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The use of a soft denture liner for chronic residual ridge soreness
BRI EF
REPORTS
The use of a soft denture liner for chronic residual ridge soreness J. David Duncan, DDS, M SD Lawrence L. Clark, DDS, M S
r
hronic resid u al ridge soreness in com plete denture patients can be one of the m ost vexing problem s a dentist en counters. The difficulty exists not only in determ ining the cause of the problem, but also in deciding on the proper course of treatm en t. W h eth er th e problem is a faulty prosthesis or sim ply the incompatability of the hard denture base press ing delicate tissue against the residual ridge m ust be determ ined by the clini cian.
D iagnosis
soreness occasionally persists after im prove m ent of diet and oral hygiene, and the elim ina tion of technical errors in the dentures. One of the m ost comm on causes of this sore ness is senile atrophy of the tissues covering th e re s id u a l rid g e . As th e p a tie n t ages, catabolism predom inates anabolism resulting in the reduction of the num ber of cell layers in the mucosa, as w ell as a reduction in th e total denture-bearing area. The normal m asticatory force com presses the sensory nerve endings in a th in m ucosa betw een the hard denture base and the often sharp residual ridge. In th is par ticular situation, a soft resilient liner betw een the hard acrylic resin base and underlying structures can prevent m uch of the nerve com pression and resultant pain.
A differential diagnosis m ust be made to de term ine w hether the problem is caused by one D iscussion or more of the following reasons: reaction of the soft tissues to the base m aterial or excessive m onom er retained w ithin the base; im proper Soft liners have been used on a routine occlusal relationships (vertical, centric, or ex basis as w ell as for special problems in cursive); poor fit of the denture base; bacterial volving chronic ridge soreness, bilater o r f u n g a l i n f e c t i o n ; p r e s s u r e o n th e ally undercut residual ridges, and pros nasopalatine nerve or pressure on the m an thetic obturators. The basic requirem ents d ibular canal; physiologic changes associated for a soft liner include: insolubility in the w ith clim ateric changes; senile atrophy, pro m outh; adhesion to and no serious effect ducing a lack of thickness in the lam ina pro on the denture base; m aintenance of soft pria covering the denture-bearing area, w hich often contains num erous sharp, bony spicules; ness and resiliency; low w ater absorp bruxism ; excessive den tu re wear; or other tion; sm all dim ensional change during problem s, such as debilitating diseases, neo processing; ease of cleaning w ith good plasm , or poor nutrition. abrasion resistance; color stability; and A proper m edical and dental history, ra satisfactory tissue tolerance. diographic evaluation, and clinical exam ina Generally, resin resilient liners are rela tion are invaluable in diagnosing the problem tively hard and have a short life. Various and determ ining a proper course of treatm ent.
other soft lining m aterials have been used in the past, but none has m et all the re Treatment quirem ents for a perm anent soft liner. For this reason, the American Dental Associa A lteration of the denture occlusion or dental tion Council on Dental Materials, Instru base, im proving the oral hygiene or diet, surgi m ents, an d E quipm ent has classified cal alteration of the residual ridge, or rem aking the denture using sound fundam ental prosth- th e se m a te ria ls as “ tem p o ra ry e x p e odontic principles can be excellent modes of dients.” 1 However, favorable results have been treatm ent that w ill usually im prove or resolve the problem. However, chronic residual ridge reported w ith the use of type A medical64 ■ JADA, V ol. I l l , Ju ly 1985
grade silicone adhesives (RTV silicones) and heat-processed silicone rubber.2,3 Certain type A, m edical grade silicone a d h e s i v e s ( P r o la s tic ) a n d a h e a tprocessed silicone rubber liner (Molloplast B) have retained resiliency indefi nitely. In addition, these materials have bonded w ell to the hard denture base resin, have been com patible w ith the oral tissues, and are relatively stain resistant, tasteless, odorless, and color stable. A n e w h e a t-p ro c e s se d p la s tic iz e d m ethacrylate resin material (Softie 49) has prom ise as a long-lasting resilient liner because of its softness, longevity, and resistance to fungal growth. How ever, this m aterial is new and does not have the proved clinical longevity of the other materials. Several authors have reported positive responses from patients who used resi lient liners to relieve discomfort caused by long-time denture wear.2'6Makila5 de scribed 18 