APPLIED ANATOMY AND BEHAVIOURAL CHANGES OF ORAL MUCOSA UNDER COMPLETE DENTURE PROSTHESIS Introduction Preservation of the residual

structures of foundational tissues constitute a consideration of paramount interesting prosthodontics. Tissues of the oral cavity are made to reveal a phenomenon of reaction consequent to being subjected to artificial environment. The reaction of the tissues is universally evident from the fact that the oral tissues will expel the irritant, big or small which enters the oral cavity. Oral tissues were designed to be exposed to oral fluids and to be stimulated by the action of tongue, chee s and lips. !ven in the dentulous state, the mucosa demonstrates a low tolerance to injury or irritation. Tolerance is further depleted if systemic disease is present. Oral mucosa does not appear to be suited to the role of bearing stress and shows little or no adaptation to this altered function. The observations " would li e to ma e in the following delibration are based on the reaction of locali#ed areas of these foundations to the dentures which would mean the applied anatomy.

%ody cavities that communicate with the external surface are lined by mucous membranes, which are coated by serous and mucous secretions.

The oral cavity is lined with an uninterrupted mucous membrane which is continuous with the s in near the vermillion border of the lips and with the pharyngeal mucosa in the region of the soft palate.

&i e s in, the oral mucosa serves to protect the underlying organs and to receive and transmit stimuli from the environment.

Deve o!"ent o# or$ "uco%$ The primitive oral cavity develops by fusion of the embyonic ' timodeum with foregut after rupture of buccopharyngeal membrane. This occurs at about () days of gestation. *o the primitive oral cavity is lived by epithelium derived from both ectiderm and endoderm. The structures that develop from the brachial arches. !g. Tongue are covered by epithelium derived from endoderm whereas, the epithelium covering the palate, chec s and gingivae are derived from ectoderm. The underlying ectomesenchyme of the epithelium forms the connective tissue of the oral mucosa.

Structure *tructure of oral mucous membrane resembles the s in in many ways. "t is composed of + !pithelium, ,onnective tissue -&amina propria. and submucosa -may or may not be present.. The ( layers form an interface that is folded into cormgations. Papilla of connective tissue protrude toward the epithelium carrying blood vessels and nerves. /lthough the nerves actually pass into the epithelium, it does not contain blood vessels. The epithelium inturn is formed into ridges that protrude towards the lamna propria. L$"in$ !ro!ri$ &amina popria may attach to the perosteum of the alveolar bone, or it may overlay the submucosa which varies in different regions of the mouth. Su&"uco%$ *ubmucosa consists of connective tissue of varying thic ness and density. "t attaches the mucous membrane to the underlying structures. 0hether this attachment is loose or firm depends on the character of the submucosa.

2lands, blood vessels, nerves and also adipose tissue are present in the layer. "t is in the submucosa that larger arteries divide into smaller branches which then enter the lamina propria.

3eratini#ing oral epithelium has 4 layers -based on morphology. $. *tratum basale, (. *tratum spinosum 1. stratum granulosum 4. *tratum corneum. / single cell after mitosis may remain in the basal layer and divide

again or it may become determined during which it migrates upwards. 5uring its migration it becomes committed to biomechanical and morphologic changes and forms a 3eratin#ed lquama, a dead cell filled with densely pac ed protein. /fter reaching the surface it desquamates. This whole process from onset to maturation stage is called 3eratini#ation. E!it'e iu" !pithelium of oral mucous membrane is stratified squamous epithelium. "t may be ortho eratini#ed, para eratini#ed or

non eratini#ed depending on the location. / common feature of all epithelial cells is that they contain eratin intermediate filaments as a component of their cytis eleton. (er$tin) "t is a sdeiroprotein which is principal constituent of epidermis, hairs, nails and organic matrix of tooth enamel. "t is a very insoluble

protein. "t contains sulphur. KERATIN IS THE END RESULT OF EPITHELIAL DEGENERATION. The layers mentioned above are characteristic of ortho eratini#ation. The cell layers o non 6 eratini#ing epithelium are referred to as stratum basale, stratum intermedium, stratum superficiale -7o stratum granulosum.. *urface cells are mediated and show no signs of eratini#ation. "n para eratini#ation, a stratum granulosum is generally absent and the surface cells retain a py notic nuclei and show some signs of eratin#ation. B$%$ ce %+ *ingle layer of cuboid or high cuboidal cells. They are separated from the connective tissue by the basement membrane. S!inou% ce %+ "rregularly polyhedral and larger than the basal cells of the 4 layers, this layer is most active in protein synthesis. Gr$nu $r ce %+ ,ontains flatter and wider cells. These cells are larger than spinous cells. This layer is named for its basophilic eratohydro granules. Corni#ied ce %+ 8ade up of eratini#ed squamae which are flatter than granular cells. 9ere all the nuclei and other cell organelles have disappeared.

