A nonsurgical approach to treating aggressive inflammatory papillary hyperplasia: A clinical report Noah P. Orenstein, DMDa and Thomas Taylor, DDS, MSDb University of Connecticut School of Dental Medicine, Farmington, Conn Preprosthetic interventions in patients with aggressive forms of inflammatory papillary hyperplasia have historically involved surgery. These procedures often involve significant postoperative discomfort and morbidity. Additionally, some patients who present with dental phobias, aversions to surgery, or underlying systemic disease may not be amenable to this type of surgical intervention. In this report, a patient with severe inflammatory papillary hyperplasia and phobias regarding the dentist and dental surgery was treated nonsurgically, following strict adherence to a clinical protocol. The methodology involved greater patient comfort during treatment, encouraged positive reinforcement to visiting the dentist for recall appointments, and effectively eliminated the underlying inflammatory papillary hyperplasia, allowing for the successful fabrication of the definitive removable prostheses. (J Prosthet Dent 2014;111:264-268) The prevalence of inflammatory papillary hyperplasia (IPH) in individuals who wear maxillary complete dentures with complete palatal coverage is reported to be from 11% to 13.9%.1,2 IPH has characteristically been described as a lesion of the mucosa. The lesion almost exclusively involves the hard palate, specifically the vault of the palate, and occasionally extends to the mucosa of the residual ridges. The lesions are typically painless, firm, pink or red, and nodular in proliferation, and they may vary from small localized projections of the palate to large multiple papillary lesions.1 Histopathologically, the lesion has been described with features of both a true papilloma and an inflammatory disease.3 Although historically some authors believed that the lesions had a premalignant component,4-6 the current predominant belief based on extensive and diverse histologic sampling is that the lesion is predominantly inflammatory in nature.3 Although the origin of the lesion is unclear, the following have been suggested as potential etiologic sources: an excessive denture palatal relief area creating negative atmospheric pressure; ill-fitting or poorly contoured dentures;
irritation of the palatal salivary glands; poor oral hygiene; and continuous day and night denture use. Papillary hyperplasia has often been associated with denture stomatitis, angular cheilitis, and the presence of Candida albicans.7 In patients with either denture stomatitis or IPH, the colonization of C albicans both on tissue and on the bearing surfaces of dentures has been found to contribute to the disease process.8 This is supported by Brown et al,9 who found a much higher concentration of C albicans in palatal tissues with papillary hyperplasia than in nonpathologic palatal tissues from the same patient. IPH is a condition that can be avoided if patients minimize the continuous wearing of their complete removable dental prostheses, clean dentures regularly, use overnight soaking in antifungal solutions such as 2% sodium hypochlorite or 2% chlorhexidine gluconate, and visit the dentist regularly for maintenance. Additionally, dentists should minimize arbitrary relief in maxillary dentures, because unnecessary relief encourages bacterial and fungal colonization. The clinician should also educate patients as to proper denture use and maintenance and should treat
lesions appropriately when they are encountered.1 The treatment of IPH varies widely among clinicians. The type of treatment rendered is related to the severity of the condition and the clinical presentation. Small localized lesions have typically been treated conservatively with topical antifungal mouthrinses or gels,10 manual massage of the affected mucosa, denture tissue conditioners or relines, and conservative surgery. When the clinical presentation is more aggressive and larger papillary lesions present, clinicians have recommended resective surgery,11 mucoabrasion,12 electrosurgery,13 cryotherapy,14,15 or laser therapy.16 Those clinicians believing IPH to be a premalignant condition even advocated mucosal and periosteal stripping.5 Regardless of lesion severity or recommended treatment, a reline of the ill-fitting prosthesis, whether soft or hard, is indicated and should always be performed. Although surgical intervention has become the standard in treating moderate to severe forms of IPH, some patients are not amenable. This is frequently due to underlying medical conditions or emotional/psychological
a
Resident, Department of Reconstructive Sciences, Prosthodontic Division. Department Head and Professor, Department of Reconstructive Sciences.
b
The Journal of Prosthetic Dentistry
Orenstein and Taylor
April 2014
265
predisposition. An alternative to surgical intervention is a method described here. This clinical report describes a nonsurgical approach to treating a patient with severe IPH before the fabrication of new definitive removable maxillary and mandibular prostheses.