patients who had chronic tis sue soreness beneath a denture that could not be relieved by bringing the denture into a functionally faultless occlusion. He fo u n d th at 71% of these p atien ts re m ained symptom-free after 3 years w hen a soft liner m aterial was used. Some relief was reported by all of the patients. The most common problems encoun tered in the use of resilient liners include: an attem pt to use the material as a cure for fundam ental technical errors; abuse of the liners from poor oral hygiene habits; im proper use of denture cleaners; diffi culty in processing the resilient material; difficulty in adjusting the cured resilient material; and the tendency in some oral environm ents for the material to harbor yeasts (Candida albicans).7 For the resilient liner to rem ain effec
BRI EF
tive over a long period, the patient m ust be instructed in proper care of the pros thesis. Silicone liners are som ew hat por ous and the fungal grow th that m ay occur internally can be detrim ental to the liner if proper care is not taken. M ost com m er cial cleaning solutions are either ineffec tive or detrim ental to resilient liners, p ar ticularly the hypochlorite (bleach) solu tions that cause rapid deterioration of the re silie n t lin e r and m u st n o t be u se d routinely.7 A bacteriostatic cleaning solutio n c o n ta in in g b u ffe re d b e n z y lam m onium chloride (Prolastic Denture Cleaner) or buffered solutions of benzalkonium chloride (Zephiran) in concentra tions of 1 oz of 1:750 concentration per quart of water, have been show n effective in retarding fungal grow th.8 Brushing the soft liner w ith a soft brush and baking soda before soaking has also been re ported to be an effective cleaning adjunct to daily soaking in bacteriostatic solu tions.2
Sum m ary Chronic residual ridge soreness in pa
tien ts w ith com plete d entures can be caused by various factors. A differential diagnosis betw een physiologic or ana tomic problems (or both) and functional deficiencies in the p atien t’s present den tures m ust be m ade. The functional de ficiencies can often be elim inated easily, w hereas physiologic and anatom ic prob lems may be more difficult to correct, es pecially in the geriatric patient. If the functional deficiencies in the pa tie n t’s dentures have been corrected and surgical procedures are not a viable alter native, placem ent of a long-term resilient liner can often resolve the chronic re sidual ridge soreness that is present in d en tu re patients. Properly placed and properly cared for silicone or silicone rubber resilient denture liners can pro vide comfort for over 70% of patients with chronic residual ridge soreness for 3 to 5 years and often longer.
T h e a u th o rs h av e n o re la tio n s h ip to a n y of the m a n u fa c tu re rs a n d are n o t a w are o f a n y fin a n c ia l or o th e r in te re s ts in th is m a n u sc rip t.
REPORTS
Dr. D u n c an is a sso c iate p ro fesso r, re s to ra tiv e d e n tistry , an d Dr. C lark is d ire c to r, g e n eral p ra c tic e re s i d e n c y , a n d a sso c iate p ro fesso r, re sto ra tiv e d e n tis try , U n iv e rsity o f M iss is sip p i S ch o o l of D e n tistry , d e p a rtm e n t of re s to ra tiv e d e n tistry , 2500 N S tate St, Jackson, M S 39216. A d d re ss re q u e sts for re p rin ts to Dr. D un can .
1. C o u n cil o n D en tal M aterials, In s tru m e n ts , a n d E q u ip m en t. D e n tists ’ D esk R eference: M ate rials, In stru m e n ts , a n d E q u ip m en t, ed 2. C hicago, A m e ric a n D ental A sso c ia tio n , 1983, p 174. 2. S e g a ll, B .W ., a n d G la s s m a n , A . U s e o f a m e d ic al-g ra d e s ilic o n e a d h e s iv e as a d e n tu re lin e r in th e tre a tm e n t of id io p a th ic o ra l m u c o sa l irrita tio n . J P ro sth e t D ent 4 7 (l):8 5 -8 7 , 1982. 3. S c h m id t, W .F ., a n d S m ith , W.E. A six -y e a r re tro sp e c tiv e s tu d y of M o llo p la st-B -lin e d d e n tu re s. L in er serv ice a b ility . J P ro sth e t D ent 5 0 :459-465,1983. 4. W oelfol, J., a n d P affenbarger, G. E v a lu a tio n o f c o m p le te d e n tu re s lin e d w ith re s ilie n t s ilic o n e ru b ber. JADA 76(3):582-590, 1968. 5. M akila, E. Soft lin in g to re lie v e so re n ess b e n ea th d e n tu re s. J O ral R eh ab il 3:145-201, 1976. 6. L aney, W.R. P ro ce sse d re s ilie n t d e n tu re lin ers. D ent C lin N o rth A m 14:531-551, 1970. 7. M ak ila, E., a n d H o p su -H a v a , V.K. M y c o tic g ro w th a n d soft d e n tu re lin in g m ate ria ls. A cta O donto l S c a n d 35 :1 9 7 -2 0 5 ,1 9 7 7 . 8. M asella, R.P.; D olan, C.T.; a n d L aney, W .R. T he p re v e n tio n o f th e g ro w th of C an d id a o n S ila stic 390 soft lin e r fo r d e n tu re s. J P ro sth e t D ent 33:250-251, 1975.
