentures without causing surface degradation of the prosthesis.
However, the long-term effects of this technique have not been investigated.
Using products specifically designed for denture cleaning
i. Brushes specifically designed for denture cleaning should be recommended.
These feature a wide handle for easy gripping, stiff bristles of one length on one
side of the head (for use against broader, flatter denture surfaces such as facial,
palatal, and lingual surfaces) and bristles set in a pyramidal arrangement on the
other side (for cleaning the tissue surface of the denture).
ii. Patients should be cautioned not to use toothpaste (other than toothpaste
specifically designed for use on dentures) as the high abrasivity of non-denture
toothpaste will scratch denture base and acrylic teeth, thereby dulling and
removing anatomic and esthetic details from the denture surface.
iii. Daily soaking in cleanser specifically designed for dentures is recommended for
assuring cleanliness and eliminating odors. Patients should be cautioned to rinse
the denture thoroughly after soaking to avoid ingesting traces of caustic cleaning
agents.
iv. Mouth should be rinsed after having food and dentures should be cleansed with a
small hand brush using soap and cold water. Gritty or abrasive powders or paste
should never be used as they remove the gloss and cause scratches which abrade
30
the surfaces and destroy the fit of the dentures. While cleaning, the dentures
should be held over a basin of water to prevent breakage in case of accident from
the hands.
v. Commercial denture cleansers are available in tablet and powder forms. They are
dissolved in the water and dentures are soaked overnight and brushed in the
morning. If the dentures are left out of the mouth for any length of time, they
should be placed in a clean water. This affords them safe and effective storage.
31
2.6 DENTURE ADHESIVE
Introduction
Clinical data shows that proper use of denture adhesive can enhance retention,
stability, bite force, and the patient¶s sense of security with even a well-fitting denture.
Dentists are the clinical experts of the mouth and should take the initiative to educate
their denture patients about these products before the patients acquire incomplete or
inaccurate information about these and related products from other less reliable sources.
Denture adhesives should be discussed in detail at the insertion appointment with all
patients who the dentist perceives will need the psychological or functional benefits of an
adhesive product.37
Patients with additional indications for using denture adhesive, such as those with
expectations for their dentures that exceed anatomic limitations, those who place extreme
demands on their prostheses or those coping with maladaptive anatomic and/or
physiological states should be identified in advance and instructed at the insertion
appointment about denture adhesive to enhance satisfaction with the newly inserted
denture. Patients who use denture adhesive should always be enrolled in a recall
schedule because less formal triggers for returning to the dentist, such as loosening of
dentures due to normal anatomic and physiologic changes over time may be obscured by
the use of adhesive.37
Denture adhesive38
Denture adhesive is a non-toxic, water-soluble material that is placed between the
denture and the tissues to enhance the normal physiological forces that hold dentures in
place. Dentures ³adhere´ to tissues because saliva adheres to both the denture and the
32
tissue. Denture adhesive does a superior job of adhering to both surfaces, thereby
improving retention. Dentures also ³cohere´ to tissues because the film of saliva between
tissue and denture resists being pulled apart. But the coherence of denture adhesive is far
greater than the coherence of saliva.
Commercially available denture adhesive formulas vary by product, but all
exhibit dramatically enhanced coherence and adherence in the presence of saliva or
water.
Indications38
i. To enhancing patient satisfaction with a properly constructed denture. Denture
adhesive can be particularly beneficial to patients who place severe demands on
their prostheses such as musicians, public speakers, teachers, social workers etc.
ii. Those who feel the need for the additional sense of security conferred by use of
the product.
iii. Denture adhesives are particularly useful for mal-adaptive patients such as those
who have severely compromised residual ridge morphology, xerostomia,
undergone maxillofacial jaw resection or are neurologically compromised due to
stroke, multiple sclerosis, or closed-head injury.
Contraindications38
i. Patient with open cuts or sores in mouth.
ii. Patient having an ill-fitting denture.
iii. A denture that has not recently been evaluated by a dentist.
iv. A patient who cannot or will not maintain adequate oral and prosthesis
hygiene.
v. A patient with a known allergy to any product ingredient.
33
Products acceptable to use as denture adhesive38
The various over-the-counter denture adhesives available to enhance the retention
and stability of prosthesis are all intended to improve function and patient satisfaction.
They vary in their formulations, their physical form (powders versus creams) and in their
performance (strength and longevity). They all share a common property of being
soluble in saliva and water. They flow under the pressure and evenly distribute the
occlusal forces on tissue bearing surfaces.
Creams offer immediate adherence that is enhanced when the product interacts
with saliva.
Powders must be applied to a moist denture and it exhibits ³hold´ only once
some water is absorbed. Both powders and creams work identically once they imbibe
water. They flow (like any liquid) under pressure thereby, move away from areas of tight
fit and concentrate where the prosthesis is not as intimately adapted to the bearing
tissues. For this reason, soluble adhesive itself is unable to cause denture trauma.
Products to avoid as denture adhesive38
Denture pads, synthetic wafers or adding thickness of unyielding material
contribute uneven load on tissue bearing surfaces. Patient must be educated to avoid
products that are insoluble. These products are unable or limited in their ability to flow
under pressure and thereby, exert adverse tissue pressures when interposed between a
denture and the bearing tissues. The most dangerous among these are the ³do-it-yourself´
reline materials, which irreversibly alter the fitting surface of the denture and can cause
severe hard and soft tissue damage.
34
Application of denture adhesives38
The following clinical technique has been advocated by several manufacturers of
denture adhesives for proper application to the denture base:
i. Clean and dry the intaglio (tissue side) surface of the dentures.
ii. For the maxillary denture, apply three or four pea-sized increments of denture
creams to the anterior ridge, midline of the palate, and posterior border.
iii. For the mandibular denture, apply three pea-sized increments of denture cream
to several areas of the edentulous ridge.
iv. If using powder adhesive (instead of cream as noted above), wet the base with
water. Apply a thin film of powder to the entire tissue-contacting surface and
shake off any excess.
v. If using pad adhesives, place the correct size onto the denture and cut off any
excess that extends beyond the denture border with sharp scissors.
vi. Seat the dentures independently. Hold each firmly in place for 5 to 10 seconds.
vii. Remove any excess material that expresses into the cheek or tongue space.
viii. Bite firmly to spread the adhesive and remove any additional excess that
expresses into the cheek or tongue spaces.
ix. Use the minimum amount necessary to provide the maximum benefit.
Cream adhesive application:38
Maxillary denture38
On a clean denture (wet or dry) three short strips of product are applied. One at
the crest of each of the ridge areas and one down the center. An alternative is to apply a
series of very small dots of product, evenly spaced. Material should be placed no closer
than 5 mm to a denture border.
35
The patient should insert and press the denture firmly in place and hold briefly.
Mandibular denture38
For the mandibular prosthesis, a short strip is placed in the depth of the left, right
and anterior ridge areas or small dots are evenly spaced. As with the maxillary denture,
the prosthesis must be clean but the product can be applied to either a wet or a dry
surface. The patient should insert and press the denture firmly in place and hold briefly.
The recommended method for applying powder adhesive is to sprinkle a thin uniform
layer throughout the moistened tissue-bearing surface of the clean denture. Excess
powder is shaken off and the denture is pressed into place. Whether using a cream or
powder denture adhesive, the patient should wait briefly (10-20minutes) before drinking
hot liquids or before chewing in order to allow the adhesive to attain its full cohesive and
adhesive strength.
Removal of adhesives from the intaglio surface of dentures
Sato39 compared the ability of edentulous patients to remove an experimental gel
and commercially available cream adhesive from both the intaglio surface of the denture
and the maxillary soft tissues. The authors colored the adhesive with 0.4% indigo
carmine to allow identification of the adhesive by the patient to facilitate its removal, and
also evaluated the patient¶s ability to remove the adhesive from the maxillary soft tissues
using a standardized five-stage method. Each stage involved the use of an undetermined
mouth rinse followed by application of cotton gauze or rinsing with hot water (700 C) for
two minutes. Each technique was repeated five times by each patient. The authors found
that repeating the process five times did not remove the cream adhesive while a single
stage completely removed the experimental gel adhesive.
36
To remove dentures containing adhesive Patient should
i. Cautiously break seal at borders with finger.
ii. Puff out cheeks.
iii. Hold warm liquid in mouth.
iv. If denture removal is resisting customary efforts, a patient should vigorously
swish with warm water for a minute or more before repeating removal attempts.
Following extended rinsing, alternating cheek puffing (the P! sound) with firm
downward force applied by finger to the most disto-facial flange area will
retrieve the prosthesis.
Denture hygiene when denture adhesive is being used38,39,40
Daily removal of the denture adhesive from the denture is important for tissue
health. Soaking the prosthesis overnight in water will loosen the adhesive material and
allow it to be readily rinsed off. Alternatively, scrubbing the tissue surfaces of the
denture under warm water will remove adherent product. Finally, when adhesive is
supplemented in the course of the day, all remaining material should be thoroughly
removed prior to adding additional material.
Advantages of using denture adhesive38
Clinical trials were identified and reviewed that focused on the use of denture
adhesives relative to their effect on denture retention, stability, movement, bite force,
ability to chew test foods, food occlusion or patient satisfaction. Most of these studies
were of short duration (same-day evaluation). Some trials randomly allocated patients to
various experimental groups (depending on numbers of adhesives investigated) and most
investigated effects on the maxillary denture only.
37
Despite limitations, several studies yielded results indicating that denture
adhesives improved retention and stability of both ill-fitting and well-fitting dentures.
Some studies measured the adhesive-related improvement in retention and stability and
showed more improvement in old or ill-fitting dentures than in new prostheses.37-56
The use of denture adhesives has been reported to significantly improve the bite
force compared with using no adhesives. Rendell and colleagues evaluated chewing rates
in denture wearers using a multichannel magnetometer tracking device and found that
the mean chewing rates increased after application of denture adhesive.51 They also
found that chewing improved immediately after applying the adhesive and continued to
increase after two to four hours.51
Toxicity of zinc-containing denture adhesive57,58
The most serious of the chronic and excessive use of denture adhesive reported to
date is potential neurotoxicity related to the presence of zinc as a component of the
adhesive. Zinc is an essential mineral normally found in some foods or used as a dietary
supplement. It is involved in numerous aspects of cellular metabolism. The daily
recommended allowances for zinc are 8 mg for women and 11 mg for men respectively.
Acute overdose can lead to nausea, vomiting, loss of appetite, cramps, diarrhea and
headaches. Tolerable upper limits of zinc have been recommended at 40 mg per day.
Unfortunately, material safety datasheets for denture adhesives do not list the specific
amounts of zinc contained by the adhesives. Case-series studies by Nations et al57 on

