Traumatic Ulcerations Frequencies and Postinsertion Adjustment Appointments in Complete Denture Patients.

BACKGROUND AND AIM: The patient who is wearing a denture after missing teeth faces traumatic ulceration very frequently. This ulceration creates difficulties in denture wearing. Hence, this study aimed to evaluate the most common locations of traumatic injuries in form of ulcerations, their frequency, and also the duration and number of adjustment visits required to achieve patient comfort following placement of complete removable dentures.
MATERIALS AND METHODS: Eighty edentulous patients were selected from a private clinic. Complete removable dentures were fabricated for all patients. All patients were evaluated for their complaints after denture insertion. Patients were followed up till the problem persisted. Descriptive analysis was done. Chi-squared test was used to differentiate the associations between lesions, postinsertion visits, and gender.
RESULTS: About 85.62% of patients need denture adjustment because of mucosal injuries during their first visit following. Approximately four appointments are needed for maxillary and six appointments needed for mandibular denture. Male and female have no difference in the number of mucosal injuries in the anatomical area evaluated in the maxilla and mandible using Fisher's exact test (P > 0.05). Mandibular dentures need more appointments than maxillary dentures after post insertion (P < 0.001).
CONCLUSION: The vestibule was the most common site for mucosal injuries which can be corrected by proper extension of denture flanges during border molding. Pressure indicator ink (arti spot) and paste is used to correct the overextended denture flanges. Copyright:

INTRODUCTION

Complete denture has less capacity to function as a comparison to natural teeth. There are some limitations in complete denture, so the success of complete denture depends on follow-up after denture insertion. The patient should be aware of complete denture limitations from his or her first appointment. The most important time for success or failure of a complete denture is the adjustment period. Traumatic mucosal ulcers are the most common problems of edentulous patients after placing the complete dentures. These painful ulcers cause patient discomfort and edentulous patients are unable to wear complete dentures. Hence, dentists need to rule out various factors responsible for mucosal ulcerations and make the patient comfortable during follow-up period and develop trust between doctor and patient. There are various reasons for mucosal injuries such as overextension of flanges, denture irregularities, denture base defects, improper adaptation of complete denture internal surface with the tissue underlying it, denture porosity, and presence of immature occlusal contact. These defects can occur at many stages such as during clinical procedure, laboratory procedure, impression taking, border molding, or denture polishing.[1]

Kivovics et al.[2] observed that after wearing a complete denture, there is always a risk of mucosal injuries whatever impression technique may be used. They evaluated 61 patients wearing complete denture showing overextension of flanges causing irritation of mucosa results in ulcerations and soreness, especially in mandibular dentures. Mandible has a greater range of movement and the tongue also dislodges the mandibular dentures, so many dentists extend the flanges as much as possible to acquire the retention causing trauma to mobile mucosa results in injuries and ulcerations. Laurina and Soboleva[3] reported that patients wearing complete dentures have complaints only when there is a problem in denture processing or denture design through a retrospective study of review of literature from 1984 to 2004 on complete denture edentulous patients having a problem with new dentures and possible real cause behind it. Brunello and Mandikos[4] reported in hundred patients that mucosal injuries and traumatic ulcerations are the most common finding main cause of pain and discomfort after denture placement. They also evaluated that there is no significant relationship between mucosal ulcerations and patient age, sex, or medical condition. However, a significant relationship was present between mucosal ulceration, patients complaints, and complete denture design faults. Dervis[5] evaluated that by using different impression methods or border molding technique, there is no any significant differences present between postadjustment appointments and complete denture fabrication methods. By using proper fabrication method sand careful extension of complete denture flanges, we can reduce the patients' complaints and postinsertion recall visits. Dervis[6] evaluated in 600 patients after 3 months of wearing newly fabricated complete dentures what are their most common complaints. He found that there is a significant relationship present between mucosal injuries and ulcerations and complete denture fabrication faults. However, there are no significant relationships that were present between patient complaints and age, sex, and medical conditions of patients.

As these studies show that most complications during denture insertions come from the wrong technique during phases of denture construction, so we can overcome these complaints after adopting proper denture construction technique. This study aims to analyze the most common location of ulcerations in the oral cavity and the total duration required to overcome this.