0hile the term ;3eratini#ation< is physiologic, the term eratosis is pathologic. 0hen eratini#ation occurs in a normally non eratini#ed

tissue, it is referred to as ; eratosis<. C $%%i#ic$tion o# or$ "uco%$ in t'e edentu ou% 8ost classifications divide the oral mucosa into 1 categories, depending on its function and location. /. M$%tic$tor* "uco%$) -9as well defined eratini#ed layer. ,overs the crest of the residual ridge, including the residual attached gingival that is firmly attached to the supporting bone, and the hard palate. %. Linin+ "uco%$) -5evoid of eratini#ed layer. "t is associated with those parts of the oral cavity which are not firmly attached to the perosteum. "t covers the lips and chee s, vestibular spaces, the alveolingual sulcus, the soft palate, the ventral surface of the tongue and unattached gingival found on the slopes of residual ridges. These tissue are freely movable because of the elastic nature of underlying lamina propria. ,. S!eci$ i,ed "uco%$) "t covers the dorsal surface of the tongue. This mucosal covering is eratini#ed and includes the speciali#ed papillae on the upper surface of the tongue.

C inic$ to!o+r$!'* o# t'e %o#t ti%%ue% o# t'e or$ c$vit* -it' t'eir "icro%co!ic $n$to"* $nd c inic$ i"!ort$nce. ,linical procedures used in ma ing impressions are directly related to gross anatomic structures of the oral cavity and their function. 9owever, the response of the individual cellular components that ma e up the basal seat determines the ultimate success of the dentures in terms of preservation of the residual ridges and comfort of the patient. Thus a constant awareness of microscopic anatomy of the mucous membrane and bone that form the residual ridge is essential in the development of -$. border form and -(. length and in -1. selective placement of pressures on the basal seat during impression procedures. The nature of the mucous membrane in different parts of the mouth varies between patients and within the same patient. The eratini#ed layer of the epithelium may be totally absent in some instances and extremely thic in others. /lthough the importance of the mucosa from a health stand point cannot be neglected, the thic ness and consistency of the submucosa are largely responsible for the support that the soft tissues afford the dentures, since in most instances the submucosa ma es up the bul of the mucous membrane.

0hen the submucosal layer is thin over the bone, the soft tissues will be non resilient and small movement of the dentures will then to brea the retentive seal.

0hen the submucosal layer is loosely attached to the periosteum of the residual ridge or is inflamed or edentulous, the tissue is easily displaceable and the stability and support of the dentures are adversely affected.

"mpression procedure requires modification to accommodate these changes in the submucosa.

I. M$/i $ A. Supporting Structures 1. Crest o t!e resi"u#$ ri"ge% "n healthy mouth it is firmly attached to the periosteum of the bone of maxilla. "t presents a grayish pin tissue because of its dense character and minimal vascularity. *tratified sqaumous epithelium is thic ly eratini#ed submucosa is devoid of fat or glandular cells, but it is characteri#ed by dense collagenous fibres. Though the submucosa is thin, it is still sufficiently thic to provide adequate resiliency for primary support of upper denture.

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0. S o!e% o# t'e re%idu$ rid+e) 9ere the tissues are loosely attached. This mar s the end of residual attached mucous membrane. The tissues here are non para eratini#ed. These loosely attached tissues will not withstand the forces of mastication or other stresses transmitted through the denture basis. 8ucosa of the labial vestibule between the residual alveolar ridge and the lips and chee s is called the valve producing area. &ess stress is placed on the movable tissues during ma ing of the final impression. This is because the final impression material in that region is close to escape ways. This fact is in accordance with the principle. 1. H$rd !$ $te) 8ucous membrane of the hard palate is tightly fixed to the underlying periosteum and therefore immovable. 9owever its thic ness and consistency varies in different locations. !pitheliumis uniform and has a well 6 eratini#ed surface ?arious regions in the hard palate differ because of the varying structure of the submucous layer. These #ones are recogni#ed. a. /nterolateral area or fatty #one eratini#ed or