al58
four patients and by Hedera et on 11 patients identified patients experiencing
progressive neurological symptoms (myelopolyneuropathy) following extended chronic
overuse of zinc-containing adhesives. This misuse of the adhesives by the patients
resulted in hypocupremia and hyperzincemia with resultant neurological symptoms.
38
2.7 POST INSERTION INSTRUCTIONS TO THE PARTIAL
DENTURE WEARERS
Partial denture patients may follow many of the same guidelines outlined as that
of complete dentures stated above. Additional points include the following:59
i. Do not use Clorox (bleach) based cleaner. It may corrode metal clasps.
ii. Do not bite the appliance into place. This may loosen and break the clasps and
teeth.
iii. Avoid biting against maxillary anterior artificial teeth as they may break rather
easily.
39
2.8 POST INSERTION INSTRUCTIONS TO THE IMMEDIATE
DENTURE WEARERS
1. Do not smoke for at least 5 days after surgery. The chemicals and gases in
tobacco smoke contain ammonia, hydrogen cyanide, lead, nicotine, pesticides,
radioactive polonium and many other deadly gases. If patient insists on smoking:
5-7,60
a. Patient will greatly increase and prolong pain and healing time.
b. Patient will have a four times greater chance of developing a µdry-socket¶.
c. Patient will significantly increase chance of infection.
2. If several teeth have been extracted then swelling, bruising, and discomfort are
normal and if the surgery was difficult, all these symptoms will be greater. Apply
ice extraorally intermittently and take analgesics to help reduce discomfort. 6,7,60
3. The dentures will act as a bandage and help to limit bleeding. However, some
bleeding for the first 24 to 48 hours is normal. Even a few drops of blood will
redden saliva. 6,7,60
4. Patient must keep the dentures in mouth for 24 hours after surgery. Pain
experienced because of the extraction of teeth will not be decreased by removing
the dentures but swelling may happen and he may not be able to get the dentures
back in his mouth. 6,7,60
5. Patient¶s bite (the way maxillary and mandibular teeth come together) usually
will be imperfect when he first gets dentures. Major imperfections will be
corrected at the time of insertion. The final refinement cannot be completed until
swelling has disappeared (one to two weeks). 6,7,60
40
6. Diet for the first 24 to 48 hours should be liquid. Gradually increase the substance
of your diet as healing progresses and he/she can tolerate firmer foods. 6,7,60
7. One to two weeks after surgery, he should begin removing the dentures at night.
Removing the dentures will allow the tissue to rest from the pressure of the
denture and help keep oral tissue healthy and preserve the bone under the tissue
for a longer period of time. 6,7,60
8. As initial adjustments are made and healing progresses, he/she will notice an
improvement in comfort and function of the denture. However, the remaining
tissue and underlying bone will continue to remodel rapidly for 6 to 9 months and
denture will gradually become looser. If a treatment reline was placed at the time
of surgery, this is only a temporary, and may need to be replaced periodically
until the dentures are relined with a hard plastic reline by the dentist who
originally made them. 6,7,60
9. Be sure to follow these instructions carefully. Only in this way patient can avoid
the complications which lead to unnecessary discomfort and delayed healing.
Patient has control over his healing by following the above mentioned
instructions. 6,7,60
41
2.9POST INSERTION INSTRUCTIONS TO THE OVERDENTURE WEARERS
i. Dentures made over the roots of teeth left in the ridges require extra care.5
ii. Remember to use a fluoridated toothpaste to clean gums around the remaining
roots and to the teeth themselves.6
iii. Fluoride rinses and treatments (in-office) are helpful in avoiding new areas of
decay.5
iv. More frequent recalls may be necessary to maintain the remaining teeth.5,6
42
2.10 FUTURE RESEARCH NEEDS
The ACP Task Force acknowledges that there are significant gaps in the literature
related to complete denture care and maintenance. While primarily higher levels of
evidence were sought in the search strategy, the task force did not attempt to categorize
the reference materials on the basis of the strength of the evidence. Additionally, on the
basis of the current level of evidence, the task force recommends that future clinical and
laboratory research focus on the following areas:
i. Further exploration of effective cleaning methods will improve the quality of
denture use. This includes the long-term clinical evaluation and improvement of
specific denture-cleaning components for safety, efficacy and ease of use.
ii. The impact of denture hygiene on oral and general health requires additional
investigation.
iii. Proper identification of the inflammatory process in denture stomatitis could
enable clinicians to prescribe proper treatments for this condition.
iv. The long-term effects (longer than 6 months) of denture adhesive use on oral
tissue health need to be determined. Additionally, methods for enhancing the
removal of adhesives from the tissue-contacting surface of dentures and oral soft
tissues should be developed.
43
2.11 CONCLUSION
Fabrication of complete denture prosthesis is the challenging game in the
dentistry. Close co-operation between the patient dentist and the physician will result in
greater service to the patient. A well balanced diet containing a high percentage of
proteins, vitamins and essential minerals and a low percentage of carbohydrates is
necessary to keep the supporting tissues of the dentures in good condition. The systemic
factors which has to be explained to the patient which implicates directly on the better
prognosis of the treatment.
44
3. Post Insertion Problems and Management

