Prevention and Treatment of Abused Tissue /cosmetic dentistry courses

Prevention and Treatment
of
Abused Tissue
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

CONTENTS
• Introduction
• Terminologies
• Abused Tissue
– Denture irritation hyperplasia
– Traumatic Ulcer
– Flabby Ridge
– Denture Stomatitis
– Burning Mouth Syndrome
– Angular Cheilitis
• Preventive Measures
– Evaluation of Tissue Side
– Evaluation of Borders
– Clinical and processing errors
– Correcting Occlusal Disharmony
• Patient remount and selective grinding
– Instructions for patients

• Treatment modalities
– Surgical removal
– Correction of occlusal disharmony
– Massage of the soft tissue
– Correction of pressure areas
– Denture lining materials
• Short term soft liners
• Long term soft liners
• Home liners
• Relining and rebasing
– Diet and nutrition
– Drug and medication
– Psychological counseling
– Use of lasers in soft tissue lesions
– Low level laser therapy
• Conclusion
• References www.indiandentalacademy.com

Sympathy & Pity

Terminologies
• Abuse (v) : to make bad use of something or to
use so much of something that it harms your
health
(n) : the use of something in a way that is
wrong or harmful
(Oxford dictionary)
• Tissue : an aggregation of similarly specialized
cells united in the performance of a particular
function
(GPT - 7)

Abused Tissue = Mucosal Reaction
Bony spicules
Faulty Occlusion
Traumatic Injuries
Continuous wearing
Dirty ill-fitting dentures
Over extension
Inflammation
Hyperkeratosis

• Denture Irritation Hyperplasia
– Papillary hyperplasia
• Pressure changes with relief chamber
• Early Stage – reversible
Well Establised
Local irritation
Poor oral hygiene
Candida
Small lesion
•Sharp curettes
•Mucoabrasion
• Electrosurgery 0
Large lesion
•Split thickness supra
periosteal excision

Epulis Fissuratum
• Hyperplastic tissue repair –
response
• Association with immediate
or interim denture
• Settling of dentures
• FEMALES
• MANDIBLE
• Varies from small single
fold to multiple folds
• Excessive amount of Post
Dam

Traumatic Ulcer Flabby Ridge
• Occurs within 1-2 days
• Over extended Flanges
• Unbalanced Occlusion
• Systemically non compromised
host
• Anterior part of maxilla
• Remaining Mandibular anteriors
• Poor support
• Extreme resorption cases

DENTURE STOMATITIS
Found in about 50% of the Denture wearers
Prevalent in women
Predisposing factors
Systemic
• Old age
• Diabetes Mellitus
• Nutrition Deficiencies
• Malignancies
• Immune Defects
Local
• Denture
• Xerostomia
• High Carbohydrate diet
• Broad Spectrum Antibiotic
• Smoking

Etiology and Pathogenesis
• Etiological changes caused by dentures
• Plaque accumulation and presence of saliva
• Aspartyl Proteinase production
• Candida isolated in up to 90% of cases
• 66% of Denture wearers harbor them
• Staph. Aureus
• Migration inhibition factor, Overactive suppressor T cells
Newton’s Classification
• Type I – Pinpoint Hyperemia – Trauma Induced
• Type II – Generalized Erythema
• Type III – Granular type
Microbial Plaque Accumulation

TYPE II TYPE III
•Lower denture mucosa
•Erythema is restricted to denture bearing areas
•No symptoms
DIAGNOSIS
MANAGEMENT

Burning mouth syndrome / oral
dysaesthesia / Stomatodynia
• Medically unexplained symptoms
• Affects 5 persons per 100000 population
• FEMALES 3:1 ratio
• Appears to follow
– Dental intervention
– URTI
– ACE or Protease inhibitor
• No specific hormonal changes
Clinical features
• Tongue > Palate > Lips > Lower Alveolus
• Burning sensation – Chronic, Bilateral
• Relieved by drinking or eating
O/E
• no detectable sign

Type Pattern of
symptom of
burning
Frequency
I waking
day
Unremitting
II On waking
Day
Unremitting
III No regular
pattern
May remit
Diagnosis of exclusion
Management
• 50% of patients remit spontaneously
• Avoid citrus drinks and spices
• Patient education and cognitive behavioral therapy
• Antidepressants

