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Rationale for Adhesives in
Complete Denture Therapy
Joseph J. Massad, DDS; William J. Davis, DMD, MS;
Richard June, DDS; William A. Lobel, DMD;
Joseph Thornton, DDS; David R. Cagna, DMD, MS
The number of people in the United States requiring removable prosthodontic therapy
has increased dramatically over the past twenty years.1-3 Current predictions suggest
that over the next two decades, the declining incidence of edentulism4,5 will be more than
compensated by a 79% increase in adults over 55 years of age.6 In the United States
alone, the number of adults requiring complete denture therapy is expected to increase
from 33.6 million in 1991 to 37.9 million in 2020.6 Considering the projected decrease in
edentulism, the expected increase in the number of older individuals, and the need for
both maxillary and mandibular complete denture by many patients, it has been estimated
that the 56.5 million complete dentures made in the United States in 2000 will increase
to more than 61 million dentures in 2020.6
Marked atrophy of alveolar bone following tooth loss7-9 complicates prosthodontic
rehabilitation. This phenomenon has been termed “reduction of residual ridges” by
Atwood7, who considered it a major oral disease entity. Although consensus regarding
etiology is lacking,10-16 alveolar bone and oral soft tissue changes observed in denture
wearers may be an inevitable consequence of the loss of natural teeth, tissue
remodelling, occlusal factors, and/or prolonged denture wear.16-26 Alveolar bone loss
subsequent to long term edentulism may be severe and the process may progress
throughout life.19,20,25,27,28 Although generally more pronounced in the mandible and
characterized by individual variability in volume and rate,7,15,20,21,24,26,29,30 advanced reduction
of residual ridges presents a significant restorative challenge.
Edentulous patients encountered in dental practice may have been wearing complete
dentures for decades. Significant atrophy of alveolar processes following the loss of
natural teeth is an all too familiar consequence of long term edentulism. This oral
1
condition complicates both the dentists’ ability to
construct adequate complete dentures, and the
patients’ ability to successfully manage their new
prostheses.
considered as an etiologic factor in alveolar
resorption. Though difficult to substantiate, an
association may exist between residual ridge
reduction and osteoporosis.7,37-39
More than 50 years ago it was suggested
that local factors were primarily responsible
for edentulous ridge resorption. Schlosser31
implicated ill-fitting dentures and associated
trauma to oral tissues as the primary causes
of rapid destruction of the denture bearing
structures. He lists faulty impressions, excessive
occlusal vertical dimension, inaccurate centric jaw
relationships, and occlusal disharmony as major
contributing factors. Lammie32 suggested that a
detrimental external molding force may adversely
impact the residual bony ridges as overlying oral
soft tissues contract or atrophy with time. This
molding force may, in turn, accelerate resorption
of the edentulous ridges.
Complete Denture Stability & Retention
For edentulous patients, successful denture
therapy is influenced by the biomechanical phenomena of support, stability, and retention.40-42
Retention, or the resistance to movement of the
denture away from the supporting tissues, is critical. Unfortunately, the physical, physiological,
and mechanical factors associated with denture
retention are not completely understood. Physical
forces influencing denture retention are believed
to include adhesion, cohesion, capillary attraction,
surface tension, fluid viscosity, atmospheric
pressure, and external forces originating from
the oral-facial musculature.43-49 Of these, the
interfacial surface tension developed as a result
of the saliva layer between the denture base and
the supporting soft tissues is quite important.
This is particularly true for maxillary prostheses.
Retention is realized as the saliva layer maximizes contact with approximating prosthetic and
mucosal surfaces. Therefore, xerostomic patients
who experience a quantitative or qualitative
reduction in saliva may have reduced complete
denture retention due to decreased interfacial
surface tension.50,51
In a review of 18 complete denture patients,
Atwood33 suggests that the deterioration of
edentulous ridges is a complex biophysical
process involving functional factors (i.e., the
intensity and duration of applied forces),
prosthetic factors (i.e., techniques and materials
used in denture construction), and metabolic
factors (i.e., systemic influences on bone
formation and resorption). For example, occlusal
parafunction may adversely affect the denture
bearing tissues. It is likely that many complete
denture wearers limit both separation of the
denture teeth and mandibular movement in order
to avoid unintentional prosthesis movement.34 If
this clenching habit occurs over extended periods
of time and with sufficient force, damage to the
denture bearing hard and soft tissues may result.