Post Insertion Problems and Management
3.1 INTRODUCTION
There is potential for problems to arise subsequent to the insertion of complete
dentures. These problems may be transient and may be essentially disregarded by the
patient or they may be serious enough to result in the patient being unable to tolerate the
dentures.
Factors causing problems may be grouped, essentially into four causes:61
i. Adverse intra-oral anatomical factors. Eg: atrophic mucosa
ii. Clinical factors. Eg: poor denture stability
iii. Technical factors. Eg: failure to preserve the peripheral roll on a master cast
iv. Patient adaptional factors
By far, the most critical factors are the patient adaptional factors. Many patients
with positive stereotypes may overcome errors of prescription. However, some patients
are unable to adapt physically and/or psychologically to dentures that satisfy clinical and
technical prosthodontics norms. Clearly it would be in the best interests of the clinician
and the patient to determine this at the assessment stage. Once a denture-wearing
problem becomes apparent, it is important that it is to be addressed in a logical and
systematic way. An adequate history of the problem must be obtained and a careful
examination of the mouth carried out so that an accurate diagnosis can be made and an
appropriate treatment plan devised. Listening to the patient is the most important first
step in the process and its importance cannot be over-emphasised.61
Due to the plethora of potential complete denture problems, this section is largely
confined to those that are most commonly encountered at the time of insertion of
replacement dentures or during review appointments in the days and weeks after
46
insertion. Despite all the shortcomings and functional deficits, edentulous patients are by
and large satisfied with their complete dentures, with less than 10% expressing complete
dissatisfaction. Patient satisfaction with treatment is highly influenced by patient
expectations. Some patients may have very unrealistic expectations, while others may
have very low expectations.62
Satisfaction with dentures is impacted by factors such as denture quality,
available denture-bearing area, the quality of the dentist-patient interaction, previous
denture experience, the patient personality and psychological well-being. No single
fabrication technique for dentures has been proven to be superior and the technical
quality of dentures accounts for less than half the total treatment success. A dentist must
realize the importance of interpersonal management skills, patient preparation, have
understanding of denture function and denture limitations. A major role of the dentist is
to guide and educate the patient through the process of complete denture therapy. The
psychological aspects of treatment need to be appreciated by the dentist and cannot be
minimized.62
Patient satisfaction is critical determinant in the success or failure of complete
denture therapy. The prosthodontist needs a thorough knowledge of anatomy,
physiology, pathology and psychology to treat these problems.62
47
3.2 COMMON COMPLAINTS
The most frequent complaints of patients wearing complete dentures are mucosal
irritation, insufficient retention and stability, food accumulation under the dentures,
difficulties in speech, masticatory inefficiency, unattractive appearance, fractured
denture and deboning of teeth.63
Mucosal irritation 63
The mucosa should be free from irritation, otherwise the functions will be
impaired. A typical location of denture irritation is either the non-mobile oral mucosa or
the regions where the mucosa is mobile during functional movements. Mucosal
irritations appear mainly due to two reasons - compression beyond physiological limits
and movement of denture during function. This is often seen at the freni, muscular
attachment regions, the hamular notch area, mandibular retromylohyoid area and buccal
area. Mucosal irritation may be due to faulty jaw relations or faulty arrangement of teeth,
i.e. decreased or increased vertical dimension, instability caused by incorrect centric
relation, premature contact in centric occlusion or by arrangement of posterior teeth
buccal to the residual alveolar ridge. Mucosal irritation may also occur as a result of
overextended borders and can be rectified by reduction of the borders. The use of a
disclosing medium on the intaglio surface of the denture can be helpful to determine the
area and extent of correction. An ³inside-out approach´ is recommended, i.e., assess
condition of foundation area, stability and retention of the denture before addressing
occlusion. The combination of laboratory and clinical remount procedures lead to
refinement of occlusion by reducing interferences and discrepancies in occlusal contacts
48
which contribute to decreased tissue irritation, pain during mastication, discomfort
during swallowing and mastication, and number of post-placement visits.
Denture stomatitis is a common occurrence in denture wearers, resulting in an
area of erythema beneath the denture. Its etiology is multifactorial, and it may be
associated with both local and systemic factors. Its management includes antifungal
therapy, correction of ill-fitting dentures, and efficient plaque control.63
Insufficient retention and stability
Patients very often complain about loose or ill-fitting dentures which may be due
to lack of retention or stability. If the patient complains of looseness always, there may
be an obvious retention fault, whereas if the patient complains of looseness but the
dentures resist a direct pull, lack of stability may be suspected. Faulty occlusal contacts
also result in movement of denture and perceived as lack of stability and retention.
Mandibular denture is often the focus of frequent patient complaints such as instability,
pain, and inability to chew. Insufficient motivation and faulty tongue position often
results in inability to chew and lack of retention. Levin advocated placement of a groove
in the anterior lingual flange of the mandibular denture to train the patient. 64 A
reasonable method is to instruct the patient to touch the groove intermittently, 10 times at
a stretch. Then hold it there for two minutes. Repeat this ten times in a session for four
sessions a day. Bohnenkamp and Garcia suggested a phonetic training technique to use
the tongue and buccinator muscles to retain and stabilize the mandibular denture by
pronouncing the long ³e´ sound.65 Retention of ageing prostheses can be improved by
including use of denture adhesives, relining, rebasing and the use of endosseous dental
implants. In a quality-of-life study patient ratings showed that denture adhesives may
cause an improvement in the denture wearer¶s perceptions regarding retention, stability,
49
and quality of life. However, there is limited evidence that masticatory function may be
improved by adhesives.
Also, saliva plays a prime role in the retention of dentures. Patients with mucous
(low surface tension) saliva experience difficulty with retention of dentures. The most
adhesive saliva is thin, containing mucous components. Thin and watery saliva is not as
effective and can be identified by its inability to draw up a column of saliva. Thick and
ropy saliva is very adhesive but tends to build up so that it is too thick under the denture
and interferes with the overall adaptation. In the latter situation, the patient should rinse
out the ropy saliva about every two to three hours with a mouthwash.66
In a study carried out by Niedernicier et al to study the significance of saliva for
the denture wearing population.67 This paper studies factors affecting mucous and serous
salivation gland secretion, the aetiology of the 'dry mouth' and its associated problems,
causative factors for hospitilization and ifs treatment. Setting: two university dental
hospitals. Subjects: 587 denture wearers and 521 control subjects, and autopsy material
Interventions: exercise, chewing, water, oestrogen, pilocarpine, and anetholtrithion
theiapy. biopsy of the minor glands. Main outcome measures: Palatal secretion (PAL,
uL/cm-/min) and parotid salivary flow (PAR), subjective complaints and clinical
findings. Results showed that the resting flow rates for PAL between 0 and 65 cm-/min
were seen in every age group. The flow rales of PAR (0 to 3.7 ml/10 min) were not
correlated with PAL. Most patients with a resting flow rate of PAL<6. ul/cm 2- suffer
from a 'dry mouth' and Burning Mouth Syndrome (BMS) or oral dysaesthesia (OD) with
or without chronic lesions of the oral mucosa. Etiological factors for the incidence of
reduced PAL and associated problems include xerostomic drugs, oestrogen deficiency,
radiotherapy, thyroid dysfunction, smoking or continuous wearing of maxillary dentures.
PAL also correlated with the retention of maxillary denture. PAL was correlated with the
50
water content of epithelial tissues. PAL and PAR were both increased by drinking ample
fluid, improving their circulation by physical exercises, chewing intensively or taking
oestrogens, pilocarpine, anetholtrithion. They concluded that variation in palatal salivary
secretion occurs and is clinically important.68
Food accumulation under the dentures
Food accumulation under the mandibular dentures could be minimized by correct
position of the tongue by the patient. Wright and co-authors suggested that the ideal
resting position of the tongue is to keep the apex of the tongue in proximity to lingual
surfaces of the mandibular anterior denture teeth, with the lateral surface touching the
posterior teeth of the denture. The less adapted the patient is in stabilizing the prosthesis
during function, greater the denture movement and greater the quantity of food particles
that would collect beneath the dentures. Unilateral chewing causes greater denture
movement, so bilateral chewing is recommended.68
Difficulties in speech
Although the majority of patients adapt to new dentures within weeks, some
patients report difficulties during speech. Tongue plays a major role in converting a