Acceptance of hepatitis B vaccine by Rhode Island dental practitioners Joseph A. Yacovone, DMD, M PH Jason W eisfeld, M D, M PH
H
epatitis B is a severe infectious dis ease that can have serious long-term con sequences for health professionals.1 Cir rhosis and prim ary hepatocellular car cinoma are serious sequelae of hepatitis B virus (HBV) infection. Dentists and para dental personnel are at high risk of HBV infection because they are in frequent contact via direct percutaneous inocula tion of infective serum or plasm a by nee dle or transfusion of infective blood or blood products; indirect percutaneous in troduction of infective serum or plasm a, such as through m inute skin cuts or abra sions; absorption of infective serum or
plasm a through m ucosal surfaces, such as the m outh or eye; absorption of other po te n tia lly in fective secretio n s su ch as saliv a th ro u g h m ucosal contact; and transfer of infective serum or plasm a via in an im ate en v ironm ental surfaces or, possibly, vectors. The fact that as many as 10% of HBV in fections result in chronic carriage of Hep atitis B Surface Antigens (HBsAg) is im portant in the continuing transm ission of h ep atitis B.2 A bout three persons per 1,000 of the general population are car riers, but several groups have a m uch higher carrier rate. These include patients
receiv in g h em o d ialy sis (7%); in s titu tionalized m entally handicapped persons (7% to 35%); p a tie n ts w ith im m unosuppressed disorders, recipients of m ul tiple blood transfusions, and drug abus ers using percutaneous routes (5%); and m ale ho m o sex u als (6% ).3 Im m igrants from endem ic areas show that up to 15% of the population are HBV-carriers. Of all health care personnel, dentists, oral surgeons, and dental hygienists are at perhaps the highest risk of HBV infec tion.4 About 13% of practicing general dentists, com pared w ith 4% of the general population, acquire HBV infections. The
Yaco vone-W eisfeld: ACCEPTANCE O F H E P A T IT IS B V A CCIN E ■ 65
REPORTS
The use of a soft denture liner for chronic residual ridge soreness J. David Duncan, DDS, M SD Lawrence L. Clark, DDS, M S
r
hronic resid u al ridge soreness in com plete denture patients can be one of the m ost vexing problem s a dentist en counters. The difficulty exists not only in determ ining the cause of the problem, but also in deciding on the proper course of treatm en t. W h eth er th e problem is a faulty prosthesis or sim ply the incompatability of the hard denture base press ing delicate tissue against the residual ridge m ust be determ ined by the clini cian.
D iagnosis
soreness occasionally persists after im prove m ent of diet and oral hygiene, and the elim ina tion of technical errors in the dentures. One of the m ost comm on causes of this sore ness is senile atrophy of the tissues covering th e re s id u a l rid g e . As th e p a tie n t ages, catabolism predom inates anabolism resulting in the reduction of the num ber of cell layers in the mucosa, as w ell as a reduction in th e total denture-bearing area. The normal m asticatory force com presses the sensory nerve endings in a th in m ucosa betw een the hard denture base and the often sharp residual ridge. In th is par ticular situation, a soft resilient liner betw een the hard acrylic resin base and underlying structures can prevent m uch of the nerve com pression and resultant pain.
A differential diagnosis m ust be made to de term ine w hether the problem is caused by one D iscussion or more of the following reasons: reaction of the soft tissues to the base m aterial or excessive m onom er retained w ithin the base; im proper Soft liners have been used on a routine occlusal relationships (vertical, centric, or ex basis as w ell as for special problems in cursive); poor fit of the denture base; bacterial volving chronic ridge soreness, bilater o r f u n g a l i n f e c t i o n ; p r e s s u r e o n th e ally undercut residual ridges, and pros nasopalatine nerve or pressure on the m an thetic obturators. The basic requirem ents d ibular canal; physiologic changes associated for a soft liner include: insolubility in the w ith clim ateric changes; senile atrophy, pro m outh; adhesion to and no serious effect ducing a lack of thickness in the lam ina pro on the denture base; m aintenance of soft pria covering the denture-bearing area, w hich often contains num erous sharp, bony spicules; ness and resiliency; low w ater absorp bruxism ; excessive den tu re wear; or other tion; sm all dim ensional change during problem s, such as debilitating diseases, neo processing; ease of cleaning w ith good plasm , or poor nutrition. abrasion resistance; color stability; and A proper m edical and dental history, ra satisfactory tissue tolerance. diographic evaluation, and clinical exam ina Generally, resin resilient liners are rela tion are invaluable in diagnosing the problem tively hard and have a short life. Various and determ ining a proper course of treatm ent.