In the maxilla, alveolar resorption may obscure
anatomic landmarks needed to identify the
postpalatal seal area. An ineffective or improperly
located postpalatal seal may compromise
denture retention.52 Therefore, reduced vertical
alveolar height in a severely atrophic edentulous
maxilla may result in poor denture stability and
inadequate denture retention.53,54
Others35,36 support Atwood’s conclusions by
suggesting that despite careful prosthodontic
management and apparent short-term successful
outcomes, aggressive reduction of residual
edentulous ridges may still occur. Consequently,
systemic disease or systemic factors must be
The typical pattern of residual ridge resorption
results in the medial-lateral and anterior-posterior
narrowing the maxillary denture foundation
and a widening of the mandibular denture
foundation.55-59 Resultant changes in horizontal
2
maxillomandibular ridge relationships may
necessitate setting the posterior denture teeth in
cross-bite. This arrangement may complicate
force distribution to the denture bearing tissues.
If cross-bite posterior denture occlusion is not
carefully developed and managed in patients
with severe residual ridge resorption, denture
instability may result.60
Complete denture retention is, in part, influenced
by denture occlusion. Most denture wearers
consciously or subconsciously perform random,
empty-mouth occlusal contacts throughout the
day. These contacts may result from functional
activity (e.g., swallowing) or parafunction (e.g.,
bruxism or clenching). A bilaterally balanced
denture occlusion will minimize the adverse
consequences of functional and parafunctional
loading by widely distributing these forces on the
denture bearing structures. Therefore, a properly
balanced denture occlusion may serve to dampen
potentially detrimental occlusal forces acting to
disrupt denture stability. A balanced occlusion
is dependent on effective clinical and laboratory
procedures. Accurate and precise registration
of maxillomandibular relationships, meticulous
articulation of master casts, careful positioning of
denture teeth, and correct processing of denture
bases must be accomplished. Both laboratory
and clinical remount procedures are essential if
optimal occlusal balance is to be achieved prior to
delivery of the prostheses. Finally, periodic recall
of all edentulous patients allows reevaluation of
the denture occlusion; a clinical remount can be
performed when correction is indicated.
The objective of complete denture therapy for
patients with severe reduction of residual ridges
is not solely the replacement of missing teeth.
Rather, complete dentures must be designed to
replace both the missing dentition and associated
supporting structures. In doing so, the denture
base may occupy a substantial volume. Since
denture base coverage of the hard palate is
necessary to satisfy mechanical requirements
of the prosthesis, and not to replace missing
anatomic structures, care must be taken to
limit denture base thickness in this area. In
addition to replacing missing oral tissues,
complete dentures structurally redefine potential
spaces within the oral cavity. Inappropriate
denture tooth positioning and physiologically
unacceptable denture base contour or volume
may result in compromised phonetics,61
inefficient tongue posture and function,56,62 and
hyperactive gagging.63-66 Carefully designed
external denture contours (i.e., cameo or polished
denture surfaces) may contribute substantially
to prosthesis stability and retention. Successful
denture wearers display patterns of oral-facial
muscular activity that serve to retain, rather
than displace, the prostheses. When optimally
contoured, complete dentures occupy space in
the oral cavity defined by the physiologic limits
of acceptable muscular function, thus acquiring
stability and retention during mastication,
deglutition, and phonation.67,68 Conversely,
poorly designed prostheses that do not
accommodate anticipated muscular function
may yield compromised denture stability and
reduced retention.
