Mohamed Hania  Introduction

 Oral & Dental Complications of RPDs

 Literature Review

 Discussion

 Conclusions

 Definition :- Removable partial (RPDs) are dental prostheses that replace one or more missing teeth but not all They receive support and retention from underlying tissues and from some, if not all, of the remaining teeth They can be removed by the patient from the oral cavity  Must have adequate support, retention, and stability  Used to restore function, , aesthetics and phonetics

 RPDs are classified according to the material which they are made  The types of RPD include Acrylic resin and Chrome- Cobalt Chrome-Cobalt Acrylic Advantages Disadvantages Advantages Disadvantages Smaller design , less Cheaper than Expensive Least comfortable bulky chrome-cobalt Difficulty in altering Require more muscle Good retention denture after made – Easy to make control cannot be relined Better masticatory Tooth preparation Can alter denture Tend to break more performance , needed design after made easily Metal components Can be used for More hygienic Least comfortable may be visible immediate dentures Fractured Better conduction of Can be transitional restorations will Less hygienic temperature denture effect fit of denture More comfortable for More difficulty in Can be relined for Less stable patient making denture better fit Zitzmann 2007  The use of RPDs in Europe varies between 13% and 29.3%

Whealton 2007  More teeth are retained in elderly population due changes in attitudes and advancements in preventative  In the Republic of Ireland the rate of edentulism of 65+ year olds has decreased from 72% in 1968 to 40.9% in 2007

Age Groups Average number Of Teeth Present In 2007 16 – 24 year olds 28.2 25 – 54 year olds 25.5 64 + year olds 14.3 Decrease in the level of Increasing elderly population edentulism

Results in an increasing number of partially edentulous patients seeking RPDs

 Given the high percentage of RPD use, it is important to note that the use of this prosthesis is associated with several dental and oral complications.

1. Deterioration in oral hygiene 2. Increased levels of plaque and 3. Increased risk of caries in abutment and non-abutment teeth 4. Clinical attachment loss in abutment and non-abutment teeth 5. The risk of teeth overeruption in the opposing arch 6. Changes in oral microflora 7. Denture 8. Traumatic ulceration 9. Denture granuloma

 These complications depend on the type of RPD used, the number and position of missing teeth  These complications are a result of poor design and/or maintenance of RPD itself

Carlsson 1976  Good oral hygiene is directly related to positive treatment outcomes

Chandler 1984  No direct evidence between RPD wearing and oral and dental breakdown

Wagner 2000 et al:  Most common complication – Poor Oral hygiene  64% of dentures had poor hygiene  Considerable difference between the levels of calculus on acrylic surfaces and metal surfaces, 36% vs 14% respectively

De Souza 2009 – Cochrane Review  Failed to identify the most effective method of maintaining denture hygiene

Author(S) , Year Design of Study Sample Size Control Results  Majority of patients need treatment for caries, periodontitis and other Carlsson, GE, 1976 13 year retrospective study 58 patients No control prosthodontic treatment  Good oral hygiene is directly related to positive treatment outcomes  RPD wearing resulted in no difference in the levels of caries, probing depths, tooth mobility and bone loss when compared to non RPD wearers. 8- to 9-year retrospective  RPDs caused increased levels of Chandler, JA, 1984 38 patients Non-RPD 9wearers study gingival inflammation in areas that were covered and in the gingivae apical to clasp arms.  No direct evidence between RPD wearing and oral and dental breakdown.  Several abutment teeth supporting an RPD had better Retrospective study success rate Wagner B, 2000 10 years after provision of 74 patients No control  Non – Clasp retained RPDs had a RPDs higher failure rate (66.7%) than Clasp Retained Partial Denture (44.8%)

 Cochrane review Six RCTs could not be compared De Souza, RF et al, 2009 Randomized controlled trials N/A N/A due to wide range of variables and different interventions. (RCTs) Bergman et al 1977,1982  RPDs that are carefully designed and accompanied with good oral hygiene and regular follow ups, caused little deterioration in periodontal health  Issues with occlusion, mastication, stability and clasp retention

Yusuf 1989  The frequency and severity of the complications tended to increase with increasing age of the RPDs