other soft lining m aterials have been used in the past, but none has m et all the re Treatment quirem ents for a perm anent soft liner. For this reason, the American Dental Associa A lteration of the denture occlusion or dental tion Council on Dental Materials, Instru base, im proving the oral hygiene or diet, surgi m ents, an d E quipm ent has classified cal alteration of the residual ridge, or rem aking the denture using sound fundam ental prosth- th e se m a te ria ls as “ tem p o ra ry e x p e odontic principles can be excellent modes of dients.” 1 However, favorable results have been treatm ent that w ill usually im prove or resolve the problem. However, chronic residual ridge reported w ith the use of type A medical64 ■ JADA, V ol. I l l , Ju ly 1985
grade silicone adhesives (RTV silicones) and heat-processed silicone rubber.2,3 Certain type A, m edical grade silicone a d h e s i v e s ( P r o la s tic ) a n d a h e a tprocessed silicone rubber liner (Molloplast B) have retained resiliency indefi nitely. In addition, these materials have bonded w ell to the hard denture base resin, have been com patible w ith the oral tissues, and are relatively stain resistant, tasteless, odorless, and color stable. A n e w h e a t-p ro c e s se d p la s tic iz e d m ethacrylate resin material (Softie 49) has prom ise as a long-lasting resilient liner because of its softness, longevity, and resistance to fungal growth. How ever, this m aterial is new and does not have the proved clinical longevity of the other materials. Several authors have reported positive responses from patients who used resi lient liners to relieve discomfort caused by long-time denture wear.2'6Makila5 de scribed 18 patients who had chronic tis sue soreness beneath a denture that could not be relieved by bringing the denture into a functionally faultless occlusion. He fo u n d th at 71% of these p atien ts re m ained symptom-free after 3 years w hen a soft liner m aterial was used. Some relief was reported by all of the patients. The most common problems encoun tered in the use of resilient liners include: an attem pt to use the material as a cure for fundam ental technical errors; abuse of the liners from poor oral hygiene habits; im proper use of denture cleaners; diffi culty in processing the resilient material; difficulty in adjusting the cured resilient material; and the tendency in some oral environm ents for the material to harbor yeasts (Candida albicans).7 For the resilient liner to rem ain effec
BRI EF
tive over a long period, the patient m ust be instructed in proper care of the pros thesis. Silicone liners are som ew hat por ous and the fungal grow th that m ay occur internally can be detrim ental to the liner if proper care is not taken. M ost com m er cial cleaning solutions are either ineffec tive or detrim ental to resilient liners, p ar ticularly the hypochlorite (bleach) solu tions that cause rapid deterioration of the re silie n t lin e r and m u st n o t be u se d routinely.7 A bacteriostatic cleaning solutio n c o n ta in in g b u ffe re d b e n z y lam m onium chloride (Prolastic Denture Cleaner) or buffered solutions of benzalkonium chloride (Zephiran) in concentra tions of 1 oz of 1:750 concentration per quart of water, have been show n effective in retarding fungal grow th.8 Brushing the soft liner w ith a soft brush and baking soda before soaking has also been re ported to be an effective cleaning adjunct to daily soaking in bacteriostatic solu tions.2
Sum m ary Chronic residual ridge soreness in pa
tien ts w ith com plete d entures can be caused by various factors. A differential diagnosis betw een physiologic or ana tomic problems (or both) and functional deficiencies in the p atien t’s present den tures m ust be m ade. The functional de ficiencies can often be elim inated easily, w hereas physiologic and anatom ic prob lems may be more difficult to correct, es pecially in the geriatric patient. If the functional deficiencies in the pa tie n t’s dentures have been corrected and surgical procedures are not a viable alter native, placem ent of a long-term resilient liner can often resolve the chronic re sidual ridge soreness that is present in d en tu re patients. Properly placed and properly cared for silicone or silicone rubber resilient denture liners can pro vide comfort for over 70% of patients with chronic residual ridge soreness for 3 to 5 years and often longer.
T h e a u th o rs h av e n o re la tio n s h ip to a n y of the m a n u fa c tu re rs a n d are n o t a w are o f a n y fin a n c ia l or o th e r in te re s ts in th is m a n u sc rip t.
