Addressing The Needs Of Denture Patients
It's not a particularly comfortable subject of conversation for patients, but focusing on their needs may alleviate future problems in the oral cavity.
by Margaret J. Fehrenbach, RDH, MS
Denture care is often an embarrassing topic of conversation for patients. Dentures are very personal, and many patients still feel guilt from having lost their teeth — even if it was many years ago and could not be prevented.
With the emphasis on the latest technology of restorative treatment, such as implants, care for patients with dentures may be lost in the shuffle. Dental professionals need to be proactive in understanding the emotional and psychological aspects patients experience with dentures. As the population ages, the number of denture-wearing patients is growing.
Many of us have seen the dramatic complications that can occur when our patients do not properly care for their dentures1. It could mean increased dental caries and periodontal disease due to the associated amounts of damaging deposits, as well as halitosis. Those deposits when stained also could mean an overall loss of oral esthetics and increased risk of poor fit. A clean denture will look better and provide the patient with an overall cleaner oral cavity, and help prevent tissue infection or irritation.
During the patient appointment, the dental staff can safely remove stubborn stains and calculus. For proper asepsis and to avoid denture damage, the denture should not be placed directly in the ultrasonic machine but in a zipper-lock plastic bag with a selected cleaning solution to avoid contamination with the ultrasonic solution. Most manufacturers make a solution that is designated for stain and calculus removal for dentures in the ultrasonic machines2.
Follow the manufacturer's directions carefully. The solution will need to be rinsed thoroughly and remaining debris scrubbed off the denture. It is strongly recommended that you avoid the use of abrasives such as prophy paste or hand instrumentation. For dentures with excessive build-up, ultrasonic instrumentation might be necessary using a light touch.
Denture home care
Now that the dentures have been professionally cleaned and examined, it is important to educate the patients on denture care at home. Patients will still need to scrub and soak dentures daily to maintain oral cleanliness. Every surface in the oral cavity, natural or prosthetic, becomes covered within about 30 minutes with salivary pellicle, which is turn serves as a base to which oral debris (such as mucin, food particles and desquamated epithelial cells) and microorganisms (bacterial plaque and fungi) readily adhere5. This process of deposition on the denture is increased in patients who have a reduced salivary flow, possibly as a side effect of medications. Routinely, dentures are fabricated out of resin with increased surface irregularities. The potential is that this increased number of niches are not readily cleansed by the tongue or other orofacial musculature, which causes an increase in plaque and calculus buildup.
Over time, we tend to accommodate certain sensory information such as in taste and smell. One example would be the problem with putting on too much of a signature perfume. It is important to note that because of the process of accommodation that sensory receptors undergo, the person with an unclean denture could be unaware of the unpleasant smell and taste of the prosthesis6. Studies have confirmed patients' experience with some impairment in taste and smell perception of external stimuli under circumstances of poor denture care.
Denture plaque, similar to deposits on teeth, can become calcified if not removed thoroughly and regularly. The surface of the mineralized calculus provides an even more hospitable surface for further plaque attachment. More plaque can mean more risk of caries and periodontal disease, as well as increased levels of halitosis. Calculus is also readily stained by tobacco, tea, coffee, certain medications (particularly iron supplements) and numerous other ingested materials.
Using denture adhesives
During dental appointments patients ask us about denture adhesives10. Many dental professionals picture outdated products and remember outdated ideas or myths. These outdated ideas include that denture adhesive can lead to pathologic abnormalities and therefore, its use should be avoided or it will mask irreversible underlying conditions11. Denture adhesives can be used regularly with no adverse effects to the oral cavity or the denture itself12,13. Research studies have concluded that there is no evidence to support the fact that the use of soluble adhesives affects natural changes in the oral cavity.
Denture plaque, similar to deposits on teeth, can become calcified if not removed thoroughly and regularly.14 A cushioning effect occurs, acting as a protective layer, and redistributes the stress of biting and chewing over the entire denture. This allows the load of the denture to be carried throughout the denture wearing area, thus minimizing trauma and spots of localized rubbing or pressure.