Angular Cheilitis
• One of the commonest
fungal lesions
• Overclosed VDO
• Coexistant denture
stomatitis in 80% of the
cases
• Rare in natural dentition
• Restoring correct VDO
and topical steroid
preparation
• Perleche

Preventive Measures
Evaluating the tissue side
• For undercut areas and accuracy of tissue
contact
• Relieved by grinding in dentures
• Areas of exostosis and mid palatine suture
• Not to relieve any pressure areas until occlusal
harmony is obtained
• Displaced paste does not necessarily reflect a
pressure area.

Evaluating the Borders
• For compatible
extension and contour
• Frenum attachments
and hamular notch
areas
• Stability during
speech and
swallowing
• Disclosing wax
instead of softened
impression compoundwww.indiandentalacademy.com

Clinical Errors
Registering the jaw relation
• Ill fitting record bases
• Shifting of record bases
• Exertion of excessive
pressure
• Unequal distribution of
stress
• Soft tissue deformation
• Systemic factors
• Errors in transfer
Mounting the cast
•Occlusal rims not being
definitely locked or keyed
•Interference of the casts
•Error in articulator
•Improperly seated record
bases
•Changes in the dental
plaster

Incorrect arrangement of posterior teeth
Changes in supporting structures
Processing errors
• Failure to close the flasks or Too much pressure in
closing
• Changes in denture base material
– High coefficient of thermal expansion
– Greatest amount of change on removal from the cast
“OCCLUSAL DISHARMONY”
•Processing errors – Lab remount
•Clinical errors – clinical remount
•Small errors in occlusion will correct themselves
•Errors may not be apparent
•Prosthesis should be maintained in water before the final
occlusal refinement www.indiandentalacademy.com

Checking for occlusal errors
• Error exists and one has to work to find it
• How to observe the error – first “feather touch” is
felt
• Stopping the instant tooth contact is felt and
then close tight
• Amount of occlusal errors and location of
deflective contacts.
• Articulating paper
– Shifting of denture bases
– Tissue distortion
– Eccentric closure by patient
– Presence of saliva
• Selective grinding done in the mouth increases
the amount of errors
• Accurate mounting in the articulator – Idealwww.indiandentalacademy.com

Intra Oral Methods
Central bearing device
• Central bearing pin works on a spring
• Metal plate
• Dentures do not shift on premature
contact
Occlusal wax
• Excellent method for correcting occlusion
in centric position only
• False markings in eccentric jaw positions
Abrasive paste
• Shifting of bases
• Not selective

Patient Remount
Interocclusal records
Advantages
• Easy to visualize locate and correct
• Stable denture bases
• Easily made articulating paper marks on
dry teeth
• Avoids misconception
Remounting the mandibular denture
Verifying the centric relation

Interocclusal Record Of Centric
Relation

Remounting the mandibular denture
• Remounting the maxillary
denture by remount occlusal
index
• No need of face bow or
protrusive records
• Raise the upper member of the
articulator about a mm
dropping the incisal pin
Verifying the centric relationwww.indiandentalacademy.com

Selective Grinding Procedure
• Realeff – Hanau
•Forces Exerted on teeth when Pt Closes the jaw
•Change in Vertical Dimension
•Development of premature contacts
Multiple remount procedure - Hanau
•No displacement of mucosa •Displacement of mucosa
Selective Grinding
Unstrained J R Strained J R
Long Centric
occlusion Short
protrusive

Selective Grinding of Anatomic teeth
• Alteration of Cusp form teeth
• Occlusal balance in lateral direction
Working side – All posterior teeth and canine
Balancing side – only Posterior
• Protrusive balance – Incisal edge contact at the same time Posterior
teeth contact
Procedure
1. Adjust horizontal and lateral condylar inclinations
2. Raise the incisal pin
3. Evaluate areas of tooth contact and functional cusps
4. Record the areas of premature contacts
5. Evaluation in eccentric positions- before starting grindingwww.indiandentalacademy.com

