Denture induced lesions- Aarti Dubey

SEMINARILL- FITTING DENTURE INDUCED LESIONSPRESENTED BY :-

AARTI DUBEY

GUIDED BY :-

DR S.B. DANGORE

DR S.S. DEGWEKAR

DR R.R. BHOWATE

PURPOSE STATEMENT

• At the end of the presentation the learners should be able to describe etiopathogenesis, clinical features, management & differential diagnosis of various denture induced lesions.

Serial no. Learning objectives Domain Level Criteria condition

1. Explain the etiopathogenesis of various denture induced lesions.

Cognitive Must know all --

2. Explain the clinical features of various denture induced lesions.

Cognitive& psychomotor

Must know all --

3. Differentiate denture induced lesions from other similar lesions.

Cognitive& psychomotor

Must know all --

4. Describe management for denture induced lesions.

Cognitive Must know all --

ILL-FITTING DENTURE INDUCED LESIONS :-

• The oral mucosa is subject to a variety of injuries as a result of wearing of artificial dentures. These may be manifested as - Traumatic ulcer

- Cheek bite -Inflammatory hyperplasia. -Fibrous Papillary hyperplasia

-Chronic atropic candidiasis

(denture stomatitis)

-Contact allergy

-Malignancy -Angular cheilitis

-Palatal perforation

-

1.TRAUMATIC ULCER ( sore spots)

Clinical Features

1. Develops within a day or two after the insertion of a new denture.2. Due to over-extension of the flanges, sequestration or spicules of bone under the denture or roughened or “high” spot on the inner surface of the denture.3. These are small, painful, irregularly shaped lesions covered by a delicate grey necrotic membrane and surrounded by an inflammatory halo.

Management

1. Correction of underlying cause.2. Relief of the flanges.4. Relief of high spots

Cheek bite

• Causes:-• Thin or overextended periphery (denture base material does not

provide enough support for the cheek)

• Loss of tone of cheek musculature in old patients

• Insufficient inter-arch clearance between distal part of denture.

• Inadequate horizontal overjet in molar region .

(posterior edge-to-edge occlusion)

Treatment• Build out thin areas, or extend the short periphery

• Trim maxillary denture buccal to tuberosity and/or from over retromolar pad of mandibular denture

•Re-set teeth in correct relationship

• Recontour and polish buccal surface of mandibular posterior teeth to create horizontal overjet

INFLAMMATORY HYPERPLASIA

The term “inflammatory hyperplasia” is used to describe a large range of commonly occurring nodular growths of the oral mucosa that histologically represent inflamed fibrous and granulation tissues.

The major etiologic factor for these lesions is generally assumed to be chronic trauma (such as that produced by ill-fitting dentures, calculus, overhanging dental restorations, acute or chronic tissue injury from biting, and fractured teeth), and chronic irritants can be convincingly demonstrated in many cases (eg, palatal papillary hyperplasia associated with aged maxillary dentures).

With some of these lesions, (eg, pregnancy epulis and the central giant cell tumor associated with hyperparathyroidism), the levels of circulating hormones also undoubtedly play a role.

The majority of lesions occur on the surface of the oral mucous membrane, where irritants are quite common.

If the chronic irritant is eliminated when the lesion is excised, the majority of inflammatory hyperplasias will not recur.

This confirms the benign nature of these lesions (as would be expected from their histologic structure).

The following are examples of inflammatory hyperplasia's:fibrous inflammatory hyperplasias (clinical fibroma, epulis fissuratum,

and pulp polyp) palatal papillary hyperplasia pyogenic granuloma pregnancy epulisEpulis granulomatosa giant cell granuloma(giant cell epulis and central giant cell tumor of the jaw) pseudosarcomatous Fasciitis proliferative myositis and Pseudoepitheliomatous hyperplasia.

Fibrous Inflammatory Hyperplasias and Traumatic Fibromas

Fibrous inflammatory hyperplasias may occur as either pedunculated or sessile (broad-based) growths on any surface of the oral mucous membrane.

They are called fibromas if they are sessile, firm, and covered by thin squamous epithelium.

On the gingiva, a similar lesion is often referred to as an epulis.

The majority remain small, and lesions that are > 1 cm in diameter are rare.

An exception to this rule occurs with a lesion that is associated with the periphery of illfitting dentures, the so-called epulis fissuratum, in which the growth is often split by the edge of the denture, one part of the lesion lying under the denture and the other part lying between the lip or cheek and the outer denture surface.

This lesion may extend the full length of one side of the denture. Many such hyperplastic growths will become less edematous and inflamed following the removal of the associated chronic irritant, but they rarely resolve entirely.