CLINICAL REPORT A 62-year-old white woman was referred from a private practice to the Department of Reconstructive Sciences, Prosthodontic Division, University of Connecticut School of Dental Medicine, in June 2011 for prosthodontic treatment. The patient reported having had her mandibular teeth removed and 2 implants placed by a periodontist 1 year before her presentation to the authors’ department. Her chief complaint was, “My dentures are old and ugly and I need new ones.” A review of the patient’s medical history found a diagnosis of osteoporosis. She had taken risedronate (Actonel) 5 mg daily for 3 years but had not been taking the medication for 1 year before her presentation. The patient had had atrial valve replacement surgery 35 years previously because of a congenital defect. The patient had no medical contraindications to dental treatment. The patient reported that her current maxillary prosthesis was more than 15 years old. Upon presentation, she explained that she had been to a dentist 10 years earlier to reattach a broken right lateral incisor tooth. She also admitted to some home repair in the replacement of the maxillary central incisors, which had fractured several years earlier. The patient reported wearing her dentures 24 hours a day, and aside from her presentation to the periodontist 1 year earlier, she did not visit the dentist regularly. The anatomy of the patient’s maxilla was favorable for complete denture fabrication. Because of many years of wearing a poorly fitting complete maxillary denture opposing the mandibular anterior natural teeth, she had reduction of the anterior maxillary alveolus, mild enlargement of the maxillary tuberosities, and IPH of the palate (Fig. 1) consistent with combination
Orenstein and Taylor
1 Intraoral occlusal view of patient’s maxilla depicting presence of large inflammatory papillary hyperplasia lesion. syndrome.17 In addition to the palate, erythematous hypertrophic tissue was identified at the mucogingival junction in the premaxilla as well as in the depth of the vestibule on the patients’ anterior left side. The patient acknowledged this hypertrophic tissue and reported that it had been present but asymptomatic for many years. The presence and severity of the papillary hyperplasia made preprosthetic intervention essential before new prostheses could be fabricated. Although the patient did not experience any symptoms as a result of the IPH, the importance of treating the lesions before fabricating new removable prostheses was reinforced. Because of the patient’s fear of dentists and dental surgery, she denied all options for surgical intervention. The patient was informed of a nonsurgical approach to resolving the lesions that would take several months and require frequent visits. The nonsurgical approach to treatment coincided much more with the patient’s treatment goals and interests. Initially, the patient was instructed on proper denture care and use. She was encouraged to remove her dentures at night and was educated on proper oral hygiene and denture maintenance. A functional impression of her existing maxillary complete denture was then fabricated with a tissue conditioner (Lynal; Dentsply Caulk). After 48 hours, the patient returned, and an intraoral
mapping of the hyperplastic lesion was performed with a t-ball burnisher (HuFriedy). The patient’s maxillary denture was then removed, and a cast was poured with Type III gypsum (Castone; Dentsply Trubyte) to allow for a heat-processed acrylic denture reline. The cast and denture were flasked and invested in a 50:50 mix of Type I and III gypsum (Lab Plaster and Denstone; Heraeus Kulzer). After the investment material had completely set, the denture was separated from the definitive cast. By using the intraoral IPH mapping, the definitive cast was marked to indicate where additional acrylic resin was needed to provide positive pressure on the IPH lesions (Fig. 2). Then by using a No. 8 round bur (Brasseler USA Dental) and a discoid-cleoid instrument (HuFriedy), the definitive cast was scored to the appropriate depth determined previously by the intraoral IPH mapping. With clear orthodontic resin (Hygenic; Coltène/Whaledent Inc), a heat-processed hard reline was completed (Fig. 3). After finishing and processing the reline, the patient returned for insertion. At the insertion appointment, the patient was informed that the denture would not seat fully and would require positive occlusal pressure for retention. Although she would encounter instability of the prosthesis initially, the patient was encouraged not to use denture adhesive for retention. Additionally, strict adherence to the following protocol was
