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Trouble shooting in complete denture prosthesis
JOSEPH
S. LANDA,
D.D.S.
IVew York, N.Y. in infants during the period of teething is a common occurrence. Tt occurs also in adolescents and adults with the eruption of the second dentition, particularly the third molars. The third dentition (complete dentures) is no exception to the rule.
H
YPERSALIVATION
SIAT.ORRFIEA
IN COMPL~TEDENTURGPATIENTS
Hypersalivation may become the main complaint of the patient with new dentures, and it may temporarily constitute a major problem. The sialorrhea during the first week may be so persistent and stubborn that the patient may refuse to wear the dentures. When sialorrhea occurs, it usually lasts only several days and gradually tapers ofi to what may be considered normal. However, in severe instances, which arc rare, 110material improvement may he observed for days and weeks, and the dentures may fail because the patient can no longer endure the discomfort. Tlerc, a calm and kind attitude by the dentist is of prime importance. The patient is thoroughly frightened and, at the same time, feels ashamed and dejected because he is unable to control himself. He is in need of the emotional support which the dentist can supply. Hypersalivation is caused by an increased flow of blood through the salivary h+nt-ls and their excessive stimulation. Etiologic factors of this syndrome are i 1 ! rmotional stress, (2) teething in infants, (3) infectious diseases, (4) inflammatory conditions of the tonsils, (5) dislocation of the mandible, (6) painful eruption of the third molars, (7) chemicotoxic substances (mercury, bismuth, iodides, bromides), (8) digestive disorders, (9) painful afflictions of the oral cavity, and i 10) refles action from stimulation by dentures as foreign bodies. The chief cause for complete denture patients is emotional stress, painful afflictions of the oral cavity, reflex stimulation of the dentures, or any combination of the three. Anxiety, pain, and even mild discomfort in the oral cavity stimulate the salivary glands to increased activity. Several important causes of excess salivation arising from the dentures are (1) incorrect centric jaw relation registrations, (2) excessive vertical dimension, (3 i overextension of denture borders, (4) pain and excessive pressure upon the oral mucosa, (5 ) pressure upon nerves and their terminal ramifications, (6) excesTart I, J. PROS. DEZ. 9:978-987, 1959; Part IV, 10:490495, 1960; Part V, 10:682-687, 1028, 1960; Part VIII, 11:79-83, 1961.
Part II, 10:4246, 1960; Part III, 10:263-269, 1960; 1960; Part VII, 10:10221960: Part VI, 10:887-890,
244
zz2E:‘2’
TROUBLE
SHOOTING
IN
COMPLETE
DENTURE
PROSTHESIS.
IX
245
sive stimulation ‘of the salivary glands by the dentures acting as a foreign body, (7) excessive thickness of the dentures restricting the tongue in its static state, as well as in function, and (8) the patient’s anxiety about possible failure of the dentures. It is very easy to imagine the pain, discomfort, and inconvenience that the patient experiences with dentures. Teething in infants, painful eruption of third molars in adults, and mandibular dislocations cause hypersalivation in nearly the same way that an incorrect centric jaw relation and overextension of denture borders engender discomfort and ulcerations. Basically, the etiologic factors in both instances are biologic in nature and, therefore, more or less the same. The mechanism by which they work and the intensity of the stimuli they transmit to the salivary glands may differ somewhat. Therefore, in treating excessive salivation caused by newly constructed dentures, all etiologic factors must be corrected. Small doses of opiates or atropine sulfate may be desirable for the first day or two in instances of severely excessive salivation. Kind treatment, sympathetic understanding, and appropriate reassurance of the patient are essential because, in some instances, they alone may effect the cure. Millerr reports a patient with excessive salivation and glossopyrosis (burning tongue) who was treated successfully by reassurance alone. XEROSTOMIA,
STOMATOPYROSIS,
AND
GLOSSOPYROSIS