6. Right side as a working side
• Excessive contact on one side- No contacts on other side
• Working side teeth too long – No contacts on balancing
side
• Single tooth at higher level – No contacts on balancing&
working
7. Left side as a working side
Note: Avoid wrinkling or doubling of articulating paper
Cover all occlusal and incisal surfaces
Rules
• If cusp is high in centric and eccentric – Reduce
• If cusp is high in centric only – deepen the fossa / marginal ridge
• Not to reduce any more

8. Balanced Gliding occlusion
• Working side – BULL
• Balancing side – Mandibular buccal cusps
Elimination of Centric cusp - Mandibular buccal cusp
 Maxillary lingual cusps - better direct the forces of mastication
- necessary for protrusive balance
• Balance in protrusive excursions
Distal inclines – Maxillary
Mesial inclines - Mandibular
9. Refining the Occlusal anatomy & Polishing

Selective Grinding of Non-Anatomic teeth
• Articulating paper tape
• Tapping the teeth together
• Simultaneous even contact areas on Rt & Lt
• Do not allow anteriors to contact
• Distal of the premolars and first molar and Mesial of the second molar
• Polishing

Occlusal equilibration of
Zero degree teeth
• Dr Gronas 1970 – Corborundum stripping technique
• Maintain flat occlusal scheme on Grinding
• water proof Corborundum abrasive paper
220 Grit – Porcelain
320 Grit - Acrylic
• Avoid rotary instrument
• Premature contacts in Centric & eccentric
• Put the strip on occlusal surface Gently close the articulator
• Apply pressure to upper member Pull the strip
• Avoid rounding of bucco-occlusal angle
• Stripping an equal number of times

Patient Instructions
Albino J E et al 1984 – expectation of the patient can
profoundly influence treatment outcomes
Maintaining tissue health
Tissue rest Denture Hygiene Cleansing of tissues
• Cleansers
• Brushing
• Sonic action Cleansers
Myers & Krol
• Gentle rubbing
( wash cloth )
• Removing
dentures at night

Treatment Modalities
1. Surgical excision
• Hyperplastic , Hypertrophied & Pendulous tissue
• Alteration of bony support
• Repositioning of sulci
2. Correction of Occlusal Disharmony
3. Massage
• 2-3 times a day
• warm salt water rinse
• washing with moist cotton balls, normal saline rinses- Boos
• Chewing gums
• Chewing inflated balloons Plastic bags
4. Correcting the Pressure areas

Denture lining material
Materials used to refit the surfaces of complete dentures and
to help condition traumatized tissues , providing an interim or
permanent cushion like effect
• Hard Liners
• Soft Liners
Soft Liners ( ISO 10139 )
Short term Long term
• Upto 30 days
• Tissue conditioners
> 30 days – 1 Yr / more

Soft Liners ( O”Brien )
Silicones Others
Heat cure RTV
• Molloplast B
Gamma methacryloxy
propyl trimethoxy silane
 Less prone to Candida
 Retains Resiliency
Limited shelf life
Less tear resistance
Acrylic
• Tissue conditioner
PEMA
+ Phthalate
+25% ethanol
Poly(fluoroalkoxy) Phosphazime
elastomeric system
Gettleman et al

Indications
1. Treatment and conditioning
2. Provisional or Diagnostic purpose- VD
3. Temporary reline-Immediate dentures / surgical splints
4. Relining Cleft palate speech aids
5. Tissue conditioning during implant healing
6. Functional impression material
• Available in P:L form or Acrylic gel sheets
• When mixed forms gel- cushioning effect
• With time plasticizer and alcohol leaches out
• Deterioration ,Contamination and fouling
• Replacement- 3 days for 2weeks or longer

Long term Soft Liners
Requirements
1. Permanent softness
2. Good bond to denture base
3. Adequate abrasion and tear resistance
4. Inhibit colonization of fungi
5. Easy to clean
6. Low water sorption and solubility
Indications
• Pts who cannot tolerate stresses
• Chronic pain ,soreness, discomfort
• sharp thin heavily resorbed ridges or severe bony undercut
Examples: 1. Plasticized acrylics
2. Silicone rubbers
3. Plasticized vinyl polymer
4. Fluoroethylene
5. Polyvinysiloxane
6. Polyphospazine fluoropolymerswww.indiandentalacademy.com

