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COMPLETE DENTURE THEORY AND PRACTICE

IMPRESSION MAKING 4

Factors which complicate impression making


1- Uncooperative patient

2- Excessive salivation

3- Dry mouth (xerostomia) 4.Nausea during Impression Making

Uncooperative patient

Some patients exhibit intolerance to prosthodontic procedure. This is may due to


fear or psychological problem

Consultation with physician and premedication is usually prescribed

Excessive salivation (Sialorrhea)


Excessive amounts of saliva, particularly of the thick mucous type, will displace the alginate
impression material and will contribute to an inaccurate impression especially in partially
edentulous patients.
1- Clinical management

Placing cotton rolls in upper buccal vestibule to control saliva from the parotid
gland

Placing cotton rolls in the floor of the mouth to control saliva from sublingual and
sub mandibular salivary gland

Ask the patient to rinse with astringent and cold mouth wash

Use saliva ejector

packing the mouth with unfolded 2 x 2 inch gauze:


In the maxillary arch one gauze strip is placed in the right buccal vestibule and
another in the left vestibule. The dentist must wipe the palatal area just before
making the impression.

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COMPLETE DENTURE THEORY AND PRACTICE

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In the mandibular arch one gauze strip is placed in each of the buccal vestibules
and another is placed in the linguoalveolar sulcus by having the patient raise the
tongue, placing the gauze in the sulcus, and then having the patient relax the
tongue to hold the gauze in position. The gauze is removed immediately before
the impression is made.
2- Drugs

The excessive saliva can be controlled by having the patient rinse the mouth with
an astringent mouthwash followed by a rinse of cold water

The parasympathetic nervous supply to the salivary glands is mediated by


cholinergic terminals. Therefore, antisialogogues are primarily anticholinergic
drugs, such as atropine and scopolamine, or drugs that have anticholinergic
properties (phenothiazines and ganglionic-blocking agents) in addition to other
effects. Oral administration of anticholinergic drugs in acceptable doses reduces
salivary output but not arrest salivation.

With excessive amount of thick mucinous saliva from the palatal salivary glands, the patients
should be instructed to rinse with an astringent mouth rinse. Then 2 x 2-inch sponges moistened
in warm water should be used to place pressure over the posterior palate in an attempt to milk the
glands. This is followed by an ice water rinse immediately before the impression is made.
With copious amounts of saliva, the use of an antisialagogue in combination with mouth rinses
and gauze packs effectively controls this salivation. (A 15-mg Pro-Banthine tablet taken 30
minutes before the impression appointment)

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COMPLETE DENTURE THEORY AND PRACTICE

IMPRESSION MAKING 4

Dry mouth (Xerostomia)

Persistent dry mouth commonly referred to as xerostomia. Xerostomia is known with


others names such as Aptyalism, Asialia, Dry mouth, Hypo salivation, oral dryness,
salivary secretion decease.

If the teeth are too dry, alginate has a tendency to stick to them. Therefore the teeth
should not be air dried before making an impression.

Function of saliva
Help in Food digestion
Protects teeth from decay
Prevents infection by controlling bacteria and fungi III the mouth (antibacterial)
Help in chewing, swallowing
Lubrication of the oral mucosa
Retention of removable dentures
Diagnosis of xerostomia
It may based on evidence obtained from the patient's history, examination of the oral cavity and \
or silometry (collection device placed over salivary gland duct orifices, and saliva is stimulated
with citric acid).
The normal salivary flow for unstimulated saliva from the parotid gland is 0.4 to 1.5 ml
/min. the normal flow rate for unstimulated "resting" whole saliva is 0.3 to 0.5 ml/min, for
stimulated saliva Ito 2 ml/min. values less than 0.1 ml/min are typically considered xerostomic,
although reduced flow may not always be associated with complaints of dryness.
Symptoms
Patients often complain of a sticky, dry sensation in the mouth. They encounter problems with
chewing, swallowing, tasting or speaking.

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COMPLETE DENTURE THEORY AND PRACTICE

IMPRESSION MAKING 4

Causes of dry mouth

Medications: Many commonly prescribed medications, particularly in elderly


individuals, have xerostomia as a possible side effect.

Aging: Salivary flow may diminish in some individuals with age.