Dry mouth, burning mouth, and burning tongue are seen frequently in people wearing complete dentures. However, complete dentures are not always the etiologic factor. Often, patients with natural teeth, particularly women, are afflicted by this condition. However, the syndrome may be in its incipient stage, and the patient may not inform the dentist of its presence. From a diagnostic standpoint, it must be determined whether the condition was present prior to the insertion of the dentures, whether the dentures served merely as the precipitating cause, or whether the dentures were entirely responsible for the syndrome. A careful case history will aid in determining the cause. Xerostomia (dry mouth) may be the result of many factors other than the insertion of new dentures, such as diabetes mellitus, diabetes incipidus, and chronic infection of some or all of the salivary glands. Also, diarrhea, fevers, vitamin A and other vitamin deficiencies, and drugs, such as opiates and derivatives of Atropa belladonna, may cause the condition. It is almost impossible to make a clear-cut diagnosis of the cause of stomatopyrosis (burning mouth). In most instances, it is caused by many complex factors at work simultaneously. Extensive surgical operations in the oral cavity, various diseases of a general nature, disorganization of the endocrine system, nutritional deficiencies, and emotional disturbances may be causal and contributing factors, Severe burning mouth is found most frequently in women in the menopausal or postmenopausal stage, between 40 and 60 years of age. They usually suffer from psychologic symptoms in conjunction with the menopause. Often, the onset of the syndrome follows extensive surgical operations, particularly those performed on the female sexual organs or in the oral cavity. Whether the mental shock of a general operation or the actual injury to certain nerves and blood vessels in oral operations is the primary cause for this syndrome is difficult to state. However,
LANDA
246
J. Pros.Den. March-April, 1961
the cancerophobia complex in many patients sets in soon after the general operations have been performed. Also, many patients complain of severe burning of the numi~ areas that result from surgical trauma soon after insertion of dentures. Allergy to denture-base materials as an etiologic factor or even a contributing factor in the burning mouth syndrome has been vastly overrated. However, some women in the menopausal stage develop an extreme hypersensitivity of the oral rnt~cosa to contact with or pressure by artificial restorations. Pressure that will not cause the sfightest discomfort to a healthy woman will cause excruciating pain to another woman who is under emotional stress during the menopausal stage. When w discover the clue to this hypersensitivity (which is probably due to a severe disturbance of the endocrine system) and its working mechanism, it will enable us in a great measure to control the burning mouth symptoms. Cancerophobia that most often accompanies these syndromes is probably a result rather than a cause of the disease. Indeed, a nervous patient, after the age of 50 ).ears, suffering from constant burning of the mouth would be likely to considcr cancer as the cause. The fear of cancer tends to make the patient more and more melancholic and indirectly may aggravate the pre-existing local condition. In many instances, the onset of symptoms follows severe shocks of the central nervous system dealt by extraordinarily depressing events in the patient’s emotional life. I TXF,,\TMFKT
The treatment of burnin g mouth should be directed at all of the possibly ctiologic factors. I.. Ml of the sources of local irritation and undue pressure by the dentures shonitl be thoroughly eliminated. 2. Centric relation should be checked and double checked. A new centric occlusion that is in harmony with centric relation should be remounted on an adjustable articulator to correct occlusal disharmonies. 3. Border extension and stability of the dentures should be explored with utmost care. 1. Whenever indicated, hormones should be administered. 5. A balanced diet rich in vitamins and essential minerals should be prescribed. 6, Psychotherapy should be instituted in mild cases by the dentist and in ~evr~e cakes by the psychiatrist. iri order for psychotherapy (even in mild cases of burning mouth) to be successful, the dentist must be fully acquainted with the past history of the patient and he must thoroughly understand the complications that may result from the environmental conditions in which the patient lives. No dentist should undertake or continue the treatment of burning mouth unless he is sure of the utmost confidence anti cooperation of the patient. Reassurance is an important factor in the treatment of this disorder, and absolute confidence of the patient is imperative.
1. I.;mda, J. S.: The Dynamics of Psychosomatic Dentistry, Brooklyn, 1953, Dental Items of Interest Publishing Co. !.%i EATT 54~rf $.r YEW JORK 22. ir. ‘Y.