b. Posterolateral area or glandular #one c. Palatine raphae or median area. a. Antero$#ter#$$&+ *ubmucosa of the hard palate contains adipose tissue. b. Posterior$& + *ubmucosa contains glandular tissue. I"!ort$nce) These tissues should be recorded in a resting condition because when they are displaced in the final impression, they tend to return to normal form within the completed denture base, creating an unseating for on the denture or causing soreness in the patientAs mouth. The secretions from the palatal glands can be an important factor in the selection of final impression material. c' (e"i#n p#$#t#$ suture% "t extends from the incisive papillae till the posterior region on the hard palate. The submucosa in this region is extremely then the mucosal layer is practically in contact with the underlying bone. *o the tissue covering the suture is non-resilient. I"!ort$nce+ &ittle or no pressure can be placed in this region during ma ing of final impression or in the completed denture. Otherwise the denture will tend to roc over the center of the palate when vertical forces are applied to the teeth.

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"n addition this part of the mouth is highly sensitive and excessive pressure can create excruciating pain. *o proper relief in the impression tray is required for accommodation of histologic nature of this tissue. 2. Inci%ive P$!i $e+ /t the anterior end of median palatal suture, there is an elongated or oral elevation of the mucosa called incisive papillae. "t covers the incisive foramen and is located behind and between the central incisors. The submucosa of the nasopalatine canal would reveal the nasopalatine nerves and vessels. I"!ort$nce+ Celief should be provided for the incisive papillae in both the final impression and completed denture to prevent pressure on the nasopalatine vessels and nerves. 3. P$ $tine ru+$e+ Cugae are irregularly shaped rolls of soft tissue in the anterior part of the palate. I"!ort$nce+ Cugae is considered to be the secondary stress bearing area as it can resist forward movement of the denture. B. Li"itin+ %tructure% $. ?estibular spaces+ "t is bounded facially by the mucosa of the lips and chee s and orally by the mucosa of the residual ridge.

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The vestibule is partly divided in the median plane by the upper and lower labial frenae and laterally by buccal frame.

/ histologic section in this region shows a relatively thin epithelium that is non eratini#ed submucosal layer is thic and contains large amounts of loose areolar tissue, and elastic fibres. *o this tissue is easily movable.

I"!ort$nce+ &abial or buccal flanges of the maxillary impression can be easily overextended or underextended. / nowledge of the si#e of the space in the vestibule available for denture flanges is the ey factor. 0. Vi&r$tin+ ine) "t is an imagninary line drawn across the soft palate that mar s the beginning of motion when the patient says ;ah<. *ubmucosa in this region contains glandular tissue similar to that in the submucosa in the postero lateral part of the hard palate. I"!ort$nce+ %ecause the soft palate does not rest directly on the bone, the tissue for a few millimeters on either side of the vibrating line can be repositioned in a controlled manner in the impression procedure. This improves posterior palatal seal.

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1. Mucou% "e"&r$ne in H$"u $r notc' $re$) *pace between the posterior part of maxillary tuberosity and pteregord hamulus is thic and made of loose aredor tissue. I"!ort$nce+ /dditional pressure can be placed on this tissue at the center of the notch to complete the posterior palatal seal. *pacer is provided in the find impression tray except in the region of vibrating line and through hamular notches. Thus the tray itself contacts the soft tissue in this region when impression is made. These tissues can be displaced without trauma. II. M$ndi&u $r edentu ou% #ound$tion% A. Supporting structures 1. Crest o t!e resi"u#$ ri"ge% 8ucous membrane covering the crest of the lower residual ridge is similar to that of the upper ridge. "n a healthy mouth it is covered by a 3eratini#ed layer firmly attached to the periosteum by the submucosa. "n same patients the submucosa is loosely attached to the bone over the entire crest of the residual ridge and the soft tissue is quite movable. I"!ort$nce+ when the soft tissues is movable, it must be registered in its resting position in the final impression. Occasionally surgical

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procedures are indicated to increase the amount of ;residual attached gingivae<. These tissues must be in a healthy condition when the final impression is made. 0. Bucc$ S'e #) 8ucous membrane covering the buccal shelf is more loosely attached and partially eratini#ed and contains a thic er submucosal layer. 9owever the bone of the buccal shelf is covered by a layer of compact bone composed of 9aversian system. 9ence this area is suitable as a primary stress bearing area of the mandibular edentulous foundations. ). Li*it#ting structures% 1. +esti,u$#r sp#ces% The mucous membrane lining these spaces is quite similar to the in nature to that of the maxillary foundation. The epithelium is their and non 3eratini#ed and the submucosa is formed of loosely arranged connective tissue fibres and elastic fibres. /nteriorly the submucosa of the mucous membrane lining the alveolingual sulcus contains components of the sublingual gland and is attached to the genioglossus muscle.

