Managing bleeding under, or adjacent to, a dental prosthesis

Bleeding under, or adjacent to, a dental prosthesis

Acute or chronic bleeding of the oral tissues directly under, or adjacent to, a fixed or removable dental prosthesis.

Presentation

Population

• Elders
• People with xerostomia
• People with thin tissues
• People with compromised manual dexterity or who receive inappropriate dental care from a caregiver
• People with special needs

Risk Factors

• Long-term prosthesis wear
• Nutritional deficiencies
• Hormonal discrepancies

Signs

• Bleeding upon examination or in response to probing or movement of the prosthesis
• Erythema and/or edema
• Localized pain
• Taste of blood
• Swelling
• Altered prosthesis fit

Symptoms

• May or may not be symptomatic
• Sore to palpation and prosthesis pressure; avoidance to wearing the prosthesis

Investigation

1. Question the patient about their medical and dental history.
   • How long have you noticed bleeding and/or discomfort?
   • Where is the bleeding coming from? Please show me with your finger.
   • Is there a time when the bleeding is worse (e.g., when eating or waking up in the morning)?
   • Do you wear the prosthesis at night?
   • Do you grind your teeth?
   • How old is the prosthesis?
   • How do you clean the prosthesis? How do you clean your teeth?
   • When was the last time you had a dental professional check the prosthesis? Did you have a denturist or someone else adjust it for you? Did you adjust it yourself?
   • Has your medication changed? Has your medical history changed?
   • When you cut yourself, does it take a long time for the bleeding to stop? Do you bruise easily?
   • Is there any numbness in your mouth or face?
   • Describe your diet.
   • Is your mouth dry?
   • Have you noticed any white or red spots in your mouth? Any areas of roughness that do not go away?
   • Do you smoke?
2. Evaluate the patient’s mouth and prosthesis.
   Before removing the prosthesis, look for, or ask the patient to point out, the bleeding area. With permission, manually move the prosthesis to attempt to stimulate bleeding and/or elicit discomfort.
3. Evaluate the occlusion. Look for balanced pressure with freedom in centric. Ensure that there is appropriate interocclusal space.
4. Remove the prosthesis and look for indents in the tissues (assess for overseating).
5. Use a pressure indicator paste (PIP) to identify areas of heavy contact when passive and active.
6. Mark the areas of soreness with a marker and relieve the prosthesis.
7. Look for sites of thin mucosa over non-yielding areas such as tori or sharp bony ridges where a denture base may have traumatized tissues. Assess path of insertion and see if insertion/removal by the patient or caregiver may have damaged tissues.
8. Clinically assess if the prosthesis is clean and assess the condition of the reline material, if any.
9. Take radiographs of the area and compare with the contralateral side to assess anatomical changes.

Diagnosis

Based on localized erythema and/or edema within a relatively short period directly associated with prosthesis wear, a diagnosis of ill-fitting prosthesis can be established.

Differential Diagnosis

• Overextended prosthesis
• Occlusal interference (vertical and horizontal dimensions)
• Inadequate relief on non-yielding areas
• Sharp ridges or projections in the resin
• Clenching or bruxism
• Inadequate diet
• Health profile (e.g., diabetes, menopause, medication)
• Oral pathologies (e.g., erosive lichen planus, carcinoma)
• Xerostomia

Treatment

Common Initial Treatments

• Localized relief of overextensions and heavy contact as indicated by PIP and assessment
• Reline of prosthesis
• Education: care and maintenance (for both the patient and caregiver)
• Prescription of chlorhexidine rinse
• Referral for further assessment

Referral to Specialist

If problem does not resolve or worsen despite cooperation from the patient, refer to an oral pathologist or surgeon for further evaluation.

• Oral pathologist: further assessment of chronic area. Biopsy and specific diagnosis of unknown etiology. If further intervention is needed, the oral pathologist will refer to either an oral surgeon or head and neck surgeon.
• Oral surgeon: further assessment of chronic area. Biopsy and specific diagnosis of unknown etiology. If further intervention is needed, the oral surgeon may refer to a head and neck surgeon.

Advice to Patient

• Document symptoms (e.g., time of day and medications taken).
• Discontinue prosthesis wear at night.
• Avoid sharp foods such as pretzels, chips, popcorn, or nuts that may worsen the symptoms. Keep a diet record until the next appointment.
• If medication has been prescribed, take it as instructed.
• If the situation worsens before the follow-up appointment, contact your dentist.

THE AUTHORS

	Dr. Cable is a prosthodontist and associate professor in restorative dentistry, University of Alberta, Edmonton. She also practices prosthodontics and maxillofacial prosthodontics at Empire Dental Associates, in Edmonton. Website: www.empiredentists.com/dr_cable.html

Correspondence to: Dr. Cheryl Cable, University of Alberta, Edmonton Clinic Health Academy, 11405 87 Avenue NW, Edmonton, AB  T6G 1C9. Email: cheryly@ualberta.ca

The author has no declared financial interests.

This article has been peer reviewed.