J. Dent.

1991; 19: 135-147 135

Review

Response of the oral mucosa to denture

wearing*

R. J. Cook
Department of Prosthetic Dentistry, Guy’s Hospital Dental School, St Thomas’ Street, London, UK

ABSTRACT
This paper reviews both past and current knowledge concerning the controversial subject of mucosal
responses associated with denture wearing. The subject has been considered in terms ofboth gross clinical and
histopathological changes arising from daily prosthesis use. Displacement of basal seat tissues during function
has been discussed, along with denture-induced alterations ofthe local microfloral ecosystems. The influences
of common drugs and therapeutic regimens such as ionizing radiation treatments have been considered, and
as with all the fields discussed, have been related to clinical use and success of prostheses.

KEY WORDS: Oral mucosa, Dentures, Review

J. Dent. 1991; 19: 135-I 47 (Received 13 August 1990; reviewed 25 September 1990; accepted 16 January
1991)

Correspondence should be addressed to: Mr R. J. Cook, 1 Burgoyne Road, Camberley, Surrey GUI 5 1 LS, UK

INTRODUCTION DISPLACEMENT
A successful prosthesis comprises an aesthetic restoration, Wills and Manderson (1977) pointed out that in the
having good functional qualities allowing comfortable periodontal ligament, 75 per cent of collagen fibres are
and confident use. Absolute success however can only be disposed to resist masticatory loading. The oral mucosa
considered if the histological and morphological provides poor intrinsic support as a denture foundation,
normality of the mucosa and deep supporting tissues is having no tibre patterns to resist occlusal loading and
maintained. probably no effective osmotic fluid recovery system such
Unyielding denture bases, repeatedly compressing and as glycosaminoglycan breakdown under pressure, as seen
abrading mucosa, may result in a wide range of responses in the periodontal ligament.
varying from transient histological change to gross When loaded, oral mucosa is displaced. Lindan (1961)
clinical abnormality. These may be of an inflammatory, stated that a loading of 0.0013 N/mm2 gave a 5 per cent
degenerative or hyperplastic nature. The function of the reduction in resting mucosal thickness. The patterns of
oral mucosa, like that of skin and gut mucosa, is to protect tissue movement recorded by Wills and Manderson using
the underlying structures. It comprises a stratified Macaque monkeys indicated early elastic tissue deforma-
squamous epithelial component, the basement membrane tion, followed by slow fluid movement away from the
and the outermost connective tissue layer or lamina compression areas, representing a creep phase. Recovery
propria (papillary and reticular layers). Accessory salivary also showed early elastic recoil and a prolonged fluid or
gland tissue, although within the submucosal domain, is viscous phase (Fig. I). Hence, a viscoelastic system of fluid
derived from oral epithelial invagination and thus is often movement responding to generated pressures had been
discussed in work on mucosal responses. demonstrated. Wills et al. (Wills and Picton, 1972; Wills et
al. 1976) and Picton (1976) showed that periodontal
*This review is based on the winning entry for the 1989 British ligament viscoelastic recovery occurred in minutes-
Society for the Study of Prosthetic Dentistry Undergraduate Essay
Competition. rather than the 3 h found for mucosa. Dynamic tests

@ 1991 Butterworth-Heinemann Ltd.

0300-5712/91/030135-13
 136 J. Dent. 1991; 19: No. 3

Little has also been written concerning the effects of the

400’ pm intentionally mucodisplacive post dam, facilitating the
posterior border seal in complete prostheses, and the food
lines on partial prostheses with the function is to exclude
300-
food and debris from beneath the baseplate, but which
may also subserve a damming function.
Considering the complete denture in normal comfort-
200 -
able function, experience indicates little clinical evidence
of mucosal change, other than a depressed zone of muco-
100’ displacement, indicating the areas of denture- mucosa
DELAYED contact. These are intentionally placed over softer
1 RECOVERY
glandular regions of the palate. The author is unaware of
,--_L__-________ff~ any work published relating to the histological changes
10 MIN
I* 4
seen in such areas.
Fig. 7. Displacement graph for a mucosal-borne plate under a The food lines on partial dentures are arbitrarily carved
constant load for 10 min (after Wills and Manderson,
into the master model and, by their linear nature, exert
1977).
greater, more localized compression when in function.
showed reduced displacements with larger compression Hence if too well defined, food lines can cause pain and
areas and reduced tissue displacement with increased ulceration. However this is rare, one more often encounters
loading rate. Repeated loading caused settling of the linear depressions in the corresponding mucosa, tending
denture bases until a position of equilibrium between to be more marked in mucosal-borne prostheses and in
displacement and recovery was established. The rate of patients with less dense submucosal connective tissue.
recovery was controlled by generation of tissue fluid There are no studies in the literature in which biopsy
pressure gradients, the viscosity and fluid flow rate and specimens have been taken across such lines to show the
the tissue density. Gersh and Catchpole (1960) showed a histological effects of the feature.
relative reduction in the aqueous rich phase of ground Differential tooth and mucosa displacement for any
substance with age. The inference from these studies is given loading can present problems for partial denture
that work on changing tissue compression in more elderly stability. Wills and Manderson (1977) found that the
denture patients could yield interesting information. mucosa may displace ten times more than an abutment
During the construction of complete denture baseplates tooth. Rigid connectors between tooth-borne elements
slight displacement of the unattached sulcular mucosa and free end saddles encourage rocking of the loaded
facilitates a border seal, so markedly improving retention. prosthesis unless a mucosal displacement impression
Overextension into the relaxed depth of the sulcus or technique is used (Walter, 1980). Flexible major con-
excessive rolled border width results in a traumatic nectors, or stress breakers, allow increased movement and
denture causing pain and ulceration in function. Active potential trauma from the mucosal-borne saddles. Thus,
perioral musculature causes severe mucosal abrasion and differential resilience can result in numerous permanent
pressure necrosis where it impinges on the acrylic. The changes in denture-bearing mucosa.
relative contribution of pressure and abrasion to the High viscosity mucodisplacing impression materials
aetiology of denture trauma has not been investigated. may yield a prosthesis of initial increased vertical
Acrylic fit surfaces are not polished and rolled borders dimension, until repeated masticatory displacement
only lightly so, to avoid destruction of the carefully produces an equilibrium of semipermanent tissue
defined contours. Hence mucosal abrasion might be displacement. However, mucostatic materials can result
expected to cause thickening and keratinization of the in the prosthesis having a displaced equilibrium position
normally thin unkeratinized epithelium, as seen in short of the desired occlusal vertical dimension. These
the traumatic occlusal linear lesion of the inner cheek. guidelines are further influenced by the recovery time
Frank ulceration and erythema represent an alternative allowed between removal of old dentures and taking new
reaction, possibly indicating a greater role of pressure in impressions.
the aetiology.
Similarly, when over-contoured rolled borders impinge
on the functional movements of fraenal attachments, HISTOPATHOLOGICAL RESPONSES
acute pain and ulceration result, despite an often smooth
and polished surface. This also lends credence to the Before considering the histological responses of mucosa
theory of ischaemia produced during fragile mucosal to denture wearing, a ‘normal’ mucosa must be defined.
compression being the cause. Such ulceration is easily Orban was the first to accept orthokeratinized mucosa as
treated by opening out the notch in the border and ‘normal’ attached gingival mucosa. In 1949 Orban
reducing the over-contouring, allowing free fraenal proposed ortho-, para- and non-keratinized areas in
movement in function and also maintaining an adjacent intraoral mucosa as representing functional adaptions to
soft tissue border seal. specific mechanical influences and functions. Thoma
 Cook: Mucosal response to denture wearing 137