sound into an intelligible phoneme. Phonetics may be evaluated by palatography. This
test consists of evaluating contact between the tongue and the palate through phonetics.
Kong and Hansen demonstrated the need to personalize the palatal contour of a maxillary
denture in relation to tongue as this procedure can reduce the period for adaptation to the
prosthesis. The length, form and thickness of the lingual flange of the mandibular
denture is also critical in speech. Adaki et al showed that there was relative improvement
of speech with rugae incorporated dentures. Among these, customized rugae dentures
51
showed better results than arbitrary rugae dentures. Improper position of the maxillary
anterior teeth could also lead to difficulties in speech. Repositioning the anterior teeth
could help to overcome the problem.69
Masticatory inefficiency
A period of 6-8 weeks is necessary to establish new memory patterns for the
masticatory muscles. Koshino et al., concluded that the basal area of the denture
foundation greatly influenced the masticatory efficiency, suggesting that the masticatory
efficiency in complete denture wearers was limited by their own residual ridges and
patients should be informed about the limitation of the recovery of masticatory ability
before the beginning of denture treatment. Patients mostly assume that any difficulty
caused during mastication is due to faulty dentures.68
They must be taught that chewing with their artificial teeth is a complicated
mechanism where the whole masticatory system is involved. Hence, patients should be
advised to chew simultaneously on both sides to aid in the stability of the dentures. They
should be instructed to start having light, non-sticky foods and gradually shift to more
resistive food substances. Patients should also be instructed to chew with their posterior
teeth, especially those who had to chew with a few anterior natural teeth before going for
the complete dentures. Patients should be educated that the chewing efficiency of the
denture wearer is less than one-sixth that of the subject with a natural dentition.
Masticatory load values using complete dentures are much lesser (50 psi) than those
produced by the natural dentition, which is of the order of 250 psi.68
52
Unattractive appearance
Patients generally want teeth which are lighter in shade and smaller in size. The
patient should be educated regarding good dental aesthetics. Patient should be informed
that natural teeth darken with age and light-shaded teeth look more artificial than darker
ones. Inform the patient that the teeth will be less translucent. A dentist must attempt to
create an appropriate smile and appearance that suits the patients¶ physical character and
aesthetic needs.68 Instead of imposing our aesthetic choices on the patient, the patient¶s
spouse and/or children should be included in decision making as they are the ones who
would appreciate the patient¶s smile. The dentures should never be processed until the
patient has accepted the arrangement with the teeth positioned in wax. A written consent
of the patients¶ approval should be sought.
A patient may complain that the mandibular teeth are not visible or may be
dissatisfied with the degree of visibility of teeth. Of course, increased visibility can be
achieved by incorporating large overbite but this may present a problem in the stability
of the dentures. Another source of complaint is drooping of the lips or presence of folds
and creases near the lips and mouth.70 A further increase of the occlusal vertical
dimension to get rid of facial wrinkles mainly due to ageing should be avoided as it may
render the adaptation to the new dentures more difficult. Careful contouring of the labial
flange and the inclination of the maxillary central incisors will preserve the contour of
the philtrum and the tubercle of the upper lip by providing adequate support. If the
patient complains of lip fullness, the width of the peripheral roll and the labial flange can
be modestly reduced from the facial aspect without compromising retention or
esthetics.71
53
Fractured denture
The cause of fracture should be determined first when a patient arrives with a
complaint of fractured denture to know the condition under which fracture occurred.
Fracture may be of two kinds ± accidental and stress induced. Any signs of porosity or
lack of adhesion of artificial teeth to denture base or presence of tori and undercuts can
be a possible reason. A large frenum compromising factor for denture retention and
resistance. Large notches that are required to accommodate such frena are considered a
µcleavage point¶. Therefore, these notches have been considered responsible for fracture
of dentures. Instances with buccally placed teeth, resorption pattern, failure to relieve
mid palatine raphe and single complete dentures are more susceptible for fractures.
Reducing the need for a deep frenal notch by a frenectomy will be beneficial.72
Incorporation of a metal mesh and higher strength polymers, notably impact-
resistant materials will reduce the tendency to fracture. Constructing dentures with metal
palates for patients with heavy occlusions has the dual advantage of providing greater
strength and better thermal stimulation of the underlying mucosa.72
Debonding of teeth
Debonding of teeth may result from wax remaining between the surface of the
artificial tooth and the denture base acrylic resin and forming an insulating layer during
acrylic resin pressing. Insufficient pressure during packing and excessive trimming of the
teeth while arrangement to accommodate heavy ridges could also be the reasons for
debonding.69
54
3.3 UNCOMMON COMPLAINTS
Patients register an amazing variety of complaints against complete dentures, but
some of the complaints are not as common as others. These include whistling,
swallowing difficulty, loss of taste sensation, altered taste, dislodgment of dentures on
having fluids, drooling at the corners of the mouth, cheek biting, xerostomia, nausea and
gagging and tingling of the lower lip.5-7
Whistling73
When the patient wears the denture for the first time, the patient may complain of
whistling while talking which could be because of increased palatal vault depth and
compressed arch form. Lowering the palatal contour should help the condition. Failure to
duplicate the rugae could also lead to this problem.
Swallowing difficulty74
Pain during swallowing is often caused by overextended peripheral extensions
such as an overextended posterior palatal seal area or overextended retromylohyoid
flange and compression on the superior constrictor. This may also be caused by an
increased vertical dimension. Reducing the overextension or the vertical dimension
should solve the problem.74
Loss of taste sensation 75
This is a common complaint with elderly edentulous patients probably because
their taste buds begin to atrophy at about the same time that dentures are first worn. The
patient should be told that most of the taste buds are on the tongue and are not covered
55
by the dentures. Placement of a denture base that decreases the stimulation and
temperature sensations to the palate may partially account for a loss of taste.
Altered taste 75
Common etiology of altered taste is poor oral hygiene. Patients should clean the
dentures daily by soaking and brushing with a nonabrasive denture cleanser. One should
follow the guidelines on the daily and long term care and maintenance of complete
denture prostheses. Tongue brushing is important for increasing taste acuity in geriatric
patients.
Dislodgement of dentures on having fluids74
This problem may occur when the dentures are first worn by the patient. The
patient should be informed that it is possible to experience loosening of dentures while
taking fluids. A patient may get used to it when the lips, cheeks and tongue learn to
manipulate the dentures.
Drooling at the corners of the mouth74
This problem may occur due to a decreased vertical dimension and an attempt
should be made to correct the vertical dimension. Also if the vertical dimension is
correct, then an attempt should be made to increase the thickness of the flange in the
modiolus area.
Cheek biting 74
Cheek biting commonly occurs due to a lack of horizontal overlap in the posterior
teeth. Posterior teeth that occlude edge to edge will often catch the cheeks. This problem
56
usually can be corrected by reducing the buccal surface of the offending mandibular
tooth to create additional horizontal overlap, thus providing an escape for the buccal
mucosa. Also, a decrease in vertical dimension contributes to cheek biting since the
cheeks tend to collapse into the occlusal area.
Xerostomia76
Many elderly patients take multiple medications and many of these drugs can
cause xerostomia which negatively affects the patient¶s ability to tolerate complete
dentures. Such patients have difficulty masticating and swallowing, particularly dry
foods. This could be overcome by instructing the patients to drink fluids while eating.
Xerostomic patients should also be advised to drink plenty of water (a minimum of eight
glasses) daily. Lack of lubrication at the denture-mucosa interface can produce denture
sores. If xerostomia is caused by a decrease of salivary gland secretions, the use of
artificial saliva and frequent mouthrinses particularly during meals may be helpful. A
palatal reservoir filled with artificial saliva will enhance the quality of life of xerostomic
denture wearing adults. Sialogogues, which are drugs that stimulate the flow of saliva
without affecting its ptyalin content, can be prescribed to the patient if some glandular
function still is present.
Nausea and gagging77,78
These complaints may be seen in patients with an exaggerated gag reflex. It may
also be caused by overextended posterior extent of the maxillary denture and the
distolingual part of the mandibular denture. In such a case the denture should be reduced
posteriorly to the posterior palatal seal area. It may also be caused by unstable and poorly