S. LANDA,
D.D.S.
IVew York, N.Y. in infants during the period of teething is a common occurrence. Tt occurs also in adolescents and adults with the eruption of the second dentition, particularly the third molars. The third dentition (complete dentures) is no exception to the rule.
H
YPERSALIVATION
SIAT.ORRFIEA
IN COMPL~TEDENTURGPATIENTS
Hypersalivation may become the main complaint of the patient with new dentures, and it may temporarily constitute a major problem. The sialorrhea during the first week may be so persistent and stubborn that the patient may refuse to wear the dentures. When sialorrhea occurs, it usually lasts only several days and gradually tapers ofi to what may be considered normal. However, in severe instances, which arc rare, 110material improvement may he observed for days and weeks, and the dentures may fail because the patient can no longer endure the discomfort. Tlerc, a calm and kind attitude by the dentist is of prime importance. The patient is thoroughly frightened and, at the same time, feels ashamed and dejected because he is unable to control himself. He is in need of the emotional support which the dentist can supply. Hypersalivation is caused by an increased flow of blood through the salivary h+nt-ls and their excessive stimulation. Etiologic factors of this syndrome are i 1 ! rmotional stress, (2) teething in infants, (3) infectious diseases, (4) inflammatory conditions of the tonsils, (5) dislocation of the mandible, (6) painful eruption of the third molars, (7) chemicotoxic substances (mercury, bismuth, iodides, bromides), (8) digestive disorders, (9) painful afflictions of the oral cavity, and i 10) refles action from stimulation by dentures as foreign bodies. The chief cause for complete denture patients is emotional stress, painful afflictions of the oral cavity, reflex stimulation of the dentures, or any combination of the three. Anxiety, pain, and even mild discomfort in the oral cavity stimulate the salivary glands to increased activity. Several important causes of excess salivation arising from the dentures are (1) incorrect centric jaw relation registrations, (2) excessive vertical dimension, (3 i overextension of denture borders, (4) pain and excessive pressure upon the oral mucosa, (5 ) pressure upon nerves and their terminal ramifications, (6) excesTart I, J. PROS. DEZ. 9:978-987, 1959; Part IV, 10:490495, 1960; Part V, 10:682-687, 1028, 1960; Part VIII, 11:79-83, 1961.
Part II, 10:4246, 1960; Part III, 10:263-269, 1960; 1960; Part VII, 10:10221960: Part VI, 10:887-890,
244
zz2E:‘2’
TROUBLE
SHOOTING
IN
COMPLETE
DENTURE
PROSTHESIS.
IX
245
sive stimulation ‘of the salivary glands by the dentures acting as a foreign body, (7) excessive thickness of the dentures restricting the tongue in its static state, as well as in function, and (8) the patient’s anxiety about possible failure of the dentures. It is very easy to imagine the pain, discomfort, and inconvenience that the patient experiences with dentures. Teething in infants, painful eruption of third molars in adults, and mandibular dislocations cause hypersalivation in nearly the same way that an incorrect centric jaw relation and overextension of denture borders engender discomfort and ulcerations. Basically, the etiologic factors in both instances are biologic in nature and, therefore, more or less the same. The mechanism by which they work and the intensity of the stimuli they transmit to the salivary glands may differ somewhat. Therefore, in treating excessive salivation caused by newly constructed dentures, all etiologic factors must be corrected. Small doses of opiates or atropine sulfate may be desirable for the first day or two in instances of severely excessive salivation. Kind treatment, sympathetic understanding, and appropriate reassurance of the patient are essential because, in some instances, they alone may effect the cure. Millerr reports a patient with excessive salivation and glossopyrosis (burning tongue) who was treated successfully by reassurance alone. XEROSTOMIA,
STOMATOPYROSIS,
AND
GLOSSOPYROSIS