(1936) also commented on the role of general health, 1. Mildest response. Thinning of stratum corneum and
metabolic deficiencies and disturbances, and endocrine occasional nuclear profiles in stratum comeum with
imbalances as influencing the mucosal responses to reduced definition of stratum granulosum. Waldeyer
dentures. (1882) had first proposed the layers as mutually
ijstlund (1958) reported post-mortem studies of denture dependant. ijstlund proposed the concept of denture base
patients Brinch’s which demonstrated fatty degeneration abrasion exceeding epithelial squame production, hence
of palatal salivary glands and thickened epithelium by producing thinning. However, Neil1 and Nairn (1983)
‘proliferation into the lamina propria’. His results are not point out that in processing, denture base shrinkage may
widely quoted, having taken no account of the effects of result in deficient palatal contact. Hence possible mucosal
fatal illness or post-mortem changes in the specimens. protection by the denture results in reduced turnover and
Brinch identified denture plaque, chemotoxic irritation, thinner keratin, similar to the phenomenon beneath
trauma and thermal insulation effects of the denture as bridge pontics.
probable aetiologies. 2. Parakeratosis. Loss of surface eosinophilia (primitive
Wright (1933) from live partially dentate human orthokeratin) is replaced by a parakeratotic epithelial
biopsies, showed that mastication resulted in physio- surface.
logical, defensive hyperkeratosis and proliferation of rete 3. Acanthosis. As soon as stratum corneum is damaged,
ridge patterns of unprotected mucosa at healed extraction changes in the stratum spinosum are seen:
sites. Greater trauma (complete tooth-mucosa overbites) a, increased epithelial mass;
showed eroded keratinized epithelium and a severely b, increased volume of cell cytoplasm;
decreased rete ridge pattern. Beneath vulcanite denture c, epithelial oedema;
bases he found areas of ‘normal histology’ and other d, increased nuclear volume.
zones of abraded epithelium, over chronically inflamed Nuclear vacuolization was considered artifactual. Similar
reticular collagen. Mucosa protected by bridgework was changes may be seen in Fig. 2.
shown to consist of a loose connective tissue (indicating 4. Mitosis rate. Elevated in very mild trauma, declining
disuse atrophy), which was frequently oedematous and rapidly with further noxious experience.
chronically inflamed. The epithelium, being devoid of
cornification, appeared erythematous. No standard of ijstlund described a loss of definition of basement
hygiene, and thus microfloral irritation beneath the membrane area and collagen tibres apparently merging
pontics, was indicated. with basal cells. The collagen pattern found confirmed the
ostlund (1959) undertook a study of 291 complete findings of Wright (1933). These were wavy dense tibre
denture-bearing palates, confirming the Nyquist (1952) bundles forming a reticular lamina propria, paralleling
study which showed female predominance of unequi- the epithelial surface and fewer papilliary libres and
vocally changed mucosa, expressed as parakeratotic, red, blood vessels perpendicularly orientated. The fibrous
inflamed palates (Table I). Only one patient showed connective tissue replacement of degenerated accessory
hyperkeratosis with 23 urn thick keratin. ijstlund had glands was in contrast to Brinch’s earlier findings of fatty
previously found the ‘normal’ thickness at 13.2 urn. It was atrophy (reported by ijstlund, 1958). However, the extent
concluded that at least 77 per cent of long-term clinically of age changes in secretory tissue (fatty replacement and
normal patients showed some form of altered histology. fibrosis) were not accounted for in either study.
However, the total number of patients showing adverse The fibrous connections between epithelium and
responses was far greater, subclinical changes representing lamina propria reported by &tlund were found in 50 per
an estimated 70 per cent of the total denture population of cent of thin keratin layer samples and 80 per cent of
that time. parakeratinized specimens. It was suggested that these
ijstlund categorized the tissue changes in order of enhanced the rete ridge pattern, resulting in ‘pointed
severity: extensions into the lamina propria’ whose proliferation
tensioned the fibres described. ijstlund considered the
epithelial responses passive. Active connective tissue
responses produced more complex rete patterns and
Table 1. Summarizing bstlund’s (1958) findings relating enhanced mucosal integrity and traumatized areas.
histological changes to the duration of prosthesis use
Pendleton (1951) conducted similar work on human
6 months’ wear Long-term wear alveolar ridge and maxillary tuberosity mucosa. He was
/%I 1%) reluctant to ascribe traumatic, mechanical or systematic
aetiologies for the responses observed. His findings
Normal histology 39
(0 prediiinance)
confirmed those of ijstlund, i.e. parakeratotic change
Early change 17 in buccal alveolar mucosa under complete dentures.
(thinned keratin layer) However, Wright (1933) reported a mixed ortho- and para-
Definite change 44 43 keratinized ridge crest mucosa. Enhanced rete patterns
(parakeratotic (9 predominance) and acanthotic stratum spinosum were also frequently
changes)
identified.
138 J. Dent. 1991; 19: No. 3

Fig. 2. Photomicrograph of mildly traumatized epithelium showing thinned stratum

corneum and occasional superficial nuclear profiles-a change to mild parakeratosis. A
mild rete hyperplasia is shown. The lamina propria demonstrates mature uninflamed
fibrous connective tissues. (X 96.) (All photomicrographs were taken by the author
under an Olvmpus Vanox microscope with an Olympus C.35 AD-2 camera and
exposure controi computer.)