Complete maxillary and mandibular dentures
have long been considered the standard of care
for treating edentulous patients. While most
edentulous patients express relative satisfaction
with their maxillary complete dentures, many do
not enjoy equally successful mandibular denture
69,70
The use of endosseous
comfort and function.
dental implants to assist in the support, stability,
and retention of removable prostheses is now
considered an effective treatment modality for the
edentulous patient. Individuals wearing implantassisted overdentures typically report improved
oral comfort and function when compared to
conventional, mucosa-supported prostheses.71-76
Except when contraindicated due to financial or
surgical considerations, implant-assisted overdentures are usually the treatment of choice.
3
Recently, a symposium held at McGill University
addressed the efficacy of implant-assisted overdentures for treatment of edentulism. After
thorough, evidence-based review of existing
information, the following consensus statement
was formulated: “The evidence currently available
suggests that the restoration of the edentulous
mandible with a conventional denture is no longer
the most appropriate first choice prosthodontic
treatment. There is now overwhelming evidence
that a two-implant overdenture should become
the first choice of treatment for the edentulous
mandible.” 77
layer, particularly in saliva-deficient patients, and
(2) eliminating voids occurring in the interfacial
space in the absence of absolute adaptation of
the denture base to the bearing tissues.49
In addition to improved retention and stability,
denture adhesives have been shown to reduce
mucosal irritation, reduce food impaction beneath
the denture base, improve chewing efficiency,
increase bite force, improve functional load
distribution across the denture-bearing tissues,
and facilitate the psychological well-being of the
patient. 49,78,80-85 For patients with xerostomia, the
use of a well-hydrated denture adhesive provides
a cushioning or lubricating effect, reducing
frictional irritation of the supporting soft tissues
and preventing further tissue dehydration.
Two currently available denture adhesives
that function well in this regard are Fixodent
(Procter & Gamble) and Denture Grip (Laclede
Research Laboratories).
The Use of Adhesives as Part of Complete
Denture Therapy
Successful complete denture therapy must involve
both technical excellence during prosthesis
fabrication and effective patient management
once the dentures are placed. Satisfying the
expectations of many patients for optimal denture
retention and stability is often beyond the
technical skills of even the most accomplished
practitioners. Discussing and implementing the
judicious use of denture adhesives may satisfy
patients’ expectations and achieve the intended
treatment goals.
The composition of most modern denture
adhesives includes constituents that promote
bioadhesion via carboxyl groups once the
adhesive is hydrated. Two commonly employed
active ingredients in denture adhesives
are poly[vinyl methyl ether maleate] and
carboxymethylcellulose. The physical chemistry
of these adhesive constituents is discussed in
detail elsewhere.49,78,86 Once placed on the intaglio
surface of the denture, the adhesive material
must be substantially hydrated in order to achieve
optimal performance.
It is appropriate to prescribe a denture adhesive
to augment retention and stability of conventional
complete dentures. Adhesives are indicated
for routine use when appropriately constructed
complete dentures do not satisfy stability and
retention expectations of the patient.49 Denture
adhesives may also prove psychologically
beneficial78,79 when the patient requires
supplemental retention and stability, particularly
during times of public interaction. Denture
adhesives are not indicated to provide retention
for ill-fitting prostheses.
Following complete denture fabrication and
prior to definitive placement of the prostheses,
it is prudent to reemphasize to the patient the
anticipated outcome of therapy. For patients
with favorable anatomic, physiologic, and
psychological factors, including extensive
denture wearing experience, the anticipated
outcome of complete denture therapy is
favorable. Conversely, for individuals who display
compromised anatomic oral conditions, poor
muscular control, psychological indifference, or
a lack of successful denture experience, a fair or
When properly managed, adhesives enhance
the interfacial surface tension occurring between
the denture base and supporting soft tissues
by (1) improving the adhesive, cohesive, and
viscosity characteristics of the interfacial film
4
Most denture wearers, at one time or another,
have attempted to use adhesive to facilitate
comfortable denture function. Unfortunately,
the concept that “more is better” does not hold
true for denture adhesives. Table 1 presents the
approach used by the authors when presenting to
the patient the appropriate method for application
of denture adhesive. It is equally important to
make certain that patients are informed about
removal of adhesive from both denture surfaces
and oral tissues on a regular basis. Appropriate
denture and oral hygiene should be accomplished
by edentulous patients at least two times each
day. Table 2 presents an effective technique for
denture adhesive removal.
guarded prognosis is more realistic. Discussing
reasonable expectations with the patient prior to
placing complete dentures may prepare them for
an otherwise disappointing experience.
