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Treatment for low tolerance to dentures: Supplemental report
Treatment
for
low
tolerance
to dentures:
report* George S. Sharp, Pasadena, Calif.
M.D.**
A
bnormal mucous membrane changes in the edentulous patient are frequently a cause of a low tolerance to dentures. To the dentist, these changes are a severe handicap in the delicate biomechanical art of denture adaptation and maintenance. To the physician, they may indicate a pattern of general mucous membrane change throughout the entire alimentary tract. To both, they may serve as a warning of future retrogressive changes unless active systemic management effects improvement. Certain liver fractions and, to a lesser extent, supplementation with gastric hydrochloric acid have been found useful in improving denture tolerance and in relieving other associated oral symptoms. INVESTIGATION
OF MUCOSAL
HEALTH
A study of oral mucous membranes was carried on as a part of a larger 10 year study begun in 1952. More than 3,000 patients with subjective complaints referable to the alimentary tract were evaluated. A sore mouth was the primary were complaint of 12 per cent of the patients. One third of these (122 patients) edentulous persons with chronic denture problems. Their complaints were not confined to the oral cavity, and most of their histories indicated long periods of gastrointestinal symptomatology. A previous article1 concerning 34 of these patients reported that their oral and gastrointestinal symptoms were extreme, as were the objective findings of generalized mucosal atrophy. In addition, 44 per cent were achlorhydric and hydrochloric acid supplementation was utilized in their management. This article reports the results with the group of 122 denture patients who have been studied since the special liver fraction became available in 1959. *The
report
of the first
phase
of this
study
appeared
in the
J. PROS.
DENT.
10:
47-52,
1960. **Assistant Clinical Professor of Surgery, School of Medicine, School of Dentistry, University of Southern California; Director, and Director, Pasadena Foundation for Medical Research.
222
and Professor of Pathology, Pasadena Tumor Institute;
%%% ‘ji
Treatment
for
low tolerance
to dentures
223
SUBJECTIVE AND OBJECTIVE SYMPTOMATOLOGY The oral symptoms of the group of 122 patients included varying degrees of soreness, rawness, burning, and dryness, primarily of the mucous membranes in contact with dentures. Most patients experienced the same symptoms to a lesser degree throughout the oral cavity and pharynx. Aside from the denture-bearing surfaces, the most commonly involved sites in descending order of frequency were the sides of the tongue, the buccal and labial surfaces, the floor of the mouth, the soft palate, and the pharynx. Removal of the dentures for several hours usually gave partial relief in the denture-bearing surfaces but did not alter complaints relative to other tissues. Therefore, the dentures were not primary traumatic agents, but were only triggering mechanisms producing an exaggeration of regional symptoms. Objectively, the basic sign of the abnormal mucous membrane when it has not been subjected to extrinsic irritation is a smoothness, thinness, and transparency due to atrophy and the decreased number of epithelial cells covering the underlying including thermal, chemical, and mechanical tissues. Primary extrinsic trauma, irritants, will produce a pronounced irritative, red, inflammatory reaction on such tissues. The poorly tolerated denture was the most constant of the extrinsic factors considered in this study. The buccal and labial mucosa and the sides of the tongue of these patients appeared to be abnormally smooth with a loss of the normal linear markings. The filiform papillae on the dorsal surface of the tongue were diminished, atrophic, or absent. However, only rarely was the tongue typically “bald.” The appearance of erythema in the tissues contacted by the dentures was increased by the transparency of the atrophic epithelium. When the oral conditions had extended over years, the atrophic submucosa had been replaced by scar tissue, resulting in a marked pallor of the surfaces. Even without scar tissue, superficial ulcerations were sometimes observed, and, in the scarred state, healing was usually prolonged and difficult. Other oral lesions such as angular cheilosis, leukodema, or leukoplakia were rarely found among these patients. Microscopic studies of tissues of the achlorhydric group of patients showed a diminished number of cell layers with submucosal hyperemia and edema. In the more advanced achlorhydria, an increase in fibrosis throughout the submucosa was observed. Normal and hyperacidic patients had a normal epithelial thickness with marked hyperemia and edema of the submucosa.