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0. Mo $r re+ion) 9ere the submucosa attaches to the mylohyoid muscle and mucous membrane covering the retromylohyoid certain is attached by its submucosa to the superior constrictor muscle. Posterior to the superior constrictor muscle fibres, when run in a hori#ontal direction is found the medial pteregoid muscle running in a vertical direction. I"!ort$nce+ &ength and form of the lingual flange of the lingual flange of lower final impression tray must reflect the physiologic activity of these structures. 1. Retro"o $r !$d) "t has at the posterior end of the crest of lower residual ridge. 9istologically mucosa of the pad is composed of a thin, non eratini#ed epithelium. "ts submucosa contains glandular tissue, loose areolar tissue, fibres of baccinator and superior constrictor muscles, the pteregomandibular raphae and the tendon of temporalis. "mportance+ because of its contents, it is recorded in a resting position in final impression. Be'$viour o# or$ "uco%$ under %tre%% Oral mucosa under compression behaves in a viscoelastic fashion similar to s in and other biologic tissues loaded in compression.

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&oads imposed on the masticatory mucosa by normal mastication and by the prosthesis consists primarily of compressive and shear forces. 9owever these forces will produce regions of tensile stresses within the mucosa.

3ydd and associates described the viscoelastic character of denture supporting tissues. a. There is an initial elastic compression of the soft tissue that ta es place instantly on application of load. b. /fter the elastic phase there is a delayed elastic deformation of the soft tissue that ta es place slowly and continues to diminish in rate of change as duration of load is extended. c. /n instantaneous elastic decompression occurs when the pressure is removed. d. This is followed by a continuing delayed elastic recovery.

They also arranged that during function and parafunction, pressures are applied by the dentures which will displace the soft tissues. These pressure deform the mucoperiosteum and interferes with circulation of blood, nutrients and metabolites.

Tissue pressure under complete maxillary dentures

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,utright and associates -$@=). recorded pressures under complete maxillary dentures. They used a closed fluid system connected to a pressure transducer and recorder to register positive and negative pressures in 4 subjects at 4 locations.

!ach subject performed a number of controlled masticatory and non masticatory activities.

Pressures were recorded as positive above a base line which equaled #ero with the denture in a passive condition and negative if they were below the base line.

Dindings indicate that a number of non masticatory activities -swallowing, smo ing and spea ing. created as much or more Eve or 6ve pressures on the supporting tissues as the masticatory activities.

Conc u%ion o# t'i% %tud* $. *table dentures produce high pressure on the supporting tissues and transmit these pressure from region to region varying with how the patient uses the denture. (. 8ost often, an opposite large or negative pressure immediately followed the production of E ve pressure at the same site beneath the denture. Thus each movement actually traumati#es the tissue twice.

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1. *wallowing which is not associated with eating or drin ing produced very high Eve and very low 6ve pressures on the tissues. E##ect o# co"! ete denture on $ veo $r "uco%$ Ostland studied the effect of complete dentures on the ;gum tissues< through observation of clinical changes and the examination of histologic sections from biopsies of palatine mucosa in denture and non denture wearers. 9e described the mucosal changes as pathologic but without fran clinical inflammation. 9e demonstrated a decrease in 3eratini#ation of denture bearing mucosa and a decrease in mucosal thic ners. Conc u%ion+ 9e concluded that a denture covering the ridge mucosa in the absence of trauma protects underlying soft tissues from injury. *o in a non denture wearer irritation from various sources chronic inflammation 8ore boneloss. *o because of continuous inflammation a non denture wearer may loose more bone than a denture wearer. 3apur and associates conducted a study to investigate the changes occurring in denture bearing mucosa after the use of removable dentures. %iopsy study was performed before and after the use of dentures. -%iopsy form crest of the ridge.. One side of posterior edentulous ridge was stimulated with a power driven tooth brush on wee days for a period of 4 wee s. The other