In the preparation of the mouth to receive dentures, these lesions are excised to prevent further irritation and to ensure a soft-tissue seal for the denture periphery.

The differential diagnosis of fibrous inflammatory hyperplasia should include consideration of the possibility that the lesion is a true papilloma (a cauliflower-like mass made up of multiple fingerlike projections of stratified squamous epithelium with a central core of vascular connective tissue) or a small verrucous carcinoma.

Fibrous inflammatory hyperplasias have no malignant potential, and recurrences following excision are almost always a result of the failure to eliminate the particular form of chronic irritation involved.

The occasional report of squamous cell carcinoma arising in an area of chronic denture irritation, however, underlines the fact that no oral growth, even those associated with an obvious chronic irritant, can be assumed to be benign until proven so by histologic study.

Thus,whenever possible, all fibrous inflammatory hyperplasias of the oral cavity should be treated by local excision, with microscopic examination of the excised tissue.

EPULIS FISSURATUM ( inflammatory Fibrous Hyperplassia, Denture Injury tumour, Denture epulis.)

-It is a tumour like hyperplasia of fibrous connective tissue.-Develops in association with the flange of ill fitting complete or partial dentures.

CLINICAL FEATURES

-Appears as single or multiple folds of hyperplastic tissue in the

alveolar vestibule.

-Flange of denture fits in to the fissure between these folds.

-Tissue is firm and fibrous.

-Some lesions appear erythematous and ulcerated.

-Size of lesion vary from localized hyperplasia's less than 1 cm in

size to massive lesions involve the entire length of vestibule.

-Anterior portion of jaws is affected more.

-Female predilection.

-Another lesion called fibro epithelial polyp or leaf like denture fibroma occurs on hard palate beneath maxillary denture.-It is a flattened pink mass attached to palate by narrow stalk.-It can easily lifted up with a probe demonstrate its pedunculated nature.-Edge of lesion is serrated and resembles a leaf.-If minor salivary glands are included they show chronic sialadenitis.-Unusual appearing products known as osseous and chondromatous metaplasia is a reactive phenomenon caused by chronic irritation by the ill fitting denture.

MANAGEMENT

1. Surgical removal.2. Ill fitting denture should be remade or relined.

• The frequency of occurrence of epulis fissuratum far exceeds that of any other exophytic lesion at the periphery of dentures.

• However the possibility of malignancy must be considered in each case: squamous and verrucous carcinomas, minor salivary gland tumours, metastatic tumours, osteosarcoma, and down reaching maxillary sinus malignancies.

PALATAL PAPILLARY HYPERPLASIA

Palatal papillary hyperplasia (denture papillomatosis) is a common lesion with a characteristic clinical appearance that develops on the hard palate in response to chronic denture irritation in approximately 3 to 4% of denture wearers.

Full dentures in which relief areas or “suction chambers” are cut in the palatal seating surface appear to be the strongest stimuli, but the lesion is also seen under partial dentures, and occasional case reports have described the lesion in patients who have never worn dentures.

The palatal lesion is usually associated with some degree of denture sore mouth (stomatitis) due to chronic candidal infection, which influences the appearance of the papillary hyperplasia.

When complicated by candidal infection, the lesion may be red to scarlet, and the swollen and tightly packed projections resemble the surface of an overripe berry. Such lesions are friable, often bleed with minimal trauma, and may be covered with a thin whitish exudate.

When the candidal infection is eliminated, either by removing the denture or by topical administration of an antifungal agent, the papillary lesion becomes little different in color from the rest of the palate and consists of more or less tightly packed nodular projections.

If tiny, the nodular projections simply give a feltlike texture to that portion of the palate, and the lesion may even pass unnoticed unless it is stroked with an instrument or disturbed by a jet of air.

It was first classified by Newton (1962) according to its clinical appearance as:

Type 1: A localized simple inflammation or pinpoint hyperaemia

Type 2: An erythematous or generalized simple type seen as

more diffuse erythema involving a part or the entire denture covered mucosa

Type 3: A granular type (inflammatory papillary hyperplasia)

commonly involving the central part of the hard palate and the alveolar ridges

• Type III often is seen in association with type I or type II.

• Type III denture stomatitis involves the epithelial response to chronic inflammatory stimulation secondary to yeast

Despite their sometimes bizarre clinical appearance, these lesions have almost no neoplastic potential, a finding that is borne out by the absence of atypia and cellular dysplasia in biopsy specimens.

