IMPROVDENT: improving dentures for patient benefit. A crossover randomised clinical trial comparing impression materials for complete dentures.

BACKGROUND: According to the UK Adult Dental Health Survey (2009) 15% of adults aged 65-74, 30% aged 75-84 and 47% aged >85 years are edentulous and require complete dentures. Patients' quality of life and nutrition status are affected by poor dentures. The quality of the dental impression is the most important issue for improving the fit and comfort of new dentures. There is paucity of RCT evidence for which impression material is best for complete dentures construction. This study aims to compare two impression materials for effectiveness and cost effectiveness. METHODS/DESIGN: IMPROVDENT is a double-blind crossover trial comparing the use of alginate and silicone, two commonly used denture impression materials, in terms of patient preference and cost-effectiveness. Eighty five edentulous patients will be recruited and provided with two sets of dentures, similar in all aspects except for the impression material used (alginate or silicone). Patients will try both sets of dentures for a two-week period, unadjusted, to become accustomed to the feel of the new dentures (habituation period). Patients will then wear each set of dentures for a period of 8 weeks (in random order) during which time the dentures will be adjusted for optimum comfort. Finally, patients will be given both sets of dentures for a further two weeks to wear whichever denture they prefer (confirmation period).Patients will be asked about quality of life and to rate dentures on function and comfort at the end of each trial period and asked which set they prefer at the end of the habituation period (unadjusted denture preference) and confirmation period (adjusted denture preference). A health economic evaluation will estimate incremental cost-effectiveness ratios of producing dentures from the two materials. A qualitative study will investigate the impact of dentures on behaviour and quality of life. FUNDING: IMPROVDENT is funded by NIHR RfPB (PB-PG-0408-16300). DISCUSSION: This trial aims to provide evidence on the costs and quality of dentures cast from two different commonly used impression materials; the intention is to significantly impact on the quality of denture production within NHS dentistry. TRIAL REGISTRATION: ISRCTN Register: ISRCTN01528038 UKCRN Portfolio ID: 8305.

Consequences of tooth loss: 2. Dentist considerations--restorative problems and implications.

UNLABELLED: Partial tooth loss is much less well tolerated by patients than was previously the case and, on occasions, when extraction is inevitable, they may seek prosthetic replacement. This paper explores some of the consequences of tooth loss that may cause difficulties in tooth replacement, particularly if replacement is delayed for some time. CLINICAL RELEVANCE: An awareness of potential difficulties, particularly with posterior tooth replacement, will allow clinicians to make treatment decisions in the light of current evidence.

Consequences of tooth loss: 1. The patient perspective--aesthetic and functional implications.

UNLABELLED: Tooth loss in adults is becoming less common, and the attitudes of patients and professionals towards it have changed dramatically over the last quarter of a century. This paper explores these changes, from the patient's perspective, in terms of psychological perspectives, aesthetics, function and the need or desire for tooth replacement. A second paper will examine the evidence available on the positional and functional changes following tooth loss. CLINICAL RELEVANCE: Clinicians need to have an awareness of changes in disease patterns, trends in patient expectations and the demand for restorative interventions.

Cosmetic rehabilitation following successful treatment of aggressive periodontitis.

UNLABELLED: With advances in periodontal therapy, many sufferers from aggressive periodontitis are retaining their teeth after successful treatment. This presents the practitioner with aesthetic and restorative challenges in these relatively young patients. Lifelong motivation is essential to the supportive therapy for these patients, and the maintenance of good aesthetics, combined with biologically acceptable corrective therapy, may help maintain a high level of motivation. Any treatment provided must naturally be conducive to maintaining long-term dental and periodontal health. This paper aims to demonstrate options for dealing with the aesthetic challenges posed by a number of patients who have undergone initial cause-related therapy for aggressive periodontitis. CLINICAL RELEVANCE: Loss of gingival tissue, tooth positional changes and tooth loss present practitioners with challenges in relation to patient satisfaction with aesthetics following advanced periodontal breakdown. A range of techniques will be required, tailored to the consequences of periodontal attachment loss, in order to satisfy patient demands.

Treatment and maintenance of a dentate patient with 'radiation caries'.

