oral mucosal lesions in denture wearers

ORAL MUCOSAL LESIONS IN DENTURE

WEARERSAree Jainkittivong, Vilaiwan Aneksuk and Robert

P. LanglaisThe Gerodontology Society and John Wiley & Sons A/S, Gerodontology 2010; 27: 26–32

AAMIR ZAHID GODILFIRST YEAR P.G.DEPARTMENT OF

PROSTHODONTICSM.A.R.D.C.

INTRODUCTION• Communication is often the key problem in

the management of the elderly

• There is a great variety of oral complaints that they may suffer. In extreme cases for example, an elderly patient may be so intellectually impaired, deaf and depressed as to make communication excessively difficult but may also have oral cancer

Cawson.R.A, Odell E.W. Intellectual and Physical Disability In: Essentials of Oral Pathology and Oral Medicine, Edition 7. Spain

2002. 33: 367

• The prevalence of oral mucosal lesions (OMLs) is usually reported to be higher in denture wearers than in non-wearers

• The area of the oral mucosa covered by a complete denture is greater than that covered by a partial denture and may therefore increase the risk of Denture Related Mucosal Lesions (DMLs)

Coelho CM, Sousa YT, Dare AM. Denture-related oral mucosal lesions in a Brazilian school of dentistry. J Oral Rehabil 2004; 31: 135–139.

ORAL MUCOSAL LESIONS IN DENTURE WEARERS

DENTURE RELATED MUCOSAL LESIONS

NON- DENTURE RELATED MUCOSAL LESIONS

TRAUMATIC ULCER FISSURED TONGUE

BETELNUT CHEWER’S MUCOSA

DENTURE INDUCED STOMATITIS

ATROPHIC TONGUE

APTHOUS ULCER

DENTURE HYPERPLASIA AMALGAM TATTOO GEOGRAPHIC TONGUE

ANGULAR CHELITIS LEUKOEDEMA TONGUE CARCINOMA

FRICTIONAL KERATOSIS LICHEN PLANUS ANKYLOGLOSSIAIRRITATION FIBROMA HAIRY TONGUE FOLIATE PAPILLITIS

CANDIDIASIS SMOKER MELANOSIS

NICOTINIC STOMATITIS

LEUKOPLAKIA HEAT BURN

Jainkittivong A., Aneksuk V., Langlais R. Oral mucosal lesions in denture wearers. The Gerodontology Society and John Wiley & Sons

A/S, Gerodontology 2010; 27: 26–32.

DENTURE RELATED MUCOSAL LESIONS

TRAUMATIC ULCER•Cause: by a denture and often seen in the buccal or lingual sulcus.

•They are tender, have a yellowish floor, and red margins; there is no induration.

•Heal a few days after elimination of the cause.

•If they persist for more than 7-10 days, or there is any other cause for suspicion as to the cause, biopsy should be carried out.

Neville B.W, Damm D.D, Allen C.M, Bouqouot J.E. Physical and Chemical Injuries In. Oral and Maxillofacial Pathology. 2nd Ed W.B. Saunder’s

Company, USA 2002; 8:256, 8.6

DENTURE INDUCED STOMATITIS

•A well-fitting upper denture cuts off the underlying mucosa from the protective action of saliva. In susceptible patients, particularly smokers, this can promote candidosis, seen as a symptomless area of erythema

•The erythema is sharply limited to the area of mucosa occluded by a well-fitting upper denture

• Not seen under the more mobile lower denture which allows a relatively free flow of saliva beneath

Neville B.W, Damm D.D, Allen C.M, Bouqouot J.E. Fungal and Protozoal Diseases In. Oral and Maxillofacial Pathology. 2nd Ed W.B. Saunder’s

Company, USA 2002; 6:193, 6.8,6.9

Management• The clinical picture is distinctive but the

diagnosis can be confirmed by finding candidal hyphae in a Gram-stained smear taken from the inflamed mucosa or the fitting surface of the denture.

