Trouble Shooting Complete

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Trouble Shooting Complete Removable Partial
Dentures

• Robert W. Loney, DMD, MS
• Professor Director
• Graduate Prosthodontics
• Faculty of Dentistry, Dalhousie University

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The Gunshot Approach

• If it hurts - GRIND
• If its loose - RELINE

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Problem for Albert Einstein

• Avert Imminent World Disaster
• Time Constraint One Hour
• His solution
• 55 minutes identifying problem
• 5 minutes fixing the problem

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Lesson

• Spend more time thinking, less time grinding

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Five Principles For Troubleshooting

• Establish differential diagnosis
• Identify variations from normal
• Have patient demonstrate problems
• Always use indicating medium when adjusting
• Have patient rate improvement after adjustment

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Principal 1Establish a Differential Diagnosis

• Form a list of possible causes
• Try to prove problem is not caused by X by
  eliminating possible causes
• Expect resolution within 10-14 days
• If no resolution, eliminate something else

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Principle 1 Differential Diagnosis

• Prioritize from common to rare
• Eliminate common etiologies first, because

Common things occur commonly Rare entities occur
rarely
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Differential DiagnosisCD or RPD Pain
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Principles of Diagnosis

• Dont limit list too early in diagnosis
• Keep an open mind
• Revisit possible causes when contradictory
  evidence is found

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Information Gathering

• Chief Complaint
• History of C.C.
• History
• Medical
• Dental
• Clinical Exam

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Dental and Medical History

• Often inadequately investigated
• Spend more time talking to narrow possibilities

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Gathering Information

• Ask open ended questions
• How does that feel?
• Not
• Does that feel better?

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History of Chief Complaint Where?

• Have patient point to problem
• Partially ignore patients position
• Dentist locate with stick, instrument or paste

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History of Chief Complaint When?

• Chewing only - Occlusion
• Gets worse throughout day - Occlusion
• When first insert dentures - Denture Base

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History of Chief Complaint Details

• How long?
• does it last?
• since it began?
• Anything make it better/worse?

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Principle 2 Identify Variations from Normal
Tissues Dentures
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Loose Denture
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Dealing with Variations From Normal

• If denture alone is not normal - correct
• If anatomy/patient not normal, vary method to
  address variation

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Principle 3 Have Patient Demonstrate Problem

• Eliminate cause - should resolve in 10-14 days

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Principle 4 Always Use Indicating Media

• Never adjust without locating exact position of
  the problem
• Use paste, indelible stick, or articulating paper

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Principle 5 Rate Improvement

• After adjustment
• Ask patient to rate improvement
• 0-100

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Denture PainCD RPD

• Occlusion
• Denture base (fit contour)
• Vertical dimension
• Infection
• Systemic disease/condition
• Allergy (rare)

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Most Overlooked Problem

• Occlusion
• Dont want the problem to be occlusion - so we
  look for other causes

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Occlusion

• Takes time to remount (prep time)
• Reduces adjustment time
• Net savings of time

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Pain OcclusionDiagnostic Strategies

• Eliminate as potential cause
• Remount denture on an articulator
• Centric relation protrusive records
• Mark centric and excursive contacts, adjust

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Dont Adjust Occlusion Intraorally

• Contact on inclines can cause denture movement
• May cause pain, or reflex avoidance
• May make interference difficult to mark

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Adjusting Occlusion Intra-Orally

• Net Result
• Cant see real Problem
• Cant eliminate the Problem

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Adjusting Occlusion

• Use an articulator
• Eliminates denture movement
• Can visualize interferences easily
• Saves time removing replacing dentures

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Pain OcclusionDental History

• Only when chewing
• Gets worse with chewing
• Gets worse during the day
• May have to remove late in the day

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Pain OcclusionClinical Exam

• Patient demonstrates problem by biting where pain
  occurs

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Pain OcclusionClinical Exam

• Occlusal contact not centered over ridge
• Tilting forces cause displacement, abrasion,
  ulceration
• Worse if xerostomia, malnourished, debilitated
  or poor adaptability

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Pain OcclusionAvoid Contact on Inclines