retained dentures. The condition is often due to unstable occlusal contacts or increased
57
vertical dimension of occlusion because the unbalanced or frequent occlusal contacts
may prevent adaptation and trigger gagging reflexes.
Tingling of the lower lip7
This problem may be seen in ACP (American College of Prosthodontists) Class
IV patients when excess resorption has lead the mental foramen to be located near the
crest of the mandibular residual ridge. If no relief is provided, then tingling and mild
paresthesia of the lower lip may occur. This area may be recorded and relieved to
eliminate the problem. A similar situation can occur in the maxillae from pressure on the
incisive papilla due to compression on the nasopalatine nerve. The patient may complain
of burning or numbness in the anterior part of the maxillae. Relief may be required in the
maxillary denture base in this region.
58
3.4 POST INSERTION PROBLEMS AND THEIR MANAGEMENT
Classification5-7
1. Looseness of dentures
i. Decreased retentive forces
ii. Increased displacing forces.
2. Discomfort associated with dentures
i. Related to impression surface of denture
ii. Related to occlusal surface
iii. Related to polished surface
iv. Related to possible systemic association
3. Support problems
4. Problems associated with retention and stability
5. Other difficulties
i. Noise on eating and speaking.
ii. Speech problems.
iii. Difficulties in eating.
iv. Altered taste sensation.
v. Gagging (nausea).
Loose denture
This is more commonly associated with mandibular denture and usually brought
to the dentist attention either soon after the dentures are placed or following a period of
successful wear when the dentures are nearing the end of useful life.5-7
59
Causes of loose denture:
i. Decreased retentive forces
a. Lack of seal because of border under extension in depth and width, resorption of
residual ridge and inelasticity of cheek.79-81 The functional depth and width of the
sulci should be utilized to provide seal and assist in optimal positioning of the
teeth. In case of residual ridge resorption and under extended border, temporarily
reline denture with tissue conditioner.
b. Air beneath the impression surface results in poor fit due to deficient
impression, damaged cast, warped denture and over adjustment.6,7 These
problems can be managed by relining, if design parameters of denture are
satisfactory. Ensure that areas of heavy contact between denture and tissues are
relieved prior to impression making. Warped denture can be corrected by using
optimum curing cycle for acrylic resin, denture must not be heated when
trimming and polishing and resultant cast must not be over trimmed or damaged.
c. Xerostomia For individual with xerostomia, retention can be a major problem.
Management of xerostomia can be done by using artificial saliva to enhance
retention and stability.82,83 Stimulating saliva with bulky diet, chewing gum,
sugar-free acidic sweets can be helpful.
d. Neuromuscular control problems5 are caused from change in shape relative to
old dentures, high occlusal plane on mandibular denture and motor neuron
disorders. Correcting any faults in denture hindering neuromuscular control,
maintaining optimal retentive forces and minimize displacing forces on existing
dentures can be helpful.
60
ii. Increased displacing force
a. Overextension of denture borders in depth and width is managed by reducing
over-extension, along with use of disclosing material if necessary.84,85
b. Poor fit ± tissue recoil is caused because of poor/inappropriate impression
technique especially in posterior lingual area and is managed by relining if all
design parameters are satisfactory, otherwise remake. Ensure that old denture is
removed from the mouth 90 min prior to impression.84-85
c. Occlusal problems such as inter-cuspal and retruded contact positions not
coincident, lack of occlusal balance in protrusive, lateral excursions and
excessive vertical overlap of anterior teeth results in loose denture. Such
problems can be corrected by removing inappropriate contacts and adjusting
occlusal contacts until balance is obtained.82,84,85
Discomfort associated with dentures
Discomfort is common complaint associated with denture soon after the dentures
are fitted or after a period of successful wear. It is more commonly associated with
mandibular denture.
Discomfort related to impression surface6,69
This may be caused due to pearls of acrylic or sharp ridge on fitting surface of
denture, denture base not relived in region of undercuts, over-extended lingual flange-
impinging on to mylohyoid ridge, or post dam too deep. Examine the impression surface
for surface irregularities by using disclosing material to identify the position and extent
of over-contour and relieve appropriately. Ensure that any trimmed acrylic is thoroughly
polished prior to re-insertion.
61
Discomfort related to polished surfaces6,69,
Patient complains of pain at posterior aspect of maxilary denture usually
associated with opening movement. Discomfort may be due to too thick flange
constraining coronoid process. Accurately define area involved using disclosing material,
relieve and re-polish.
Discomfort related to occlusal surfaces6.69,82
a) Pain on eating in presence of occlusal imbalance is because of anterior or
posterior prematurity, incisal locking, or lack of balanced articulation. Determine
occlusal pre-maturities and adjust occlusion by selective grinding.
b) Pain or inflammation on labial aspect of mandibular ridge is due to lack of incisal
overjet causing incisal locking which is treated by reducing incisal vertical
overlap and if appearance is compromised, resetting the incisors may be required.
c) Pain about periphery of dentures, possibly accompanied by pain in masseter and
posterior temporalis muscles which tends to intensify as day progresses is due to
vertical dimension of occlusion more than patient can tolerate.
d) Tongue biting is usually due to combination of posterior teeth being placed in
lingual position together with sharpness of cusps. Management done by reduction
and smoothening of teeth on lingual aspect.
e) Cheek biting is likely to happen if width of sulcus is not restored. Restoration of
functional sulcus width is advised to avoid cheek biting. Lip biting is due to
absence of adequate lip support, excessive anterior horizontal overlap, corrected
by grinding mandibular incisors to provide more incisal guidance angle.
62
Discomfort related to systemic factors
a) Burning mouth syndrome (BMS)83,86,87- Some patients complain of burning sensation
in wearing complete denture. The symptoms are so severe that denture cannot be
tolerated for more than few hours. It is relevant to differentiate between burning
mouth sensation and burning mouth syndrome. In the former group, the patient's oral
mucosa are often inflamed or an allergic reaction. In patient suffering from burning
mouth syndrome, the oral mucosa usually appears clinically healthy. Majority of
patients affected from burning mouth syndrome are older than 50 years, females and
wearing complete denture. The females are usually postmenopausal women. Burning
mouth syndrome is managed by correcting any denture faults, antidepressant therapy,
and good oral hygiene.
In contrast to denture stomatitis, which is often not painful, burning mouth syndrome
(BMS) is a condition characterized by burning and painful sensations in a mouth with
normal mucosa. It may occur in subjects with all types of dental status and is thus not
limited to denture wearers. The tongue is reported to be the most frequent site of
BMS, denture-bearing mucosa being another frequent location. It is most prevalent in
middle aged people and more frequent in women (4%) than in men (1%). BMS has a
multifactorial cause comprising local, systemic, and psychogenic factors. There are
conflicting opinions about the importance of denture factors in BMS. Some
investigators consider the causative factors such as local denture pressure, Candida
albicans and bacterial infections, and allergic reactions to be the same for both
denture stomatitis and BMS.
Among systemic factors of etiologic influence, hormonal, vitamin, and iron
deficiencies have frequently been suggested but the evidences of associations
between such factors and BMS is not strong.87 Currently, great emphasis has been
63
placed on psychologic factors. It has been found that anxiety and depression are
frequent among patients with BMS and their personality characteristics indicate that
they are more concerned with their health and more socially isolated, depressed,
anxious, distrustful, and easily fatigued than control subjects. Such findings have led
some authors to suggest that the burning sensations are psychosomatic symptoms.
Other authors warn against the conclusion that BMS is primarily a psychogenic
disorder and maintain that changes noted in the psychologic profile may simply be a
reaction to chronic pain conditions and not necessarily its cause. Optimizing deficient
dentures is a natural first step in the management of BMS in complete denture
wearers. However, if there are no obvious denture deficiencies, the prosthodontist
should be careful and not escalate the prosthetic treatment until a psychologic
evaluation has been performed and psychogenic causes have been ruled out. If
psychologic and/or psychosocial disturbances are diagnosed, adequate treatment
should be offered. Any extensive prosthodontic treatment, such as an implant-
supported prosthesis, should be carried out as a collaborative effort between the
psychologist/psychiatrist and the prosthodontist.
b) Herpetic ulcers- are caused by herpes simplex or herpes zoster virus and are
treated by prescription of appropriate medication (e.g. acyclovir) and oral
hygiene instructions.5
c) Patient allergic to denture material- relate to higher residual monomer content
of acrylic. This problem can be managed by rebasing denture using controlled
heat cure cycle or making denture in polycarbonate or other non-polymethyl
methacrylate resin, if excess residual monomer is detected.5