MATERIALS AND METHODS

We have selected 80complete edentulous patients (47 males and 33 females) after examining their oral tissues and taking dental and medical histories from private clinics of Bihar from 2017 to 2020. The mean age of the patients was 57.05 ± years (a range of 45–70 years). The inclusion criteria were:

Patient having not any diabetic history, xerostomia, bruxism, neurologic and mental disorder, and immunologic diseases

Patient who is having completely healed extraction site and socket for the first time denture wearer

Patient having not any hyperplastic or inflammatory mucosal lesions

Patient having not any fungal infection like candida

Patient having not any history of autoimmune diseases associated with recurrent mucosal ulcers

Patient having no bony undercuts or irregularities in denture's insertion path

Patient not using tobacco

Patient using contraceptives and pregnant women is excluded

Age between 45 years and 70 years.

By using the conventional method for all the selected patients, complete dentures were fabricated as advocated by Zarb et al.[7] The material used is the same all complete dentures and all steps are supervised by the prosthodontist. The complete denture edentulous patients have given appointmentson 1st, 2nd, and 3rd days after placement of the complete denture. Complete denture patient has given appointment consequently after 2 days following 3rd-day appointment till mucosal ulcerations problem vanishes out completely and the patient is in a comfortable position. The location of the area and denture causing injuries were marked in every recall visit and recorded. By using SPSS version 24 software, descriptive statistical analysis study was performed to find out the correlation between mucosal injuries and postinsertion day and the relationship between lesions and gender of the patient. If P value is smaller than 0.05, it means that data are statistically significant.

RESULTS

The complete denture edentulous patients were given appointments on the 1st, 2nd, and 3rd days after placement of the complete denture. Complete denture patient has given appointment consequently after 2 days following 3rd-day appointment till mucosal ulcerations problem vanishes out completely and the patient is in comfortable position. As we can see in Table 1, the first appointment shows that 57 complete maxillary dentures out of 80 maxillary dentures needed adjustments and all 80 mandibular complete dentures require adjustments due to trauma and mucosal injuries caused by them that results in pain and discomfort to patients. After doing adjustments in follow-up appointments, gradually, complete dentures require less adjustment. We can see that in maxillay dentures, third visit is enough to rule out all the problems, no adjustments are required in the fourth visit. However, almost a double visit is required for complete mandibular denture mandibular dentures, third visit is not enough, and almost sixth visit is needed to rule out all the problems [Table 1]. Pearson Chi-squared test value is 29.58, P < 0.001 showed a significant correlation between the number of maxillary and mandibular dentures requiring adjustments and postinsertion visits [Graph 1].

Table 1

Number of patients requiring maxillary and mandibular dentures adjustments after denture placement

	Total	Adjustment 1 (%)	Adjustment 2 (%)	Adjustment 3 (%)	Adjustment 4 (%)	Adjustment 5 (%)	Adjustment 6 (%)	Adjustment 7 (%)
Maxilla	80	57 (71.25)	43 (53.75)	31 (38.75)	17 (21.25)	0	0	0
Mandible	80	80 (100)	77 (96.25)	71 (88.75)	61 (76.25)	29 (36.25)	11 (13.75)	0
Total	160	137 (85.62)	120 (75)	102 (63.75)	78 (48.75)	29 (18.12)	11 (6.87)	0

Graph 1

Graph depicting total number of appointments required post insertion of maxillay and mandibular dentures

In this study, we can see results that postinsertion recall visits for adjustment were significantly higher for mandibular dentures comparative to maxillary complete dentures in all patients.

Maxillary complete dentures show that posterior palatal seal area in the soft palate (31.76%) is the most frequently involved area for mucosal ulcerations, after that buccal slope of the residual alveolar ridge (15.29%), then distobuccal sulcus (15.29%) and maxillary labial frenum (11.76%). Mandibular dentures show that the retromylohyoid area (48.57%) is the most frequently involved area for mucosal ulcerations, after that buccal sulcus (10.16%) near the buccal shelf area, then retromolar pad (8.94%) and mandibular frenum (8.73%) [Tables 2 and 3].