• The infection responds to antifungal drugs, but topical agents such as nystatin or amphotericin can only gain access to the palate if the patient leaves out the denture while the tablets are allowed to dissolve in the mouth.Cawson.R.A, Odell E.W. Diseases of Oral Mucosa: Introduction and

Mucosal Infections In: Essentials of Oral Pathology and Oral Medicine, Edition 7. Spain 2002. 12:187-8

DENTURE HYPERPLASIA

Denture-induced granuloma (Papillary hyperplasia)

•Denture-induced hyperplasias ('denture granulomas') often form at the edge of dentures

• These swellings are pale and firm but may be abraded and ulcerated, and then inflamed.•'Leaf fibroma'' is another fibrous overgrowth which forms under a denture but has become flattened against the palate

• It may be difficult to see until lifted away from its bed.

'Leaf fibroma‘Flat lesions formed between the denture and mucosa are often termed leaf fibromas because of their shape. Raising this example with a probe reveals its pedunculated shape.

Management•Fibrous nodules should be excised together with the small base of normal tissue from which they arise

•There should be no recurrence if this is done thoroughly and the source of irritation is removed

Cawson.R.A, Odell E.W. Diseases of Oral Mucosa: Introduction and Mucosal Infections In: Essentials of Oral Pathology and Oral

Medicine, Edition 7. Spain 2002. 12:

ANGULAR CHEILITISAngular stomatitis is typically caused by leakage of candida infected saliva at the angles of the mouth

It can be seen in infantile thrush, in denture wearers or in association with chronic hyperplastic candidosis.

•In elderly patients with denture-induced stomatitis, inflammation frequently extends along folds of the facial skin extending from the angles of the mouth

•These folds are due to sagging of the facial tissues with age

•Furrows at the angles of the mouth are made deeper by loss of vertical dimension and by loss of support to the upper lip by resorption of the underlying bone.

Management

• Though establishment of correct vertical dimension and increasing the thickness of the labial flange of the upper denture can slightly lessen these furrows, they can rarely be eliminated in this way.

• Plastic surgery is required when patients are anxious to have these signs of age removed

• Treatment of intraoral candidal infection alone causes angular stomatitis to resolve– Apply miconazole gel24 mg/ml QDS to the angles of the mouth 10-14 days or

fusidic acid cream

Angular stomatitis Cracking and erythema at the commissure is due to leakage of saliva containing C. albicans, constantly reinfecting the lesion.

Cawson.R.A, Odell E.W. Diseases of Oral Mucosa: Introduction and Mucosal Infections In: Essentials of Oral Pathology and Oral

Medicine, Edition 7. Spain 2002. 12:186

FRICTIONAL KERATOSIS

•White patches can be caused by prolonged mild abrasion of the mucous membrane by such irritants as a sharp tooth, cheek biting or dentures

•At first, the patches are pale and translucent, but later become dense and white, sometimes with a rough surface

•Removal of the irritant causes the patch quickly to disappear.

•Biopsy is necessary only if the patch persists

Frictional keratosis. A poorly-defined patch of keratosis on the buccal mucosa is due to friction from the sharp buccal cusp of a grossly carious upper molar

Regezi J.A, Sciubba J.J, Jordan R.C. White Lesions Id. Oral Pathology: Clinical Pathologic Corelations. 4th Ed Saunders, St Louis, Missourie, 2003. Reactive Lesions 3:78, 3.4

IRRITATION FIBROMA•It is a reactive hyperplasia of fibrous connective tissue in response to local irritation or trauma

•Appears as smooth surface, pink nodule similar in color to surrounding mucosa

•In some cases it may appear white due to hyperkeratinisation from continuous irritation

•Asymptomatic, unless secondary traumatic ulceration occurs

•Treated by conservative surgical excision, recurrence is rare

•Histopathological evaluation of excised mass must be performed to exclude similar benign and malignant lesions

Neville B.W, Damm D.D, Allen C.M, Bouqouot J.E. Fungal and Protozoal Diseases In. Oral and Maxillofacial Pathology. 2nd Ed W.B. Saunder’s Company, USA 2002; 12:442-3

CANDIDIASIS•In nonimmunocompromised, denture wearing patients, it appears as generalised area of red atrophic tissue commonly found under maxillary dentures on the palate

Management

• If a denture is worn:– Cease night-time wear– Check denture hygiene and advise– Soak denture overnight in antifungal (dilute hypochlorite,

chlorhexidine mouthwash) or, less effective, apply miconazole gel to denture fit surface while worn

• Drug of choice and regime:– Nystatin 100 000 units QDS for 7-10 days as suspension or

pastilles or– Amphotericin 10 mg QDS as lozenges or suspension10-14 days.