MacCallum (1940) proposed mechanical trauma from osteoclasts. The mucosa only became severely inflamed
the denture base as the primary cause of mucosal changes, and ulcerated if denture wear resulted in penetration of
the nature of the irritant and tissue involved determining the epithelium by the fragment. He proposed surgical
the inflammatory response. Pendleton promoted an removal of such fragments and ridges rather than denture
inherent mucosal tolerance concept, inflammation base relief as the treatment of choice.
and other responses arising when noxious stimuli (e.g. Van Thiel(l960) also confirmed that long-term denture
abrasion) exceeded tissue tolerance. Gysi (1929) reported wearing resulted in increased epitheliunl depth (support-
that alveolar bone resorption altered the oral anatomy ing &tlund), but he proposed enhanced keratinization
resulting in new resultant baseplate movements, poten- contrary to ijstlund and Pendleton. Van Thiel also noted
tially exceeding mucosal tolerance. Pendleton (195 1) had chronically inflamed coarser libred connective tissue and
considered alveolar mucosa resistant to the rigors of atrophic minor salivary glands. He did not record fibrous,
denture wearing. Inflammation resulting from exceeded fatty or other degenerative changes.
tolerance occurred only when systemic factors are reduced Wright, Pendleton and ijstlund all demonstrated
and focal forces raised. clinical and histological responses ascribed to denture
Pendleton confirmed the earlier normal connective wearing. However, similar changes, of possibly lesser
tissue patterns of parallel reticular and perpendicular extent, were noted in edentulous non-denture wearers.
papillarycollagenfibres.Henotedcoarser(largerdiameter) Pendleton described parakeratotic acanthotic epithelium
libres in non-denture wearers. Chronic inflammatory over a mild chronically inflamed lamina propria and
infiltrates were often identified in the lamina propria and submucosa, the basement membrane of which showed an
vascular submucosal areolar connective tissue. Although irregular pointed (normally sinusoidal) form. Thus, the
not universally demonstrated, Pendleton identified extent to which the mucosal responses reported are due to
‘elastic fibres’ above the mucogingival junction ramifying the rigors of denture wearing or to an adaption of the
towards the alveolar ridge. Despite inconclusive evidence, greater traumas of normal function without tooth protec-
he suggested that elastic tibres were common to tissue tion, has not yet been established.
frequently tensioned. Van Thiel(l960) reviewed past work and proposed that
The typical mucosal response of pain to the placement increasing age results in mucosal degeneration, involving
of a denture over a sharp bony ridge or mineral spicules hypokeratotic and parakeratotic epithelial changes. The
was noted by Pendleton, who clearly demonstrated bone disorganized, shrunken atrophic connective tissue
and dental fragments within the underlying mucosa. showed reduced blood supply and cellularity, with a
Surprisingly, the tissues around such fragments were not resultant reduction in elasticity. (cf. Pendleton’s claim of
inflamed but surrounded by active osteoblasts and enhanced elastic fibres under dentures.) Wentz et al.
 Cook: Mucosal response to denture wearing 139