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side served as control. This was done in order now the relation between tissue stimulation to wearing of dentures. -"n a previous study it was demonstrated that stimulation of edentulous alveolar mucosa with an automatic tooth brush resulted in increased eratini#ed.. A veo $r "uco%$ !rior to denture in%ertion Micro%co!ic e/$"in$tion reve$ ed a. / distinct layer of eratin. This was of para eratotic variety with cell nuclei visible within stratum comeum. b. ,onnective tissue was infiltrated with varying numbers of lymphocytes, plasma cells 6 chronic inflammatory cells. c. !dentulous mucosa that had been stimulated with automatic tooth brush for a period of a 4 wee s showed a generali#ed increase in width of stratum corneum as compared to unstimulated mucosa. d. *timulated mucosa also showed greater downward extension of rete pegs than unstimulated mucosa. /lveolar mucosa following the wearing of dentures for 1 months

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Micro%co!* %'o-ed a. 5istinct increase in width of stratum corneum in specimens ta en after dentures had been worn. "t was mainly ortho3eratin -hyperortho 3eratini#ation. but it but was #ones of mainly ortho3eratin were

-hyperortho eratini#ation. occasionally in evidence.

para eroatosis

b. The stimulated and non stimulated mucosa presented an equal amount of eratini#ation indicating that the stimulation of mucosa prior to

insertion of dentures had no relationship to subsequent tissue reaction. c. ,hronic inflammatory infiltration was minimal and connective tissue collagen appeared dense and well formed. Conc u%ion+ These results are in some variance with those of ostland. *ince ostlundAs biopsies were ta en in posterior palatal seal areas, the changes may have been due to continuous pressure from denture base in this region %iopsy specimens of the ridge -as in 3apurAs study. presents a more accurate picture of mucosal reactions to well-adapted dentures. "t eratini#ation is a mechanism where by tissues gain a greater degree of protection against local irritation or trauma, then it appears a well adapted denture base stimulates, the underlying mucosa to produce eratin.

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&ac of inflammation in subjacent ,.T. indicates that well adapted denture is not an irritant. %iomechanical principles of denture construction, its relation to eratini#ation The purpose of this study conducted by mar ov was to see whether amount of eratini#ation of edentulous ridges had something to do with biomechanical qualities of dentures such as occlusion, stability, vertical dimension of occlusion, palatal relief in maxillary denture. *mears were made from tissues scrapings collected from mucosa and were stained and examined microscopically. Conc u%ion+ Dundamental biomechanical principles of good denture construction are of paramount importance to the health of the mouth under complete dentures. The principles include, $. 2ood Occlusion (. *tability 1. !stablishment of correct vertical dimension of occlusion 4. Palatal relief in the midline of maxillary denture.

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Hi%to o+ic$ c'$n+e% o# or$ "uco%$ under %tre%%. *ignificant changes occurred in the epithelium and connective tissue depending on the amount of force applied. E!it'e iu") under :g'mm( of force epithelium showed no cytologic changes until a 4 hour load duration was reached. /t this stage intercellular and intracellular C'$n+e% -ere %een ,hanges consisted of vacuoli#ation, decreased staining of cytoplasm, cellular swelling and increased nuclear si#e. The parts of epithelium in which these changes too place were the middle and upper layers of stratum spinosum. ,ells of basal layer appeared unaffected. /t ) hours duration, isolated damaged cells were more frequent. L$"in$ !ro!ri$ $nd %u&"uco%$) &ength and width of papilla appeared o be decreaed. *ometimes they were completely obliterated. *ubmucosa of mucoperiosteum that contained major blood vessel was completely occluded under heavy loading.

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Conc u%ion) with relatively small occluding forces -B.(@'mm(. the denture supporting oral mucosa can be intruded upto (BF of resting thic ness. This indicates that impression materials must flow readily with minimal pressure when an impression is made. Denture in# $""$tion $nd $%%oci$ted %o#t ti%%ue c'$n+e% Cesponse of human s in to everyday wear and tear is to become eratini#ed and tough. The oral mucosa does not behave in the same manner. !ven the dentulous state, the mucosa demonstrates a low tolerance to injury or irritation. This tolerance is further reduced if systemic disease is present. The mucosa does not appear to be suited to complete-denture load bearing rate and demonstrates little or no ability to respond to this altered function. "t appears that if the tolerance of the mucosal tissues is exceed -eg. %y overextended border., injury and inflammation will result and the denture cannot be worn. "f on the other hand, initial tolerance is high and the trauma tolerable, a fibrous response is elicited and the residual ridge is replaced with flabby hyperplastic tissue. 5entures are frequently worn over such tissue without discomfort. "n between these two extremes be the majority of patients, in whom chronic mucosal irritation proceeds quietly and painlessly.

