TROUBLE SHOOTING IN COMPLETE DENTURE PROSTHESIS

Part V. Local and Systemic Involvements*

JOSEPH S. LANDA, D.D.S.

New York, N. Y.

are insufficient to determine which of the con-

P RESENT DIAGNOSTIC TECHNIQUES
tributing factors oxidation and ventilation is most responsible for sore mouths
of denture patients. However, these etiological factors are important both indi-
vidually and collectively.

OXIDATION

The oral mucosa needs oxidation by direct access of outside air as does the
skin, but the border seal of complete dentures blocks off this air. Therefore, it
might be reasoned that it would be beneficial to eliminate the border seal entirely.
Experience, however, teaches that more sore mouths are observed when the border
seal is totally lacking. The conclusion must be that the benefit derived by the
mucosa from direct access of air through the denture borders is nullified by factors
which the lack of a seal engenders. Retention and stability are greatly impaired with
the loss of the seal, and this impairment causes inflammatory conditions in the
denture-supporting structures.

VENTILATION

Ventilation exposes the mucosa which supports the dentures to fresh air for
oxidation purposes. It also allows accumulated vitiated air to escape, thereby
freeing the tissues from noxious gases. To improve oxidation of the mucosa, the
patient should rinse the mouth several times a day with a mild antiseptic, oxidizing
mouthwash. For better ventilation and “rest” of the tissues, the dentures should
be removed from the mouth several times a day. Thus, the blood circulation will
be activated and the oxidation and nutrition of the tissues improved. A diseased
or disturbed organ or tissue is in need of rest to mobilize all its defensive mechan-
isms to alleviate the condition

EXCESSIVE RETENTION

Excessive retention is seldom mentioned as a cause of inflammatory conditions

of the denture-supporting structures. This condition causes complaints of severe
jaw fatigue toward the end of day or necessitates removal of the dentures from the

*Part I, .I. PROS. DEN. 9:978-987, 1959; Part II, J. PROS. DEN. 10:42-46, 1960; Part III, J. PROS.
DEN. 10:263-269, 1960; Part IV, J. PROS. DEN. 10:490-495, 1960.
682
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h-umber 4
TROUBLE SHOOTING IN COMPLETE DENTCRE PROSTHESIS. V 683

mouth. The dentist may find that the retention of one or both dentures is vouch i:lt
cncess of customary retention. Force may be required to dislodge the denture frorl
its position because of the excessive adhesion.
Excessive retention may be of two types : (1) that which results from ex-
tremely favorable adhesion and cohesion and (2) that caused by extreme intin1ac.y
of contact between the denture and the mucosa. Such intimacy is not of a physio-
logic nature, but is of pathologic origin. This condition is found usually in people
who are in a state of tension and grind and gnash their teeth to excess. The den-
tures may be of high quality with balanced occlusion.
Bruxism drives complete dentures in good balanced occlusion into excessive
intimacy of contact with the underlying mucosa. This leads to a chronic inflam-
matory condition of the oral mucosa because the excessive pressure interferes with
the blood circulation. The patient may not experience any particular pain, but is
beset, instead, with a heavy, numb, and tired feeling throughout the entire exter.t
of the dentures.
This symptomatology should not be confused with that arising from traumatic
occlusion. In traumatic occlusion, the patient’s complaint of a heavy and tired fee’-
ing is limited usually to one side and there is some slight pain. Also, a differential
diagnosis must be established between excessive retention and good retention that
accompanies a correct border seal. With correct retention, the dull, heavy, and tired
feeling subsitles within the first 2 weeks after the insertion of the dentures.

INADEQUATE RETENTION

The chief problem in sore mouth conditions arises from inadequate retention.
Inadequate retention causes damage to the mucosa in two ways : ( 1) the movemerIt
of the denture injures various sections of the supporting and adjacent structures
and (2) the patient acquires the habit of reseating the dentures with the fingers
and tongue. In either instance, the physiologic endurance of the mucosa is over-
taxed and pathologic readaptation of the tissues follows. In acldition, loose dentures
have a disturbing effect upon the patient’s psyche which leads to the formation
of tenacious and stubborn habits.
The lingual surface of the mandibular ridge is the most important target of
the loose lower denture. Irritations appear in various sections, particularly on the
sharp mylohyoid line. These irritations can hardly be seen, because the loose
denture does not hit the same spot repeatedly enough to form a clear-cut ulceration.
However, the experienced eye will discern small grayish white irritations in the
desquamation of the superficial layers of epithelium. If the spot is painful to pal-
pation and some slight morphologic change is suspected, the denture may be re-
duced slightly and polishecl. However, this is a palliative treatment. The only way
to cure this condition is to correct the inadequate retention.
The inadequate retention is caused usually by denture border overextension,
denture border underextension, or both. A slightly overextended denture is to be
preferred to a slightly underextended one, but correct extension should always be
the goal (Fig. 1) . An adequate occlusion develops intimacy of contact between the
denture and its supporting structures, thereby greatly improving denture retentiol?.
684 J. Pros. Den.
July-August, 1960

SYSTEMIC DISEASES

Dentists must be familiar with local manifestations of a general origin. A

patient whose resistance has been lowered by a general ailment experiences two
types of difficulties : (1) the oral tissues are more vulnerable to trauma and infec-
tion and (2) their healing qualities are lowered considerably. The severely dia-
betic person develops sores on the denture-supporting structures, whereas a
healthy person under similar circumstances does not. Furthermore, the sores of
the diabetic patient will respond poorly to treatment as long as the blood sugar
level remains high. With its descent to a normal level, there is improved response