266
Volume 111 Issue 4
2 Invested definitive cast marked with red pencil to indicate where cast surgery was to be performed before hard reline.
positive pressure was being applied to the areas of IPH. At each of these appointments, changes in the location and severity of the lesion were noted, and a denture pressure indicating paste was used to verify adequate position and placement of pressure spots on the denture bearing surfaces (Fig. 4). If a reduction in pressure was required, this was performed with acrylic resin rotary cutting instruments; if additional pressure was required, this was performed with fast-set polymethyl methacrylate resin (Super-T; American Consolidated Manufacturing Co). All additions made to the intaglio surface of the denture were assessed and verified with the pressure indicating paste. After 5 months of treatment and resolution of the IPH lesions (Fig. 5), the patient returned for the fabrication of a maxillary complete denture and mandibular overdenture. At the insertion of the definitive prosthesis, the patient was instructed in routine denture maintenance and home care and was scheduled for 6-month denture recall appointments to minimize the recurrence of the IPH.
DISCUSSION
3 Maxillary denture after clear orthodontic resin heat-processed hard reline was completed. advised. The patient should remove the dentures for a minimum of 6 to 8 hours per day, and upon removal the dentures should be soaked in a 1:8 sodium hypochlorite and water solution. The patient was also instructed to brush the palate with a conventional toothbrush and a 0.12% chlorhexidine gluconate solution (Peridex; 3M ESPE) 2 to 3 times daily. Two days after insertion of the prosthesis, the patient returned for an
evaluation and adjustment. After denture pressure indicating paste (Pressure Indicating Paste (PIP); Keystone Industries/Mizzy) was applied and after selective grinding of the intaglio surface of the denture, a minimal peripheral seal of the denture was obtained. Again, the patient was encouraged to minimize the amount of denture adhesive used. Over the next 5 months, the patient was seen every 2 to 3 weeks to ensure adequate
The Journal of Prosthetic Dentistry
The management of patients with IPH has historically involved the surgical management of the disease process. Although patients may accept this treatment, a substantial amount of morbidity may be involved in the surgical treatment and the postoperative phase of treatment. Whether surgical management of IPH is the best treatment for a patient rests with the surgeon, prosthodontist, and patient. Should any party not believe that surgery is in the best interests of the patient, a nonsurgical option should be provided. The treatment regimen described is a multifactorial approach to eliminating IPH lesions. The acrylic resin added to the intaglio surface of the denture provides for selective pressure atrophy of the IPH lesions. By eliminating the nocturnal use of the dentures or by removing the dentures for 6 to 8 hours daily, along with frictional stimulation and cleansing of
Orenstein and Taylor
April 2014
267 might not occur and subsequent surgical intervention would be required.
SUMMARY
4 Intraoral occlusal view of patient’s maxilla at 3-month follow-up visit.
Achieving the desired resolution to IPH lesions before the fabrication of definitive removable prostheses has historically been performed with surgical protocols. A nonsurgical technique for the treatment of severe IPH lesions has been described. The advantages of this technique include the elimination of surgical appointments and the reduction of postsurgical healing and morbidity. This technique may apply in patients with either phobias or extensive underlying systemic medical conditions restricting them from surgery. Assuming the appropriate patient is selected, this may be an effective treatment.