Table 2

Number of maxillary injuries related to clinical anatomic sites and gender (80 patients and 170 corrections)

Anatomical sites	Adjustment 1			Adjustment 2			Adjustment 3			Adjustment 4			Adjustment 5			Total
	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total
Labial frenum	9	5	14	2	1	3	1	1	2	0	1	1	0	0	0	20
Buccal frenum	5	3	8	2	1	3	1	1	2	1	0	1	0	0	0	14
Maxillary tuberosity	1	1	2	1	1	2	1	0	1	0	0	0	0	0	0	5
Hamular notch	2	4	6	2	3	5	2	2	4	1	1	2	0	0	0	17
PPS	10	12	22	8	10	18	5	5	10	2	2	4	0	0	0	54
Incisive papilla	1	0	1	0	0	0	0	0	0	0	0	0	0	0	0	1
Midpalatal suture	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
rugae	0	0	0	0	0	0	0	1	1	0	0	0	0	0	0	1
Palatal torus	0	1	1	0	0	0	0	0	0	0	0	0	0	0	0	1
Hard palate	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Crest of residual ridge	4	3	7	2	2	4	1	0	1	1	0	1	0	0	0	13
Labial sulcus	3	1	4	4	1	5	0	0	0	0	0	0	0	0	0	9
Buccal sulcus	2	0	2	2	0	2	2	1	3	2	0	2	0	0	0	9
Distobuccal sulcus	3	4	7	6	4	10	3	3	6	2	1	3	0	0	0	26

PPS: Posterior palatal seal

Table 3

Number of mandibular injuries related to clinical anatomic sites and gender (80 patients and 492 corrections)

Anatomical sites	Adjustment 1			Adjustment 2			Adjustment 3			Adjustment 4			Adjustment 5			Adjustment 6			Adjustment 7			Total
	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total	Male	Female	Total
Labial frenum	10	7	17	8	4	12	5	2	7	3	1	4	1	1	2	1	0	1	0	0	0	43
Buccal frenum	3	1	4	2	1	3	1	0	1	2	1	3	0	0	0	0	0	0	0	0	0	11
Retromolar pad	7	6	13	9	6	15	4	5	9	2	3	5	1	1	2	0	0	0	0	0	0	44
Plica sublingualis	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Mylohyoid ridge	3	1	4	3	2	5	3	1	4	2	1	3	1	1	2	0	0	0	0	0	0	18
Mandibular torus	0	0	0	0	0	0	0	0	0	0	0	o	0	0	0	0	0	0	0	0	0	0
Lingual sulcus (premylohyoid)	3	1	4	2	1	3	0	2	2	2	1	3	1	1	2	1	0	1	0	0	0	15
Lingual sulcus (mylohyoid)	1	0	1	0	1	1	1	1	2	0	1	1	1	0	1	0	0	0	0	0	0	6
Lingual sulcus (retromylohyoid)	38	22	60	36	22	58	33	20	53	23	17	40	9	8	17	8	3	11	0	0	0	239
Slope of residual ridge	4	4	8	3	4	7	2	6	8	0	2	2	1	0	1	1	0	1	0	0	0	27
Crest of residual ridge	9	0	9	6	0	6	3	2	5	2	1	3	0	0	0	0	0	0	0	0	0	23
Labial sulcus	1	1	2	1	0	1	0	1	1	0	1	1	0	0	0	0	0	0	0	0	0	5
Buccal sulcus	10	4	14	8	5	13	7	6	13	4	3	7	2	1	3	0	0	0	0	0	0	50
Distobuccal sulcus	0	2	2	1	1	2	1	3	4	0	1	1	0	2	2	0	0	0	0	0	0	11
Total	89	49	138	79	47	126	60	49	109	40	33	73	17	15	32	11	3	14	0	0	0	492

Maxillary complete dentures show that hard palate and mid-palatal suture (0%) is the least commonly injured area for mucosal ulcerations, then maxillary rugae and incisive papilla shows (0.58%) mucosal injuries, maxillary tuberosity shows (2.94%), and maxillary labial sulcus and buccal sulcus shows (5.29%) mucosal injuries. The mandibular complete denture shows that the least frequently involved area for mucosal ulcerations is sublingual fold of mandible (0%), mandibular mylohyoid area of the lingual sulcus and labial sulcus (1.21%), and area of mandibular buccal shelf and mandibular buccal frenum (2.23%) [Tables 2 and 3]. In this study, we also found that there were no significant differences observed between gender males and females, and the frequency of mucosal injuries in all the mentioned areas of maxilla and mandible was calculated using Fisher's exact test (P > 0.05). Pearson Chi-square test for maxilla is 0.555, P = 0.91, and for mandible is 6.13, P = 0.294, in relation to gender [Tables 4, 5 and Graphs 2, 3].