d) Denture stomatitis5-7,88 (Denture-sore mouth, Inflammatory papillary
hyperplasia, Chronic atrophic candidiasis)- Chief complaint is burning or itching
64
sensation of palatal mucosa.5 Usually has frictional element (ill-fitting denture)
plus opportunistic candidal infection. Treated by advising tissue conditioner and
cleaning of denture by scrubbing and soaking in hypochlorite solution is
recommended. Antifungal therapy may also be required.
Many denture wearers develop an inflammatory reaction in the denture-bearing
mucosa, most frequently in the palate. It is usually a benign disorder and most patients
are unaware of their denture stomatitis. The lesions may be local or general in nature and
the surface may show small or more extended areas of erythema of a smooth or granular
type. The prevalence reported for denture stomatitis vary greatly, with up to two thirds of
the maxillary and one fifth of the mandibular mucosa diagnosed as inflamed in complete
denture wearers.5
Etiology of denture stomatitis- The predisposing factor for denture stomatitis is
the presence of a denture, and denture-wearing habits are therefore correlated with
denture stomatitis. Four to five decades ago, the most important etiologic factors were
thought to be trauma from the dentures. Later, Candida albicans infections were
considered to be the most important factors. Today, the multifactorial background of
denture stomatitis is acknowledged. Poor oral hygiene that results in microbial plaque on
the fitting surface of the denture and bacterial and Candida albicans infections appear to
be of great etiologic importance. Traumatic factors such as mechanical, thermal, and
chemical irritations and allergic reactions to components in the denture material may also
be responsible for the development and maintenance of denture stomatitis. Recently,
immunologic aspects have also been added to the multifactorial pathogenesis of the
condition.
Management- The treatment is usually simple if the varying etiologic factor is
acknowledged. Good oral hygiene, thorough denture cleaning and an increased period of
65
rest for the denture-bearing tissues are essential and when indicated, may be combined
with antifungal therapy and the correction of traumatizing factors associated with ill-
fitting dentures. The use of antifungal drugs as the sole method of treatment is not
recommended because Candida albicans infections often recur if hygiene has not
improved and the dentures have not been optimized. Surgical elimination of papillary
hyperplasia in the granular type of denture stomatitis may be necessary to achieve
optimal mucosal hygiene but in mild cases, antifungal treatment without surgery may be
an acceptable alternative.88
e) Angular cheilitis5,6- 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 indicates that an infection is frequently present.
Soft tissue hyperplasia
Flabby ridges5-7- When hyperplastic tissue replaces the bone, a flabby ridge
develops, which is often seen in long-term denture wearers and clearly related to the
degree of residual ridge resorption. The reported prevalence for this condition also varies
among investigators, but it has been observed in up to 24% of edentulous maxillae, and
in 5% of edentulous mandible, and in both jaws most frequently in the anterior region.
Even if surgical elimination of the flabby ridge is a logical treatment in many situations,
care must be used when the ridge is extremely reduced. Although the flabby ridge may
provide poor retention for the denture, it may still be better than no ridge at all.
66
Denture irritation hyperplasia5-7- The mucosal response to chronic irritation
from an overextended and/or ill-fitting denture may be a fibrous tissue hyperplasia. It has
been reported to occur in 5% to 10% of jaws fitted with dentures, with the higher figure
for the maxillae. Healing is usually uneventful after reduction of the offending flanges
and/or minor surgery.
Traumatic ulcers7- Sore spots and ulcers are frequent findings the first few days after
placement of new dentures. They are usually caused by overextended flanges and
occlusal disturbances and can be expected to heal rapidly after the dentures have been
modified. In cross-sectional studies of long-term denture wearers, traumatic ulcers in the
mandible have been observed in up to 7% of the patients and in the maxillae in up to 1%.
Diseases that impair the resistance of the mucosa to mechanical irritation are
predisposing to such lesions and make healing more difficult and recurrences more
frequent.7
Residual ridge resorption5-7,89
Impact and etiology- Atwood called the continuous reduction of residual ridges in
complete denture wearers ³a major oral disease entity.´ It appears to be a process
encountered in all patients. Albeit, there is considerable inter-individual variation in the
rate of bone loss after tooth extraction and the wearing of complete dentures, residual
ridge resorption may proceed throughout the lifetime of the denture wearer. It is accepted
that resorption is a consequence of bone remodeling due to the altered functional
stimulus on the jaw bone. However, the causes of the great individual variations are not
well understood. Two decades ago, Woelfel et al. listed 63 factors that could possibly be
related to bone resorption under removable dentures. In their analysis, they found no
single dominant factor to explain the variability of bone loss. Even today, we must admit
67
that little is known about which factors are most important for the observed variations in
residual ridge resorption. Despite the large number of recent studies, a single dominant
factor for residual ridge resorption as yet to be found. Factors often used in correlation
analyses are gender, age, facial structure, duration of edentulousness, denture wearing
habits, number of dentures worn, oral hygiene, oral parafunctions, occlusal loading,
denture quality, nutrition, general health, medication, systemic diseases, and
osteoporosis.
Some studies have reported statistically significant correlations between residual
ridge resorption and one such factor. However, a simple, probable association between
duration of edentulousness and residual ridge resorption was not proven to be
statistically significant in several cross-sectional studies. There are also contradictory
reports on the influence of gender on residual ridge resorption: Most state that women
have more advanced bone loss than men.
The researchers concluded that systemic factors control the final stage of residual
ridge resorption, whereas local factors (surgical method, healing capacity, bite force)
dominate the first phase after extraction. The best explanation that can be offered today
is that combinations of anatomic, metabolic, psychosocial, mechanical and most
probably unknown or yet-to-be analyzed factors are of importance for residual ridge
resorption.
An example showing the influence of unexpected factors was the inclusion of
smoking among conventional clinical variables in a multivariate analysis of peri-implant
bone loss. When smoking was included in the analyses, it was found that smoking was of
greater significance than any clinical factor in a long-term study of peri-implant bone
loss. This does not indicate that smoking is of similar importance for residual ridge
resorption, it only suggests that new knowledge about the cause of residual ridge
68
resorption may emerge when multivariate analyses are applied to research data and
previously unanalyzed variables are included.
Epidemiology- More than 25 years after Atwood´s statement, it remains that
residual ridge resorption can be considered ³a major oral disease entity.´ On an
individual level, it is true today, even though implant-supported prostheses provide a
favorable solution for some edentulous patients who suffer from the consequences of
residual ridge resorption, How is it on an epidemiologic level? The prevalence of the
edentulous condition is rapidly decreasing in many countries, but great geographic and
socioeconomic differences still exist. Despite this beneficial improvement in oral health
and the decline in the rate of the edentulous condition, there remains a substantial
number of complete denture wearers among elderly people. A rough estimate indicates
that on a global level, only about one in every thousand totally and partially edentulous
people have benefited from treatment with implant-supported prostheses. The number of
edentulous elderly persons may even increase because of the current expansion of the
oldest segment of the population. Treatment of edentulous people will therefore continue
to be a challenge for the dental profession.
Management- The consequences of residual ridge resorption are obvious,
sometimes less so for the patient than for the prosthodontist who encounters increasing
problems in the fabrication of well-functioning complete dentures. Many prosthodontic
and surgical treatments have been attempted in situations of severe residual ridge
resorption, but none has been completely predictable. The best treatment is to avoid total
tooth extraction, preserve a few teeth, and make overdentures, which are associated with
much lower rates of bone resorption. The placement of dental implants and the insertion
of an implant-supported prosthesis have been shown to reduce substantially bone loss in
69
the edentulous jaw, indicating the importance of altered functional stimulus to the bone
tissue.
Temporomandibular disorders5,61.69
Complete denture wearers and people with other types of dentition can both be
afflicted by temporomandibular disorders (TMD) in a similar way. However, it seems
that severe signs and symptoms are rare, even in subjects with old dentures of poor
quality. This can perhaps explain why in general there have been relatively few complete
denture wearers in samples of patients with TMD. That differences in the prevalence of
TMD, with respect to dental state has not been well-established and the role of dental
occlusion in the cause of TMD is still controversial. Some investigators have found