(1952) showed that basement membrane form does not corneum depth in 67 per cent of patients (27 per cent
change significantly with age, or sex, alteration being the showed reduced thickness). Uninflamed connective tissue
result of other stimuli. was observed for all subjects.
Turck (1965) accounted for these findings by comparing Watson (1978) investigated palatal mucosa medial to
partial denture bearing and dentate mucosa from the the first molar region in patients with and without
same patient. He demonstrated, as had Lammie (1956) complete dentures. He found positive correlations between
that maxillary ridge crest mucosa was thicker than age and increasing epithelial and stratum corneum
mandibular ridge crest mucosa (1.4-2.9 mm compared to thickness in non-denture wearers. To avoid the possible
1.1-1.3 mm). Unlike Gstlund, Turck found thinned effects of hormonal changes and sex differences, all
mucosa in denture wearers when studying foveal, rather patients investigated were male. However, prosthesis
than alveolar, mucosa. The buccal epithelium below the wearers showed significant negative correlation of age
mucogingival junction (MGJ) was thicker in edentulous with stratum comeum thickness, but no relationship with
patients regardless of previous denture experience. This duration of denture wearing was found. Both groups
was interpreted as a physiological adaption to increased showed no correlation of rete pattern complexity and age,
food abrasion, on the loss of the protection from the but demonstrated more regular patterns under dentures,
natural dentition. Mild acanthosis proportional to the the complexity progressing with denture experience. No
degree of trauma was noted, along with a more convoluted significant difference between denture wearers and non-
basement membrane outline in edentulous areas. Elastic wearers was found concerning epithelial and stratum
Van Gieson stain failed to reveal elastic fibres above the comeum thickness, implying that dentures may retard the
mucogingival junction-refuting Pendleton. More dense, age changes noted above. Watson found incomplete
coarser collagen was typical, especially over the ridge keratosis under dentures worn for many years but more
crest, perpendicular fibres being most enhanced. Turck often complete orthokeratosis in non-denture-wearing
noticed a more complex rete pattern but thought that it edentulous patients. Similar patterns of change were seen
might be a feature associated with previous extractions. 1 year after denture fit indicating the rapidity of the
The cellular phase was reduced, chronic inflammation mucosal responses.
only being present in areas of masticatory or denture Sharma and Mirza (1986) also researched complete
trauma. Lammie (1956) proposed that the resorption of denture-bearing palatal mucosa, finding consistently
the ridge crest away from the denture base reduced contact raised mitotic rates (unlike Gstlund), and prominent
trauma. Turck found gingival rete ridge length constant, stratum granulosum but a thinned or absent stratum
regardless of denture history, and the epithelium to be corneum. The specimens were predominantly para-
slightly, though not significantly, thicker in denture- keratinized, with mixed and non-keratinized areas. Rete
bearing mucosa. Alveolar crest mucosa showed consis- patterns were shorter and saw toothed, the basement
tently greater epithelial depth and a more complex rete membrane of normal appearance and gross epithelial
pattern, the correlation between the two features being thickness mildly increased. The latter observations sup-
strongest under dentures. ijstlund (1958) showed kera- ported Pendleton’s and Gstlund’s work. Reduced basement
tinization, acanthosis, mitosis rate and rete form changing membrane activity and lower glycogen content were cited
only if the stratum corneum was disrupted. as possible explanations for the disordered mucosal
One explanation for such mild responses being found surface. However, Van Thiel (1960) Kapur and Schklar
could be the biopsy site. This was only half a unit behind (1963) and Jani and Bhargava (1976) had reported hyper-
the denture abutment beneath a free end saddle and was ketatosis, a constructive rather than detrimental response.
very protected by the element of tooth support for the Chronic inflammation throughout condensed irregu-
denture. Greater trauma would be anticipated to the larly organized fibres of connective tissue, whose
mucosa beneath complete dentures. Turck found non- vascular@ was slightly increased, were reported and are
denture-bearing ridges often showed mixed ortho- and consistent with previous findings. However, contrary to
para-keratinization, whereas that covered by dentures was Van Thiel, ijstlund and Brinch, no change in mucosal
routinely ortho-keratinized, indicating protection of the salivary glands was reported.
mucosa from the rigors of function and by the denture Sharma and Mirza (1986) used elastic Van Gieson and
(after Nyquist, 1952). In comparison with ijstlund, Turck resorcinol/fuschin stains to demonstrate oxytalan tibres,
found elevated epithelial mitotic rates beneath dentures predominantly in zones of condensed collagen fibres. The
whether or not the stratum corneum was disrupted. nature of this fibre type is unclear. Fullmer (1960)
Jani and Bhargava (1976) used a more uniform stimulus proposed immature elastin, Selvig (1968) thought it to be
by constructing new complete dentures by a standard immature collagen and Boggins (1966). Following the
technique for all subjects. Palatal mucosa biopsies before, work of Edwards (1968) and Boese (1969) Sharma and
and 3 months after fit, showed 70 per cent of patients Mirza proposed their function as anchorage enhancement
having a statistically significant increase in epithelial in an attempt to withstand abnormal conditions beneath
thickness (rete ridge increases greater than inter-rete dentures. How these tibres relate to &tlund’s enhanced
regions-indicating rete ridge hyperplasia). Unlike anchorage tibres (?fact or artifact) and Pendleton’s elastin
Zjstlund’s, this study demonstrated increased stratum tibres (which Turck refuted) is not yet clear.
140 J. Dent 1991; 19: No. 3

hyperorthokeratosis resulting from exposure to prostho-

dontic masticatory stresses. Histologically, this represents
a normal adaptation to altered functional conditions,
similar to those seen when natural dentition opposes an
edentulous saddle area where prostheses are not worn.
Histologically hyperkeratosis represents a successful
distancing of the mesodermal tissues from the noxious
stimuli, facilitated by an increased epithelial basal layer
turnover rate.
However, the parakeratotic changes often reported,
while not considered clinically significant, may be
regarded as less desirable. It indicates an altered or
immature keratin product being expressed at the
mucosal surface as a result of prosthesis imposition.
Associated chronic inflammation, acanthosis and rete
hyperplasia are usually clinically undetected but also
represent further departures from conventional tissue
architecture. When associated with basal layer derange-
ments and a dysplastic epithelium, specific forms of rete
hyperplasia are sinister indicators. However, in this
context, the rete pattern represents a functional adjust-
ment of lamina propria and basal epithelial cells to
excessive stresses imposed by the prosthesis. What has yet
to be established is which histological changes represent
responses beyond the mucosal adaptive limit and whether
or not these changes are at a clinical or subclinical
level.
The nature of salivary tissue responses are also still
unclear but, as previously discussed, the poorly constructed
studies so far undertaken inevitably resulted in contra-
dictory findings. That glandular atrophy was identified in
some studies should be taken as an indication of a
Fig. 3. Photomicrograph of a denture traumatized, palatal potentially deleterious response. The slight resultant
mucosa showing acanthosis, rete hyperplasia and a para-
reduction in total saliva production is unlikely to be
keratinized surface. The lamina propria showed a chronic
inflammatory infiltrate. (X 100.) noticed by clinician or patient, but may produce local
microenvironmental changes. These would especially
relate to the antimicrobial and lubricating functions of the
saliva, and therefore be regarded as deleterious.
THE CURRENT SITUATION
The pain felt when a prosthesis causes traumatic
Mucosal responses to denture use is still a controversial ulceration may be considered an advantageous response,
topic. The comparison of past studies is complicated by indicating a problem to the patient. The associated
factors such as varying biopsy sites and analytical inflammatory response, while advantageous in that
method. New denture construction methods, materials, infections are defended by the host, is also deleterious in
and improved technical standards have resulted in non- that local host tissue damage is often a feature (e.g. the
standardized ‘traumas’ being compared. Despite the very release of lysozomal enzymes into the tissues on neutro-
different behaviour of partial and complete dentures, they phi1 death). However, removal of the noxious stimulus
too have been freely compared, further complicating allows the beneficial aspects of the response to facilitate
interpretation. It appears that denture wearing elicits a resolution of pain and mucosal healing.
host of mucosal responses, the nature and extent of which Further quantitative work is still required to establish
are unique for a given patient and quality of denture any correlations between trauma and mucosal response.
trauma. Some features, such as acanthosis, rete hyper- The use of animal models in such work is controversial,
plasia, parakeratotic change and mild chronic lamina the similarity of tissue responses between species being
propria inflammation, were common to the majority of uncertain but the ethics of human studies are also
studies (Fig. 3). Other responses such as salivary gland questionable. The factors governing the limits of mucosal
atrophy, epithelial and keratin layer depth changes are tolerance also require further investigation, along with a
still not agreed upon. definition of the boundary between physiologically
Some of the reported changes can be regarded as acceptable and histopathologically unacceptable varia-
advantageous host defence, especially the gingival tions from normal.
 Cook: Mucosal response to denture wearing 141

Fig. 4. Photomicrograph of epithelial margin of a chronic ulcerated acanthotic mucosal

surface. The lack of epithelial hyperplasia and ingrowth (left) indicates that the stimulus
was still present at the time of biopsy. Fibrinopurulent material (right) lined the ulcerated
surface. (X 96.)