UNLABELLED: Patients with xerostomia are presenting dental practitioners with challenges in caries control, long-term restoration and prosthodontic difficulties. In many cases, extraction may be the best option, but for younger, dentate patients, this may be inappropriate. This paper describes the management of a young partially dentate patient with severe xerostomia following irradiation of the salivary glands. Preventive and restorative management are discussed, together with treatment and healing of peri-radicular pathology. The case report demonstrates that long-term stabilization and management of caries and peri-radicular lesions are possible over a seven-year period for a patient with severe radiation caries. CLINICAL RELEVANCE: Many dental patients present with some degree of xerostomia due to age, side-effects of anti-hypertensive and psychotropic drugs and also as a side-effect of radiotherapy. General dental practitioners are ideally placed to monitor and provide early intervention for this highly caries-susceptible group of patients. With good patient motivation and professional support, tooth loss is not inevitable and this case report suggests strategies and demonstrates the clinical stages in the management of severe caries due to xerostomia.

The use of a removable appliance to relieve symptoms of burning lower lip in a dentate patient.

UNLABELLED: The treatment of burning mouth Syndrome, in all its forms, is a challenge to the management of some older patients. The multi-factorial aetiology of this problem requires careful diagnosis and treatment planning to address the major aetiological factors for a given individual. This case report describes the treatment given to an elderly dentate female patient, whose main symptom was intense burning of her lower lip. The patient was aware of tooth clenching and various splints had been provided in the past, with limited improvement in symptoms. A simple removable appliance to prevent trapping of the soft tissues of the lower lip was provided, which produced a rapid and sustained reduction in symptoms. CLINICAL RELEVANCE: Solutions to some common, yet distressing, problems may well be appropriate for use in the Primary Dental Care setting. This solution to the problem of burning lower lip, may be useful for other patients with similar symptoms. It may be adapted for different clinical situations and is relatively non-invasive and reversible.

Overeruption--another challenge?

UNLABELLED: Awareness of the occlusal changes following individual tooth loss may be increasingly important when planning treatment for patients who are likely to retain a relatively intact dentition throughout life. Some evidence exists to support dentists who are considering prevention or treatment of overeruption. This paper explores the literature available on the changes in the prevalence of tooth loss, the prevalence and presentation of overeruption, its relevance to dental restoration and the prevention and treatment of overeruption. CLINICAL RELEVANCE: This article reviews the prevalence and consequence of overeruption in posterior teeth.

The use of a removable appliance to improve oral continence in an elderly dentate patient.

Challenges in the treatment of our older dentate patients are arising more frequently, and novel solutions may be required to overcome them. This case report describes the treatment given to an elderly dentate female patient, whose lax peri-oral musculature was preventing a satisfactory oral seal from being achieved. This resulted in constant "drooling" and much social disability in an otherwise fit and gregarious lady. A simple removable appliance was provided to increase support to the tissues at the angles of the mouth. An immediate relief of the salivary leakage was achieved and maintained. Simple solutions may be available to problems which may cause great distress to our patients reducing the quality of their lives. This solution to the problem of peri-oral leakage, of a normal volume of saliva, may be useful for many other patients with similar problems, following loss of peri-oral muscle tone with age.

An aid to the management of xerostomia in the partially dentate patient.

Xerostomia is becoming more frequently encountered, often in relation to the use of pharmacological agents. This paper describes the management of a patient with xerostomia, both in terms of her dry mucosa and the difficulties in constructing new dentures.

Occlusal changes following posterior tooth loss in adults. Part 3. A study of clinical parameters associated with the presence of occlusal interferences following posterior tooth loss.

PURPOSE: Tooth positional changes following posterior tooth loss may alter arch forms and occlusal planes. This may result in the development of occlusal interferences. The purpose of this study was to determine clinical parameters associated with the presence of retruded contact position (RCP) contacts and occlusal interferences associated with posterior tooth loss. MATERIALS AND METHODS: Diagnostic casts of 100 patients with at least one unopposed posterior tooth and 100 control patients were scanned and analyzed to record clinical parameters described in the earlier publications in this series. Clinical examinations identified the presence of RCP contacts and occlusal interferences. Five generalized linear models were developed to investigate the parameters associated with presence of RCP contacts, protrusive interferences, working side interferences, and nonworking side interferences. RESULTS: RCP contacts were associated with the degree of supraeruption of the unopposed tooth and the presence of other types of interferences. Protrusive interferences were associated with the presence and position of a tooth distal to the extraction site and the presence of other types of interference. Working side interferences were associated with tipping of the tooth mesial to the extraction site and the presence of other interferences. Nonworking side interferences were associated with the presence of other types of interference only. CONCLUSION: Unopposed posterior teeth are more likely to be involved in RCP contacts or interferences than their matched controls. Many teeth were involved in multiple interferences, and there appears to be a number of interrelationships between these. Initial RCP contacts have associations with the extent of supraeruption of the unopposed teeth. The presence and position of the teeth distal to extraction sites was significant when modeling protrusive interferences. Protrusive interferences are more prevalent where the site of tooth loss was bounded. Mesial tipping of the teeth distal to extraction sites reduced this effect. Working side interferences were associated with tipping of teeth mesial to the site of tooth loss. No associations between patient or tooth factors were found for nonworking side interferences, and the only association found for these interferences were with protrusive interferences at the sites.

