Burning palate, food trapping and a lone terminal abutment in a 12-year-old denture
A 71-year-old woman attends complaining of a burning palate, food collecting under her lower partial denture, and looseness of her upper denture. The maxillary complete denture is 12 years old; the mandibular cobalt-chromium partial denture replaces 45, 46 and 47, is retained by a lingual bar and has 44 as its only terminal abutment. She wears both prostheses day and night and cleans them with toothpaste. Her medical history includes type 2 diabetes (HbA1c 7.2%), hypertension treated with a thiazide, and dry mouth. Examination shows diffuse erythema sharply limited to the denture-bearing mucosa of the palate, angular cheilitis, bilateral mandibular tori about 6 mm high, a lingual frenum attached 3 mm from the ridge crest, 2 mm of attached gingiva on 44, a 5 mm mesial pocket on 44 with grade I mobility, and generalised 30% bone loss. The partial denture has a rest on the mesial of 44, a wrought-wire clasp on 43, and an ill-fitting distal extension base that rocks when she opens.
1. What is your diagnosis for the burning palate and angular cheilitis, and how would you manage it before any new prosthesis is made?
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Diagnosis
The erythema confined exactly to the denture-bearing area is the classic picture of denture stomatitis, with Candida albicans biofilm on the acrylic as the principal driver. The angular cheilitis is usually candidal, staphylococcal or mixed, and is aggravated by reduced vertical dimension and pooling of saliva at the commissures.
Why she has it - the contributing factors
- Continuous wear, so the mucosa never gets a night's rest.
- Toothpaste is abrasive and scratches acrylic, giving the biofilm somewhere to live.
- Xerostomia from the thiazide reduces the protective washing effect of saliva.
- HbA1c 7.2% indicates suboptimal glycaemic control, predisposing to candidiasis and impairing healing.
Management
- Stop wearing both prostheses at night - the single most effective measure.
- Daily denture disinfection, for example soaking in chlorhexidine for 15 minutes or dilute sodium hypochlorite, plus mechanical cleaning with soap and a soft brush rather than toothpaste.
- A tissue conditioner, renewed weekly, to break the biofilm and rest the mucosa.
- Topical antifungal cover for the mucosa and the denture intaglio, or systemic fluconazole for 7-14 days if severe or recurrent, checking interactions with her current medication.
- Combined antifungal-antibacterial ointment for the angular cheilitis.
- Saliva substitutes and sips of water; ask her physician to review the diuretic.
- Recheck the HbA1c with her physician.
Do not take impressions or start a remake until the mucosa is healthy, or the new denture will simply reproduce the problem.
2. How would you redesign the mandibular partial denture, given a lone abutment with a 5 mm pocket, bilateral tori and a high lingual frenum?
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First, the abutment
44 is the only terminal abutment and therefore the design's weak point. A 5 mm mesial pocket with grade I mobility needs scaling and root planing and re-assessment. If the pocket resolves to 3 mm or less without furcation involvement, keep the tooth and protect it; if it does not, the design must be reconsidered, for example extending the framework to include 43 for cross-arch stability or accepting that the distal extension will be a free-end saddle.
Lingual bar versus lingual plate
A lingual bar needs roughly 4 mm between the free gingival margin and the floor of the mouth, and adequate attached tissue. Here the frenum is attached 3 mm from the crest - a bar would cross it - and the 6 mm tori would interfere with a bar's path of insertion and create a food trap. A lingual plate covering the tori with relief, carried high enough to clear the frenum, is the better choice: it splints 44, provides reciprocation and distributes load broadly, which matters with one abutment.
Other design points
- A mesio-occlusal rest on 44 with a guide plane and reciprocating element.
- Keep the framework clear of the tori rather than relieving it so much that it rocks.
- An altered cast impression for the distal extension, so the base records the functional form of the ridge. Without it the base will rotate about 44 and load the lone abutment - which is exactly the fault in her current denture.
3. Should the maxillary denture be relined or remade, and how would you sequence the whole treatment?
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Reline or remake?
Base the decision on several findings, not on age alone:
- Tissue: stomatitis must be resolved first.
- Ridge form and resorption: with generalised bone loss, the fit will have deteriorated substantially over 12 years.
- Occlusion: 4 mm of wear and angular cheilitis suggest lost vertical dimension; a reline will not correct a worn occlusal plane.
- Borders and seal: if the borders are short, a reline will not restore extension.
A 12-year-old acrylic denture with these findings is a remake, not a reline. Relining may only buy one or two years if fit alone were the problem, which is not the case here.
Sequence
- Treat the stomatitis and the angular cheilitis; stop nocturnal wear.
- Periodontal treatment of 44 and re-assess.
- New records: primary impressions, custom trays, border moulding, altered cast for the mandible, CR record at a tested vertical dimension.
- Interim reline of the old upper denture to test tolerance of change while the new one is made.
- Definitive dentures; review at 24 hours, one week, one month and three months.
- Written instruction that night-time removal and daily disinfection are permanent, and a recall that includes a fungal check, since the diabetes and dry mouth will not go away.