REFERENCES
5 Intraoral occlusal view of patient’s maxilla at 5-month follow-up appointment. the IPH lesions with 0.012% chlorhexidine gluconate, the denture-bearing mucosa was allowed to relax and C albicans in the patient’s tissues was reduced. Lastly, soaking the dentures in a diluted sodium hypochlorite solution disinfected them and reduced C albicans colonization on the denture surface. In the present report, the authors have described a nonsurgical technique for resolving aggressive IPH. The choice of materials used was based on clinician preference. A functional impression technique for the hard reline was chosen, although many clinicians prefer to make a wash type impression of the
Orenstein and Taylor
denture with an addition silicone or polyether impression material. Clear autopolymerizing resin was used for the heat-processed reline, but any heatprocessed acrylic resin is adequate for this procedure. This patient was highly motivated to change previous habits, cooperated in following treatment requirements, understood the increased length of treatment in comparison with surgical interventions, and acknowledged the number of regular follow-up appointments required. She was informed that if strict adherence to the protocol was not followed, complete resolution
1. Ettinger RL. The etiology of inflammatory papillary hyperplasia. J Prosthet Dent 1975;34:254-61. 2. Lambson GO, Anderson RR. Palatal papillary hyperplasia. J Prosthet Dent 1967;18:528-33. 3. Johannessen AC, Isacsson G, Nilsen R, Bergendal T. In situ characterization of the inflammatory cell infiltrates of hyperplastic denture stomatitis. Acta Odontol Scand 1986;44:185-92. 4. Waite DE. Inflammatory papillary hyperplasia. J Oral Surg 1961;19:210-4. 5. Robinson HBG. Neoplasms and “precancerous” lesions of the oral regions. Dent Clin North Am 1957:621-6. 6. Thoma KH. Papillomatosis of the palate. J Oral Surg 1952;5:214-8. 7. Vaz Goulart MC, Lara VS. Inflammatory papillary hyperplasia of the palate: quantitative analysis of Candida albicans and its negative correlation with microscopic and demographic aspects. Int J Prosthodont 2011;24:235-7. 8. von Fraunhofer JA, Loewy ZG. Factors involved in microbial colonization of oral prostheses. Gen Dent 2009;57:136-43. 9. Brown LR, Merrill SS, Lambson CO. Microbiologic aspects of papillary hyperplasia. J Oral Surg 1969;28:545-51. 10. Salonen MA, Raustia AM, Oikarinen KS. Effect of treatment of palatal inflammatory papillary hyperplasia with local and systemic antifungal agents accompanied by renewal of complete dentures. Acta Odontol Scand 1996;54:87-91. 11. Antonelli JR, Panno FV, Witko A. Inflammatory papillary hyperplasia: supraperiosteal excision by the blade-loop technique. Gen Dent 1998;46:390-7.
268
Volume 111 Issue 4 12. Jolly M. Soft tissue surgery in general dental practice. Aust Dent J 1968;13:1-16. 13. Guernsey LH. Reactive inflammatory papillary hyperplasia of the palate. J Oral Surg 1965;20:814-27. 14. Amaral WJ, Frost KR, Howard WR, Cheatham JL. Cryosurgery in treatment of inflammatory papillary hyperplasia. J Oral Surg 1968;25:648-54. 15. Getter L, Perez B. Controlled cryotherapy in the treatment of inflammatory papillary hyperplasia. J Oral Surg 1972;34:178-86.
16. Infante-Cossio P, Martinez-de-Fuentes R, Torres-Carranza E, Gutierrez-Perez JL. Inflammatory papillary hyperplasia of the palate: treatment with carbon dioxide laser, followed by restoration with an implantsupported prosthesis. Br J Oral Maxillofac Surg 2007;45:658-60. 17. Saunders TR, Gillis RE Jr, Desjardins RP. The maxillary complete denture opposing the mandibular bilateral distal extension partial denture: treatment considerations. J Prosthet Dent 1979;41:124-8.
Corresponding author: Dr Thomas D. Taylor Department of Reconstructive Sciences L-6078 263 Farmington Ave Farmington, CT 06030 E-mail: [email protected] Copyright ª 2014 by the Editorial Council for The Journal of Prosthetic Dentistry.