ETIOLOGY The relationship between a number of oral mucosal changes and specific dietary deficiencies is well known. Mansor? introduced this concept many years ago in his treatise on sprue. Deficiency diseases with oral manifestations, such as rickets, were known long before the isolation of the specific vitamins-involved and before the causal vitamin D relationship was demonstrated. In 1926, before the isolation of vitamin B12 and the factors needed in its assimilation, Minot and Murphy3 found that supplementing the diet with raw liver could reverse the irritation and inflammation of the mucosa in pernicious anemia. The fundamental physiologic changes that produce abnormal mucous mem-
224
J. Pros. Dent. March, 1967
Sharp
branes in problem-denture patients are not known. The known vitamins have been tried repeatedly and none, in combination or separately, has relieved the symptoms or improved objective signs. 4, 5 The hypothesis is offered that these patients are not able to assimilate or retain a sufficient amount of proper nutritive substances even from the most carefully directed diets. The gastric digestive nonfunction of the achlorhydric patient and its related altered utilization of proteins explains onI!, part of the problem. A more basic abnormal metabolic change, not yet understood, must be proposed. EXAMINATION
OF PATIENTS
The patients in this study were under the care of their personal dentists and were a selected group in that they were “problem” patients from a wide variety of situations. The referring dentists often believed that replacement of dentures was justified, but that the procedure should be deferred until an improvement in the condition of the tissues was achieved. This selected group did not include disinterested patients or neglected mouths. A complete medical history was obtained for each patient, with emphasis on chronic disease, anemia, history of gastric or duodenal ulcer, indigestion and gas, colitis, dysenteries, and diverticulitis. The diet history of the edentulous patient with oral soreness, burning, and pain often indicated a selection of a ?oft” diet with the exclusion of meat and vegetables from most meals. Further diet restrictions were frequently reported because of gastrointestinal complaints. Laboratory work-up for this group always included blood and urine examination, as well as the Azure-A test for gastric hydrochloric acid secretion. All achlorhydric patients and those with gastrointestinal symptoms received a full roentgenographic study. TREATMENT Treatment of oral symptoms was started immediately upon completion of physical and laboratory evaluation. A tablet containing 375 mg. of liver fraction 2 (N.F.), 375 mg. of a special liver protein fraction, 5 mcg. of vitamin R12, and 1.5 mg. of riboflavin was prescribed. * The initial dose was six tablets daily, two after each meal for several weeks. A degree of symptomatic relief was reported by most patients in two to four weeks. At that time, a high protein diet was routinely advised. Of the 122 patients, 108 were observed after a minimum of three months. Symptomatic and objective improvement was noted in 75 patients (70 per cent) from this therapy alone, and they were advised to proceed with the new dentures. The remaining 33 patients (30 per cent) were not relieved. Of these, 25 were found to have achlorhydria, 2 hyperacidity, and 5 chronic colon disease. The role of achlorhydria is further substantiated for these problem-denture patients since 62 (60 per cent) of the 108 were achlorhydrics. They, as well as the 30 per cent who were not relieved by the special liver therapy, were advised to continue the tablets and to add supplementary acid tablets containing 440 mg. of *Mucoplex,
The
Stuart
Co.,
Div.
Atlas
Chemical
Ind.,
Inc.,
Pasadena,
Calif.
Treatment
low tolerance
for
to dentures
225
Table I Treatment
of achlorhydric
patients 108 patients
with
60 per cent
low tolerance were
50 per cent relief A from Mucoplex
from *Approximate
percentage
since
to dentures
achlorhydrics*
l30
20 per Mucoplex
per cent relief from Normacid
cent relief and Normacid
6 patients
were
not
benefited
by
any
treatment.
betaine hydrochloride, 100 mg. of methyl cellulose, and (1 to 10,000) 32.4 mg. of pepsin.* The tablets were taken during the early part of each meal to provide timed release of hydrochloric acid. Many of the patients had been achlorhydric for years, and some tolerated only half a tablet with smaller meals. Greater acid supplementation was the rule as the size of the meal increased. Of the 62 achlorhydric patients (60 per cent) from the 108 observed, 30 patients (50 per cent) obtained relief from acid supplementation alone. Eleven (20 per cent) of the group were benefited only by both acid and liver supplementation. Six patients (5 per cent) 3 with achlorhydria, 2 with chronic colitis, and 1 extremely nervous patient, were not relieved at all (Table I).
ADDITIONAL
FOLLOW-UP INFORMATION
Follow-up information from this group of patients, dating back from 1 to 6 years, was recently collected. Personal interviews or return postal card questionnaires were used. The response was low in comparison with our usual 95 per cent response among patients with oral cancer. However, current information was obtained from 30 per cent of the 108 patients. Among these 31 patients, 15 reported continued symptomatic relief and normal tolerance to dentures with continued use of liver supplementation. Ten patients had continued use of acid supplementation and were maintaining normal comfort with their dentures. Three patients had experienced a return of the symptoms in spite of continued although interrupted liver supplementation. Three patients could not remember. Twenty-five of 31 patients
obtained
continuing
relief
from
complaints
of denture
intolerance.
