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IMPACT OF MARGINAL CONTACT OF REMOVABLE

ACRYLIC PARTIAL DENTURES ON PERIODONTAL

PARAMETERS

Rasika Manori Jayasingha*

Aruni Tilakaratne**

Najith Amarasena***

Florian Mack****

Thillaiampalam Anandamoorthy**

*Teaching Hospital, Kurunegala

**Faculty of Dental Sciences

University of Peradeniya

Peradeniya, Sri Lanka

***School of Dentistry, University of Adelaide, Adelaide, Australia

**** School of Dentistry and Oral Health

Griffith University, South Port, Australia

Correspondence

Dr. R.M.Jayasingha, Consultant in Restorative Dentistry, Teaching Hospital, Kurunegala

Sri Lanka

Tel: 0094777806314 E mail: [email protected]

ABSTRACT 2

AIM to assess the periodontal parameters, plaque score, bleeding on probing, probing pocket depth, gingival recession and loss of attachment of teeth in contact with removable partial dentures and to compare them with teeth in the contra lateral side of the same arch not in contact with the acrylic resin base.

METHODS Sample consisted of 46 partially edentulous patients. Maxillary acrylic partial dentures which were designed as the gingival margin of two teeth on one side of the arch was in contact with the acrylic resin base (control side). The same teeth on contra lateral side of the arch were kept relieved from the denture base. Initial periodontal assessment with plaque score (PLS), bleeding on probing (BOP), probing pocket depth (PPD), gingival recession (GR) and loss of attachment (LOA) was carried out. All patients were periodontally assessed after denture insertions.

RESULTS Measurements for periodontal parameters were increased significantly at 3 and 6 months of denture wearing in the control side. The changes of all parameters in the test side were not significant.

CONCLUSIONS Acrylic partial dentures tend to adversely affect periodontal parameters when teeth are in contact with resin base. This effect is increased with longer duration of RPD wear.

KEY WORDS: bleeding on probing, periodontal parameters, plaque score, probing pocket depth, removable partial dentures

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INTRODUCTION significant increase in the prevalence of plaque

bacteria, gingivitis and gingival recession in

Removable partial dentures (RPDs) are and around the RPD abutment teeth, especially considered a widely accepted means of in areas within 3mm of the RPDs. 7 However, replacing missing natural teeth thereby in other studies, patients with RPDs have restoring function and aesthetics in partially reported only marginal inflammation.8,9 edentulous patients.1 Although other options are available, such as fixed prosthesis and It has been established that a critical feature implant-retained-overdentures, RPDs still play of removable prostheses is the relationship of a major role in prosthetic rehabilitation owing acrylic resin denture bases to the gingival to financial issues, patient compliance and margins of RPD abutment teeth. 10 One study residual height of edentulous ridges.2,3. In concluded that gingival areas covered by

South East Asian countries such as Sri Lanka, RPDs, without relief, show the most adverse

RPDs are still considered the main treatment periodontal reactions clinically and modality for replacement of missing teeth. histologically, uncovered the least affected.11

Another study included assessment of

Since RPDs are at least partially periodontal parameters, plaque index, gingival supported/retained by remaining natural teeth, index, probing pocket depth, gingival recession various studies have been carried out in order and mobility in relation to teeth in direct to assess their effects on periodontal health, contact with the acrylic base of prosthesis.12 especially plaque accumulation, gingival inflammation, mobility, pocket depth and bone Although there are many studies available in loss.4,5 Carlsson et al in their 4-year the literature regarding the detrimental effects longitudinal study investigated abutment teeth of RPDs on periodontal health and parameters, associated with partial dentures, found an 6,8,12-14 one included the teeth in the same arch increased incidence of gingival inflammation, as the test and controls10. Therefore, the deepened gingival pockets, mobile abutment purpose of this study was to assess the teeth, alveolar bone loss and dental caries periodontal parameters, plaque score, bleeding compared to the base line.6 Yeung et al in their on probing, probing pocket depth, gingival study of cobalt-chromium RPDs, reported a recession and loss of attachment of teeth in 4 contact with denture base of RPDs and to compare them with teeth in the opposite side Parameters were defined for the actual of the same arch not in contact with the sample in order to minimize confounding denture base. The null hypothesis for this study factors that could otherwise significantly affect is that there will be no significant differences the data and results. Patients were selected for between teeth in the same arch with contact or inclusion in the study if they met the following no contact with RPD base, subjected equally to criteria: factors contributing to retention of plaque, 1. Absence of significant medical history, i.e. bleeding on probing and loss of attachment. neither diagnosed with any medical condition