Dry mouth, burning mouth, and burning tongue are seen frequently in people wearing complete dentures. However, complete dentures are not always the etiologic factor. Often, patients with natural teeth, particularly women, are afflicted by this condition. However, the syndrome may be in its incipient stage, and the patient may not inform the dentist of its presence. From a diagnostic standpoint, it must be determined whether the condition was present prior to the insertion of the dentures, whether the dentures served merely as the precipitating cause, or whether the dentures were entirely responsible for the syndrome. A careful case history will aid in determining the cause. Xerostomia (dry mouth) may be the result of many factors other than the insertion of new dentures, such as diabetes mellitus, diabetes incipidus, and chronic infection of some or all of the salivary glands. Also, diarrhea, fevers, vitamin A and other vitamin deficiencies, and drugs, such as opiates and derivatives of Atropa belladonna, may cause the condition. It is almost impossible to make a clear-cut diagnosis of the cause of stomatopyrosis (burning mouth). In most instances, it is caused by many complex factors at work simultaneously. Extensive surgical operations in the oral cavity, various diseases of a general nature, disorganization of the endocrine system, nutritional deficiencies, and emotional disturbances may be causal and contributing factors, Severe burning mouth is found most frequently in women in the menopausal or postmenopausal stage, between 40 and 60 years of age. They usually suffer from psychologic symptoms in conjunction with the menopause. Often, the onset of the syndrome follows extensive surgical operations, particularly those performed on the female sexual organs or in the oral cavity. Whether the mental shock of a general operation or the actual injury to certain nerves and blood vessels in oral operations is the primary cause for this syndrome is difficult to state. However,
LANDA
246
J. Pros.Den. March-April, 1961
the cancerophobia complex in many patients sets in soon after the general operations have been performed. Also, many patients complain of severe burning of the numi~ areas that result from surgical trauma soon after insertion of dentures. Allergy to denture-base materials as an etiologic factor or even a contributing factor in the burning mouth syndrome has been vastly overrated. However, some women in the menopausal stage develop an extreme hypersensitivity of the oral rnt~cosa to contact with or pressure by artificial restorations. Pressure that will not cause the sfightest discomfort to a healthy woman will cause excruciating pain to another woman who is under emotional stress during the menopausal stage. When w discover the clue to this hypersensitivity (which is probably due to a severe disturbance of the endocrine system) and its working mechanism, it will enable us in a great measure to control the burning mouth symptoms. Cancerophobia that most often accompanies these syndromes is probably a result rather than a cause of the disease. Indeed, a nervous patient, after the age of 50 ).ears, suffering from constant burning of the mouth would be likely to considcr cancer as the cause. The fear of cancer tends to make the patient more and more melancholic and indirectly may aggravate the pre-existing local condition. In many instances, the onset of symptoms follows severe shocks of the central nervous system dealt by extraordinarily depressing events in the patient’s emotional life. I TXF,,\TMFKT
The treatment of burnin g mouth should be directed at all of the possibly ctiologic factors. I.. Ml of the sources of local irritation and undue pressure by the dentures shonitl be thoroughly eliminated. 2. Centric relation should be checked and double checked. A new centric occlusion that is in harmony with centric relation should be remounted on an adjustable articulator to correct occlusal disharmonies. 3. Border extension and stability of the dentures should be explored with utmost care. 1. Whenever indicated, hormones should be administered. 5. A balanced diet rich in vitamins and essential minerals should be prescribed. 6, Psychotherapy should be instituted in mild cases by the dentist and in ~evr~e cakes by the psychiatrist. iri order for psychotherapy (even in mild cases of burning mouth) to be successful, the dentist must be fully acquainted with the past history of the patient and he must thoroughly understand the complications that may result from the environmental conditions in which the patient lives. No dentist should undertake or continue the treatment of burning mouth unless he is sure of the utmost confidence anti cooperation of the patient. Reassurance is an important factor in the treatment of this disorder, and absolute confidence of the patient is imperative.
1. I.;mda, J. S.: The Dynamics of Psychosomatic Dentistry, Brooklyn, 1953, Dental Items of Interest Publishing Co. !.%i EATT 54~rf $.r YEW JORK 22. ir. ‘Y.