Recent studies demonstrate that denture adhesives can enhance the performance of all dentures, including well-fitting dentures15,16 in terms of retention and stability due to the increased hold an adhesive provides. These studies show that adhesives offer patients the ability to bite harder without dislodgment and enjoy a wider range of foods. Studies determine this by measuring maximum biting force and rhythmic masseter muscle activity during mastication. Denture adhesives can give your patients a sense of confidence when wearing their dentures, especially in social situations. They may give the patient confidence that helps prevent food from collecting under the denture. An adhesive also can be used as a temporary support for a patient who is awaiting a new denture or needing repair. In addition, adhesives are particularly useful for patients with special needs, such as patients suffering from poor neuromuscular control or dementia. Manufacturers have enhanced denture adhesive formulations so they are available with or without flavors.
Advise patients that they need to apply the denture adhesive to a clean dry denture, keeping the cap and nozzle dry to prevent future clogging. Some adhesives have flat nozzles that allow a thinner, flatter ribbon of adhesive to cover the denture surface. It is placed in strips or dots as shown in the package insert to distribute the adhesive evenly on the tissue-bearing surface of the denture, making sure not to get too close to the flanges or edges of the denture. Recommend that your patients use the minimum amount necessary to provide the maximum benefit and apply or reapply when necessary to provide the desired effect. The latest commercial formulations react with saliva to form a tight seal17. Companies can provide the dental office with essential kits for denture wearers.
These kits contain all the necessary supplies for denture care as well as helping patients adjust successfully to their dentures.
It is important to communicate contraindications to the use of denture adhesives18,19. When the use of adhesives is contraindicated, other means of denture support must be sought out since the patient is unable to use the adhesives. Educate patients to visit their dental professional should any of these occur20:
• Ill-fitting dentures that are not being replaced
• Dentures that have not recently been evaluated by a dentist
• When oral hygiene cannot be maintained
• Long-term use without the supervision of a dentist
• Known allergies to any product ingredient
Expectations are sometimes shared with the dental hygienist. These expectations include that their denture will last forever or they will fit and function like natural teeth. Take this opportunity to discuss realistic expectations with patients to help them cope with denture use. Most patients have an unrealistic expectation — up to 85 percent — who believe their dentures will be as good as their natural teeth. Even if a denture is well-made and well-fitting, dentures can never replace the strength, mechanical action and strong occlusal surface of natural teeth.
Therefore, the function of a denture will never be equal to natural teeth, because patients only retain up to one-third of their original occlusal force. The retention of a maxillary denture is based on suction, which is dependent upon the shape of the oral cavity and the amount of saliva produced.
Dry mouth issues
For patients with dry mouth, the denture base materials seem to stick more to the dry mucous membrane of the basal seat and other oral surfaces21. Adhesion is not very effective for retaining dentures, and predisposes the patient to mucosal abrasions and ulcerations because of the lack of salivary lubrication. It is annoying to patients to have denture bases stick to the lips, cheeks, and tongue.
An ethanol-free rinse containing aloe or lanolin, or a water-soluble lubricating jelly can be helpful for patients suffering with dry mouth conditions22. The lubricating jelly can be placed in the base of the denture and allowed to be released over time. For patients whose mouths are dry due to irradiation or an autoimmune disorder such as Sjögren's syndrome, salivary stimulation through a prescription from your supervising dentist (5-10 mg of oral pilocarpine three times daily) can be very beneficial if the patient can tolerate the likely side effects of increased perspiration and (occasionally) excess lacrimation.
Continued and routine dental appointments need to be emphasized for denture wearers23. This allows the dentist to examine the fit of the denture, as well as perform further orofacial examinations. Any inflamed red areas, burning sensations, white patches or growths that the patient notices need to be brought to the attention of his dental office.
Discussion of denture care by the dental hygienist with any patient can be timely and encourage the overall health of the oral cavity.
The following are recommended denture-cleaning procedures for the entire staff to use. These steps should be carried out using proper asepsis techniques 3,4.
1. Place one denture at a time in a heavy-weight zipper-lock plastic bag. Hold and pour the selected fresh cleaning solution slowly into the bag, using a paper towel to open the bottle. Pour and cover the denture with solution. Carefully seal the plastic bag.