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"t may be the character of the underlying bone that determines the tolerance and response of denture bearing mucosa. %ergman and associates showed a causal relationship between trauma and denture stomatitis and that stomatitis was greater in those patients in whom the residual ridge was displaceable. *oft tissue to long term denture wearing which are frequently encountered are /. *oft tissue 9yperplasia %. 5enture *tomatitis A. So#t ti%%ue '*!er! $%i$) 9yperplasia of the soft tissue under or around a complete denture is the result of a fibroepithelial response to complete denture wearing. "t is often asymptamatic and may be limited to the tissues in the vestibule or palatal regions or it may occur on all or part of the residual ridge. i. Dibrous hypoplasia on ridge crest "t consists of rolls of hyperplastic tissue under the denture base. &esion is slow to develop and painless

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"t may be due to bone resorption, with the lesion filling the space under the denture base caused by bone loss.

"t is most often found on anterior part of maxillary ridge. / single maxillary denture opposed by natural lower anterior teeth only will usually lead to formation of this tissue.

Tre$t"ent) E$r * %t$+e Tissue recovery period may be all that is necessary.

/dvanced stage -Tissues allow excessive denture movement. *urgical removal 7ew dentures are constructed.

ii4 E!u i% #i%%ur$t$) "t is the hyperplasia occurring around the border of a denture. "t occurs in the free mucosa lining the sulcus or at the junction of free and attached mucosa. "t develops as a result of chronic irritation from overextended dentures. ,linical examination reveals, these tissue are hyperaemic and swollen.

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Tre$t"ent) Inci!ient5%t$+e "mpound dentures, until healing is complete 5entures may be worn with tissue conditioner after removal of the irritant. C'ronic %t$+e *urgical removal, ,are must be ta en to avoid excising any attached mucosa. 5entures can be worn as surgical dressing Cema e the prosthesis The flabby hyperplastic tissues found in denture wearers should be excised to minimi#e progressive resorption of residual ridges. iii4 P$!i $r* '*!er! $%i$) "t is a granular type of inflammation seen in the palatal regions of maxillary arch. "t consists of numerous closely arranged papillary projections that give the region a warty appearance. Dactor most li ely to be involved in the formation of papillary hyperplasia is negative pressure. / similar condition exists when relief chambers are made in palatal regions of max, denture. 0hen a

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palatal relief is provided, the edge of the relief not be detectable to the finger tip. This condition is not reversible. This lesion is not innocuous. "t has been suggested that these lesions show precancerous tendencies designated pathologically as

pseudoepitheliomatous hyperplasia. "nfrequent cases show fran carcinoma. *ome authors agree that this lesion is entirely innocuous and malignancy does not develop from this hyperplasia. Tre$t"ent) *urgical curettage and excised tissue for microscopic examination. "mpound the dentures until healing is complete. Celief or rema e the prosthesis. !nsure > hours of tissue rest per day with new dentures.

B. In# $""$tor* !roce%% under denture &$%e% i4 Denture %to"$titi%) "t is a chronic inflammation of the denture bearing mucosa. "t may be locali#ed or generali#ed in nature. ?arious causes have been suggested.

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Trauma from illfitting dentures, parafunctional habits, nocturnal denture wear, hypersensitivity, infection with candida albicans, and poor and hygiene. there is redness of tissue under the denture base, with pain, buring of the tissues and metallic tastes in the mouth. The patient may be asymptamatic also. "t tends to occur more frequently in the maxillary arch.

Tre$t"ent) "mpounding dentures, so that tissues return to good health 8aticulous oral hygiene procedures. Gse of antifungal drugs. One nystabin tablet ta en 1 times a day for $B-$4 days is usually sufficient to control the infection. 9owever antifungal drugs are used only after confirming infection with candida albicans. Gse of (F solution of chlorhexidine gluconate and gingival massage with tooth brush. 7ew well fitting dentures, after the conditions has subsided.

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ii4 Denture %ore "out') 0hen one encounters mucosal complaints that do not fit into the general descreption of denture stomatitis, it is diagnosed as ;denture sore mouth< syndrome. "t is diagnosed when the treatment methods just mentioned for denture stomatitis is unsuccessful. "t is probably the result of an underlying abnormal metabolic or hormonal function, a nutritional deficiency. !g+ 5iabetes *ymptoms are bi#arre spectrum of itching, painful, irritated and tender denture bearing areas. ,linical findings are usually negative and in such patients mucosal tolerance is very low. "ron deficiency, insufficient protein and incomplete intestinal absorption have been cited as contributory factors. Tre$t"ent) Patients systemic status should be investigated Gprage quality of dietary inta e "mpound dentures, until inflammation subsides.