Fig. 1,The anatomic landmarks from a stone cast are superimposed upon the oral struc-
tures. The arrows show slitlike ulcerations in the lining mucosa on the undersurface of the
tongue. In this area, the lining mucosa is not keratinized and is highly sensitive to irritation.

to treatment. A similar relationship exists with other general diseases, such as

tuberculosis, syphilis, and blood dyscrasias. The inflammatory condition is not
due so much to the severity of the trauma as to the low resistance of the tissues.
Dental offices should be equipped to perform basic biologic tests for anemia,
determination of the blood sugar level, sugar and albumin in the urine, etc. This
does not imply that the dentist is assuming the role of the physician, but the dentist
is frequently in an excellent position to note the presence of general disease from
the behavior and reactions of the oral tissues. I have seen numerous complete
dentures in which the occlusion and denture borders were mutilated by over-
~~‘~~~
‘4” TROUBLE SHOOTING IN COMPLETE DENTURE PROSTHESIS. V 68.5

Fig. 2.-The features of border extension for stability and retention that are inherent in -this
impression should be retained permanently in the completed denture. (From Swenson, M.:
Complete Dentures, St. Louis, 1940, The C. V. Mosby Company.)

enthusiastic adjustments (Figs. 2 and 3). These dentures were given up as failures
by the dentists, only to have them learn that the real cause for the failure was a
general physical or emotional disturbance.
Lichen planus may become the chief cause for failure of complete dentures.
Patients afflicted by this condition are usually emotionally hypersensitive and fre-
quently suffer from cancerophobia. They fear that the lichen planus patches rubbing
against the buccal surfaces of the posterior teeth and the denture-base material
may lead to cancer. Dentures are mutilated by setting the teeth so far away from
the cheeks that the tongue becomes completely imprisoned. The lower denture b,ase
is rendered useless by gradually reducing it until it becomes flagrantly under-
extended. If a proper diagnosis had been established originally, with proper
psychologic preparation of the patient, mutilation of the dentures would not have
occurred.

Fig. 3.-Incorrect adjustments result in an excessively underextended lower denture with

complete mutilation of the denture borders.
686 LANDA J. Pros. Den.
July-August, 1960

The dentist should be extremely alert in the diagnosis of lichen planus (and
its concomitant skin lesions) and what resembles it, but is a much more serious
condition, leukoplakia. The latter may be a piecancerous lesion and should always
be kept under strict supervision by both the dentist and physician, Leukoplakia on
the palatal vault and alveolar ridges often disappears when covered and well pro-
tected by dentures. The tissue surface of the denture over leukoplakia must be
relieved properly and polished smoothly. In addition, the dentures must be stable
and the occlusion well balanced. Ideal cleanliness of the dentures is imperative and
the dentures must be inspected frequently.
All diseases that tend to lower the vitality of the individual lower the re-
sistance of the oral mucosa. The oral cavity, one of the organs of the human body,
suffers whenever the entire organism is affected. The degree depends upon the
type and severity of the systemic disease.

ENDOCRINE AND EMOTIONAL DISTURBANCES

The ill effects of endocrine dysfunctions and emotional disturbances upon the
mucosa are extremely difficult to differentiate. There is such intimate interplay and
reciprocity between these two factors that it is best to treat them together.
A great number of women in menopause or, more so, in the postmenopausal
state present a definite problem to the prosthodontist. They complain at frequent
intervals of vague, diffuse pain of the denture-supporting structures. On exami-
nation, no specific irritation or ulceration is found. Instead, the entire mucosa
under the dentures manifests a red, glossy appearance and is slightly edematous.
The sensitivity of these tissues to finger pressure or mere contact and the observed
morphologic deviation suggest that two main factors may be at work simultane-
ously : (1) traumatic occlusion and (2) poor cornification of the mucosa because
of a deficiency of estrogenic hormones. A similar picture, on rare occasions, may
be observed in men. They manifest nervous and emotional tension very characteris-
tic of women in the stage of menopause. Cancerophobia is an outstanding affliction.
The condition of the mucosa resembles that classified by some periodontists as
desquamative gingivitis.
The oral or topical administration of estrogenic hormones by an endocrinolo-
gist has been found by some investigators l to be useful. Our patients who have
benefited have been treated by simultaneous perfection of the occlusion, administra-
tion of estrogenic hormones, improvement in diet and nutrition, vitamin administra-
tion, and reassurance. We do not know to what extent the condition has been
,;benefited by any one of these therapeutic agents. However, we do know that en-
docrine dysfunctions themselves are decreased by proper nutrition, a balanced
diet, and an adequate intake of vitamins.

SUMMARY

The diagnosis and treatment of inflammatory conditions in the oral cavity

cannot be limited to one area alone. The boundaries must be extended to include
a complete history of the patient’s life with its ramifications into every department
E%z‘4” TROUBLE SHOOTING IN COMPLETE DENTURE PROSTHESIS. V 687

of human endeavor. Certain oral conditions are due to the patient’s occupation.
Others are a local manifestation of a general condition, such as poor nutrition and
endocrine dysfunctions. Systemic therapy in these instances is conducive to best re-
sults, whereas topical treatment fails.

REFERENCE

1. Miller, S. C. : Oral Diagnosis and Treatment, ed. 3, New York, 1957, Blakistorl Compa.ny.

136 EAST 54~~ ST.

NEW YORK 22, N. Y.