If the alveolar ridges are surgically prepared for new dentures, papillary hyperplasia lesions are usually excised or removed (by electrocautery, cryosurgery, or laser surgery), and the old denture or a palatal splint is used to maintain a postoperative surgical dressing over the denuded area.

If florid papillomatosis of the palate occurs or persists in the absence of dentures, the differential diagnosis should also consider several granulomatous diseases that may manifest intraorally in this fashion (eg, infectious granulomas,Cowden disease, and verrucous carcinoma), particularly when the papillary lesions are white and extend beyond the palatal vault and onto the alveolar mucosa.

• Nicotine stomatitis may also feature multiple small nodules on palate, which are reddish before hyperkeratosis develop.

• The following observations help in the differentiation of this condition from IPH;

1. Nicotine stomatitis on the hard palate occurs almost exclusively in pipe smokers who do not wear full maxillary dentures.

2. The pattern in nicotine stomatitis is linear and angular, and the segments are flatter and broader but less elevated.

3. The segments in nicotine stomatitis have a characteristic red dot in their approximate center, which is not seen in PHP.

DENTURE STOMATITIS(CHRONIC ATROPHIC CANDIDIASIS)

Chronic atrophic candidiasis includes denture stomatitis (denture sore mouth), angular cheilitis, and median rhomboid glossitis.

Denture Stomatitis (Denture Sore Mouth)

Denture stomatitis is a common form of oral candidiasis that manifests as a diffuse inflammation of the maxillary denture-bearing areas and that is often (15 to 65% of cases) associated with angular cheilitis.

At least 70% of individuals with clinical signs of denture stomatitis exhibit fungal growth, and this condition most likely results from yeast colonization of the oral mucosa, combined with bacterial colonization.

Three progressive clinical stages of denture sore mouth have been described;

The first stage consists of numerous palatal petechiae

The second stage displays a more diffuse erythema involving most (if not all) of the denture- covered mucosa

The third stage includes the development of tissue granulation or nodularity (papillary hyperplasia) commonly involving the central areas of the hard palate and alveolar ridges.

Antifungal treatment will modify the bright red appearance of denture sore mouth and papillary hyperplasia specifically but will not resolve the basic papillomatous lesion, especially if the lesions have been present for more than 1 year.

Antifungal therapy and cessation of denture wearing usually is advisable before surgical excision since elimination of the mucosal inflammation often reduces the amount of tissue that needs to be excised.

Yeast attached to the denture plays an important etiologic role in chronic atrophic candidiasis

The attachment of yeast to the patient’s appliances is increased by mucus and serum and decreased by the presence of salivary pellicle, suggesting an explanation for the severity of candidiasis in xerostomic patients.

Rinsing the appliance with a dilute (10%) solution of household bleach, soaking it in boric acid, or applying nystatin cream before inserting the denture will eliminate the yeast.

Disinfection of the appliance is an important part of the treatment of denture sore mouth.

Soft liners in dentures provide a porous surface and an opportunity for additional mechanical locking of plaque and yeast to the appliance.

In general, soft liners are considered to be an additional hazard for patients who are susceptible to oral candidiasis.

Denture sore mouth is rarely found under a mandibular denture.

One possible explanation for this is that the negative pressure that forms under the maxillary denture excludes salivary antibody from this region, and yeast may reproduce, undisturbed, in the space between the denture and mucosa.

The closer adaptation of the maxillary denture and palate may also bring the large number of yeasts adhering to the denture surface into contact with the mucosa.

• The clinical picture of denture stomatits is rather specific; few if any other diseases appear the same.

• Infections by other organisms, however could be responsible for a similar diffuse redness either alone or I association with candida.

• Contact allergy to denture base occurs occasionally.

• In such cases redness will not be restricted to tissue under the denture, but all mucosal surfaces in contact with the acrylic will be red.

• Epicutaneous tests of the material will be diagnostic .

ANGULAR CHEILITIS (perleche, angular cheilosis.)

Inflammation of skin and mucous membrane at angle of mouth.Characterised by redness, fissuring, scaling or crustation.

ETIOLOGY

1. Nutritional deficiency- Riboflavin, Folate, Iron and protein deficiency.2. Reduced vertical dimension in complete dentures.3. Candida,Streptococcus, staphylococcus infection.4. Manifestation of HIV/ AIDS.5. Systemic condition: Diabetis, Neutropenia

CLINICAL FEATURES

-Occurs as an area of redness, linear deep fissure, peeling of skin, dry crust at the angle of mouth.- Symptomatic.-Pain and bleeding at site.-Difficulty in mouth opening.-Occurs bilaterally.-RHAGADES :- linear furrow or fissures radiating from the angle of mouth are seen in severe forms, especially in denture wearers.