Side of the maxillary arch in contact with the nor taking any medication on a regular basis; denture base was considered as the 2. Non-smokers; experimental variable. 3. Fewer than four maxillary teeth missing;

4. Complete mandibular dentitions

METHODS

Prior to prosthetic treatment, all necessary

The initial group of the study consisted of 46 dental treatment and restorations were patients at the Department of Prosthetic completed. These included oral hygiene

Dentistry, University of Peradeniya, Sri Lanka instructions, full mouth scaling and polishing during the year of 2009. The sample size, and root surface debridement of teeth with determined with a power of 80%, was doubled probing pocket depth of 4-7 mm under local initially to allow for patients lost to follow-up anaesthesia, and surgical root surface at the end of 6 months. The group at the end of debridement of teeth with probing pocket

6 months consisted of 10 males and 12 females depths greater than 7 mm with open flap between the ages of 21 and 43 years. The mean procedures under local anaesthesia. Restorative age of the study sample was 28.3 years. treatment including correction of overhanging

Patients were educated and informed about the restorative margins, endodontic treatment and difference between both sides of the denture restorations were also carried out. base and requested to report any experience of discomfort. Written consent was obtained prior The prosthetic treatments associated with to clinical procedures. acrylic resin partial dentures were carried out

4 5 by the principal investigator to avoid inter- Initial periodontal assessments were examiner variability. Maxillary partial dentures accomplished prior to fabrication of the partial were designed in such a way that the gingival dentures. All patients were recalled at 2 week, margins of two teeth on one side of the arch 3 month and 6 month intervals after denture were in contact with the acrylic resin denture insertions. Similar readings were obtained at bases (control side). The contra lateral teeth each visit. Periodontal assessments at each had no contact with the acrylic resin denture visit were accomplished by the principal bases (test side) (6 x 10mm in bucco-lingual investigator to avoid inter-examiner variability. and mesial/distal dimensions. Therefore the Intra-examiner variability was ascertained by peripheral margins of one side (right/left) of re-examining 10% of the measurements on a the denture bases did not contact the gingival particular session. During the follow up period, margins of the teeth (e.g.: right side of the all patients were given standard maintenance denture base in the premolar region in fig.1). care with advice on plaque control according

The denture base on the contra lateral side was to the criteria for maintenance care adhered to designed to contact the gingival margins of the by the Division of Periodontology, Faculty of teeth (e.g.: left side of the denture base in fig.1 Dental Sciences. contact with premolars). Assignment of arch to test/control group was randomized prior to Plaque (PLS) and bleeding scores (BOP) patient examination. were calculated by measuring distopalatal,

All patients were educated and advised on midpalatal and mesiopalatal aspects of test and denture maintenance procedures with control teeth. The average value was demonstrations. They were advised to brush considered as a percentage of total number of the dentures and to keep them out of mouth (in teeth surfaces. The readings for pocket depths water of room temperature) every night after (PPD) and gingival recession (GR) were cleaning. Dentures were routinely evaluated in recorded on the palatal aspects of test and every visit for plaque, stains and deposits and control teeth. Three readings were made for were cleaned accordingly. The importance of each tooth i.e., mesio-palatal, mid-palatal and denture hygiene was reinforced on each visit. disto-palatal, the mean pocket depths were