Illnesses: Specific illnesses and disease processes are associated with xerostomia, such as
chronic diarrhea, liver dysfunction, diabetes, anemia, Sjogren's syndrome.

Radiation therapy: The radiation treatment of cancer patients, particularly when affected
areas involve the head and neck regions, may result in dry mouth. The type and amount
of radiation used will determine the extent of damage caused to the oral salivary glands
and, in turn, the degree of saliva reduction.

Oral habits: as Chronic mouth breathing and inadequate fluid consumption.

Why is saliva important to denture wearers? In order for dentures to be comfortably stable in
the mouth, intimate contact between the dentures and the underlying gums must be achieved
during chewing, swallowing, and speaking. When the denture fits accurately, the physical
adherence of saliva to the denture and to the gums provides a force which aids in denture
retention and stability. In the absence of salivas the lubricating effects, the gum, cheek and lip
tissues may become irritated as the dentures move during chewing, swallowing and speaking.

Management of dry mouth


Modify medications: consulte the patients physician to permit substitution to an equally
effective drug that does not cause dry mouth, or causes it to a lesser extent.
Saliva can be stimulated by :
1.Mechanical (Masticatory, Gustatory sialagogues) Stimulants

Foods which require mastication (apples, carrots, celery, hard breads and rolls, meats,
etc)

Sugarless Gums

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Sugarless Tablet
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COMPLETE DENTURE THEORY AND PRACTICE

IMPRESSION MAKING 4

2. Chemical Stimulants

Mouth-Kote Solution : Mucopolysaccaharide Sol., contains citric acid

Optimoist Solution : Contains citric acid

3. Electrical Stimulant
4. Pharmacologic Stimulant, sialagogues (parasympathomimetic)

Salagen (Pilocarpine HCl); Cholinergic agonist

Evoxac (Cevimeline HCl); Cholinergic agonist

5. Oral Moisturizers / Salivary Substitutes


WATER

Regularly drinking of water may both hydrate tissues and facilitate


some increase in saliva production.

Salivart
Solutions

Oralube

Contain carboxymethyl cellulose and hydroxyethyl cellulose

Xero-Lube

Gel

Plax

Water-glycerin agent

Oral Balance

Glycerate polymer

6. Acupuncture
Are there alternative denture treatments for patients suffering from xerostomia?
Those patients who are not able to comfortably wear conventional dentures, due to severe
xerostomia, should consider implant-supported dentures. The increased denture stability offered
by dental implants may reduce tissue irritation caused by movement of the denture during
chewing, swallowing and speaking. These patients should understand that when dental implants
are used to support dentures, intense oral hygiene practices are required to maintain healthy
implants in the presence of reduced salivary production.
Consultation with a qualified dentist will help the patient determine which treatment approach is
best for them.
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COMPLETE DENTURE THEORY AND PRACTICE

IMPRESSION MAKING 4

Nausea during Impression Making, Pakistan Oral & Dental Journal Vol 27, No. 1\\ IJMDS - 2009;1(1) 54-65
Gagging is an involuntary contraction of the muscles of the soft palate or pharynx that results in
retching. it is a normal protective reflex to prevent foreign bodies from entering the trachea. In
some cases this problem is so severe that it requires definite treatment.
Gagging has been generally classified as either

somatogenic, or

psychogenic. Psychogenic gagging is induced by anxiety ,fear, and apprehension

Etiology of gagging.
1. Local and systemic disorders
2. Anatomic factors
3. Psychological factors
4. Physiologic factors
5. Iatrogenic factors
A. Local and systemic disorders1. Nasal obstruction

8. Chronic gastritis peptic ulceration

2. Postnasal drip

9. Carcinoma of stomach

3. Sinusitis

10. Hiatus hernia

4. Nasal polyp

11. Uncontrolled diabetes

5. Mucosal congestion of URTract

12. Catarrh and alcoholism

6. Dry mouth
7. Chronic GI disease
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COMPLETE DENTURE THEORY AND PRACTICE

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B. Anatomic factorsAnatomic abnormalities, oral and pharyngeal sensitivity predispose a patient to gag when
dentures are poorly constructed.
1. A long soft palate
2. Sudden drop at the junction of hard and soft palate
3. An atonic and relaxed soft palate elicits gagging by allowing the uvula to contact the
tongue and the soft palate to touch the posterior pharyngeal wall.
C. Psychological factors- like fear, noise, and smell can also trigger this response.
Some Systemic conditions that have psychosomatic components are1. Temporomandibular pain dysfunction syndrome
2. Atypical facial pain
3. Denture intolerance
4. Burning mouth syndrome
D. Physiologic factorsExtraoral stimuli:

The mere sight of a mouth mirror or impression tray is stimulus enough to cause some
patients to gag..