Occlusal changes following posterior tooth loss in adults. Part 2. Clinical parameters associated with movement of teeth adjacent to the site of posterior tooth loss.

PURPOSE: Much anecdotal evidence is available on tooth positional changes following loss of an adjacent tooth, but only a few studies are available. In Part 1 of this series, supraeruption was assessed and Generalized Linear Models were made to determine the clinical parameters associated with the supraeruptive process. The models demonstrated that clinical parameters were not only associated with the extent of supraeruption, but also with the type of eruption present. This investigation of tooth positional changes adjacent to sites of posterior tooth loss attempts to provide increased understanding of the magnitude, direction, and associated features that may be helpful in decision making and treatment planning in the clinical setting. MATERIALS AND METHODS: One hundred patients with an unopposed posterior tooth, with 100 age, sex, and bone level matched controls, were drawn from patients undergoing routine restorative care at Leeds Dental Institute. Study models were scanned, and the extent of eruption, type of eruption of the unopposed tooth, the overbite, overjet, buccal occlusion, and degree of crowding in the dentition, tipping, rotation, and buccal movement of the teeth associated with the edentulous site were recorded. Generalized Linear Models were developed to examine associations between each tooth movement and patient or dental factors. RESULTS: A statistical significance in the degree of tipping of teeth both mesial and distal to the extraction site was detected between the subject and control groups. There was also a significant difference in rotation of the tooth mesial to the site. Four Generalized Linear Models were produced of the types of non-vertical movements found in teeth associated with sites of tooth loss. CONCLUSIONS: Teeth adjacent to the site of tooth loss may undergo non-vertical movements. Teeth mesial to the extraction site had a tendency to tip distally. The degree of tipping was increased in upper teeth and in subjects with a cusp-to-cusp buccal occlusion. Rotation of teeth mesial to the extraction site was more prevalent in the lower arch. Tipping of the tooth distal to the extraction site could be extreme and was found to be more prevalent in subjects with a reduced (Code 1) overbite and in the lower arch. Rotation of teeth distal to the extraction site was greater in the upper arch and was also associated with a reduced (Code 1) overbite. It also had an association with rotation of the tooth mesial to the extraction site. Models of non-vertical movement are likely to be of limited value due to overdispersion, indicating a high degree of variability within the model.

Occlusal changes following posterior tooth loss in adults. Part 1: a study of clinical parameters associated with the extent and type of supraeruption in unopposed posterior teeth.

PURPOSE: One of the barriers to restoring an edentulous space may be the supraeruption of an unopposed tooth to occupy some or all of the space needed for prosthetic replacement. The aim of this study was to determine the extent and type of supraeruption associated with unopposed posterior teeth and to investigate the relationship between these and oral and patient factors. MATERIALS AND METHODS: Diagnostic casts of 100 patients with an unopposed posterior tooth and of 100 control patients were scanned and analyzed to record the extent of supraeruption, together with other clinical parameters. The type of eruption present was defined for each subject as Periodontal Growth, Active Eruption, or Relative Wear. Generalized Linear Models were developed to examine associations between the extent and type of supraeruption and patient or dental factors. The extent of supraeruption for an individual was modeled to show association between the degree of supraeruption and clinical parameters. Three models were produced to show associations between each type of supraeruption and clinical parameters. RESULTS: The mean supraeruption for subjects was 1.68 mm (SD 0.79, range 0 to 3.99 mm) and for controls, 0.24 mm (SD 0.39, range 0 to 1.46 mm). The extent of supraeruption was statistically greater in maxillary unopposed teeth than in mandibular unopposed teeth. Supraeruption was found in 92% of subjects' unopposed teeth. CONCLUSIONS: A Generalized Linear Model could be produced to demonstrate that the clinical parameters associated with supraeruption are periodontal growth, attachment loss, and the lingual movement of the tooth distal to the extraction site. Three types of supraeruption, which may be present singly, or in combination, can be identified. Active eruption has an association with attachment loss. Periodontal growth has an inverse association with attachment loss, is more prevalent in younger patients, in the maxilla, in premolars, and in females. Relative wear has an association with increasing age and is more prevalent in unopposed mandibular teeth.