correlations between signs and symptoms of TMD on one side, and the wearing of
dentures, the quality of the dentures, and denture-wearing habits on the other, and others
have not.
Even if the multifactorial character of TMDs is acknowledged and the importance
of occlusal factors is questioned by many experts, it appears sensible to combine the
counseling, so essential in all management of TMDs, with correction of poor dentures
when treating denture-wearing patients who have TMD. Positive effects on signs and
symptoms of TMD have been shown in several studies by fitting new complete dentures.
Problems associated with Support5,61
a) On fibrous displaceable ridge when forces of mastication is exerted cause denture
to sink into and tilt on supporting tissues, thus disrupting retentive seal. Relining/
rebasing of denture, giving additional vent holes in labial/ buccal/ lingual flanges
and low-viscosity impression material can be used to manage the problem.
70
b) Bony prominence covered by thin mucosa (e.g. Tori, maxillary midline suture)-
denture rock over the prominence which may be covered with inflamed tissue. It
is corrected by providing optimum balanced occlusal contacts to prevent rocking
over the fulcrum tissues.
c) Pain avoidance mechanisms - To relieve pain produced by denture,
tongue/cheeks lift appliance away from tissue or patient uses excessive amounts
of fixative, or self applied reline material in attempt to relieve contact with
supporting tissues. Eliminating the cause of pain is important.
d) Resorbed ridge results in little resistance to forces in lateral and anteroposterior
directions. Hence dentures are liable to move. This is treated by allowing optimal
border extension in depth and width, considering endosseous implants and
surgical deepening of sulcus, if bone is insufficient for implants.11
Problems associated with Retention and Stability5-7,61
Retention as related to artificial dentures is the resistance offered to a force
directed at right angles to the seating surface which tends to lift the denture from the
supporting surface of the tissues. Stability refers to the maintenance of equilibrium and
to the resistance to displacement when the masticatory forces act in general, towards the
seating surfaces . Most of the patients complained about the looseness and mis-fitting of
their dentures. Additionally, loss of retention caused dissatisfaction of patients related to
function. The loss of retention of the dentures may have impaired the patients' ability to
chew. This complication is the main reason of need for replacement of their dentures.
71
Other difficulties5-7,61
There are a number of other difficulties which are reported from time to time by
complete denture patients. They are nevertheless important as they are not infrequently
encountered in dental practice.
i. Noise on eating/speaking is because of excessive occlusal vertical dimension,
occlusal interference, loose dentures. It is also found that porcelain teeth create
more impact noise than acrylic. These are corrected by addressing specific faults
or remake as required.
ii. Speech problems are usually uncommon but presence is of great concern to the
patient. It may be because of new tongue positions, new occlusal relationships or
new teeth orientation and it can be easily managed by ensuring that palatal
contour should not allow excessive tongue contact or air leakage.
iii. Eating difficulties may result from unstable dentures, incorrect occlusal vertical
dimension or blunt teeth which results from excessive abrasion of occlusal
surface as a result of adjusted occlusion or prolonged wear. This can be corrected
by accurate assessment of occlusal vertical dimension, and careful explanation of
rationale is needed while using non anatomic teeth.
iv. Appearance, Although it has to be stressed that appearance cannot fully assessed
until 4 to 6 weeks after insertion of finished denture. This is because of
adaptation of lip and facial muscle to underline denture. Management is done
upon accurate assessment of patient¶s aesthetic requirements, giving ample time
to the patient to comment at the trial stage or using any available evidence-
photographs /previous dentures.
v. Gagging77,78 is because of loose denture, thick distal border of upper denture or
lingual placement of posterior teeth. Hence management is done by psychological
72
assessment if indicated or use of conditioning appliance e.g. extended base for
home use.
vi. Altered taste sensation:90 Dentures do not cover many taste buds, thus no
physiological basis for this complaint. Thickness and low thermal conductivity of
acrylic base material could be the cause. This is managed by decreasing palatal
cover so long as retentive forces deemed adequate.
73
3.5 PATIENT SATISFACTION WITH COMPLETE DENTURES
Prosthodontists have rightly maintained that they have been able to successfully
rehabilitate edentulous subjects with an artificial dentition, such as complete dentures.
³Over the years, dentists have demonstrated considerable skill at replacing depleted
dentitions and in compensating for the resultant deficit in periodontal support. Prosthetic
care has evolved into an applied clinical skill of variations on a theme of ingenious
salvage.´ The great majority (70% to 85%) of edentulous patients has also acknowledged
the benefit of complete denture treatment and declared themselves satisfied with their
dentures. Older patients have been found to be more satisfied with poorly fitting dentures
and less prepared to seek denture improvement. Measurements of masticatory function,
such as bite force and the ability to comminute a test food, are substantially reduced in
complete denture wearers in comparison with people with natural dentitions, as well as
with implant-supported prostheses. Nevertheless, studies have shown that only a small
proportion of denture wearers (8%) consider their chewing ability to be poor or express a
subjective need for dental implants.91
In a Swedish epidemiologic study, only 8% of the totally edentulous subjects
would accept dental implants if available. The most important reason for declining
implant treatment (83%) was that they were satisfied with their present dentures. Even if
most edentulous people are satisfied with their complete dentures, there are some who
have complaints that need to be addressed. The diagnosis is usually simple and the
problems can, in most situations, be eliminated by counseling and either correction of the
dentures or fabrication of new ones, provided that treatment is carried out on an
individual basis. However, all who have worked with complete dentures know that
patient satisfaction is not based solely on the technical quality of the dentures.
74
Psychologic and emotional factors may be of great importance in maladaptive patients,
even though they seek technical advice. To help such patients, the dentist must be able to
listen and communicate effectively. The ³iatrosedative interview´ has been suggested to
be an effective method of communication for helping patients who are unable to adapt to
dentures for various reasons. Although this method has not been systematically
evaluated, several studies have demonstrated the great impact of the dentist-patient
relationship and psychologic factors on patient acceptance of new dentures. The
correlations between patients¶ satisfaction with their dentures and ³objective´
measurements of anatomic conditions, denture quality such as retention and stability, and
masticatory performance are in general surprisingly weak and often statistically
nonsignificant.91
Results from the evaluations of maxillary and mandibular dentures often differ,
making ³a total assessment´ problematic. Improving denture quality has been shown to
increase patient satisfaction but not to substantially alter the chewing ability of denture
wearers. A number of assessment methods for measuring patient satisfaction with their
complete dentures has been presented over the years. However, there does not seem to be
any reliable means for predicting a patient¶s acceptance of new dentures. Work has been
in progress to find better methods for studying these relationships. The complex nature
of adaptation to and satisfaction with complete dentures must be acknowledged in the
construction of such assessment methods.92
75
3.6 CONCLUSION
There is a vast difference in the magnitude and number of the complaints, many
of which may arise at a later stage. Some of these complaints can be minimized, a few
can be eliminated and some for which the dentist and the patient must contend with.
The patient should be dealt with in a sympathetic manner, keeping in mind that
such complaints are very important to patient. A careful scrutiny based on a thorough
knowledge of normal and abnormal tissue response as well as of the fundamentals of
complete denture prosthesis is essential in treating the problems connected with complete
denture use. There are many ways that dentures can be improved and dentists should be
able to assess the quality of a denture in terms of aesthetics, support, retention, stability,
occlusion, vertical dimension and extension of the denture bases.
Denture placement is not the last stage of complete denture fabrication process.
Post placement adjustments are important clinical phase following fabrication and
placement of a complete denture. Hence, a patient should always be recalled so that the
remaining complaints can be eliminated. Tooth loss will continue to be a problem and
require prosthetic restoration for the immediate future. Complete dentures restore
esthetics and function to some degree. A majority of edentulous patients adapt well to
their disability and their prostheses, while others experience a great deal of functional
and psychological disturbances. These maladaptive patients may benefit from implant
therapy. Neither conventional, implant-assisted, nor implant supported mandibular
and/or maxillary dentures restore function to dentate levels and there appears to be only
limited advantages of one treatment over the other.
76

