Key Points
In this part, we will discuss
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The benefits of RPDs
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Tissue damage associated with RPDs
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Preserving oral health
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The importance of teamwork
New publications:
All the parts which comprise this series (which will be published in the BDJ) have been included (together with a number of unpublished parts) in the book A Cinical Guide to Removable Partial Dentures (ISBN 0-904588-599) and A Clinical Guide to Removable Partial Denture Design (ISBN 0-904588-637). Available from Macmillan on 01256 302699
Abstract
This article describes the benefits and risks of providing RPDs. It emphasises the importance of co-operation between the dental team and patient to ensure that the balance of this 'equation' is in the patient's favour.
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The title of this part of the series requires immediate explanation. The term 'equation' refers to the balance that must be struck between the good and the bad which can arise from the wearing of RPDs. In this chapter we explore the benefits which can be conferred on patients by RPDs and, at the same time, highlight the possible risks of tissue damage that can be associated with such prostheses.
Every prosthetic treatment is associated with the placement of a foreign object (the prosthesis) in the mouth of the patient. As a direct consequence of such placement the burden on the tissues in the oral cavity will be increased. For example, plaque more readily accumulates on alloplastic materials than biologic ones. Furthermore, even non-toxic materials will release small amounts of their components into the oral cavity. To justify prosthetic treatment and to ensure that it is beneficial to the patient, the need for such treatment must be established, the patient must be appropriately motivated, and the dentures properly designed, constructed and maintained. Thus the initial step in determining if prosthetic treatment is indicated must always be the assessment of:
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The patient's wishes and concerns
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The relevant dental and medical history
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The results of the extra-oral and intra-oral examinations Oral hygiene habits and status
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The essential oral functions of appearance, mastication and speech.
It is only after this analysis has been completed that the decision of whether or not to treat a particular patient can be taken. For example, prosthetic treatment must not begin until it has been verified that there is a significant reduction in one or more of the essential oral functions. A simple determination of the number and position of the remaining teeth is not a sufficient foundation for making the decision of whether or not to initiate treatment. If it is indicated, a treatment plan is then devised identifying the various stages and the most appropriate type of prosthesis.
Benefits of RPDs
The potential benefits of RPDs which will be considered in this section are their contribution to the following.
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Appearance
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Speech
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Mastication
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Maintaining the health of the masticatory system:
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preventing undesirable tooth movement
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improving distribution of occlusal load
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Preparation for complete dentures.
Maintaining the health of the masticatory system
The provision of an RPD can make a positive contribution to oral health by preventing, or minimising, the undesirable consequences of tooth loss, as described in the following paragraphs.
From the foregoing examples it will be appreciated that if tooth loss is restored in sufficient time to prevent tooth movement, or to avoid excessive stress being placed on the remaining structures, the subsequent health of the oral tissues can benefit considerably.
However, the point should be made that severe damage to the existing structures is not an inevitable consequence of tooth loss. The implications of this statement will become apparent later in this section when the damaging effects of the dentures themselves are described.
Preparation for complete dentures
Most of this book is devoted to the treatment of patients who are expected to retain their remaining natural teeth for a considerable number of years, thus allowing the RPD to be regarded as a long-term restoration. But we should remember those patients whose remaining teeth carry a relatively poor prognosis and for whom, in due course, complete dentures are inevitable. If simple acrylic RPDs are provided, the patient is able to serve a prosthetic 'apprenticeship' with appliances which receive some stability from the few remaining teeth. In the fullness of time these transitional dentures become more extensive as further teeth are extracted and the patient is gradually eased into the totally artificial dentition. This form of transitional treatment can be of considerable benefit, especially for the elderly patient.
Causes of damage related to the wearing of RPDs
Harmful effects can arise from the wearing of RPDs in a variety of ways: from the plaque which is likely to accumulate around any RPD; from direct trauma by individual components of the denture; from excessive functional forces which will be transmitted by an ill-designed prosthesis and from errors in the occlusion.
If the patient, with the help of the dental team, can maintain optimal plaque control the hygiene-related complications of wearing RPDs, such as caries and periodontal disease, can be avoided. However, frequent technical maintenance of RPDs is still required if optimal oral function and health are to be preserved.
When tissue damage does occur it is sometimes referred to as the 'biological price' of wearing RPDs. The possible causes of damage and their sequelae are summarised in the following table and are discussed in more detail in the subsequent sections.
Increased plaque accumulation
A considerable amount of research effort has been directed towards an understanding of the relationship between plaque accumulation and the wearing of RPDs. It is possible that the presence of a denture influences the quality of the plaque; it certainly affects the quantity. Not only does more plaque accumulate around the teeth in the jaw in which the denture is placed, but also more is found around the teeth in the opposing jaw unless the patient is instructed in meticulous oral hygiene procedures.
Transmission of excessive force
Functional forces are transmitted by an RPD to the tissues with which it is in contact. If a denture is supported primarily by the natural teeth most of the forces will be transmitted to the alveolar bone through the fibres of the periodontal ligament. Bearing in mind the orientation of most of these fibres, it will be appreciated that the forces are tensile in nature and are dissipated over a relatively large area. A very different state of affairs exists when a denture is supported only by the mucosa. Here the forces, largely compressive in nature, are transmitted over a more restricted area.
Balancing the RPD equation
A number of longitudinal clinical studies of RPDs have shown that the types of damage itemised in the last section may be commonly found amongst wearers of RPDs. Of considerable concern are reports that many patients expressed satisfaction with their dentures, in spite of the fact that dental health had deteriorated markedly. Perhaps this finding is not altogether surprising when we remember the insidious nature of the progression of caries and periodontal disease.
With greater understanding of the relationship between plaque and dental disease and of the importance of plaque control, reports have appeared whose findings make for more encouraging reading. There is now firm evidence that the wearing of RPDs can be compatible with continued oral health. This satisfactory outcome depends upon a three-fold effort, that of the clinician, the dental technician and the patient.
The second area of responsibility of the clinician is in relation to the design and construction of the denture. Accuracy of the clinical procedures must, of course, be ensured. In addition, the clinician should produce a design based on criteria that have been shown to promote continued oral health:
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Effective support
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Clearance of gingival margins
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Simpbullicity
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Rigid connector.
These criteria are considered in greater detail in our BDJ book 'A Clinical Guide to Removable Partial Denture Design'.
For every patient, when a denture is contemplated, it is the dentist's responsibility to assess the advantages and disadvantages for that particular individual. The level of disadvantage is influenced primarily by the patient's dental awareness and plaque control. When the balance of the equation leans towards disadvantage it is likely that it will be in the patient's best interest that a denture is not prescribed. Of course, where a denture is required to replace an anterior tooth or teeth, the demand from the patient will usually be overwhelming even if the level of plaque control is less than satisfactory.
Further reading
References
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Davenport, J., Basker, R., Heath, J. et al. The removable partial denture equation. Br Dent J 189, 414–424 (2000). https://doi.org/10.1038/sj.bdj.4800787
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DOI: https://doi.org/10.1038/sj.bdj.4800787