Denture related pathosis and its management

The oral environment is highly altered when a removable dental prosthesis is inserted. This further causes adverse effects on the integrity of the oral tissues. A rough surface on a denture may cause mechanical irritation resulting in a mucosal reaction, surface irregularities or porosities may result in accumulation of microbial plaque on the dentures, sometimes the constituents of the dental materials itself may induce an allergic reaction. A constant pressure on the bony ridge results in residual ridge resorption. Wearing complete denture significantly alter the masticatory function, indirectly resulting in nutritional deficiency. The sequelae of wearing complete denture reaction may be a direct or an indirect one. © 2020 Published by Innovative Publication. This is an open access article under the CC BY-NC license (https://creativecommons.org/licenses/by-nc/4.0/)


Introduction
The use of complete dentures is never considered trouble free. The dentures can produce severe side effects, which if left unchecked will produce, destabilization of occlusion, loss of retention, decreased masticatory efficiency, poor esthetics, increase ridge resorption, tissue injury. These problems when ignored, will progress to a stage where the patient is considered maladaptive and even, cannot wear the denture. 1 This can be totally avoided by providing proper post insertion instructions to the patient, educating the patient on denture care and maintenance and importance of regular dental visits for check-up.

Classification
Depending on the effect of the prosthesis on the tissues, the sequelae of complete denture wear can be classified 2 as follows:

Denture stomatitis
Also called as denture stomatitis, inflammatory papillary hyperplasia and chronic atrophic candidosis. 4

Diagnosis
The presence of mycelia or psuedohyphae in the direct smear confirms the diagnosis. Management:

Supportive measures
A. To follow effective oral and denture hygiene methods and correction of the prevailing denture wearing habits. B. Educating the patient on proper usage of dentures which include: 1. Removing of the dentures during night times and placing it in water. 2. Removing of denture after meals and to scrub it before reinserting.
C. Smoothening the rough areas of the denture to avoid trauma.

Drug therapy
Local therapy with antifungal mouth wash which include nystatin, amphotericin B are preferred to systemic therapy because resistance of candida species occur regularly when ketoconazole is used systemically. The antifungal drugs are continued for four weeks to avoid relapse.

Surgical management
The deep crypts in type III denture stomatitis requires surgical intervention which is preferably done by cryosurgery.

Flabby ridge
Flabby ridge is due to replacement of bone by fibrous tissue which is mobile and highly resilient. It is seen most commonly in the anterior part of the maxilla with opposing anterior teeth in the mandible. It is usually caused due to excessive load of the residual ridge and unstable occlusal condition. They provide poor support for the denture.

Management
Surgical treatment has to be considered depending on amount of bone resorption 5 because in case of complete atrophy removal of the flabby ridge will eliminate the vestibule.

Trauamatic ulcers (sore spots)
Overextended borders or unbalanced occlusion are the usual causes of traumatic ulcers.

Clinical features
These ulcers are small, painful and usually develop within few (1-2) days after the placement of a new denture. They are often covered by a grey necrotic membrane surrounded by an inflammatory halo with firm elevated borders. 6

Management
1. Usually the ulcer heal within few days after correcting the dentures. 2. If no treatment is provided, it may progress into a denture irritation hyperplasia.

Epulis fissuratum (inflammatory fibrous hyperplasia, denture injury tumour, denture epulis)
It is a hyperplastic reaction of the oral mucosa that occur along the borders of the dentures and usually caused due to the trauma from the thin denture flanges of an unstable denture.

Clinical features
1. Usually it appears as a single or numerous flaps of connective tissue while some appear erythematous and ulcerated. 2. The flange of the associated denture fits conveniently into the fissure between the folds. 3. It usually develops on facial aspect of alveolar ridge and the anterior regions of the jaw.

Management
1. Treatment consists of removing the offending denture or shortening the flange to permit tissue rest and healing. 2. Denture or borders are corrected with soft denture liners or tissue conditioning agent.
3. Surgical removal is attempted only if this treatment fails to bring about resolution. 4. Tissue rest is generally enough to cause regression of the epuli and complete healing. 5. Suturing after surgery may decrease sulcular depth of the vestibule once scar contracture occurs. In such cases vestibuloplasty should be considered. 7

Oral cancer in denture wearers
An association of denture wearing and oral cancer has been strongly claimed, but there is no definite proof to this statement. The factors which lead to oral cancer in denture wearing patients are heavy smoking, consumption of alcohol, poor oral hygiene and low socio-economic status. 8 3.9.1. Management 1. Any persistent sore spot remaining even after the correction of dentures are often suspected for malignancy. 2. Regular recall visits at duration of 6 months has to be followed for comprehensive oral examination.

Burning mouth syndrome
It is characterised by the burning sensation in the oral tissues which are in contact with the dentures without any visible changes. Most commonly seen in women denture wearers above the age of 50 (post-menopausal). 9,10

Clinical features
The pain usually starts in the morning and aggravates during the day and the burning sensation is often associated with dry mouth and persistent alteration in the taste .Other associated symptoms include headache, insomnia, decreased libido, irritability fatigue.

Management
Identifying the causative factor is important and it should be removed. Vitamin therapy is provided when associated with its deficiency. If psychogenic / psychosocial disturbance are diagnosed, adequate treatment should be offered through counselling and use of tranquilizers if required.

Gagging
Gag reflex is considered a normal. It is a healthy defence mechanism that prevents the foreign bodies from entering into the trachea.

Causes
It can be triggered by tactile stimulation of the posterior portion of the tongue, soft palate and faucial pillars. Other stimuli include taste, sight, noise or psychological factors can also stimulate gagging. The placement of new dentures can stimulate gag reflex in sensitive patients. Overextended denture borders in posterior part of maxillary or the distolingual part of the mandibular denture often result in a persistent gagging. 11,12 3.9.8. Management 1. It reduces gradually within few days as patient adapts to the new denture. 2. Correction of the posterior extensions of the denture.

Residual ridge resorption
It is the most common sequelae of wearing complete denture in which there is a continuous loss of bone not only after the extraction of teeth but also after the placement of dentures. Residual ridge resorption is a normal physiologic process wide variation in the rate of resorption. 13 In order to achieve equivalent reduction of food the number of chewing strokes required by a denture wearer is more than the person with natural dentition.

Preventive measurement and Management
1. Retention of teeth and using as over denture abutment will improve masticatory performance of individual. 2. Implant supported over denture is usually followed by improved masticatory efficiency.

Nutritional Deficiency
Nutritional deficiencies seen in older patients is often due to decreased food intake which can be due to reduced masticatory function or even due to reduced taste perception. However, some individuals even with poor masticatory function, rarely show nutritional deficiencies. Prosthodontic therapy should be indicated to improve the masticatory function. Other factors that effect nutrition include General health, socioeconomic status and dietary habits. 17 3.10.5. Management 1. Restoring the masticatory function by providing a prosthesis or by preventing the sequelae of complete denture. 2. Modification of the dietary habits.

Conclusion
There are many problems related to complete denture treatment. Several can be easily solved according to research and clinical experience. For others lack of evidence based knowledge making treatment unpredictable. Therefore continuing investment in clinical research and follow up on denture wearing patients are required.

Source of Funding
None.

Conflict of Interest
None.