Noteworthy Abstracts of the Current Literature Effects of thickness, processing technique, and cooling rate protocol on the flexural strength of a bilayerceramic system Lima JM, Souza AC, Anami LC, Bottino MA, Melo RM, Souza RO Dent Mater 2013;29:1063-72 Objective: To determine whether the thickness, processing technique, and cooling protocol of veneer ceramic influence the flexural strength of a bilayer ceramic system. Materials and Methods: Sixty-four bar-shaped specimens (20mm4mm1mm) of yttria-stabilized tetragonal zirconia (Vita In-Ceram YZ, Vita) were fabricated (ISO 6872) and randomly divided into 8 groups (n=8) according to the factors “processing technique” (P - PM9 and V - VM9), “thickness” (1mm and 3mm), and “cooling protocol” (S - slow and F - fast). The veneer ceramics were applied only over one side of the bar-shaped specimens. All specimens were mechanically cycled (210(6) cycles, 84N, 3.4Hz, in water), with the veneer ceramic under tension. Then, the specimens were tested in 4-point bending (1mm/min, load 100kgf, in water), also with the veneer ceramic under tension, and the maximum load was recorded at first sign of fracture. The flexural strength (s) was calculated, and the mode of failure was determined by stereomicroscopy (30). The data (MPa) were analyzed statistically by 3-way ANOVA and Tukey’s test (a¼0.05). Results: ANOVA revealed that the factor “thickness” (p¼0.0001) was statistically significant, unlike the factors “processing technique” (p¼0.6025) and “cooling protocol” (p¼0.4199). The predominant mode of failure was cracking. Significance: The thickness of the veneer ceramic has an influence on the mechanical strength of the bilayer ceramic system, regardless of processing technique and cooling protocol of the veneer ceramic. Copyright ª 2013 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.
The Journal of Prosthetic Dentistry
Orenstein and Taylor
irritation of the palatal salivary glands; poor oral hygiene; and continuous day and night denture use. Papillary hyperplasia has often been associated with denture stomatitis, angular cheilitis, and the presence of Candida albicans.7 In patients with either denture stomatitis or IPH, the colonization of C albicans both on tissue and on the bearing surfaces of dentures has been found to contribute to the disease process.8 This is supported by Brown et al,9 who found a much higher concentration of C albicans in palatal tissues with papillary hyperplasia than in nonpathologic palatal tissues from the same patient. IPH is a condition that can be avoided if patients minimize the continuous wearing of their complete removable dental prostheses, clean dentures regularly, use overnight soaking in antifungal solutions such as 2% sodium hypochlorite or 2% chlorhexidine gluconate, and visit the dentist regularly for maintenance. Additionally, dentists should minimize arbitrary relief in maxillary dentures, because unnecessary relief encourages bacterial and fungal colonization. The clinician should also educate patients as to proper denture use and maintenance and should treat
lesions appropriately when they are encountered.1 The treatment of IPH varies widely among clinicians. The type of treatment rendered is related to the severity of the condition and the clinical presentation. Small localized lesions have typically been treated conservatively with topical antifungal mouthrinses or gels,10 manual massage of the affected mucosa, denture tissue conditioners or relines, and conservative surgery. When the clinical presentation is more aggressive and larger papillary lesions present, clinicians have recommended resective surgery,11 mucoabrasion,12 electrosurgery,13 cryotherapy,14,15 or laser therapy.16 Those clinicians believing IPH to be a premalignant condition even advocated mucosal and periosteal stripping.5 Regardless of lesion severity or recommended treatment, a reline of the ill-fitting prosthesis, whether soft or hard, is indicated and should always be performed. Although surgical intervention has become the standard in treating moderate to severe forms of IPH, some patients are not amenable. This is frequently due to underlying medical conditions or emotional/psychological
a
Resident, Department of Reconstructive Sciences, Prosthodontic Division. Department Head and Professor, Department of Reconstructive Sciences.
b
The Journal of Prosthetic Dentistry
Orenstein and Taylor
April 2014
265
predisposition. An alternative to surgical intervention is a method described here. This clinical report describes a nonsurgical approach to treating a patient with severe IPH before the fabrication of new definitive removable maxillary and mandibular prostheses.