SUMMARY A program for the symptomatic and objective relief of sore mouth and low tolerance to dentures has been described. This program was successful in over 90 per cent of the patients observed. The following steps are followed: 1. Obtain a complete history, physical examination, and laboratory studies. *Normacid,
The
Stuart
Co.,
Div.
Atlas
Chemical
Ind.,
Inc.,
Pasadena,
Calif.
226
J. Pros. Dent. March. 1967
Sharp
‘2. Initiate therapy with the combined liver fraction tablet. 3. After two to four weeks, give the patients who have achlorhydria the slob release acid supplementation tablet with each meal, in addition to the liver fraction tablet. 4. Place emphasis on increased food intake as denture tolerance permits, with special emphasis upon protein needs. 5. Proceed with replacement of dentures as indicated. These patients are willing experimentors and the periodic omission of either or both of the supplements or the reduction of dietary foods may be expected. A return of symptoms will usually lead to continuation of the beneficial regimen. References 1. Sharp, G. S.: Treatment for Low Tolerance to Dentures, J. PROS. 2. Manson, P.: Sprue, in Albutt, T. C., and Holliston, H. D., Editors: 3. 4.
5.
6.
10: 47-52, 1960. A System of Medicine,
DENT.
New York, 1907, The Macmillan Co., Vol. 2: pp. 545-566. Minot, G. R., and Murphy, W. P.: Treatment of Pernicious Anemia by Special Diet, J. A. M. A. 87: 470-476, 1926. Martin, H., and Koop, C. E.: Precancerous Mouth Lesions of Avitaminosis B, Their Etiology, Response to Therapy, and Relationship to Intra-oral Cancer, Am. J. Surg. 57: 195-224, 1942. Sharp, G. S., and Hazlet, J. W.: Premonitory Mucosal Symptoms and Signs of Oral Carcinoma, in Symposium on Cancer of the Head and Neck (Annual Scientific Session, American Cancer Society), New York, 1957, American Cancer Society, pp. 28-33. Sharp, G. S.: Diagnosis and Treatment of Achlorhydria; Preliminary Report of New Simplified Methods, West. J, Surg. 61: 353-360, 1953. 635 EAST PASADENA.
UNION CALIF.
ST.
91 lot
for
low
tolerance
to dentures:
report* George S. Sharp, Pasadena, Calif.
M.D.**
A
bnormal mucous membrane changes in the edentulous patient are frequently a cause of a low tolerance to dentures. To the dentist, these changes are a severe handicap in the delicate biomechanical art of denture adaptation and maintenance. To the physician, they may indicate a pattern of general mucous membrane change throughout the entire alimentary tract. To both, they may serve as a warning of future retrogressive changes unless active systemic management effects improvement. Certain liver fractions and, to a lesser extent, supplementation with gastric hydrochloric acid have been found useful in improving denture tolerance and in relieving other associated oral symptoms. INVESTIGATION
OF MUCOSAL
HEALTH
A study of oral mucous membranes was carried on as a part of a larger 10 year study begun in 1952. More than 3,000 patients with subjective complaints referable to the alimentary tract were evaluated. A sore mouth was the primary were complaint of 12 per cent of the patients. One third of these (122 patients) edentulous persons with chronic denture problems. Their complaints were not confined to the oral cavity, and most of their histories indicated long periods of gastrointestinal symptomatology. A previous article1 concerning 34 of these patients reported that their oral and gastrointestinal symptoms were extreme, as were the objective findings of generalized mucosal atrophy. In addition, 44 per cent were achlorhydric and hydrochloric acid supplementation was utilized in their management. This article reports the results with the group of 122 denture patients who have been studied since the special liver fraction became available in 1959. *The
report
of the first
phase
of this
study
appeared
in the
J. PROS.
DENT.
10:
47-52,
1960. **Assistant Clinical Professor of Surgery, School of Medicine, School of Dentistry, University of Southern California; Director, and Director, Pasadena Foundation for Medical Research.