Plasticized acrylics
Powder
Liquid
PEMA &
Benzoyl peroxide
Higher methacrylate monomer+ plasticizer
Ethyl ,n-butyl, 2ethoxy ethyl
 If chemically activated – peroxide tertiary amine system
 Chair side relining
Tendency to foul and Debond
Prescence of free monomer

Silicone soft liners
Heat activation Room temperature
vulcanization (RTV)
polydimethyl siloxane
+
Silica
+
Benzoyl peroxide
• Single paste
Good durable bond
More resistant to candida growth
Acceptable tear strength
Better abrasion resistance
Less resilient
Hardens by time
• Paste & liquid
Condensation reaction
catalyzed by organo tin
compound
Low bond strength
Less resistant to candida growth
Low tear strength
Low abrasion resistance
Highly resilient
Retains softness & elasticity

Self administered soft liners ( HOME liners )
• Simple tool to improve a clinically acceptable prosthesis
-diff components of soft liners affect the growth ,acid production
& colonization of Candida
-amount of ethyl alcohol content and type of plasticizer used
made a significant difference
Nikawa et al 1995
S Parker & M Braden 1982
-Formulated a soft liner using 1. polymerizable plasticizer system
2. powder elastomers
- There was no extractable plasticizer
Braden et al-
-allows uniform distribution of stress but does not necessarily
reduce the transmitted forces

Relining and Rebasing
Reline –to resurface tissue side o f the denture with new base material
Rebase - to replace entire denture base material on an existing prosthesis
Treatment rationale
Adversely changing denture foundation
Variable change in VD & Occlusal relationship
Induces more adverse Stresses
Magnitude of the observed changes
Reline
Rebase
Remakewww.indiandentalacademy.com

Diet and Nutrition
Abuse of tissue – complicated by a weakened host response or repair
Poor nutrition – Reduce tissue recovery
Deterioration of supporting tissues
Xerostomia,burning and sore tongue,RRR,
angular stomatitis,thin & friable mucosa
Diet – Prescribed by the dentist- discussed with the patient

Drugs and Medication
Local management
Topical local anesthetic in an emolient base
Tincture of benzoin – ulcerated area
30% Trichloro acetic acid – granulation tissue
Topical steroids – generalized inflammatory response
Warm saline solution – most therapeutic ,effective & economic rinse
Psychologic Counseling
Patient who had considerable denture prosthesis experience
without apparent success
Appropriate mental preparation of the patient can be as significant as
physical conditioning of the supportive tissueswww.indiandentalacademy.com

LASER
Light Amplification by Stimulated Emission of Radiation
• Alternative to Conventional surgical technique
• Selection of wavelength best absorbed by the target tissue
• Each wave length has different absorption coefficient
based on composition of oral structures
• water – erbium and carbon dioxide wavelengths
• oral mucosa – extremely high water content
• Treatment of – Hyperplastic tissue
Nicotinic stomatitis
Denture stomatitis
Epuli and other problems

Low level LASER therapy ( Therapeutic lasers )
Soft , Cold, Low intensity laser therapy unlike surgical lasers
Wound Healing Reduced Pain
ATP production - Mitochondria Synthesis of Endorphins
C – fiber activity
Bradykinin
Altered pain threshold

LIST OF REFERENCES:-
•Prosthodontic treatment of edentulous patients; Zarb & Bolender;12th
ed.
•Essentials of complete denture prosthodontics: Sheldon winkler;2th
ed.
•Textbook of complete dentures;Heartwell;5th
ed.
•Complete prosthodontics – problems , diagnosis & management: Grant
•Diagnosis &treatment of prosthodontics ; William.R.Laney
•Atlas of diseases of oral mucosa; J.J.Pindborg
•Burkets oral medicine- diagnosis & treatment ;10 th
ed.
•Diseases of oral mucosa & lips; Bork et al
•DCNA jul 2004;48:3 Removable prosthodontics
•DCNA Oct 2004;48:4 LASERs in clinical dentistrywww.indiandentalacademy.com

Irritation & discomfort..!!!
Warmth & Comfort…!!!

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