A common response to chronically ill fitting dentures is

GROSS CLINICAL RESPONSES
libroepithelial hyperplasia, typically associated with
The traumatic ulcer often arises shortly after fitting new denture borders. Prolonged local trauma results in
dentures. Sharp bony ridges, spicules and tit surface high chronic inflammation. The granulation tissue resolves,
spots produce localized trauma during tissue compres- libroblastic hyperplasia producing firm masses of coarse-
sion, resulting in subepithelial acute inflammation. libred, relatively avascular and acellular collagen, covered
Severe cases result in inter- and intra-epithelial oedema. by stratified squamous epithelium. This may be ortho- but
chronic inflammation and cell death, so producing frequently para-keratinized and acanthotic due to trauma,
ulceration (Fig. 4). which if severe may result in ulceration. If occurring
Recovery is only achieved by removal of the direct palatally, it may take the form of a broad, thin, flattened,
cause, thus alleviating the acute localized increase in pedunculated leaf granuloma.
pressure in function. Where a baseplate may impinge on a Toto (1966) reported the presence of ‘mucopoly-
bony feature (torus, mylohyoid ridge or genial tubercle), saccharide keratin dystrophy’ or pooling of homogeneous
the denture design must be carefully planned either to eosinophilic material in the stratum spinosum seen in this
avoid covering usually thin vulnerable overlying muco- and other irritated mucosal lesions. The significance of
periosteum or to include the area within the basal seat and the observation is not yet known. Excision of fibrous
avoid problems by either incorporating relief spaces in the hyperplasia and construction of a new, more stable
tit surface, or removing the prominence by surgical denture may reduce the associated inflammatory lesions
reduction to a smooth contour. This approach is indicated but complete regression is unusual.
if accommodation of the difficult anatomy will render the Inflammatory papillary hyperplasia, found as palatal
finished prosthesis too bulky for practical use or too papillamatosis, is an unusual condition often associated
fragile to function reliably. Relief areas may be provided with poor oral hygiene and poorly fitting dentures. Other
either by use of foils adapted over the master model before unknown predisposing factors must be involved as many
baseplate manufacture or by burring off the fit surface such cases presenting with these features do not show
where indicated by pressure relief areas at tit or review pathology. Bhaskar et al. (1970) reported a 10 per cent
appointments. The former approach is preferred. incidence of papillary hyperplasia among denture
Mucosal healing involves fibroblasts and angioblasts patients, rising to 20 per cent among those who wore
populating the deep chronic inflamed tissue to produce a dentures 24 h per day. This association was confirmed by
vascular, fibrous granulation tissue which reorganizes Ettinger (1975) who proposed denture bases as the main
and condenses. Epithelial hyperplasia produces stratum aetiology, the lesion usually being confined within the
spinosum projections which close the superficial defect denture outline. No age or sex predeliction is known.
previously lined by a more acute phase tibrinopurulent Clinically the pseudoepitheliomatous hyperplastic areas
slough. (Hence secondary intention healing.) show multiple erythematous papillae l-2 mm in diameter.
142 J. Dent 1991; 19: No. 3

rather than acrylic bases were in use. Unfortunately no

design details were given of the prostheses which were
placed and this might have influenced the findings.
Other possible explanations for Bissada’s conclusion
that metallic bases are more conducive to mucosal health
can be resolved to three points:

1. Electra-brightened metal surfaces have little surface

porosity offering few foci for adherent infection or debris
aggregation.
2. Cobalt-chromium alloy being more thermoconduct-
ing, allows a more normal range of thermal stimuli to be
experienced.
3. Better fit of the prosthesis when cast in metal. The
higher Young’s modulus also reduces in service deforma-
tion and trauma.

MUCOSAL SORENESS
A complaint of generalized soreness and burning of the
lower alveolar mucosa, increasing with prolonged
prosthesis wear, is a common response to a prosthesis
having an excessive vertical dimension. Often no ulcera-
tion or inflammatory lesions are seen. The pain results
from persistent pressure, mucosal ischaemia and masti-
catory muscle fatigue being unable to achieve a resting
length until the lower denture is removed.
Mucosal soreness unrelated to the duration of denture
wear can have many potential causes such as anaemia,
vitamin B,, deficiency and hormonal aetiologies.
Haematological investigations may therefore play an
important rble in differential diagnosis.
Fig. 5. Photomicrograph showing an oblique section through Successive areas of alveolar mucosal ulcerations may
a parakeratotic palatal mucosa specimen of suspected be caused by faulty jaw relations or poor occlusal contacts.
palatal papillomatosis. The complex nature of the rete The persistent baseplate movements produce multiple
pattern in this disorder is shown togood effect. However, the
areas of local trauma.
connective tissue chronic inflammatory infiltrate is not seen
in this field. (X 100.)