REPORTS
Dr. D u n c an is a sso c iate p ro fesso r, re s to ra tiv e d e n tistry , an d Dr. C lark is d ire c to r, g e n eral p ra c tic e re s i d e n c y , a n d a sso c iate p ro fesso r, re sto ra tiv e d e n tis try , U n iv e rsity o f M iss is sip p i S ch o o l of D e n tistry , d e p a rtm e n t of re s to ra tiv e d e n tistry , 2500 N S tate St, Jackson, M S 39216. A d d re ss re q u e sts for re p rin ts to Dr. D un can .
1. C o u n cil o n D en tal M aterials, In s tru m e n ts , a n d E q u ip m en t. D e n tists ’ D esk R eference: M ate rials, In stru m e n ts , a n d E q u ip m en t, ed 2. C hicago, A m e ric a n D ental A sso c ia tio n , 1983, p 174. 2. S e g a ll, B .W ., a n d G la s s m a n , A . U s e o f a m e d ic al-g ra d e s ilic o n e a d h e s iv e as a d e n tu re lin e r in th e tre a tm e n t of id io p a th ic o ra l m u c o sa l irrita tio n . J P ro sth e t D ent 4 7 (l):8 5 -8 7 , 1982. 3. S c h m id t, W .F ., a n d S m ith , W.E. A six -y e a r re tro sp e c tiv e s tu d y of M o llo p la st-B -lin e d d e n tu re s. L in er serv ice a b ility . J P ro sth e t D ent 5 0 :459-465,1983. 4. W oelfol, J., a n d P affenbarger, G. E v a lu a tio n o f c o m p le te d e n tu re s lin e d w ith re s ilie n t s ilic o n e ru b ber. JADA 76(3):582-590, 1968. 5. M akila, E. Soft lin in g to re lie v e so re n ess b e n ea th d e n tu re s. J O ral R eh ab il 3:145-201, 1976. 6. L aney, W.R. P ro ce sse d re s ilie n t d e n tu re lin ers. D ent C lin N o rth A m 14:531-551, 1970. 7. M ak ila, E., a n d H o p su -H a v a , V.K. M y c o tic g ro w th a n d soft d e n tu re lin in g m ate ria ls. A cta O donto l S c a n d 35 :1 9 7 -2 0 5 ,1 9 7 7 . 8. M asella, R.P.; D olan, C.T.; a n d L aney, W .R. T he p re v e n tio n o f th e g ro w th of C an d id a o n S ila stic 390 soft lin e r fo r d e n tu re s. J P ro sth e t D ent 33:250-251, 1975.
Acceptance of hepatitis B vaccine by Rhode Island dental practitioners Joseph A. Yacovone, DMD, M PH Jason W eisfeld, M D, M PH
H
epatitis B is a severe infectious dis ease that can have serious long-term con sequences for health professionals.1 Cir rhosis and prim ary hepatocellular car cinoma are serious sequelae of hepatitis B virus (HBV) infection. Dentists and para dental personnel are at high risk of HBV infection because they are in frequent contact via direct percutaneous inocula tion of infective serum or plasm a by nee dle or transfusion of infective blood or blood products; indirect percutaneous in troduction of infective serum or plasm a, such as through m inute skin cuts or abra sions; absorption of infective serum or
plasm a through m ucosal surfaces, such as the m outh or eye; absorption of other po te n tia lly in fective secretio n s su ch as saliv a th ro u g h m ucosal contact; and transfer of infective serum or plasm a via in an im ate en v ironm ental surfaces or, possibly, vectors. The fact that as many as 10% of HBV in fections result in chronic carriage of Hep atitis B Surface Antigens (HBsAg) is im portant in the continuing transm ission of h ep atitis B.2 A bout three persons per 1,000 of the general population are car riers, but several groups have a m uch higher carrier rate. These include patients
receiv in g h em o d ialy sis (7%); in s titu tionalized m entally handicapped persons (7% to 35%); p a tie n ts w ith im m unosuppressed disorders, recipients of m ul tiple blood transfusions, and drug abus ers using percutaneous routes (5%); and m ale ho m o sex u als (6% ).3 Im m igrants from endem ic areas show that up to 15% of the population are HBV-carriers. Of all health care personnel, dentists, oral surgeons, and dental hygienists are at perhaps the highest risk of HBV infec tion.4 About 13% of practicing general dentists, com pared w ith 4% of the general population, acquire HBV infections. The
Yaco vone-W eisfeld: ACCEPTANCE O F H E P A T IT IS B V A CCIN E ■ 65