It is appropriate to prescribe adhesive to augment
retention and stability of conventional complete
dentures. Anticipating suboptimal stability and
retention in the presence of compromised patient
factors, e.g., xerostomia, is sound therapy.
Informing patients that the proper use of a limited
amount of denture adhesive can supplement
existing denture stability and retention is
both clinically acceptable and prudent patient
management. The need for denture adhesive
is not necessarily an indication of suboptimal
therapy, or admission of failure by either to dentist
or patient.
Table 1.
Appropriate Application of Denture Adhesive
1. Inform the patient that, due to existing
conditions, achieving optimal complete
denture retention and stability may not be
possible. Also suggest that the proper
use of denture adhesive is an acceptable
means of augmenting the stability and
retention of a new prosthesis. Honest and
realistic communication of the anticipated
results of therapy may ease future patient
management problems.
2. The use of small amounts of hydrated
paste adhesives (e.g., Fixodent, Procter
& Gamble) works well due to favorable
adhesive, cohesive, and viscosity
characteristics.
5
Table 1. (continued)
Appropriate Application of Denture Adhesive
3. A small amount of the paste should be
dispensed onto the clean and dry intaglio
surface of the denture. The use of
excessive adhesive will likely interfere with
proper placement of the denture on the
bearing tissues. For the maxillary denture,
adhesive should be dispensed in the
midpalatal region (Figure 1), while for the
mandibular denture very small amounts can
be placed in two or three locations along the
ridge crest (Figure 2).
Figure 1.
Adhesive
application
to maxillary
denture.
Figure 2.
Adhesive
application to
mandibular
denture.
4. Once dispensed onto the dentures, the
patient should evenly disperse the paste
over the entire intaglio surface of the
prosthesis with a clean, dry finger
(Figure 3). This will result in a thin,
even layer of adhesive.
Figure 3.
Adhesive
dispersed
over intaglio
surface.
5. The denture is submersed in a container
of cool water to maximally hydrate
the adhesive (Figure 4). The denture
should remain submersed in water for
approximately 20 to 30 seconds.
Figure 4.
Denture
submersed
in cool water
to hydrate
adhesive.
6. The denture is then placed in the mouth
and firmly seated with finger pressure
for approximately 10 seconds (Figure 5).
Maintenance of seating pressure will cause
the adhesive to flow throughout the interfacial space between the denture base and
the denture bearing soft tissues.
Figure 5.
Denture
placed and
firmly seated.
6
Table 1. (continued)
Appropriate Application of Denture Adhesive
7. The patient may be provided with the sample
container of adhesive used during the demonstration. Suggesting local stores that carry this
product will emphasize that adhesive use is a
component of regular denture use. The patient
should be told that the use of excessive adhesive
may indicate an inadequate fit, necessitating
denture reline or remake procedures.
Table 2.
Technique for Denture Adhesive Removal
1. Use of an electric toothbrush can enhance
thorough cleaning of both denture surfaces
and denture bearing oral tissues (Figure 6).
Inexpensive, battery powered brushes are
now widely available to consumers (e.g.,
Crest SpinBrush Pro, Procter & Gamble).
A small amount of toothpaste on the electric
toothbrush will serve to freshen the patient’s
breath and improved taste (Figure 7).
Figure 6.
Battery
powered
toothbrush
and tooth
paste.
Figure 7.
Small amount
of toothpaste
dispensed
onto
toothbrush.