Table 4

Number of adjustments required postinsertion of maxillary denture in different genders

	Adjustment 1	Adjustment 2	Adjustment 3	Adjustment 4	Adjustment 5	Pearson χ2	P
Male	40	29	16	9	0	0.555	0.91
Female	34	23	14	5	0

Table 5

Number of adjustments required postinsertion of mandibular denture in different genders

	Adjustment 1	Adjustment 2	Adjustment 3	Adjustment 4	Adjustment 5	Adjustment 6	Pearson χ2	P
Male	89	79	60	40	17	11	6.13	0.294
Female	49	47	49	33	15	3

Graph 2

Number of maxillary injuries related to clinical anatomic sites and gender

Graph 3

Number of mandibular injuries related to clinical anatomic sites and gender

DISCUSSION

Complete denture edentulous patients were recalled after denture insertion for the first few days for adjustments. Our present descriptive analytical study shows that approximately 85.62% of complete denture patients needed adjustments after denture insertion within 24 h. The adjustment needed in second recall visits was 75%, in the third recall visits was 63.75%, in the fourth recall visits was 48.75%, in the fifth recall visits was 18.12%, and sixth recall visits show that 6.6% the minimum needed adjustments. This means after insertion of complete denture, patients need utmost care in follow-up appointments. A study done by Kivovics et al. shows that there is a need of postinsertion adjustment in 87% of new complete denture patients in their first recall visits. There is a similarity of results with the present study. It is seen that after 2 weeks generally after the sixth visit, there is no need of adjustment in complete dentures due to healing of mucosal ulcers.

We can see from this study that mandibular denture adjustments are required in all the patients (100%) in their first postinsertion appointment. For mandibular dentures, higher adjustment visits are required and a significantly higher number of mandibular mucosal injuries are seen in all the postinsertion appointments comparative to the maxilla. Thus, during denture fabrication we should give attention to every step such as border molding, final impression taking, complete denture proper tissue adaptation, and extension of denture flanges as required for retention when fabricating mandibular dentures to reduce mucosal injuries as much as possible. We know that mandible has less mean denture-bearing area 12.25cm2 compared to maxilla mean denture-bearing area 22.96 cm2, thus mandible has less retention and denture support as compared to maxilla. The mandibular denture tends to have greater degree of movement due to presence of tongue, which makes stability and retention complicated, thereby resulting in more mucosal injuries.

According to Kivovics et al., to overcome the retention problem, dentists tend to extend flanges as much as possible and that is why the highest frequency of injuries was seen in borders and flanges in the retromylohyoid area (48.6%), the buccal sulcus adjacent to the buccal shelf (9.8%), and the retromolar pad (9.5%). By applying a pressure indicating paste and detection of overextended borders/flanges at delivery or postinsertion stages, mucosal injuries can be avoided and patient satisfaction achieved. In this study, the posterior palatal seal area shows the highest number of maxillary ulcerations. The most common area of mucosal injuries is the area of bony undercuts in the alveolar ridge. The second highest area of traumatic mucosal injuries is the canine area and molar area of the residual alveolar ridge. The mucosa is very thin in these areas, thus causes repetitive trauma and ulceration after wearing a complete maxillary denture.

According to Cleary et al.[8] during the first few days after the denture placement, intake of diet has an important role in causing mucosal injuries and ulcerations. In general, women have habit of taking less hard foods than men, thus causing less trauma and mucosal ulcerations compared to men. They observed that men have more mucosal ulcerations than women. The number of mucosal ulcers between men and women shows no statistically significant differences in the present study. After placing a complete denture, the patient should be trained for using denture correctly, and for the first few days, only soft food should be eaten.

After complete denture placement within the limitations of this study, it is of utmost important to communicate with the patient in follow-up appointments and make necessary adjustments; otherwise, poor communication can lead to failure of denture. Well-made denture results in patient comfort, adequate function, and appearance.

Ulcerations and soreness caused by overextended denture flanges can be easily identified and relieved. Through various studies, we know that the highest mucosal injuries normally occur in denture border areas, so we must take care of adequate extension of flanges during border molding. For increasing patient comfort, pressure indicator paste should be used to relieve the pressure-causing area in the denture, thus results in less trauma, mucosal injuries, and ulcerations. After denture insertion, patients should be trained for correctly using their dentures. For the first few days, the patient should be instructed to take a soft chewing diet and slowly switch to hard foods.

CONCLUSION

Hence, in conclusion, we should examine every anatomical area before delivering a complete denture and all necessary adjustments should be done; by doing this, we can lessen postinsertion patient visits. Postinsertion complete denture visit is necessary for successful rehabilitation of complete denture, so follow-up must be done until the patient comfort is not achieved.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.