222
and Professor of Pathology, Pasadena Tumor Institute;
%%% ‘ji
Treatment
for
low tolerance
to dentures
223
SUBJECTIVE AND OBJECTIVE SYMPTOMATOLOGY The oral symptoms of the group of 122 patients included varying degrees of soreness, rawness, burning, and dryness, primarily of the mucous membranes in contact with dentures. Most patients experienced the same symptoms to a lesser degree throughout the oral cavity and pharynx. Aside from the denture-bearing surfaces, the most commonly involved sites in descending order of frequency were the sides of the tongue, the buccal and labial surfaces, the floor of the mouth, the soft palate, and the pharynx. Removal of the dentures for several hours usually gave partial relief in the denture-bearing surfaces but did not alter complaints relative to other tissues. Therefore, the dentures were not primary traumatic agents, but were only triggering mechanisms producing an exaggeration of regional symptoms. Objectively, the basic sign of the abnormal mucous membrane when it has not been subjected to extrinsic irritation is a smoothness, thinness, and transparency due to atrophy and the decreased number of epithelial cells covering the underlying including thermal, chemical, and mechanical tissues. Primary extrinsic trauma, irritants, will produce a pronounced irritative, red, inflammatory reaction on such tissues. The poorly tolerated denture was the most constant of the extrinsic factors considered in this study. The buccal and labial mucosa and the sides of the tongue of these patients appeared to be abnormally smooth with a loss of the normal linear markings. The filiform papillae on the dorsal surface of the tongue were diminished, atrophic, or absent. However, only rarely was the tongue typically “bald.” The appearance of erythema in the tissues contacted by the dentures was increased by the transparency of the atrophic epithelium. When the oral conditions had extended over years, the atrophic submucosa had been replaced by scar tissue, resulting in a marked pallor of the surfaces. Even without scar tissue, superficial ulcerations were sometimes observed, and, in the scarred state, healing was usually prolonged and difficult. Other oral lesions such as angular cheilosis, leukodema, or leukoplakia were rarely found among these patients. Microscopic studies of tissues of the achlorhydric group of patients showed a diminished number of cell layers with submucosal hyperemia and edema. In the more advanced achlorhydria, an increase in fibrosis throughout the submucosa was observed. Normal and hyperacidic patients had a normal epithelial thickness with marked hyperemia and edema of the submucosa.
ETIOLOGY The relationship between a number of oral mucosal changes and specific dietary deficiencies is well known. Mansor? introduced this concept many years ago in his treatise on sprue. Deficiency diseases with oral manifestations, such as rickets, were known long before the isolation of the specific vitamins-involved and before the causal vitamin D relationship was demonstrated. In 1926, before the isolation of vitamin B12 and the factors needed in its assimilation, Minot and Murphy3 found that supplementing the diet with raw liver could reverse the irritation and inflammation of the mucosa in pernicious anemia. The fundamental physiologic changes that produce abnormal mucous mem-
224
J. Pros. Dent. March, 1967
Sharp
branes in problem-denture patients are not known. The known vitamins have been tried repeatedly and none, in combination or separately, has relieved the symptoms or improved objective signs. 4, 5 The hypothesis is offered that these patients are not able to assimilate or retain a sufficient amount of proper nutritive substances even from the most carefully directed diets. The gastric digestive nonfunction of the achlorhydric patient and its related altered utilization of proteins explains onI!, part of the problem. A more basic abnormal metabolic change, not yet understood, must be proposed. EXAMINATION
OF PATIENTS
The patients in this study were under the care of their personal dentists and were a selected group in that they were “problem” patients from a wide variety of situations. The referring dentists often believed that replacement of dentures was justified, but that the procedure should be deferred until an improvement in the condition of the tissues was achieved. This selected group did not include disinterested patients or neglected mouths. A complete medical history was obtained for each patient, with emphasis on chronic disease, anemia, history of gastric or duodenal ulcer, indigestion and gas, colitis, dysenteries, and diverticulitis. The diet history of the edentulous patient with oral soreness, burning, and pain often indicated a selection of a ?oft” diet with the exclusion of meat and vegetables from most meals. Further diet restrictions were frequently reported because of gastrointestinal complaints. Laboratory work-up for this group always included blood and urine examination, as well as the Azure-A test for gastric hydrochloric acid secretion. All achlorhydric patients and those with gastrointestinal symptoms received a full roentgenographic study. TREATMENT Treatment of oral symptoms was started immediately upon completion of physical and laboratory evaluation. A tablet containing 375 mg. of liver fraction 2 (N.F.), 375 mg. of a special liver protein fraction, 5 mcg. of vitamin R12, and 1.5 mg. of riboflavin was prescribed. * The initial dose was six tablets daily, two after each meal for several weeks. A degree of symptomatic relief was reported by most patients in two to four weeks. At that time, a high protein diet was routinely advised. Of the 122 patients, 108 were observed after a minimum of three months. Symptomatic and objective improvement was noted in 75 patients (70 per cent) from this therapy alone, and they were advised to proceed with the new dentures. The remaining 33 patients (30 per cent) were not relieved. Of these, 25 were found to have achlorhydria, 2 hyperacidity, and 5 chronic colon disease. The role of achlorhydria is further substantiated for these problem-denture patients since 62 (60 per cent) of the 108 were achlorhydrics. They, as well as the 30 per cent who were not relieved by the special liver therapy, were advised to continue the tablets and to add supplementary acid tablets containing 440 mg. of *Mucoplex,
The
Stuart
Co.,
Div.