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85
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Dr. Mayank R Lunia, MDS

The elderly population is remarkably increasing world-wide.1 The fast growing

due to a deficiency in various micronutrients, leading to a uncompromised immune

A dental prosthesis is defined as ³an artificial replacement (prosthesis) of one or

or removable dental prostheses. (Glossary of prosthodontics term GPT-8)

Complete denture is defined as ³removable dental prosthesis that replaces the

entire dentition and associated structures of the maxillae or mandible.´(GPT 8) It is

indicated in edentulous patients to restore the appearance and to assist in maintaining

1.2 STAGES OF PATIENT EDUCATION

Communication (Patient-Doctor rapport):4

Establishing good communication between doctor and patient early in treatment

expectations at the time of denture insertion. A review of the patients¶ self-image is

beneficial in predicting acceptance. Good communication should continue throughout

approaches are valuable at insertion time.

All patients have a ³threshold of acceptability´ that determines their response to

General classification based on extensive clinical experience of complete denture

The Philosophic Patient:

(i) Accepting of dentist and oral condition.

The Indifferent Patient:

(i) Little concern about oral health and dentist.

(ii)Treatment insisted on by a significant other.

(iii) Gives up easily

The Critical Patient:

(i) Finds fault with everything.

(ii) Directs the treatment.

(iii) Usually have poor health leading to poor personality.

(iv)Medical consultation advisable before treatment.

The Skeptical Patient:

(i) Previous bad experience with dentist/dentures.

(iii)Often have a series of personal tragedies.

Behavioral factors affecting insertion:5-7

There are wide spectrum of behavioral problems associated with denture

complaints are of excessive discomfort, usually of a general nature, poor function or of

such recognition is accomplished, problem solving is an orderly procedure.

Complete denture insertion stage:9

Denture insertion represents the culmination of a series of carefully considered

obtained. It is indicative of a satisfying experience to both dentist as well as patient,

1.3DENTURE INSERTION PROCEDURE

fabrication. It may be regarded as a pause in treatment to provide an overview that takes

account of all phases of treatment.5

Pre insertion denture evaluation:

Before the insertion appointment, dentures are inspected to determine

(ii) That no imperfections on tissue surface remain.

Steps in insertion procedure:

Evaluating patient¶s mouth5-7

The synergy between base adaptation and occlusion cannot be precisely

dentures. Words of encouragement are very important to ensure success. Whenever

possible, the patient should be provided with printed material summarizing or

elaborating on the most important spoken instructions.

Evaluating tissue side5-7

the reflection of the tissues in the hamular notch area.

compound; therefore slight overextensions that might be developed with

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