2. Remove the dentures from the mouth, and
thoroughly scrub the entire intaglio surface
of the dentures with the electric toothbrush
(Figure 8). This procedure is not intended
to eliminate adhesive from the dentures.
Rather, this initial scrubbing will loosen
residual adhesive material, facilitating
subsequent removal.
Figure 8.
Initial scrubbing
of the denture.
7
Table 2. (continued)
Technique for Denture Adhesive Removal
3. The denture is then held submerged in a
container of warm water and simultaneously scrubbed using the electric toothbrush
(Figure 9). Firm pressure should be applied
to the brush in order to eliminate adhesive from the denture surface. Particles or
clumps of adhesive material will be seen rising to the surface of the water (Figure 10).
This procedure is continued until the entire
denture surface is free of residual adhesive.
Figure 9.
Final scrubbing
with denture
submerged in
warm water.
4. To clean and stimulate the oral tissues, the
electric toothbrush may again be used. A
small amount of toothpaste is applied to the
brush. All denture bearing soft tissues and
tissues that contact the cameo surfaces of
the dentures, including the tongue, are gently
massaged (Figure 11). At first, this may
cause a tingling sensation for the patient. This
sensation will disappear with repeated use.
Figure 11.
Initial massaging
of oral tissues
with toothbrush.
5. Following thorough massaging of the oral
soft tissues, warm water is introduced into
the patient’s mouth (Figure 12). Holding this
water in the mouth, the electric toothbrush
is again used to massage all oral soft
tissues (Figure 13). The patient is then
instructed to expectorate the water and
residual debris into a sink, leaving the oral
tissue free of adhesive.
Figure 12.
Introduction
of warm water
into patient’s
mouth.
Figure 10.
Particulate
debris
removed from
denture is
seen rising
to surface of
warm water.
Figure 13.
With warm
water in
mouth, patient
continues
oral tissues
massage
until adhesive
elimination is
complete.
8
Conclusion
The phenomenon of residual ridge reduction
following loss of the natural teeth, and its impact
on successful complete denture therapy, have
been reviewed. Anatomic, physiologic, and
mechanical factors associated with the stability
and retention of complete dentures are important
for achieving optimal therapeutic results. The
proper use of denture adhesive to supplement
sound complete denture therapy should be
carefully presented to patients prior to delivery of
the prostheses. Denture adhesives can effectively
augment denture stability and retention to improve
overall denture performance, and patient comfort
and satisfaction.
Authors
Dr. Massad is Adjunct Associate Professor, Tufts University School of Dental Medicine, and Adjunct
Associate Professor, Department of Prosthodontics, University of Texas Health Science Center at San
Antonio, and Adjunct Associate Professor, Department of Forensic Sciences, Oklahoma State University
Center for Health Sciences, and Adjunct Associate Professor, University of Oklahoma College of
Dentistry. He is also Associate Faculty, The Pankey Institute.
Dr. Davis is Professor, Division of Dentistry, Department of Otolaryngology, Medical College of Ohio,
and Adjunct Associate Professor, University of Oklahoma College of Dentistry. Additionally he serves
as Director, General Practice Residency Program, and Director, Continuing Medical Education, Medical
College of Ohio. He is also Associate Faculty, The Pankey Institute.
Dr. June is Adjunct Associate Professor, University of Oklahoma College of Dentistry. He is also in
private practice, Peoria, Illinois.
Dr. Lobel is Assistant Clinical Professor, Department of Restorative Dentistry, Tufts University School of
Dental Medicine, and Adjunct Associate Professor, University of Oklahoma College of Dentistry.
Dr. Thornton is Adjunct Associate Professor, University of Oklahoma College of Dentistry. He is also in
private practice, Duluth, Georgia.
Dr. Cagna is Associate Professor, Department of Prosthodontics, University of Texas Health
Science Center at San Antonio, and Adjunct Associate Professor, University of Oklahoma College of
Dentistry. He is a Diplomate, American Board of Prosthodontics and a Fellow, American College of
Prosthodontists.
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