Atlas
Chemical
Ind.,
Inc.,
Pasadena,
Calif.
Treatment
low tolerance
for
to dentures
225
Table I Treatment
of achlorhydric
patients 108 patients
with
60 per cent
low tolerance were
50 per cent relief A from Mucoplex
from *Approximate
percentage
since
to dentures
achlorhydrics*
l30
20 per Mucoplex
per cent relief from Normacid
cent relief and Normacid
6 patients
were
not
benefited
by
any
treatment.
betaine hydrochloride, 100 mg. of methyl cellulose, and (1 to 10,000) 32.4 mg. of pepsin.* The tablets were taken during the early part of each meal to provide timed release of hydrochloric acid. Many of the patients had been achlorhydric for years, and some tolerated only half a tablet with smaller meals. Greater acid supplementation was the rule as the size of the meal increased. Of the 62 achlorhydric patients (60 per cent) from the 108 observed, 30 patients (50 per cent) obtained relief from acid supplementation alone. Eleven (20 per cent) of the group were benefited only by both acid and liver supplementation. Six patients (5 per cent) 3 with achlorhydria, 2 with chronic colitis, and 1 extremely nervous patient, were not relieved at all (Table I).
ADDITIONAL
FOLLOW-UP INFORMATION
Follow-up information from this group of patients, dating back from 1 to 6 years, was recently collected. Personal interviews or return postal card questionnaires were used. The response was low in comparison with our usual 95 per cent response among patients with oral cancer. However, current information was obtained from 30 per cent of the 108 patients. Among these 31 patients, 15 reported continued symptomatic relief and normal tolerance to dentures with continued use of liver supplementation. Ten patients had continued use of acid supplementation and were maintaining normal comfort with their dentures. Three patients had experienced a return of the symptoms in spite of continued although interrupted liver supplementation. Three patients could not remember. Twenty-five of 31 patients
obtained
continuing
relief
from
complaints
of denture
intolerance.
SUMMARY A program for the symptomatic and objective relief of sore mouth and low tolerance to dentures has been described. This program was successful in over 90 per cent of the patients observed. The following steps are followed: 1. Obtain a complete history, physical examination, and laboratory studies. *Normacid,
The
Stuart
Co.,
Div.
Atlas
Chemical
Ind.,
Inc.,
Pasadena,
Calif.
226
J. Pros. Dent. March. 1967
Sharp
‘2. Initiate therapy with the combined liver fraction tablet. 3. After two to four weeks, give the patients who have achlorhydria the slob release acid supplementation tablet with each meal, in addition to the liver fraction tablet. 4. Place emphasis on increased food intake as denture tolerance permits, with special emphasis upon protein needs. 5. Proceed with replacement of dentures as indicated. These patients are willing experimentors and the periodic omission of either or both of the supplements or the reduction of dietary foods may be expected. A return of symptoms will usually lead to continuation of the beneficial regimen. References 1. Sharp, G. S.: Treatment for Low Tolerance to Dentures, J. PROS. 2. Manson, P.: Sprue, in Albutt, T. C., and Holliston, H. D., Editors: 3. 4.
5.
6.
10: 47-52, 1960. A System of Medicine,
DENT.
New York, 1907, The Macmillan Co., Vol. 2: pp. 545-566. Minot, G. R., and Murphy, W. P.: Treatment of Pernicious Anemia by Special Diet, J. A. M. A. 87: 470-476, 1926. Martin, H., and Koop, C. E.: Precancerous Mouth Lesions of Avitaminosis B, Their Etiology, Response to Therapy, and Relationship to Intra-oral Cancer, Am. J. Surg. 57: 195-224, 1942. Sharp, G. S., and Hazlet, J. W.: Premonitory Mucosal Symptoms and Signs of Oral Carcinoma, in Symposium on Cancer of the Head and Neck (Annual Scientific Session, American Cancer Society), New York, 1957, American Cancer Society, pp. 28-33. Sharp, G. S.: Diagnosis and Treatment of Achlorhydria; Preliminary Report of New Simplified Methods, West. J, Surg. 61: 353-360, 1953. 635 EAST PASADENA.
UNION CALIF.
ST.
91 lot