2. Place the bag in the ultrasonic machine, with the top of the closed bag lying over the rim. Using another paper towel on the machine's cover handle, tightly cover the machine to prevent air-borne droplet contamination.
Run the machine for 10 minutes or more, depending on the deposit level or as indicated by manufacturer specification instructions.
3. Remove the bag from the machine using paper towels to catch any drips and to hold the machine's handle cover. It is recommended that the machine cover not be placed face down on the counter. With another paper towel on the faucet handle, turn on the water over a sink lined with paper towels in case the denture is dropped accidentally. Rinse the closed plastic bag in the sink under moderately running water. Gently open the bag and remove the denture, allowing the solution to go down the drain as the water is running. Carefully dispose of the plastic bag. Return the sealed container of cleaning solution to its place for future uses.
4. Rinse the denture completely under the running water to remove the cleaning solution. Scrub any remaining debris with a cold sterilizable denture toothbrush. A nice touch is to put the cleaned denture into a paper cup with mouthwash and deliver a pleasant-tasting denture to the patient.
The following steps are educational tips that dental professionals can share with a patient when discussing cleaning their dentures.7,8,9
1. To prevent breaking the denture, recommend that the patient brush it over a towel or over sink half-filled with water. They should lightly brush dentures with a soft nylon toothbrush or recommended denture brush, possibly using a denture paste. Brushes with stiff, coarse bristles can cause wear to denture materials. Recommend that the patient massage any gingival-bearing areas for at least one minute once daily with a soft toothbrush or as directed.
2. Have the patient place the denture in a commercial cleanser overnight or for at least 30 minutes daily. A morning quick soak also can be performed. This should reduce bacterial counts (achieving a 99 percent kill rate of most organisms) and remove most stains by their effervescent compounds, detergents, oxidizing agents and enzymes. The soak also will reduce the incidence of oral infections and halitosis. After soaking, thoroughly remove all cleanser by light brushing under cold running water. Most people soak while they are in the shower to maintain privacy without their teeth. Remind patients that mouthwash is directed for oral use and not for denture cleaning.
3. To clean dentures with metal parts such as partial dentures, the patient should follow the above steps. Some new commercial products are made especially for partial dentures that contain oxidants or bleaching agents to protect metal surfaces. Recommend gently cleaning the clasp area that lays against the teeth for support.
Margaret J. Fehrenbach, RDH, MS, is an educational consultant.
1 Shay K: Denture Hygiene: A review and update. Journal of Contemporary Dental Practice 2000 Feb;(1)2: 028-041. Website accessed on August 13, 2003 at http://www.thejcdp.com/issue002/index.htm.
2 Shay K: Denture Hygiene: A review and update. Journal of Contemporary Dental Practice 2000 Feb;(1)2: 028-041. Website accessed on August 13, 2003 at http://www.thejcdp.com/issue002/index.htm.
3 Fehrenbach, MJ. Aseptic Techniques with the Ultrasonic, RDH Magazine, 1982.
4 Shay K, Grasso JE, Barrack, KS: The Complete Denture Prosthesis: Clinical and Laboratory Applications: Fabricating the Trial Denture and Insertion, Patient Adaptation, and Post-Insertion Care. Accessed on September 8, 2003 at http://www.dentalcare.com/soap/ce108pc/intro.htm and http://www.dentalcare.com/soap/ce109pc/intro.htm
5 Shay K: Denture Hygiene: A review and update. Journal of Contemporary Dental Practice 2000 Feb;(1)2: 028-041. Website accessed on August 13, 2003 at http://www.thejcdp.com/issue002/index.htm.
6 Shay K: Denture Hygiene: A review and update. Journal of Contemporary Dental Practice 2000 Feb;(1)2: 028-041. Website accessed on August 13, 2003 at http://www.thejcdp.com/issue002/index.htm.
7 Shay K: Denture Hygiene: A review and update. Journal of Contemporary Dental Practice 2000 Feb;(1)2: 028-041. Website accessed on August 13, 2003 at http://www.thejcdp.com/issue002/index.htm.