Cawson.R.A, Odell E.W. Diseases of Oral Mucosa: Introduction and Mucosal Infections In: Essentials of Oral Pathology and Oral Medicine,

Edition 7. Spain 2002. 12:189, 12.1


FISSURED TONGUE

ATROPHIC TONGUE

AMALGAM TATTOO

LEUKOEDEMA


LICHEN PLANUS

HAIRY TONGUE

SMOKER’S MELANOSIS

LEUKOPLAKIA


BETELNUT CHEWER’S MUCOSA

APTHOUS ULCER

GEOGRAPHIC TONGUE

TONGUE CARCINOMA


ANKYLOGLOSSIA

FOLIATE PAPILLITIS

NICOTINIC STOMATITIS HEAT BURN

STATISTICAL ANALYSIS• The most common DMLs were traumatic ulcer (19.5%) and

denture-induced stomatitis (18.1%)

• When analysed by type, traumatic ulcer, denture hyperplasia, frictional keratosis and candidiasis were more common in complete denture wearers, whereas denture-induced stomatitis was more common in partial denture wearers

• Frictional keratosis was more common in men than in women

• The prevalence of OMLs not related to denture wearing was higher in complete denture wearers than in partial denture wearers, and the most common OML was fissured tongue(27.6%)

• No association between DMLs and systemic conditions or xerostomic drugs was noted.

Jainkittivong A., Aneksuk V., Langlais R. Oral mucosal lesions in denture wearers. The Gerodontology Society and John Wiley & Sons

A/S, Gerodontology 2010; 27: 26–32.

Table: Number and percentage of oral biopsied lesions in elderly and non-elderly patients.

Correa L. et al. Oral lesions in elderly population: a biopsy survey using 2250 histopathological records. The Gerodontology Association and

Blackwell Munksgaard Ltd, Gerodontology 2006;

23: 48–54

CONCLUSION• Importance of long term follow up

• Patient counseling and compliance

• Minimize the risk of deleterious and debilitating effects due to dentures

CRITIQUE• Repetitive with random and unorganized style of writing

• Replica of an earlier study done by the same authors, without a specified purpose

• Devoid of clinical differentiating factors (e.g. candidiasis and denture sore mouth)

• Lack of association between the lesions and systemic conditions or xerostomic drugs is questionable

• Association with allergies, nutritional deficiencies and atrophy of masticatory muscles not evaluated

REFERENCES• Correa L. et al. Oral lesions in elderly population: a biopsy survey using

2250 histopathological records. The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2006; 23: 48–54

• Coelho CM, Sousa YT, Dare AM. Denture-related oral mucosal lesions in a Brazilian school of dentistry. J Oral Rehabil 2004; 31: 135–139.

• Cawson.R.A, Odell E.W. Diseases of Oral Mucosa: Introduction and Mucosal Infections In: Essentials of Oral Pathology and Oral Medicine, Edition 7. Spain 2002.

• Regezi J.A, Sciubba J.J, Jordan R.C. White Lesions Id. Oral Pathology: Clinical Pathologic Corelations. 4th Ed Saunders, St Louis, Missourie, 2003.

• Neville B.W, Damm D.D, Allen C.M, Bouqouot J.E. Physical and Chemical Injuries In. Oral and Maxillofacial Pathology. 2nd Ed W.B. Saunder’s Company, USA 2002

• Shafer, Hine, Levy. Physical and Chemical Injuries of Oral Cavity In. Rajendran R., Sivapathasundharam B. ed. Shafer’s Textbook of Oral Pathology. 7th Ed; Elsiever New Delhi, India 2012

Thank You

oral mucosal lesions in denture wearers

Health & Medicine