CLINICAL REPORT A 62-year-old white woman was referred from a private practice to the Department of Reconstructive Sciences, Prosthodontic Division, University of Connecticut School of Dental Medicine, in June 2011 for prosthodontic treatment. The patient reported having had her mandibular teeth removed and 2 implants placed by a periodontist 1 year before her presentation to the authors’ department. Her chief complaint was, “My dentures are old and ugly and I need new ones.” A review of the patient’s medical history found a diagnosis of osteoporosis. She had taken risedronate (Actonel) 5 mg daily for 3 years but had not been taking the medication for 1 year before her presentation. The patient had had atrial valve replacement surgery 35 years previously because of a congenital defect. The patient had no medical contraindications to dental treatment. The patient reported that her current maxillary prosthesis was more than 15 years old. Upon presentation, she explained that she had been to a dentist 10 years earlier to reattach a broken right lateral incisor tooth. She also admitted to some home repair in the replacement of the maxillary central incisors, which had fractured several years earlier. The patient reported wearing her dentures 24 hours a day, and aside from her presentation to the periodontist 1 year earlier, she did not visit the dentist regularly. The anatomy of the patient’s maxilla was favorable for complete denture fabrication. Because of many years of wearing a poorly fitting complete maxillary denture opposing the mandibular anterior natural teeth, she had reduction of the anterior maxillary alveolus, mild enlargement of the maxillary tuberosities, and IPH of the palate (Fig. 1) consistent with combination
Orenstein and Taylor
1 Intraoral occlusal view of patient’s maxilla depicting presence of large inflammatory papillary hyperplasia lesion. syndrome.17 In addition to the palate, erythematous hypertrophic tissue was identified at the mucogingival junction in the premaxilla as well as in the depth of the vestibule on the patients’ anterior left side. The patient acknowledged this hypertrophic tissue and reported that it had been present but asymptomatic for many years. The presence and severity of the papillary hyperplasia made preprosthetic intervention essential before new prostheses could be fabricated. Although the patient did not experience any symptoms as a result of the IPH, the importance of treating the lesions before fabricating new removable prostheses was reinforced. Because of the patient’s fear of dentists and dental surgery, she denied all options for surgical intervention. The patient was informed of a nonsurgical approach to resolving the lesions that would take several months and require frequent visits. The nonsurgical approach to treatment coincided much more with the patient’s treatment goals and interests. Initially, the patient was instructed on proper denture care and use. She was encouraged to remove her dentures at night and was educated on proper oral hygiene and denture maintenance. A functional impression of her existing maxillary complete denture was then fabricated with a tissue conditioner (Lynal; Dentsply Caulk). After 48 hours, the patient returned, and an intraoral
mapping of the hyperplastic lesion was performed with a t-ball burnisher (HuFriedy). The patient’s maxillary denture was then removed, and a cast was poured with Type III gypsum (Castone; Dentsply Trubyte) to allow for a heat-processed acrylic denture reline. The cast and denture were flasked and invested in a 50:50 mix of Type I and III gypsum (Lab Plaster and Denstone; Heraeus Kulzer). After the investment material had completely set, the denture was separated from the definitive cast. By using the intraoral IPH mapping, the definitive cast was marked to indicate where additional acrylic resin was needed to provide positive pressure on the IPH lesions (Fig. 2). Then by using a No. 8 round bur (Brasseler USA Dental) and a discoid-cleoid instrument (HuFriedy), the definitive cast was scored to the appropriate depth determined previously by the intraoral IPH mapping. With clear orthodontic resin (Hygenic; Coltène/Whaledent Inc), a heat-processed hard reline was completed (Fig. 3). After finishing and processing the reline, the patient returned for insertion. At the insertion appointment, the patient was informed that the denture would not seat fully and would require positive occlusal pressure for retention. Although she would encounter instability of the prosthesis initially, the patient was encouraged not to use denture adhesive for retention. Additionally, strict adherence to the following protocol was
266
Volume 111 Issue 4
2 Invested definitive cast marked with red pencil to indicate where cast surgery was to be performed before hard reline.
positive pressure was being applied to the areas of IPH. At each of these appointments, changes in the location and severity of the lesion were noted, and a denture pressure indicating paste was used to verify adequate position and placement of pressure spots on the denture bearing surfaces (Fig. 4). If a reduction in pressure was required, this was performed with acrylic resin rotary cutting instruments; if additional pressure was required, this was performed with fast-set polymethyl methacrylate resin (Super-T; American Consolidated Manufacturing Co). All additions made to the intaglio surface of the denture were assessed and verified with the pressure indicating paste. After 5 months of treatment and resolution of the IPH lesions (Fig. 5), the patient returned for the fabrication of a maxillary complete denture and mandibular overdenture. At the insertion of the definitive prosthesis, the patient was instructed in routine denture maintenance and home care and was scheduled for 6-month denture recall appointments to minimize the recurrence of the IPH.