HYPERSENSITIVITY
The epithelium is stratified and usually parakeratotic,
covering severely chronically inflamed connective tissue Contact sensitivity to denture base materials, especially
(Fig 5). The inflammatory response usually includes methyl methacrylate-an acrylic resin monomer-has
accessory sialadenitis possibly showing squamous meta- often been proposed. The mucosal response seen is a
plasia in severe instances. Renewal or relining the denture generalized erythematous, chronic inflammation. Patch
reduces the oedema and erythema but the lesions persist, testing of the acrylic base applied to the forearm for 48 h is
normal morphology only returning after excision. used to assist in diagnosis but false-positive results due to
Features on the fit surface of metal partial dentures, pressure phenomena must be guarded against. Similar
such as dams or ‘food lines’, produce indentations in the tests for cobalt-chromium alloys very occasionally reveal
supporting mucosa but the nature of the histological a positive type IV hypersensitivity response, for example
changes has not been investigated. However, in a review of when nickel is included in the alloy. Most researchers are
bounded saddle areas, Bissada et al. (1974) consistently sceptical of the legitimacy of denture base hypersensitivity,
found chronic marginal epithelial inflammation, rete peg usually considering it to be an exaggerated denture sore
proliferation, ulceration of periodontal crevice epithelium mouth condition.
and mucosal acanthosis in the saddle end abutment areas.
Metal denture bases showed statistically significant
GINGIVAL RESPONSE TO PARTIAL
extents ofchange after the 12 month review stage, whereas
DENTURES
severe changes were noted at the 6 month review in acrylic
denture patients. It was also noted that uninvolved Every’s partial denture design philosophy as discussed by
mucosa close to the denture was far healthier if metallic Dyer (1972) suggests that the further the denture borders
 Cook: Mucosal response to denture wearing 143

are kept from the marginal gingival mucosa, the less long- Hobkirk and Strahan recommendation of minimal relief
term pathology will result. Bates (1986) suggested that the but only where unavoidable.
coverage of marginal mucosa by any part of the prosthesis, From these studies it would seem that universal support
major connector, saddle, guide plane or minor connector is given for avoiding marginal mucosa if at all possible yet
will enhance the potential for pathogenesis by increasing no agreement is available on what design should be used
plaque deposits held in proximity to the gingival tissues. if unavoidable, but Every’s principles have resulted in
Hence the suggestion that despite poorer aesthetics, many healthy prostheses being worn for long periods.
occlusally approaching clasps and minor connectors are Little comment has been passed concerning the influence
to be favoured. He further suggested that gingival of cleaning frequency and efficiency from the open or
coverage, especially with acrylic, produced locally elevated closed mucosal relief areas.
temperatures, synonymous with inflammation. It may be
proposed that such areas of increased temperature may
facilitate enhanced plaque growth by accelerating micro- ALTERED MICROFLORAL RESPONSES
floral life processes.
Cawson (1984) considered denture stomatitis (chronic
Relief of the baseplates in tooth-borne prostheses has
atrophic candidosis (Lehner, 1967)) an iatrogenic disorder
been suggested, in the style of the wash-through pontic,
resulting from candidal infection and mucosal coverage
but research evidence indicates that tissue relief areas
by a close-fitting denture base (Shafer et al., 1983).
allow mucosal proliferation and hypertrophy into the
Holbrook and Rogers (1980) identified dentures as the
available space. (Other studies have shown greater
main predisposing factor in 66 per cent of stomatitis cases.
pathological change where no mucosal relief has been
Denture bases are often the richest harvest site of&n&da
provided. The difference of opinion has yet to be resolved
albicans in denture stomatitis and far more productive
among researchers.)
than mucosal or salivary sources. Greatest evidence for
Fermin et al. (1973) proposed that gingival injury
yeasts being the main cause of the condition is derived
resulted not only from increased plaque associated with
from the resolution of signs on the use of oral antimycotic
partial prostheses but also that direct mucosal trauma
agents (e.g. nystatin, amphotericin B) but 7 day plaque
through inadequate rest seats for tooth-borne designs, and
bacteria counts stay constant (Saramanayake et al., 1980).
poor clasp positioning frequently occurred. Such stimuli
Possibly C. afbicans is required for normal oral flora to
regularly result in mucosal and periodontal epithelial
become irritant. Catalan et al. (1987) confirmed the
ulceration, adjacent tissue swelling and false pocket
finding of Budtz-Jorgensen etal. (1983) that no significant
formation. Fermin suggested that the provision of relief
changes occurred in denture plaque in stomatitis and
areas and good patient oral hygiene would alleviate these
healthy samples except proliferated C. albicans and
problems.
Acfinomyces, at the expense of other Gram-positive rods
Owall(1974) stated that gingival health was coincident
(Fig. 6).
with avoiding mucosal margin covering and should thus
Budtz-Jorgensen and Bertram (1970) isolated C.
be used as a design concept.
albicans from 90 per cent of denture stomatitis patients.
Hobkirk and Strahan (1979) investigated bounded
Budtz-Jorgensen and Thielade (1988) showed that despite
relief chambers of known dimension cut into acrylic
a lOO-fold overgrowth of C. albicans, how few were
baseplates worn by dentate patients for 3 weeks-except at
required to constitute a pathogenic challenge to the oral
mealtimes. Gingival hypertrophy was identified beneath
mucosa:
all plates, it being minimal where no relief was provided.
Proliferation into 2 mm2 and 3 mm* chambers occurred at
an equivalent and faster rate than into 1 mm2 chambers, 0 ISOLATES LOST

indicating a maximum growth rate. The authors suggested

GRAM-NEGATIVE
that closed test relief areas were not representative of RODS
typical embrasure spaces of partial prostheses and that GRAM-NEGATIVE
ia
the rapid plaque and debris aggregation within the COCCI

chambers may well have altered the nature of the

mechanical stimuli provided. However, they suggested
that where mucosal marginal involvement is unavoidable,
minimal relief should be provided.
?? ACTINOMYCES

Lechner (1985) reported significantly greater deteriora-

tion in mucosal health where margins of prostheses ii%! STAPHYLOCOCCI

approached closer than 2 mm to the mucosa-abutment

margin, but retained a relief space. The mucosal pathology
was also increased with greater hours of prosthesis wear STOMATITIS HEALTH
per day and was worse if distal extension saddles Fig. 6. Predominant bacterial flora from denture fit
were considered, indicating an increased element of surfaces in health and disease-data selected from Budtz-
mechanical trauma. Hence Lechner’s support of the Jorgensen and Thielade (1988).
144 J. Dent. 1991; 19: No. 3