Kearn 2001  Disproportionately more number of abutment teeth being lost compared to non- abutment teeth (26.4% vs 14.2% respectively)  Recommended Maintenance regime

Zlataric et al 2002  Natural abutment teeth had the highest levels of plaque(PI) and gingivitis(GI) similar levels to surveyed crowns on abutments  Mobility(TM) of abutment teeth was grade one in 50% of cases.  Non abutment performed better for levels of PI, GI and TM but had significantly more gingival recession  Recommended Maintenance regime

Author, Year Design of Study Sample size Control Results

 RPDs did not result in the deterioration of the periodontal status of the remaining teeth.  Low number of new caries lesion was Bergman , 1977 6-year retrospective study 28 patients No control observed.  Deterioration was found of occlusion, articulation, stability and clasp retention of RPDs in the long term.  RPDs did not result in the deterioration of the periodontal status of the remaining teeth.  Low increase in the number of decayed and Bergman, 1982 10-year longitudinal study 27 patients No control filled tooth surfaces was found.  Deterioration of the RPD required corrective prosthetic procedures.  The wearing of RPDs resulted in higher levels Plaque, Gingivitis compared to the controls. Teeth in the opposing  Older dentures caused more plaque retention Yusuf, Z, 1989 Retrospective study 18 patients arch not opposed to any and gingivitis. prosthesis  Poor Hygiene while wearing dentures resulted in a negative impact on the periodontium.  RPDs caused an increase in probing depths and tooth mobility.  The abutment teeth of the non-clasp retained Retrospective study Kern, M, 2001 74 patients No control RPDs suffered more deterioration than the 10 year study abutment teeth of the clasp retained RPDs.  Lack of maintenance regime may have caused these complications.  RPDs caused an increase in probing depths and tooth mobility.  There was substantial difference in the levels Plaque, Gingivitis, Calculus, Tooth mobility, Probing Depths and Gingival recession Zlatarić, DK, 2002 Retrospective study 205 patients No control between abutment and non-abutment teeth.  Good design and oral hygiene are needed to minimise the negative impact of RPD on the periodontium.

Budtz-Jorgensen 1990  Caries detected at six times the frequency in RPD wearing than patients who were provided with cantilever resin bonded bridges

Jepson (RCT) 2001  RPD wearers had nearly five times more caries lesions when compared to those with fixed prostheses

Steele 1997 & Nevalainen 2004  Increased susceptibility to root caries

Author, Year Design of Study Sample Size Control Results

 Bigger increase in the levels of new and recurrent caries lesions Randomised control trial Cantilever resin bonded Jepson, NJ, 2001 60 patients in patients wearing RPDs than 2 years bridges (RBBs) patients provided with cantilever RBBs.  Caries was 6 times more likely in patients with RPD than patients with FPD.  Occlusion and function Fixed partial denture opposing Budtz-jorgensen, 1990 A 5 year longitudinal study 53 patients deteriorated in the RPD patients complete upper denture only.  RPD patients needed more follow-upprosthodontic treatment than FPD patients.  RPD patients had higher levels of salivary microbes and higher Nevalainen, MJ, 2004 5 year follow-up study 113 patients No control root caries incidence than those with natural teeth.

 RPDs increased the risk of having root caries. Control is previous disease  RPDs use should precipitate Steele J.G 1997 Cross sectional study 1228 patients history additional steps to prevent root caries. Kiliardis 2000 & Craddock 2004  Overeruption of molars with no opposing dentition occurred in 82% to 83% of cases

Matsuda 2014  Overeruption can occur in 38.1% of cases in patients provided with RPDs, 57.1% in unopposed teeth, and 4.1% in teeth opposed by natural dentition  This may be due to wearing of the artificial teeth and/or the displacement of denture by residual ridge resorption  Which can be minimized by having regular relining and/or replacement of artificial teeth i.e. maintenance regimes

John MT 2004  Provision of fixed partial dentures, RPDs, and complete dentures  He found there was an improvement in quality of life in all patients  The provision of fixed partial dentures resulted in the greatest improvement in the patient’s quality of life Aleem 2009 & Jepson 1995  Observed that just replacing RPDs will have a positive effect on patient’s quality of life  Patient acceptance and satisfaction with RPDs was still poor Baxter 1984 & Krall 1998  Found that there was either little or no relationship between fully dentate patients and patients with RPDs on nutrition  Factors such as financial and socioeconomic status were more likely to be a significant factor on nutrition Shinkai 2001  RPDs had poorer masticatory performance, compared with fully dentate patients  Nutritional intake did not differ