DISCUSSION
3 Maxillary denture after clear orthodontic resin heat-processed hard reline was completed. advised. The patient should remove the dentures for a minimum of 6 to 8 hours per day, and upon removal the dentures should be soaked in a 1:8 sodium hypochlorite and water solution. The patient was also instructed to brush the palate with a conventional toothbrush and a 0.12% chlorhexidine gluconate solution (Peridex; 3M ESPE) 2 to 3 times daily. Two days after insertion of the prosthesis, the patient returned for an
evaluation and adjustment. After denture pressure indicating paste (Pressure Indicating Paste (PIP); Keystone Industries/Mizzy) was applied and after selective grinding of the intaglio surface of the denture, a minimal peripheral seal of the denture was obtained. Again, the patient was encouraged to minimize the amount of denture adhesive used. Over the next 5 months, the patient was seen every 2 to 3 weeks to ensure adequate
The Journal of Prosthetic Dentistry
The management of patients with IPH has historically involved the surgical management of the disease process. Although patients may accept this treatment, a substantial amount of morbidity may be involved in the surgical treatment and the postoperative phase of treatment. Whether surgical management of IPH is the best treatment for a patient rests with the surgeon, prosthodontist, and patient. Should any party not believe that surgery is in the best interests of the patient, a nonsurgical option should be provided. The treatment regimen described is a multifactorial approach to eliminating IPH lesions. The acrylic resin added to the intaglio surface of the denture provides for selective pressure atrophy of the IPH lesions. By eliminating the nocturnal use of the dentures or by removing the dentures for 6 to 8 hours daily, along with frictional stimulation and cleansing of
Orenstein and Taylor
April 2014
267 might not occur and subsequent surgical intervention would be required.
SUMMARY
4 Intraoral occlusal view of patient’s maxilla at 3-month follow-up visit.
Achieving the desired resolution to IPH lesions before the fabrication of definitive removable prostheses has historically been performed with surgical protocols. A nonsurgical technique for the treatment of severe IPH lesions has been described. The advantages of this technique include the elimination of surgical appointments and the reduction of postsurgical healing and morbidity. This technique may apply in patients with either phobias or extensive underlying systemic medical conditions restricting them from surgery. Assuming the appropriate patient is selected, this may be an effective treatment.
REFERENCES
5 Intraoral occlusal view of patient’s maxilla at 5-month follow-up appointment. the IPH lesions with 0.012% chlorhexidine gluconate, the denture-bearing mucosa was allowed to relax and C albicans in the patient’s tissues was reduced. Lastly, soaking the dentures in a diluted sodium hypochlorite solution disinfected them and reduced C albicans colonization on the denture surface. In the present report, the authors have described a nonsurgical technique for resolving aggressive IPH. The choice of materials used was based on clinician preference. A functional impression technique for the hard reline was chosen, although many clinicians prefer to make a wash type impression of the
Orenstein and Taylor
denture with an addition silicone or polyether impression material. Clear autopolymerizing resin was used for the heat-processed reline, but any heatprocessed acrylic resin is adequate for this procedure. This patient was highly motivated to change previous habits, cooperated in following treatment requirements, understood the increased length of treatment in comparison with surgical interventions, and acknowledged the number of regular follow-up appointments required. She was informed that if strict adherence to the protocol was not followed, complete resolution
1. Ettinger RL. The etiology of inflammatory papillary hyperplasia. J Prosthet Dent 1975;34:254-61. 2. Lambson GO, Anderson RR. Palatal papillary hyperplasia. J Prosthet Dent 1967;18:528-33. 3. Johannessen AC, Isacsson G, Nilsen R, Bergendal T. In situ characterization of the inflammatory cell infiltrates of hyperplastic denture stomatitis. Acta Odontol Scand 1986;44:185-92. 4. Waite DE. Inflammatory papillary hyperplasia. J Oral Surg 1961;19:210-4. 5. Robinson HBG. Neoplasms and “precancerous” lesions of the oral regions. Dent Clin North Am 1957:621-6. 6. Thoma KH. Papillomatosis of the palate. J Oral Surg 1952;5:214-8. 7. Vaz Goulart MC, Lara VS. Inflammatory papillary hyperplasia of the palate: quantitative analysis of Candida albicans and its negative correlation with microscopic and demographic aspects. Int J Prosthodont 2011;24:235-7. 8. von Fraunhofer JA, Loewy ZG. Factors involved in microbial colonization of oral prostheses. Gen Dent 2009;57:136-43. 9. Brown LR, Merrill SS, Lambson CO. Microbiologic aspects of papillary hyperplasia. J Oral Surg 1969;28:545-51. 10. Salonen MA, Raustia AM, Oikarinen KS. Effect of treatment of palatal inflammatory papillary hyperplasia with local and systemic antifungal agents accompanied by renewal of complete dentures. Acta Odontol Scand 1996;54:87-91. 11. Antonelli JR, Panno FV, Witko A. Inflammatory papillary hyperplasia: supraperiosteal excision by the blade-loop technique. Gen Dent 1998;46:390-7.
