13.4 Denture Stomatitis, Tissue Conditioning & Pre-Prosthetic Surgery

13.4 Denture Stomatitis, Tissue Conditioning & Pre-Prosthetic Surgery

Maintaining mucosal health is a prerequisite for successful removable prosthodontic therapy. Ill-fitting prostheses, continuous nocturnal wear, and poor oral hygiene induce chronic mucosal inflammation, fungal colonization, and tissue distortion. For candidates sitting the ADC Written Examination, expertise in Newton's classification of denture stomatitis, antifungal pharmacology, flabby ridge impression techniques, tissue rehabilitation, and pre-prosthetic surgical principles is essential.

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1. Denture Stomatitis (Chronic Atrophic Candidiasis)

Denture stomatitis is a prevalent inflammatory condition affecting the palatal mucosa beneath removable full or partial dentures.

Etiology & Risk Factors

• Primary Pathogen: Opportunistic infection dominated by Candida albicans, forming biofilms on PMMA acrylic surfaces.
• Exacerbating Factors: Continuous nocturnal denture wear (creates an anaerobic, un-cleansed environment beneath the denture); poor denture hygiene; hyposalivation / dry mouth; broad-spectrum antibiotic therapy; inhaled corticosteroid use; systemic immunosuppression; diabetes mellitus.

Newton's Clinical Classification

Hygiene & Disinfection Protocols

• Nocturnal Removal: Mandatory removal of prostheses for at least 6–8 hours daily (overnight) to allow mucosal oxygenation and salivary cleansing.
• Denture Disinfection Soaks:
  • Acrylic-Only Complete Dentures: Soak in 0.2% Chlorhexidine gluconate or dilute Sodium Hypochlorite (1:10 dilution) for 15–30 minutes daily.
  • Metal-Framed Partial Dentures: Contraindication: Sodium hypochlorite corrodes cobalt-chromium and gold alloys. Use 0.2% Chlorhexidine or alkaline peroxide soaking tablets instead.

Pharmacological Antifungal Therapy

Topical therapy is the first-line medical intervention:

• Nystatin Oral Suspension / Pastilles: $100,000\text{ units/mL}$; hold in mouth 4 times daily for 14 days.
• Amphotericin B Lozenges: $10\text{ mg}$ lozenges 4 times daily for 14 days.
• Pharmacological Contraindication Alert: Miconazole oral gel inhibits hepatic cytochrome P450 enzyme CYP2C9. In patients taking Warfarin, Miconazole significantly impairs Warfarin metabolism, leading to dramatically elevated INR levels and life-threatening hemorrhage risks. Nystatin or Amphotericin B must be prescribed for patients on Warfarin.

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2. Angular Cheilitis & Flabby Ridge Management

Angular Cheilitis

Characterized by erythema, painful fissuring, and maceration at the labial commissures.

• Etiology: Dual infection involving Candida albicans and Staphylococcus aureus, compounded by collapsed Vertical Dimension of Occlusion (VDO), which creates deep facial skin folds retaining saliva.
• Treatment: Topical antifungal/antibacterial combination ointment (e.g., Miconazole/Hydrocortisone 1% or Fusidic acid/Hydrocortisone) combined with prosthetic restoration of correct VDO.

Kelly's Combination Syndrome & Flabby Ridge

• Kelly's Combination Syndrome: Occurs when a complete upper denture opposes natural lower anterior teeth (Kennedy Class I RPD). Excessive anterior occlusal loading causes severe anterior maxillary residual ridge resorption, replaced by mobile, fibrous flabby tissue, alongside tuberosity enlargement, palatal papillary hyperplasia, and lower anterior extrusion.
• Flabby Ridge Impression Mechanics (Window Technique): Standard impression techniques displace hyperplastic fibrous tissue, resulting in denture instability. A zero-pressure Window Custom Tray Technique is required:
  1. A custom tray is fabricated with an open window cut out over the flabby anterior ridge area.
  2. A secondary impression of firm basal seat areas is taken using ZOE or heavy-body PVS.
  3. Impression Plaster or light-body PVS wash is painted through the window over the flabby tissue without pressure, capturing the tissue in its undistorted, static state.

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3. Pre-Prosthetic Surgical Principles

Surgical correction of hard and soft tissue anomalies optimizes basal seat contours and denture stability.

Common Surgical Interventions

• Frenectomy (Labial or Lingual): Prominent labial frenula attached near the ridge crest break the peripheral seal. Lingual frenum attachments (ankyloglossia) dislodge mandibular dentures. Excision via Z-plasty or simple excision.
• Alveoloplasty: Surgical smoothing and recontouring of sharp alveolar ridge spicules or undercut bone shelves post-extraction to prevent mucosal pinching under denture loading.
• Torus Reduction:
  • Torus Palatinus: Surgical reduction indicated if the torus is large, pedunculated, or extends posteriorly to the vibrating line, preventing posterior palatal seal formation.
  • Torus Mandibularis: Indicated when lingual tori create severe undercuts that prevent lingual flange extension or lingual bar connector placement.
• Tuberosity Reduction: Surgical excision of fibrous or bony tuberosity enlargements that impinge on interarch space, preventing correct occlusal plane establishment.