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*low release hydrogen chloride in achlorhydric patient, ascorbic tablets dissolved sublingually may be helpful.

Therapy with liver fraction tablets may rejuninate the oral mucosa. Cefit or rema e the prosthesis

iii4 Sto"$titi% venen$t$+ *ome people react differently to certain drugs and materials than others. Ceactions found in the mouth to drugs and materials used have been termed ;stomatitis venenata<. *ince the introduction of methyl methacrylate for dentures, some dentists have been concerned with possible sensiti#ation of denture wearness to this material. This material of the denture base is not a factor in mouth reactions. This opinion is supported by the clinical observation than duplicating the denture in a different material does not relieve the symptoms. Turrell -$@))., has concluded that the concentration of the residual mnomer in a properly cured acrylic resin is unli ely to elicit a clinical response. iv4 Monit$%i%) "t is a disease entity and the occurrence of disease is related to the pathologic activity of certain monila.

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"t is generally agreed that, moniliasis is usually found in unclean mouths or in debilitated patients. / systemic disease such as diabetes and all unhygienic conditions will facilitate establishment of moniliasis.

/ll dentures materials have a significant degree of porosity. This is true whether it is acrylic or metal. 8onila which are very resistant organisms, enter the porous structures and remain there for long periods.

*ymptoms include redness with pain, swelling of denture supporting tissues.

"t may also occur in the form of white lesions. The affected region may resemble a wet cigarette paper adhering the mucosa anywhere in the mouth. "t can be carefully separated, leaving a raw red area underneath.

-0hile lesion chronic hyperplastic condiasis, /ssociated dentures stomatitis chronic atrophic condidiasis.. Tre$t"ent) 5iscarding the existing dentures. /pplication of gentian violet 1 times a wee *uspension of mystatin held against oral lesions

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7ew dentures after disease has been controlled.

Mec'$nic$ irrit$nt% Decu&it$ u cer+ They result from pressures that exceed the physiological endurance of the tissues and may be very painful. "t is usually associated with insertion of new dentures. "nitially there is only slight redness at the site of the ulcer with minimum pain. "f untreated the lesion becomes white due to necrosis. This calls for scheduling the first adjustment appointment for (4 hours after insertion of new dentures. /dditional visits should be scheduled as needed. U cer$tive e%ion% An+u $r c'ei iti%) 5entures stomatitis is occasionally accompanied by angular stomatitis which is also nown as angular cheititis or perleche. %ilateral lesions develop at the angles of the lips. 5eep fissures or crac s may develop which appear ulcerated and an exudative crust may be present. Dor several years the clinical condition was though to occur due to reduction of vertical dimension of occlusion.

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%ergendal -$@>(. has shown that this condition is usually secondary to a denture stomatitis and the result of candida infection from contaminated saliva.

Tre$t"ent) /ngular stomatitis responds to antifungal therapy. ,ombined treatment approach to denture stomatits and angular stomatitis is mandatory. 7on infections local diseases affecting oral cavity 6'ite e%ion% i4 Leu7o! $7i$) "t is used to describe an oral lesion with a white, leathery plaque that is neither painful nor tender. 8ost common sites in edentulous mucosa are the buccal mucosa and palate. Tobacco is often a causative factor. %iopsy is mandatory as leu opla ia may show dys eratosis. 0ith a negative biopsy report, the palate may be safely covered with a well fitting denture and the primary cause should be eliminated.

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ii4 Lic'en ! $nu%) 8ost li ely to occur on the buccal surfaces of chee s, appearing as fine lines and forming a lacy pattern which is not painful. &ichen planus of erosive type is of far greater concern to the dentist. The lesions are very painful and occur bilaterally. %allae may develop with painful ulcerations. 0hen the ulcerations are on denture supporting tissue, wearing of a denture is virtually impossible. Tre$t"ent) Topically applied corticosteroids have been recommended. Cefitting or rema ing the prosthesis after healing of the lesion.

iii4 H*!er7er$to%i% 8ay be observed in the regions of low grade chronic trauma, in particular at denture border, lesions may vary from mild leu oedema to fran leucopla ia. Tre$t"ent) Cemoval of the irritant M$ i+n$nt e%ion%) Patients who need complete dentures are usually in the age group that is most susceptible to oral cancer. eratosis to

14

*o a routine recall of denture patients at ) months interval is very important.