Nordlund 2009  Streptococcus Mutans and Lactobacilli are the microorganisms responsible for the caries process Beighton 1990 & Tanka 2009  They are found in higher levels in patients wearing RPDs than in patients with fixed prostheses & natural dentition  Candida Albican was detected to be three times higher in RPD wearers Mihalow 1998  Levels of Strep Mutans increased within 4-6 months of RPD wearing Preshaw 2011  -causing pathogens were found to be in insignificant levels in RPD wearing patients compared to non-RPD wearing patients

Sample Control Results Author, Year Design of Study Size  Missing teeth and the presence of RPDs are predictors of nutrition. Prospective 1,231  Preventative measures and Replacement of missing Krall 1998 No control observational study patients teeth help people maintain a healthy diet and reduce risk of diet related chronic disease.

 Masticatory factors are not indicative of diet quality Shinkai, RS, 2001 Cross-sectional study 731 patients No control across all socio-demographic groups.

 18% of molars did not overerupt.  Less than 2mm of overeruption in molars occurred in 58% of cases.  24% of molars showed signs of moderate to severe Retrospective study of Kiliardis 2005 53 patients No control overeruption. 10 years  Molars are less likely to overerupt in older age of patients when their antagonist is lost.  Maxillary molars are more likely to rotate.  Mandibular molars are more likely to tip.  RPD increase Lactobacillus numbers and more cariogenic than FPD. Tanaka, J, 2009 Longitudinal 3-year. 22 patients No control  RPD may cause increased risk of caries when compared to FPD.  Overeruption was observed in 38.1% of teeth opposed by RPDs. Control is unrestored  Overeruption was observed in 4.1% of teeth opposed by Matsuda, 2014. Retrospective study 33 patients opposing dentition natural teeth.  Overeruption was observed 57.1% of teeth that were unopposed. Definition :- Denture stomatitis is defined as an inflammation of the denture bearing mucosa caused by microbial plaque composed of bacteria and/or candida species  Candida involvement in 90% of cases  It is caused by night-time denture wearing and poor denture hygiene  It affects older dentures more

 Traumatic ulcers which are a break in the lining of epithelium caused by mechanical injury to the mucosa by RPDs

 Chronic irritation by a denture can result in a condition called denture granuloma  benign hyperplasia of fibrous connective tissue and is most commonly found in the sulci where the denture is overextended

 It is clear from the research of the literature that well-designed, randomised controlled studies with large sample size is lacking  It is difficult to extrapolate valuable conclusions regarding RPD complications, as the baselines of the patient’s oral health have not been established and poor level of evidence in the literature  It can be reasonable to assume that some oral and dental complications can be a result of certain risk factors (poor oral hygiene and diet, untreated periodontal disease etc) of patients remaining following prosthodontic treatment  RPDs alone is not a major risk factor  Nonetheless complications of RPDs are extensive and real.  The design of the RPD is very critical in maintaining periodontal health and a need for a maintenance regime Kratochvil, 1963  In distal extensions RPDs – RPI system Kapur (RCT) 1994  I Bars vs Occlusally approaching clasps McHenry 1992  Lingual bars causes significantly less gingival inflammation than lingual plates Zlataric 2002  RPDs should be located as far away from the gingival margin as possible to prevent gingival trauma and inflammation.

Every effort should be made to retain posterior teeth for the distal extensions The options of implant supported dentures or the use of attachments should be explored

 The oral and dental complications of RPDs are extensive and can be severe but that should NOT preclude them as a treatment modality

 The complications that are widely known can be minimised if not eliminated with careful design, beginning at mounted study cast stage and a regular maintenance regime following delivery of prosthesis