8 American Dental Hygienists Website: Senior Oral Health, accessed August 13, 2003 at http://www.adha.org/oralhealth/seniors.htm.
9 Shay K, Grasso JE, Barrack, KS: The Complete Denture Prosthesis: Clinical and Laboratory Applications: Fabricating the Trial Denture and Insertion, Patient Adaptation, and Post-Insertion Care. Accessed on September 8, 2003 at http://www.dentalcare.com/soap/ce108pc/intro.htm and http://www.dentalcare.com/soap/ce109pc/intro.htm
10 American Dental Association Website: Dentures FAQ, accessed August 14, 2003 http://www.ada.org/public/faq/dentures.html#adhesive>
11 Shay K and Astroth J: Denture Adhesives: A New Perspective, Panel Discussion, Washington, DC, June 28, 1993. Accessed on September 8, 2003 at http://www.dentalcare.com/soap/pr_forum/prostho/dent_adh/index.htm
12 Slaughter A, Katz RV, Grasso JE: Professional attitudes toward denture adhesives: A Delphi technique survey of academic prosthodontists.
J Prosthet Dent. 1999 Jul;82(1):80-9, abstract accessed on September 8,2003 at http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10384167&dopt=Abstract>
13 Shay K, Grasso JE, Barrack, KS: The Complete Denture Prosthesis: Clinical and Laboratory Applications: Fabricating the Trial Denture and Insertion, Patient Adaptation, and Post-Insertion Care. Accessed on September 8, 2003 at http://www.dentalcare.com/soap/ce108pc/intro.htm and http://www.dentalcare.com/soap/ce109pc/intro.htm
14 Shay K and Astroth J: Denture Adhesives: A New Perspective, Panel Discussion, Washington, DC, June 28, 1993. Accessed on September 8, 2003 at http://www.dentalcare.com/soap/pr_forum/prostho/dent_adh/index.htm
15 American Dental Association Website: Dentures FAQ, accessed August 14, 2003 http://www.ada.org/public/faq/dentures.html#adhesive>
16 Perez P, Kapur KK, Garrett NR: Studies of biologic parameters for denture design. Part III: Effects of occlusal adjustment, base retention, and fit on masseter muscle activity and masticatory performance.
J Prosthet Dent. 1985 Jan;53(1):69-73, accessed abstract on September 8, 2003 at http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=3882951&dopt=Abstract>
17 DentalResourceNet Website: Plaque Inhibition with Denture Adhesive Use, accessed on August 14, 2003 at http://www.dentalcare.com/soap/journals/pgresrch/posters/iadr02/pp459.htm
18 Shay K, Grasso JE, Barrack, KS: The Complete Denture Prosthesis: Clinical and Laboratory Applications, Fabricating the Trial Denture. Accessed on September 8, 2003 at http://www.dentalcare.com/soap/ce108pc/intro.htm
19 Shay K, Grasso JE, Barrack, KS: The Complete Denture Prosthesis: Clinical and Laboratory Applications: Fabricating the Trial Denture and Insertion, Patient Adaptation, and Post-Insertion Care. Accessed on September 8, 2003 at http://www.dentalcare.com/soap/ce108pc/intro.htm and http://www.dentalcare.com/soap/ce109pc/intro.htm
20 Shay K and Astroth J: Denture Adhesives: A New Perspective, Panel Discussion, Washington, DC, June 28, 1993. Accessed on September 8, 2003 at http://www.dentalcare.com/soap/pr_forum/prostho/dent_adh/index.htm
21 Shay K: Treatment of an edentulous patient with a dry mouth. Journal of Contemporary Dental Practice. 2000 Aug 15;1(3):98. Website accessed on August 13, 2003 at http://www.thejcdp.com/issue003/index.htm.
22 RDH Magazine Website: Slaking the Dryness by Frances Dean Wolfe, accessed on August 14, 2003 at http://rdh.pennnet.com/Articles/Article _Display.cfm?Section=Archives&Subsection=Display&ARTICLE_ID=110236&KEYWORD=denture>
23 American Academy of General Dentists Website: What Is A Denture?, accessed August 14, 2003 at http://www.agd.org/consumer/topics/dentures/ main.html>