• No teeth set over ascending portion of ramus

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Occlusal Point of Loading

• Browning, JPD 1986
• Removable partial dentures
• Loaded centrally, M, D, L, B
• B caused unseating
• Central loading better than distal loading

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Clinically

• Drop 2nd premolar if necessary
• Ensures posterior contacts not too distant
• Avoids ascending portion of ridge
• Ensures adequate occlusal table (maintains 2
  molars)

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Clinically

• Place load over the mandibular ridge

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Pain OcclusionAvoid Contact on Inclines

• No contact on inclines of denture bases

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Pain OcclusionClinical Exam

• Severe Curve of Spee

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Pain OcclusionClinical Exam

• Minimal overjet (horizontal) of anterior and/or
  posterior teeth

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Pain OcclusionClinical Exam

• Severe disclusion of posterior teeth in
  excursions (lack of balance)

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Avoid Setting Teeth in Tongue Space

• Tongue

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Denture PainCD RPD

• Occlusion
• Denture base (fit contour)
• Vertical dimension
• Infection
• Systemic disease/condition
• Allergy (rare)

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Pain Denture BaseDental History

• Problem starts in AM
• tight, sore
• Discomfort when not chewing
• Often not progressive through day

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Pain Denture BaseClinical Exam

• Discrete area of inflammation or ulceration
• Similar to appearance of occlusal problems

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Pain Denture BaseIndicating Pastes

• Place paste with coarse brush - leave streaks
• Mostly colour of the indicating paste
• Press FIRMLY over first molar - dont fulcrum

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Pain Denture BaseIndicating Pastes

• Burnthrough excessive pressure
• No streaks proper contact
• Streaks lack of tissue contact

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Pressure Pastes Other Areas
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Pressure Pastes Goal Relatively Even, Minimal
Streaks
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Avoid Impinging on the Mylohyoid Ridge
X-section through Mandibular ridge in 2nd Molar
region
Buccal

• A problem if prominent or sharp

Mylohyoid Ridge
Attachments To Hyoid
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Pain Denture BaseClinical Exam

• Indelible sticks show position but not degree
  of problem
• Use in immediate denture (paste in sockets)

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Pain Denture BaseClinical Exam

• Expect some burnthrough close to undercuts
• Denture should seat easily, otherwise adjust
  undercut

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Pain Denture Base Retromylohyoid Overextension

• Sore throat
• Denture moves when swallow
• From retromolar pad, flange should go straight
  down or angle forward, never backward

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Pain Denture Base Severe Tissue Undercuts

• If the ridge is severely undercut, the flange
  cannot be placed to the depth of the vestibule,
  otherwise the denture will not seat or ulceration
  will occur

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Pain Denture Base

• Hamular Notches
• Commonly sharp flange
• Sometimes long
• Use PIP

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Pain Denture Base

• Labial frenum
• Should be thin and deep, not broad
• Round internal and external angles

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Denture PainCD RPD

• Occlusion
• Denture base (fit contour)
• Vertical dimension
• Infection
• Systemic disease/condition
• Allergy (rare)

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Denture PainOcclusal Vertical Dimension (OVD)

• Excessive OVD
• Sore over entire ridge
• Gets worse during day
• Muscle/joint pain
• Dentures click
• Esthetic complaints too full

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Denture PainOcclusal Vertical Dimension (OVD)

• Insufficient OVD
• lack of chewing power
• minimal ridge discomfort
• angular chelitis
• esthetic complaints
• chin prominent
• poor lip support

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Denture PainOcclusal Vertical Dimension (OVD)

• Solution
• Check physiologic rest postion and phonetics
  carefully to confirm
• Provide time to ensure no adaptation
• Reset teeth as adjustment alone usually not
  possible

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Denture PainCD RPD

• Occlusion
• Denture base (fit contour)
• Vertical dimension
• Infection
• Systemic disease/condition
• Allergy (rare)

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Denture PainInfection

• Poor denture hygiene
• Localized (lack of tissue contact)
• Generalized

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Denture PainInfection Localized

• Porous denture surface
• Palatal relief chamber
• Voids from chairside relines
• If denture cleanser not rinsed, also get
  inflammation