 RPDs are still an effective treatment modality , have a major role in replacing missing teeth which can restore function, occlusion, aesthetics and phonetics  Shinkai, RS, 2001. Oral function and diet quality in a community based sample, Journal of Dental Research 80:1625-1630  Nordlund, A, 2009. Improved ability of biological and previous caries multimarkers to predict caries disease as revealed by multivariate PLS modelling , Biomed Central Oral Health 9,28  Tanaka, J, 2009. Longitudinal research on the oral cavity of elderly wearing fixed or removable prostheses , Journal of Prosthodontic Research 53:83-8  Beighton, D, 1990. Associations between salivary levels of mutans streptococci ,lactobacilli , yeasts and black pigmented bacteroids spp and dental variables in elderly patients, Archives of Oral Biology 35, 173s-175s  Milhalow, DM, 1988. The influence of removable partial dentures on the level of strep mutans in saliva, Journal of Prosthetic Dentistry, 59, 49-51.  Preshaw, P.M, 2011. Association of removable partial denture use with oral and systemic health, Journal of Dentistry, 08, 18  Tanaka, J, 2009. Longitudinal research on the oral cavity of elderly wearing fixed or removable prostheses, Journal of Prosthodontic Research 53:83-8  Jean B, 2003. Reassessing the presence of Candida albicans in denture related stomatitis . Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics 95: 1  Scully, C, 2008. Oral and maxillofacial medicine: the basis of diagnosis and treatment. 2nd ed. Edinburgh: Churchill Livingstone.  Tyldesley, AF, 2003. Tyldesleys's Oral Medicine. 5th ed. Oxford: Oxford University Press.  Newton, A.V 1962. Denture sore mouth. British Dental Journal 112:357-60,  Neville, BW, 2002. Oral &Maxillofacial pathology. 2nd ed. Philadelphia: W.B. Saunders.

 Chandler, JA, 1984. Clinical evaluation of patients 8 to 9 years after placement of removable partial denture Journal of Prosthetic Dentistry 51;736-43  Zlatarić, DK, 2002. The effect of removable partial dentures on periodontal health of abutment and non-abutment teeth Journal of Periodontology 73(2): 137-144  Yusuf, Z, 1989. Periodontal status of teeth in contact with denture in removable partial denture wearers Journal of Oral Rehabilitation 16:119-26  Kern, M, 2001. Periodontal findings in patients 10 years after insertion of removable partial dentures Journal of Oral Rehabilitation 28:991-997  Kratochvil, f, 1963. Influence of occlusal rest position and clasp design on movement of abutment teeth Journal of Prosthetic Dentistry 13,114-124  Kratochvil, f, 1963. Influence of occlusal rest position and clasp design on movement of abutment teeth Journal of Prosthetic Dentistry 13,114-124  Kapur, KK, 1994. A randomized clinical trial of two basic removable partial denture designs Part 1 comparisons of five-year success rates and periodontal health Journal of Prosthetic Dentistry 72:268-282  McHenry, 1992. The effect of removable partial denture framework design on gingival inflammation a clinical model Journal of Prosthetic Dentistry 68:799-803  Zlatarić, DK, 2002.The effect of removable partial dentures on periodontal health of abutment and non-abutment teeth Journal of Periodontology 73(2): 137-144  Dinh X. Bui. Removable Partial Denture and its Effects on Periodontal Health. [ONLINE] Available at: http://www.drbui.com/artrpd.html.  Budtz-jorgensen, 1998. Alternate frame work designs for removable partial dentures , Journal of Prosthetic Dentistry 80:58-66  Jepson, NJ, 2001. Caries incidence following restoration of shortened lower dental arch in randomised controlled trial British Dental Journal 191:140- 144  Budtz-jorgensen, 1990. A 5 year longitudinal study of cantilevered fixed partial dentures compared with removable partial dentures in a geriatric population, Journal of Prosthetic Dentistry 64:42-47  Nevalainen, MJ, 2004. A 5 year follow-up study on the prosthetic rehabilitation of the elderly in Finland, Journal of Oral Rehabilitation 31;647-653  Steele, JG, 1997. Partial denture as an independent indicator of root caries risk in group of older adults ,Gerodontology 14:67-74  Carlsson, GE, 2005. Tooth movement, British Dental Journal 198:420-421 ,  Kiliaridis, 2000. Vertical position , rotation and tipping of molars without antagonists, International Journal of Prosthodontics 13:480-486  Craddock, HL, A study of the incidence of over eruption and occlusal interferences in unopposed posterior teeth British Dental journal 196:341-348  Matsuda, 2014. Over eruption of teeth opposing removable partial denture : a preliminary study, International Journal of Prosthodontics 27:475-476  John, MT, Oral health-related quality of life in patients treated with fixed , removable and complete dentures , International Journal of Prosthodontics 17:503-511  John, MT, Oral health-related quality of life in patients treated with fixed , removable and complete dentures , International Journal of Prosthodontics 17:503-511  Aleen, PF, 2009. Determining the minimally important difference for the oral health impact profile, European Journal of Oral Science 117:129-34  Jepson, NJ, 1995.The influence of denture design on patient acceptance of partial dentures, British dental journal 178:296-300  Makila, 1969. Effects of complete dentures on dietary intake and serum levels of pantothenic acid , folic acid and iron in edentulous person, Suomen Hammaslaakariseuran Toimitukisia 65:299-311  Baxter, JC, 1984. The nutritional intake of geriatric patients with varied dentitions , Journal of Prosthetic Dentistry 51:164-168  Krall, E, 1998. How dentition status and masticatory function affect nutrient intake , Journal of the American Dental Association 129:1261-1269