Stomatitis 0.3 per cent viable organisms are C. opportunistic pathogenesis, an oral candidiasis often
albicans. having a denture base infection reservoir.
Health 0.002 per cent viable organisms are C. The use of partial dentures is often associated with
albicans. increased plaque deposits which produce the initiative
stimulus for gingival hyperplasia. Despite differing
Cawson (1984) pointed out that the lower denture is a
pharmacological functions, nifedipine, cyclosporin and
poorer fit, lifting under the action of the masticatoty
epanutin, as well as oral contraception and the pregnant
musculature and facilitating salivary dilution of bacterial
state facilitate enhanced hyperplastic responses above
and fungal organisms, irritant waste products and
that of denture-enhanced plaque.
noxious enzymes. Hence the rarity of mandibular denture
Christen et al. (1989) showed nicotine in chewing gum
stomatitis.
had little deleterious effect on mucosa but when associated
The clinical mucosal response is typically an asympto-
with hot gases, oils and tars of cigarette smoke may
matic erythema corresponding to the denture-mucosa
enhance basal seat inflammation and promote smokers’
contacts, sharply demarcated from the healthier pinkness
(hyper) keratosis.
of unaffected mucosa. Guimelli and Hirigoyen (1985) and
Over 50 per cent of an ‘elderly’ population studied by
Martinez et al. (1985) demonstrated inflamed and
Kreher ef al. (1987) using hyposalivatory drugs demon-
oedematous mucosa, reduced density of collagen and a
strated a reduced state of basal seat health, greater
monocyte, polymorph, lymphocyte and plasma cell rich
inflammation and ulceration and poorer masticatory
chronic inflammatory infiltrate. The epithelium is acan-
performance. Massler (1984) however attributed mucosal
thotic and frequently with oedema of the superficial
fragility to dietary deficiency of protein, calcium and
layers. The erythema results from prominent superficial
vitamins and a negative fluid balance. This was proposed
blood vessels, despite epithelial hyperplasia.
as an explanation for failure of technically excellent
Saramanayake et al. (1980) showed in vitro enhanced
prostheses.
adherence of C. albicans and other plaque species to
Driezen (1978) noted the importance of an intact
acrylic in the presence of serum, mucosal inflammation
mucosa in resistance to infection spread. Their 1986
potentially enhancing the aetiological agent. Perleche
survey of chemotherapy patients showed 30 per cent
(angular cheilitis) is often the presenting complaint, the
developing oral infection, 20 per cent a mucositis and 15
candidal infection results in cracked ulcerated mucosa
per cent an oral haemorrhage. Myelosuppression-
and skin, which is macerated by saliva. Treatment
especially granulocytopenia-produces a burning muco-
involves correcting soft tissue support for the lips by the
sitis as a prodrome to painful ulceration, and a high risk of
dentures, denture and oral hygiene and antimycotic drugs
superinfection.
if necessary.
Barrett (1987) however found only 20 per cent of
Denture stomatitis is frequently mild, but infection can
patients with oral infection, and unlike Driezen considered
spread giving glossitis and gut and pharyngeal coloniza-
keratinized mucosa to be far less vulnerable to drug
tion, representing reservoirs for repeated infection. Oral
potentiated traumatic ulceration. Greater turnover rate
candidiasis, especially if combined with heavy smoking, is
and inherent resilience to antigenic stimuli were proposed
a significant factor in the aetiology of speckled leuko-
to explain this phenomenon. Despite thorough pre-
plakia. The malignant transformation potential of this
treatment assessment no marker of patient vulnerability
form is greater than for other leukoplakias. Severe yeast
has been discussed.
infections are also markers for, and present problems
Thus, dentures present a great traumatic hazard and
with, immunocompromised patients, e.g. cancer therapies,
risk of superinfection to a fragile and compromised
leukaemias, transplant immunosuppressants, high dose
mucosa, especially the delicate non-keratinized sulcular
steroids (topical and systemic) and HIV patients. Iron,
tissues. Solid tumour chemotherapy tends to be less
vitamin B,, and folate deficiencies, diabetes mellitus
myelosuppressive and careful case selection for prosthetic
and endocrine dysfunction also predispose to oral
treatment can provide a greatly improved quality of
candidiasis.
life.
Postradiotherapy care is also highly controversial due
to the uncertain prevalence of necroses, patient tolerance,
DRUGS, THERAPEUTICS AND DENTURE-
primary beam position and the inevitable involvement of
MUCOSAL RESPONSES
adjacent tissues (Robinson, 1976). Early postradiation
With the development of new drugs comes the potential mucositic erythema is lost as oedema restricts local blood
for new oral-mucosal responses (Cawson, 1987). Aldomet flow, so producing a leukoplakic region of retained
may produce an erosive lichenoid reaction and similar squames. Minimal trauma, e.g. wearing a denture, causes
lesions have been noted with ibuprofen and allopurinol. shedding, leaving painful ulcers which heal by fibrotic
Such lesions can easily mimic denture trauma to the scaring long after the cancericidal dose. The radiation
unwary. source is significant in mucosal repairs, that from radium
Immunosuppressive topical and systemic steroids, needles producing more mucodestruction than cobalt-60
and the use of broad-spectrum antibiotics facilitate or ortho- and super-voltage therapies. Reduced endosteal
 Cook: Mucosal response to denture wearing 145