considered to be the score. Probing pocket

depths were measured to the nearest millimetre 6 from the gingival margin to the base of the Variance Test was used for comparison data pocket using a periodontal probe (University related to plaque scores and bleeding scores in of Michigan “O” with William marking pre op, 2 weeks, 3 months and 6 months in diameter tip 0.5mm) placed parallel to the long test/control groups. axis of the tooth. PPD of each site was Multiple comparisons for plaque scores and bleeding scores were carried out. categorized into less than or equal to 3mm All Pair wise Multiple Comparison (≤3mm) and more than 3mm (>3mm). A Procedures were used to compare data between similar procedure was carried out for gingival baseline, 2 weeks, 3 months and 6 months within the same group (e.g.: to compare data recession (GR), except that the measurements between baseline, 2weeks, 3 months and 6 were recorded from the gingival margins to the months in plaque score test group) cemento-enamel junctions. The mean values Chi-square was used to compare data related obtained for PPD and GR of a corresponding to probing pocket depths, loss of attachment tooth were totalled to obtain the mean value for and gingival recession in test and control sides attachment loss (LOA) of a given tooth. GR of pre treatment. McNemar test was used to was considered as less than or equal to 1mm compare PPD, LOA and GR between baseline, and more than 1mm (≤1mm and >1mm). LOA 2weeks, 3 months and 6 months on test and was noted to be less than or equal to 3mm control sides. The level of significance was

(≤3mm) and more than 3mm (>3mm). p<0.05. The differences between initial values

of the test and control sides (PT-t vs. PT-c)

All study related procedures were approved were compared. by the Ethics Review Committee at the Faculty of Dental Sciences, University of Peradeniya. RESULTS

(Approval number: FDS-

RERC/2009/02/MJAYAS 1) Although 46 patients received the prosthetic

treatment, only 22 patients returned for follow

Statistics up 6 months post RPD placement. Thus, 48%

of the patients who received RPD returned for

Paired t test was used to compare data related follow-up. Baseline measures (PT) for the to plaque scores in pre op test and control. initial group and follow up group were

Two-way repeated Measures Analysis of compared; no significant difference was noted.

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The difference between PT values of test and Table 3 shows the frequency distribution of control sides for all parameters was not PPD in relation to the test and control sides. statistically significant. The percentages of sites with PPD ≤ 3mm and

≥ 3mm were clearly defined. It was 0%, 0%,

Table 1 shows the distribution of plaque 2% and 4% for the PPD >3mm for the test scores for the test and control sides at each sides for pre prosthetic treatment, 2weeks, 3 visit (pre-prosthetic treatment, 2 weeks, 3 months and 6 months recall visits, whereas months and 6 months post RPD insertion 3%, 3%, 21% and 46% for the control sides respectively). A general trend regarding an respectively during similar visits. Although 2 increase in PLS for the control sides was noted weeks recall data does not show a significant as the duration of RPD wear increased. difference in PPD more than 3mm between test

and control sides, data for 3 months and 6

The changes associated with PLS for 2 weeks months show a highly significant difference in post RPD placement were not significant. A the control side with p<0.001. statistically significant difference was found on control side between baseline values and at 3 Table 4 contains data in relation to LOA months and 6 months post RPD insertion. considering percentage of sites with less than

[53.5% (p>0.05) and 66.64% (p<0.001) at 3 or equal to 3mm and more than 3mm. They months and 56% (p>0.05) 78.77% (p<0.001) at were 0%, 0%, 2% and 6% of LOA more than

6 months respectively]. 3mm for the test side and 1%, 6%, 24% and

79% for the control side during pre prosthetic

The frequency of distribution of BOP, test treatment, and at the 2 week, 3 month and 6 versus controls, at each visit is shown in Table month recall visits respectively. The 3 and 6

2. The difference at 2 weeks’ recall was not months recall data show a significant significant. However, data for 3 months and 6 difference in LOA more than 3 mm in the months recall were 29.77% and 32.65% for the control side (p<0.001) whereas no such test sides and 40.18% and 44.15% for the significant difference was observed in the test control sides, demonstrated a statistically side. significant difference in the latter side. 8

The values for GR are shown in Table 5. The used in this study attempted to reduce values in the test side were 25%, 23%, 27% confounding factors associated with systemic and 32% for GR => 1mm for the test side and and environmental considerations such as the relevant values for the control side were smoking and the use of other prostheses. Use