268
Volume 111 Issue 4 12. Jolly M. Soft tissue surgery in general dental practice. Aust Dent J 1968;13:1-16. 13. Guernsey LH. Reactive inflammatory papillary hyperplasia of the palate. J Oral Surg 1965;20:814-27. 14. Amaral WJ, Frost KR, Howard WR, Cheatham JL. Cryosurgery in treatment of inflammatory papillary hyperplasia. J Oral Surg 1968;25:648-54. 15. Getter L, Perez B. Controlled cryotherapy in the treatment of inflammatory papillary hyperplasia. J Oral Surg 1972;34:178-86.
16. Infante-Cossio P, Martinez-de-Fuentes R, Torres-Carranza E, Gutierrez-Perez JL. Inflammatory papillary hyperplasia of the palate: treatment with carbon dioxide laser, followed by restoration with an implantsupported prosthesis. Br J Oral Maxillofac Surg 2007;45:658-60. 17. Saunders TR, Gillis RE Jr, Desjardins RP. The maxillary complete denture opposing the mandibular bilateral distal extension partial denture: treatment considerations. J Prosthet Dent 1979;41:124-8.
Corresponding author: Dr Thomas D. Taylor Department of Reconstructive Sciences L-6078 263 Farmington Ave Farmington, CT 06030 E-mail: [email protected] Copyright ª 2014 by the Editorial Council for The Journal of Prosthetic Dentistry.
Noteworthy Abstracts of the Current Literature Effects of thickness, processing technique, and cooling rate protocol on the flexural strength of a bilayerceramic system Lima JM, Souza AC, Anami LC, Bottino MA, Melo RM, Souza RO Dent Mater 2013;29:1063-72 Objective: To determine whether the thickness, processing technique, and cooling protocol of veneer ceramic influence the flexural strength of a bilayer ceramic system. Materials and Methods: Sixty-four bar-shaped specimens (20mm4mm1mm) of yttria-stabilized tetragonal zirconia (Vita In-Ceram YZ, Vita) were fabricated (ISO 6872) and randomly divided into 8 groups (n=8) according to the factors “processing technique” (P - PM9 and V - VM9), “thickness” (1mm and 3mm), and “cooling protocol” (S - slow and F - fast). The veneer ceramics were applied only over one side of the bar-shaped specimens. All specimens were mechanically cycled (210(6) cycles, 84N, 3.4Hz, in water), with the veneer ceramic under tension. Then, the specimens were tested in 4-point bending (1mm/min, load 100kgf, in water), also with the veneer ceramic under tension, and the maximum load was recorded at first sign of fracture. The flexural strength (s) was calculated, and the mode of failure was determined by stereomicroscopy (30). The data (MPa) were analyzed statistically by 3-way ANOVA and Tukey’s test (a¼0.05). Results: ANOVA revealed that the factor “thickness” (p¼0.0001) was statistically significant, unlike the factors “processing technique” (p¼0.6025) and “cooling protocol” (p¼0.4199). The predominant mode of failure was cracking. Significance: The thickness of the veneer ceramic has an influence on the mechanical strength of the bilayer ceramic system, regardless of processing technique and cooling protocol of the veneer ceramic. Copyright ª 2013 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.
The Journal of Prosthetic Dentistry
Orenstein and Taylor