/ biopsy should be made for any lesion that cannot be identified by other means.

/lthough tobacco is involved in the history of most of the carcinomas, patients who do not use tobacco and have illfitting dentures are seen with carcinomas.

9oboc

reported :)B patients with direct intraoral epidermoid

carcinomas. (B4 more prosthesis and in >) there was a direct connector between irritant by the prosthesis and development of carcinoma. They had these factors in common. a. They had worn illfitting dentures for years b. The dentures had irritated or chafed the soft tissues for a prolongued period of time. c. /n epidermoid carcinoma was found in the region covered by the prosthesis or was found to be in contact with the prosthesis. "nfluence of systemic and nutritional factors on oral mucous membrane

1:

!valuating the systemic and nutritional factors before starting the fabrication of denture may prevent failure of treatment. One of the most important and simple ways of evaluating these systemic factors is by ta ing a proper history. This should include personal, medical and dietary information. A. Met$&o ic Di%e$%e% /ll tissues in the body are influenced to some extent by hormones and oral mucosa is no exception. Di$&ete% "e itu%) ,hronic disorder of carbohydrate metabolism. ,ause is either a deficiency of decreased effectiveness of insulin. "n some instances antiinsulin hormonous may be produced in excess which counter act the effects of insulin. Oral lesions are non specific. There is usually a reduced resistance to trauma and healing is poor. ,ondidal stomatitis is often present. The increased susceptibility to infection is probably due to elevated sugar content in tissues, alteration in amino acid pool unsetting antibody production. Tre$t"ent) "mpounding of dentures until the blood sugar comes to normal level.

1)

"t impressions have to be made in these patients, a material which has good flow must be used since the tissue rebounding is more in a diabetic -8"7"8/& PC!**GC! T!,97"HG!..

Nutrition$ di%order% "nsufficient of essential nutrients can result from defective diet, malabsorption from gut, factors inhibiting metabolic need etc. Vit A+ "t is a well established fact that vit / is concerned primarily with process of differentiation of epithelial cells fail to differentiate. This means cells in basal layer loose there specificity. Thus one of the basic changes is eratini#ing metaplisa of epithelial cells. The epithelium of the alveolar mucosa becomes acanthotic and in prolonged deficiencies shows eratini#ation. 8ost changes described are reversible with administration of vit / to deficient patients. B Co"! e/ +rou! i4 Vit B0 8Ri&o# $vin4) 5eficiency is associated with malabsorption, chronic infection and other metabolic disorders. Tissues of ectodermal origin are mainly affected. blood transport, increased

1=

7on specific glossitis and /ngular chelitis are the features.

Tre$t"ent) /dministration of % ,omplex vitamin will reverse this condition. B ood D*%cr$%i$% i4 Iron de#icienc*) Oral manifestations are common and many patients complain of a burning sensation especially on the tongue. 5ry mouth, angular chelitis and rarely difficulty in swallowing are seen. !pithelial atrophy will be most evident on the tongue giving it a smooth gla#ed appearance. "nfection with candida albicans producing angular chelitis is not uncommon because of a defect in cell mediated immunity in anaemia. 9istological changes show atrophy of lingual papillae and chronic inflammatory cell infiltration in connective tissue is used an increase in si#e of nuclei is also seen. Tre$t"ent) $. "ron therapy

1>

(. 9igh protein diet ii. ?it %$( deficiency+ Pervicious anaemia is the commonest feature. "t is caused by lac of production of intrinsic factor in the stomach. Deatures are similar to iron deficiency anaemia. Tre$t"ent) /dministration of ?it %$(. A+ein+ $nd or$ "uco%$ ,linical picture is that of atrophy. !pithelial layers are less in number and the mucosa and submucosa show decrease in thic ness. The depleted repair potential renders the denture bearing mucosa and basal seat friable and easily traumati#ed. 8ucosa blanches easily. *o there is a reduction in surface area of oral mucosa. /n atrophying denture-bearing mucosa is frequently encountered during menopause. Etio o+*) Ceduction in estrogen output Tre$t"ent) Ceplacement therapy can be helpful.

1@

/ change in tissue displaceability can also be demonstrated as being a function of age. / longer period of time is needed for the recovery of displaced mucosa in elderly people when compared with young adults.

4B