MANAGEMENT

1. Removal of the cause.2. Nutritional supplement:- Vitamin B and Iron supplements.3. Ketoconazole: 200mg tab once daily for 1-2 weeks orFluconazole: 100mg tab once daily for 1-2 weeks.4. For severe candidiasis - Fluconazole is drug of choice.

Palatal Perforation

Even though it is well known about the harmful effects of suction disk use in complete dentures, they are still popular in rural and semi urban areas of India as a cheap means to achieve retention in maxillary dentures.

For retention suction cups produces negative pressure on the mucosa which it contacts.

This negative pressure induced by them has a destructive effect on the palatal tissues.

This negative pressure reduces the blood circulation in the underlying tissues , which causes hypoxia in the affected area and necrosis of tissue.

The underlying bony part may also be affected by this leading to tissue perforation

• These pathological changes are more severe if the patient is in the habit of continuously wearing the dentures 24 hrs a day.

TREATMENT:-• surgically close the opening and allow complete

healing using a healing plate and followed by fabrication of new complete denture.

Precautions to be taken by the Dentist to avoid these problems• There should be adequate relief .• There should be no overextension of the lingual

flange into the lateral throat form.• The vertical dimension must be accurate.• There shouldn’t be any deflective occlusal

contacts.• The denture borders should not be overextended.• There should be sufficient horizontal overlap of

posterior teeth.• Note that the borders are rounded and smooth,

and the palate is highly polished and the proper thickness.

CONCLUSION

Proper denture care is important for both the health of dentures and patients mouth.

Handle dentures with great care. To avoid accidentally dropping them, stand over a folded towel or a full sink of water when handling dentures.

Brush and rinse dentures daily:-•Like natural teeth, dentures must be brushed daily to remove food and plaque.

• Brushing also helps prevent the development of permanent stains on the dentures.

•Use a brush with soft bristles that is specifically designed for cleaning dentures.

•Avoid using a hard-bristled brush as it can damage or wear down dentures.

•Gently brush all surfaces of the denture and be careful not to damage the plastic or bend attachments.

• In between brushings, rinse dentures after every meal.

Denture care when not being worn:-•Dentures need to be kept moist when not being worn so they do not dry out or lose their shape.

•When not worn, dentures should be placed in a denture cleanser soaking solution or in water.

•However, if the denture has metal attachments, the attachments could tarnish if placed in a soaking solution.

•Dentures should never be placed in hot water, as it can cause them to warp.

Clean with a denture cleaner:-• Hand soap or mild dishwashing liquid can be used for cleaning dentures.

• Household cleansers and many toothpastes may be too abrasive for dentures and should not be used.

•Also, avoid using bleach, as this may whiten the pink portion of the denture.

•Ultrasonic cleaners can be used to care for dentures.

•These cleaners are small bathtub-like devices that contain a cleaning solution.

• The denture is immersed in the tub and then sound waves create a wave motion that dislodges the undesirable deposits.

• Use of an ultrasonic cleaner, however, does not replace a thorough daily brushing.

• Products with the American Dental Association (ADA) Seal of Acceptance are recommended since they have been evaluated for safety and effectiveness.

REFERENCES

• MARTIN S. GREENBERG,MICHAEL GLICK; Burket’s oral medicine Diagnosis & Treatment Tenth Edition

• Norman.k Wood, Paul.W.Goaz; DIFFERENTIAL DIAGNOSIS of ORAL and MAXILLOFACIAL LESIONS;5th edition

• B. C. Webb,C. J. Thomas et al; Candida-associated denture stomatitis . Aetiology and management : A review. Part 2 Oral diseases caused by candida species Australian Dental Journal 1998;43:(3):160-6

• Tatiana PEREIRA-CENCI, Altair Antoninha DEL BEL CURY, Wim CRIELAAR, Jacob Martien TEN CATE DEVELOPMENT OF CANDIDA-ASSOCIATED DENTURE STOMATITIS: NEW INSIGHTS; J Appl Oral Sci. 2008;16(2):86-94

• Hrizdana Hadjieva, Mariana Dimova, S. Todorov; STOMATITIS PROSTHETICA-A POLYETIOLOGIC DISORDER; Journal of IMAB - Annual Proceeding (Scientific Papers) 2006, book 2

• GAUTAM BAGCHI, DEVENDRA MANDHYAN AND DILIP KUMAR NATH; REHABILITATION OF A PATIENT WITH PALATAL PERFORATION DUE TO

PROLONGED USE OF DENTURE WITH SUCTION DISK: A CASE REPORT; (JRAAS) 27:62-64, 2012

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