46%, 55%, 66% and 82% respectively. Data of the same patient as test and control for the 3 month and 6 month recall shows a minimized the individual differences. significant increase in the percentage of sites with GR =>1mm in control side. Categorization of teeth in contact and not in

contact with RPDs is considered to be an

DISCUSSION established method to study possible effects of

denture wearing on oral health.15 Various

Although there are numerous studies in the studies have investigated the factors that might literature 4-9 regarding the relationship between be related to occurrence of plaque, calculus

RPDs and periodontal health, no papers have accumulation and gingival inflammation, been published specifically regarding the Sri changes in PPD, tooth mobility and GR on

Lankan population. Sri Lanka differs from its abutment and non abutment teeth in patients neighbouring South Asian countries due to its wearing RPDs.4, 16 medium-level socioeconomic status, availability of government based free heath Studies by Bergman, Bates & Addy, care and educational facilities. Therefore, such McHenry& Johannsen et al, and Brill & Tryde a study would also facilitate one aspect of the et al have shown that partial dentures in the cost effectiveness of education and oral health mouth increase plaque formation4, 17, 18, 19 care provided mostly free of charge by the particularly, as shown by Ghamrawy, on tooth government. surfaces in contact with the partial dentures.20

The results of this study also confirmed this by

Out of the sample of 46 patients, only 48% demonstrating significant increases in plaque remained for follow up at the end of 6 months. score on teeth in contact with denture bases 3

Other studies have also experienced similar months and 6 months post denture wearing. difficulties regarding long term follow up of Bissada et al (1974) concluded that gingival prosthetic patients.9, 12. The selection criteria areas covered by parts of RPDs without relief

8 9 demonstrated the most adverse periodontal and tooth mobility in RPD wearers.22 Yeung et reactions both clinically and histologically, al in a clinical study with cobalt-chromium whereas the uncovered areas were the least RPDs found that there were significant affected.11 The most severe gingival changes (p<0.001) increases in probing depths around were seen in areas where an acrylic resin teeth in contact with RPDs.7 Tawse-Smith, denture base covered the gingival margins. Rivillas et al compared the short term clinical

Based on the data in the present study, the effects of an experimental acrylic removable authors propose that a distance of 5 to 6 mm be appliance. Their study revealed that the side of maintained from the gingival margins for all the arch in contact with acrylic resin base

RPD components. Findings from the present showed significantly higher gingival index study support those from a 1994 study by scores and probing depth measurements during

Yusof and Isa, who reported a significant the 21 days of the study when contrasted with increase in plaque index, gingival index and the side of the arch relieved from the acrylic

LOA of teeth in contact with acrylic resin resin bases.10 After the test prosthesis was denture base of RPDs when compared with discontinued, the PPD measurements returned other teeth in the opposing arch not related to to baseline levels or better on both sides. The any prosthesis.12 authors concluded that there were potential

irritant effects of various denture base designs

Bissada, Ibrahim et al, Brill, Tryde et al and on gingival tissues.

Stipho, Murphy et al have shown that coverage of marginal gingival tissues with RPDs The results of this study are compatible with enhances gingival inflammation around the above studies that reported increased abutment teeth.11,19,21 This finding is confirmed findings regarding PPD, GR and LOA in teeth by the present study as it demonstrated an in contact with RPDs. Multiple authors have increase in BOP on the side of RPD in contact suggested simpler designs, less tissue coverage with teeth at 3 and 6 months of denture and frequent recalls for all patients. A number wearing. of clinical studies have concluded that proper

plaque control in RPD wearers depend on strict

In a 10 year retrospective study Kern & recall and optimal personal oral hygiene.23, 24, 25

Wagner reported an increase in probing depth It is suggested that a denture base kept well 10 relieved from the gingival margin with regular 3. Kapur, K. K. Veterans Administration denture and periodontal maintenance will Cooperative Dental Implant Study-- improve periodontal health in RPD wearers. comparisons between fixed partial

dentures supported by blade-vent

CONCLUSION implants and removable partial

dentures. Part IV: Comparisons of

Removable acrylic resin partial dentures tend patient satisfaction between two to adversely affect periodontal parameters treatment modalities. J Prosthet Dent when teeth are in contact with resin base. This 1991; 66(4): 517-30. effect is increased with longer duration of RPD 4. Bergman, B. Periodontal reactions wear. Therefore, it is recommended to keep the related to removable partial dentures: dentures well relieved (at least 6x10mm) from a literature review. J Prosthet Dent the gingival margin wherever possible. 1987; 58(4): 454-8.