 Carr, AC, 2005. McCracken’s Removable Partial Prosthodontics. 5th ed. St. Louis, Missouri: Elsevier Mosby  Carr, AC, 2005. McCracken’s Removable Partial Prosthodontics. 5th ed. St. Louis, Missouri: Elsevier Mosby  Zitzmann, NU, 2007. What is the prevalence of various types of prosthetic dental restorations in Europe?, Clinical Oral Implants Research 18:20-33  Preshaw, P.M, 2011. Association of removable partial denture use with oral and systemic health. Journal of Dentistry, 08, 18  Whelton, H. A Ten year longitudinal study: Oral health of Irish adults 2000-02. Department of Health and Children. Brinswick Press LTD. Final report ,April 2007  Whelton, H. A Ten year longitudinal study: Oral health of Irish adults 2000-02. Department of Health and Children. Brinswick Press LTD. Final report ,April 2007  Whelton, H. A Ten year longitudinal study: Oral health of Irish adults 2000-02. Department of Health and Children. Brinswick Press LTD. Final report ,April 2007  Vaupel, JW, 2010. Bio demography of human ageing. Nature, 464  Douglas, CW, 1988. Need and effective demand for prosthodontic treatment. Journal of Prosthetic Dentistry, 59, 94-104  Carr, AC, 2005. McCracken’s Removable Partial Prosthodontics. 5th ed. St. Louis, Missouri: Elsevier Mosby  Carr, AC, 2005. McCracken’s Removable Partial Prosthodontics. 5th ed. St. Louis, Missouri: Elsevier Mosby  Preshaw, P.M, 2011. Association of removable partial denture use with oral and systemic health. Journal of Dentistry, 08, 18  Wagner B, 2000. Clinical evaluation of Removable partial denture 10 years after insertion Clinical Oral Investigations 4:74-80  Wagner B, 2000. Clinical evaluation of Removable partial denture 10 years after insertion Clinical Oral Investigations 4:74-80  De Souza, RF et al, 2009. Intervention for cleaning dentures for adults (Cochrane review) CD007395  Carlsson, GE, 1976. Late results of treatment with removable partial denture Journal of Oral Rehabilitation 3,267-272  Wagner, B, 2000. Clinical evaluation of Removable partial denture 10 years after insertion, Clinical Oral Investigations 4:74-80  Kratochvil, f, 1963. Influence of occlusal rest position and clasp design on movement of abutment teeth, Journal of Prosthetic Dentistry 13,114-124  Chandler, JA, 1984. Clinical evaluation of patients 8 to 9 years after placement of removable partial denture , Journal of Prosthetic Dentistry 51;736-43  Bergman,B ,1982.Caries, periodontal and prosthetic findings in patients with removable partial dentures , Journal of Prosthetic Dentistry 48,506-514  Bergman B, 1977.Caries and periodontal status in patients fitted with removable partial dentures. 4,132-146  Bergman,B ,1982.Caries, periodontal and prosthetic findings in patients with removable partial dentures: a ten-year longitudinal study, Journal of Prosthetic Dentistry 48,506-51