SEMINAR

ILL- FITTING
DENTURE
INDUCED
LESIONS
PRESENTED 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 Cognitive Must know all --

etiopathogenesis of
various denture
induced lesions.

2. Explain the clinical Cognitive& Must know all --

features of various psychomotor
denture induced
lesions.

3. Differentiate denture Cognitive& Must know all --

induced lesions from psychomotor
other similar lesions.

4. Describe management Cognitive Must know all --

for denture induced
lesions.
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 epulis
Epulis 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 or
Fluconazole: 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 circu

lation 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
THANKYOU!