and periosteal vitality allows little further alveolar infections only serve to aggravate an already painful and
remodelling in irradiated areas, and coupled with fibrous distressing radiation mucositis.
and fatty marrow replacement increases the likelihood of
osteoradionecrosis-especially in the vulnerable and
poorly innervated mandible. CONCLUSION
Thus a very fragile mucosa overlying an irregular non-
remodelling alveolus is at severe risk of trauma from This review demonstrates that with a functionally success-
minimal denture function. Beumer et al. (1972) suggest ful prosthesis supported on clinically healthy mucosa,
radical alveolotomy at preradiotherapy clearance to many subclinical, histological responses may occur.
provide a smooth favourable alveolar and mucosal These include altered keratin production, acanthosis, rete
contour. In the 1976 review of 88 patients up to 2 years hyperplasia, mild chronic inflammation and disrupted
postradiotherapy, Beumer et al. found live cases of soft lamina propria collagen patterns.
tissue necrosis below dentures which all healed without The altered environment beneath a denture base,
further sequelae. The prostheses were fitted 8 months especially in relation to the maxilla, predisposes to
postradiotherapy, and close monitoring and good hygiene overgrowth of oral flora elements, especially C. albicans.
contributed to their success. They concluded that the risks When held undisturbed in close proximity to the mucosa,
of unfavourable mucosal response to early prosthodontic these organisms promote a response in denture stomatitis,
treatment were overstated and only patients with un- the most florid forms being seen in immunocompromised
favourable alveolar contours should have prostheses individuals.
delayed to allow any further remodelling and increase in There are also many potential prosthodontic problems
mucosal resilience. Pharyngeal and tonsillar tumours for chemotherapy and radiotherapy patients relating to
present the greatest problems. the primary beam involving the lack of resilience of the mucosa after treatment and the
extensive areas of mandible and inevitably much salivary unpredictable extent of trauma from the prosthesis.
tissue. Marx et al. (1985) are currently researching the use The role of drugs in mucosal responses to prostho-
of hyperbaric oxygen to increase vascular and cellular dontic appliances has also been discussed, along with the
density for faster healing. Goldberg (1986) is currently significance of the nature of the material contacting the
investigating the role of prostaglandin synthesis inhibition mucosa when in function, metallic bases being preferable
in the protection of parotid function during and after to acrylic ones.
irradiation therapy. Jani and Bhargava (1976) reported several studies
The use of soft denture linings is of little value as regular indicating that oral mucosal responses to well-constructed
replacement is required due to leaching of the plasticizing and hygienically maintained prostheses in healthy
agents. Silicone liners, being hydrophobic, can cause patients are clinically acceptable. This emphasizes the
severe abrasive trauma to the fragile mucosa, but lubrica- clinician’s responsibility to provide good functional
tion with silicone oils gives some relief. Obturators for dentures and hygiene education so that inevitable mucosal
postsurgery and radiotherapy patients are subject to very stresses and noxious stimuli do not exceed biological
regular review, being fabricated from soft materials at tissue tolerance. These responsibilities are multiplied
least in the early stages of healing. Hard acrylic trauma many times when treating immunocompromised patients.
will facilitate inflammation and secondary infection in Regular reviews of the oral mucosa’s response to the
such friable tissues. wearing of dentures, ensuring rapid treatment of breaches
Postradiotherapy xerostomia presents many problems. of tolerance and deviations from acceptable clinical
Glandular atrophy and fibrous replacement allow far less normality, are thus an essential part of prosthetic
saliva production, and a dry, adherent and easily trauma- dentistry.
tized mucosa. Unlike others, Pykonen et al. (1986)
demonstrated some salivary recovery but found acinar
Acknowledgements
recruitment above resting salivary flow was absent. Frank
et al. (1965) showed that avoidance of parotid salivary I should like to record my thanks to Dr J. D. Walter and Dr
tissue reduced the cariogenic and prosthodontic dry P. R. Morgan of Guy’s Dental School for their help, advice
mouth difficulties. Shields and masks are used to protect and encouragement during the writingofthis paper and to
and hold tissues out of the primary beam in modern Jane Bowden-Dan for her invaluable word-processing
radiotherapy (Epstein er al., 1985). Pykonen showed that services.
postradiation changes occur in the oropharyngeal flora.
Brown et al. (1975) showed constant microbial mass but a
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Book Review
Patient Care: A Dental Surgeon’s Guide, 2nd edition.
C. Scully. Pp. 324. 1989. London, British Dental Journal.
Softback, f 12.95.
The new edition of this book again sets out to bridge the
gap between the undergraduate course and the early,
formative postgraduate years. The text has been widened
to include aspects which would be relevant to dentistry in
dental practice, the community and developed countries.
Its strength lies in the symptom-associated tables which
are clearly a very valuable aid for the recently qualified
house officer. The medical and surgical management of
hospital patients still forms much of the text but too high
a proportion is devoted to the diagnosis of many common
medical conditions of greater relevance to medical rather
than dental graduates. The dental surgeon should be
more aware of the implication of the medical problems to
proposed patient management rather than to their
diagnosis. It is now recognized that the immediate
management of the traumatized patient is a special skill
and should not be delegated to less well-trained staff. A
patient is usually resuscitated long before the dental staff
Cook: Mucosal response to denture wearing 147
Van Thiel H. (1960) Alterations in tissues underlying
complete dentures. Znt. Dent. .I 10, 518-525.
Walter J. D. (1980) Removable Partial Denture Design.
London, BDA Publications.
Watson I. B. (1978) The effect of complete dentures on oral
mucosa.J. Dent. 6, 171-178.
Wentz F. M., Maier A W. and Orban B. (1952) Age changes
and sex differences in the clinically ‘normal’ gingiva. J.
Periodon tel. 23, 13-24.
Wills D. J. and Manderson R. D. (1977) Biomechanical
aspects of the support of partial dentures. J. Dent. 5,
310-318.
Wills D. J. and Picton D. C. A. (1972) A study of the
viscoelastic properties of the periodontium in monkeys. J.
Periodont Res. 7, 42-51.
Wills D. J., Picton D. C. A. and Davies W. I. R. (1976) A
study of the fluid systems of the periodontium in Macacque
monkeys. Arch. Oral Biol. 21, 175-185.
Wright W. H. (1933) Morphological changes in the mucous
membrane covering edentulous areas of the alveolar
process in the human mouth. J. Dent Res. 13, 159-160.
are asked to assess the facial injuries. On the other hand,
the simple, practical ward procedures, such as
venepuncture and intravenous infusion technique, are
rightly dealt with in depth. There is a well balanced view
of the merits and disadvantages of newer imaging
techniques. In the therapeutics section, some drugs are
rightly categorized as expensive but it would help if, in
addition, the relative costs of all drugs were shown. The
advice on medicolegal matters is sound and the
information on furthering patient communication sensible.
The new material, on the other hand, covers children’s
dentistry, orthodontics, restorative dentistry and minor
oral surgery in condensed lecture note form and adds
very little of real practical value. The final section on
employment is worthwhile and answers many of the
questions junior staff ask about their curriculum vitae,
interviews and general duties and behaviour. I would
recommend this second edition to new graduates
working in a hospital but for those in general dental
practice or the community service there are other books
more appropriate to their needs.
FL Mitchell