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12 Table 1-The frequency distribution of PLS in test and control sides of denture-percentage of sites with comparison between each recall appointment –significance is tested to baseline or within baseline PT (Baseline) 2 Weeks 3Months 6 Months Test (t) side 53.77% 48.50% 53.05% 56%

*Group p P>0.05 P>0.05 P>0.05 value(test side) Control (c) side 51.50% 54.50% 66.64% 78.77%

*Group p P>0.05 P<0.001 P<0.001 value(contro l side)

#Initial p P>0.05 value

PT=Pre treatment *comparing the differences in percentages between baseline and relevant follow up appointment #comparing the difference between test and control sides at baseline

Table 2-The frequency distribution of BOP in test and control sides of denture- percentage of sites with comparison between each recall appointment PT (Base line) 2 Weeks 3 Months 6 Months Test (t) side 24.27% 26.50% 29.77% 32.65%

*Group p P>0.05 P>0.05 P>0.05 value(test side) Control(c)side 23.27% 30.91% 40.18% 44.15%

*Group p P>0.05 P<0.001 P<0.001 value(control side) #Initial p value P>0.05

PT=Pre treatment *comparing the differences in percentages between baseline and relevant follow up appointment #comparing the difference between test and control sides at baseline

Table 3-The frequency distribution of PPD in test and control sides –percentage of sites with comparison between each recall appointment PT (Base line) 3 Months 6 Months Test (t) side <=3mm >3mm <=3mm >3mm <=3mm >3mm <=3m >3mm 100% 0 100% 0 98% 2% m 4% 96%

*Group p p>0.05 P>0.05 P>0.05 value(test side)

Control (c) side <=3mm >3mm <=3mm >3mm <=3mm >3mm <=3m >3mm 97% 3% 97% 3% 79% 21% m 46% 54% *Group p P>0.05 P<0.05 P<0.001 value(control side) #Initial p P>0.05 value

PT=Pre treatment *comparing the differences in PPD between baseline and relevant follow up appointment #comparing the difference between test and control sides at baseline

Table 4-The frequency of distribution of LOA in test and control sides –percentage of sites with comparison between each recall appointment PT (Base line) 2 Weeks 3 Months 6 Months Test (t) side <=3mm >3mm <=3mm >3mm <=3mm >3m <=3mm >3mm 100% 0 100% 0 98% m 94% 6% 2%

*Group p p>0.05 p>0.05 p>0.05 value(test side) Control (c) <=3mm >3mm <=3mm >3mm <=3mm >3m <=3mm >3mm side 99% 1% 94% 6% 76% m 21% 79% 24%

*Group p p>0.05 P<0.001 P<0.001 value(contro l side) #Initial p P>0.05 value

PT=Pre treatment *comparing the differences in LOA between baseline and relevant follow up appointment #comparing the difference between test and control sides at baseline

Table 5- The frequency of distribution of GR in test and control sides –percentage of sites with comparison between each recall appointment PT (Base line) 2 3 Months 6 Months Weeks Test (t) side 0 mm =>1mm =>1mm 0 mm =>1mm 0 mm =>1mm 75% 25% 23% 73% 27% 68% 32%

*Group p p>0.05 p>0 value(test .05 side) Control (c) side 0 mm =>1mm =>1mm 0 mm =>1mm 0 mm =>1mm 54% 46% 55% 34% 66% 18% 82%

*Group p P<0.05 P< value(control 0.001 side) #Initial p value P>0.05

PT=Pre treatment *comparing the differences in GR between baseline and relevant follow up appointment #comparing the difference between test and control sides at baseline

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