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Denture PainInfection Generalized

• Patient debilitated
• diabetes, leukemia, AIDS, etc.
• Drugs
• chemotherapy, steroids, antibiotics
• Poor nutrition
• Xerostomia
• drug/radiation induced
• systemic condition (Sjogrens)

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Denture PainInfection Generalized

• Denture Stomatitis (Denture Sore Mouth)
• Usually Candida albicans
• Bright red, often no white plaques
• Usually maxilla
• Generalized pain

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Denture StomatitisTreatment

• 1. Remove source of infection
• Tissue rest
• Remove surface acrylic, soft reline
• Reline frequently
• Clean with
• 2 Sodium Hypochlorite

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Candidal Infections

• Remove gross calculus or debris (scalers, lathe
  wheel)
• Clean denture in ultrasonic
• Soak in sodium hypochlorite redness disappears

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Denture StomatitisTreatment

• 2. Eliminate infection from tissues
• Fluconazole 100mg
• 200mg on 1st day then 100mg, once a day
• minimum of 2 weeks to prevent relapse
• Topical Nystatin ointment (less effective)
• Nyaderm (15, 30 g tubes , 454g jar)
• Apply 1-4 x per day
• Oral suspension
• Nyaderm (24, 48 ml bottle)

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Denture StomatitisTreatment

• Sometimes very persistant
• May need to change drug
• May need to use systemic medication

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Denture PainInfection Generalized

• Before Medicating
• Improve hygiene
• Consult present medications
• Address nutrition

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Nutrition

• Quantity and quality of food
• Comfort important for mastication
• Neuromuscular control to chew
• Patient able to use cutlery

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Nutrition

• Saliva important for taste
• Vit C deficiency common
• Bleeding (ulcers, hemorrhoids) causes loss of
  iron, protein

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Drug Induced Xerostomia

• Antiarrhythmics, Anticonvulsants,
  Antidepressants, Antihistamines, Diuretics,
  Hypotensives, Muscle Relaxants, Narcotics and
  others
• Health history is important

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Importance of Saliva

• Retention
• Lubrication
• Removal of debris
• Anti-bacterial, -fungal, -viral
• Taste digestion

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Burning Mouth Syndrome

• Burning mouth (palate)
• Burning tongue, lips
• No clear cut cause
• No uniformly successful tx

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Burning Mouth Syndrome

• Bacterial or fungal infection
• Strep., Staph., C. albicans
• Xerostomia, dysgeusia (taste)
• Nutrition (Vit B complex, iron)
• Anemias

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Burning Mouth Syndrome

• Neurologic or psychogenic problems
• Diabetes
• Hormonal
• Mechanical trauma / other
• Altered amount and makeup of saliva
• Increased IgM IgG
• Disturbed perception due to altered ionic
  composition
• (Herschkovich Nagler, 2004)

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Burning Mouth SyndromeTreatment

• Try to eliminate potential causes
• Cultures, nuitrition counselling, medications
• Offer no great optimism or easy solution

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Burning Mouth Syndrome Treatment

• Patient may have to live with problem
• Dont give up too soon - refer widely
• If problem solved, grateful patient

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Denture PainCD RPD

• Occlusion
• Denture base (fit contour)
• Vertical dimension
• Infection
• Systemic disease/condition
• Allergy (rare)

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Systemic Disease or Condition

• Comfort/Retention
• Diabetes, Ectodermal Dysplasia, Sjogrens
  Syndrome, Neoplasm, Vesiculo-Bullous Diseases,
  STD,etc.
• Coordination
• Stroke, Muscle or Neurologic Disorders

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Denture PainCD RPD

• Occlusion
• Denture base (fit contour)
• Vertical dimension
• Infection
• Systemic disease/condition
• Allergy (rare)

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Denture Base Allergies

• Extremely rare
• Generalized reaction, wherever base touches
  tissues
• Usually reaction to free monomer leaching out
• Patch test, as last resort

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Denture Base Allergies

• Use porcelain teeth
• Other material for base
• Triad - Urethane dimethacrylate
• Non-Nickel containing framework alloy