Acoustic stimuli- The sound of the wife gagging was sufficient to precipitate an attack of
gagging in the husband.

Olfactory stimuli - certain smells may cause a patient to gag. The smell of various dental
substances, cigarette smoke on the dentist fingers and even perfume have been reported
as olfactory stimuli to the gag reflex.

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COMPLETE DENTURE THEORY AND PRACTICE

IMPRESSION MAKING 4

Intraoral stimuli

The palate is divided into hyposensitive and hypersensitive regions. Line drawn through
the fovea palatinae demarcated relatively hyposensitive anterior and hypersensitive
posterior portion.

The tongue was similarly divided into the hyposensitive anterior and hypersensitive
posterior one third.

Landa reported that the upper surface of the posterior one third of tongue is the most sensitive
area in oral cavity.
5. Iatrogenic factorsSensitive tissues may be stimulated because of rough or careless technique and temperature
extremes of instruments or because ofFrom prosthodontic point of view,

use of thin consistency of impression material,

large size impression tray or

Tactile stimulation of soft palate, posterior part of tongue, fauces can also induce
gagging.

Inadequate PPS and loose denture

Overloaded impression trays

Unstable & poorly retained prosthesis-produced movement of the denture base, which
produces a tingling sensation and gagging.

Overextended border of prosthesis particularly in the posterior area of palate and


retromylohyoid space, distolingual part of mandibular denture- this impinges one or more
of the trigger areas and thus produce gagging.

Placing maxillary teeth too far in a palatal direction and mandibular teeth too far
lingually, so that dorsum of the tongue is forced into pharynx during the act of
swallowing.

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COMPLETE DENTURE THEORY AND PRACTICE

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Symptoms
Extra oral symptomsThese include excessive salivation, lacrimation, coughing, fainting or in minority of patients, a
panic attack and sweating; at times a full-body response may occur.
Intra oral symptomsThe patient who gags may present with a range of disruptive reaction; from simple contraction of
palatal or circumoral musculature to spasm of the pharyngeal structures, accompanied by
vomiting.
Trigger Zone of gag reflexGagging may be elicited by nontactile and tactile stimulation of certain intraoral structures.
Five intraoral areas are known as trigger zones:
palatoglossus & palatopharyngeal folds,
Base of tongue,
Palate,
Uvula and
Posterior pharyngeal wall
Nontactile sensations such as Visual,
Auditory and
Olfactory stimuli

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COMPLETE DENTURE THEORY AND PRACTICE

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Gagging severity index (GSI) : The gagging reflex is:


I -Very mild, occasional and controlled by the patient
II.- Mild, and control is required by the patient with reassurance from the dental team
Ill.- Moderate, consistent and limits treatment options
IV -Severe and treatment is impossible
V -Very severe: affecting patient behavior, dental attendance and making treatment impossible.

Management
Before starting any dental procedure detailed history must be taken. Enquire any un pleasant
previous dental treatment experience.
A positive history about gagging will require certain precautionary measures.

a) Psychological management

A firm sympathetic manner of self-confidence on the operator's part.

Assure the patient that no difficulty will be experienced if instructions are


followed and that the discomfort will be minimized as much as possible, being
in any case, only for a short time.

Behavior modification- Generally the objective is to reduce anxiety and


unlearn the behavior that provokes gagging. Relaxation, distraction,
suggestion and systemic desensitization.

Hypnosis

Praise patient

Pleasant environment

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COMPLETE DENTURE THEORY AND PRACTICE

IMPRESSION MAKING 4

Acupuncture-Acupuncture is a system of
medicine in which a fine needle is inserted
through the skin to a depth of a few
millimeters, left in place for a time,
sometimes manipulated and then withdrawn.
Dental treatment was then carried out and the
effectiveness of acupuncture is assessed.

The technique involves the insertion of one, fine, single-use disposable needle of
7mm length into the anti-gagging point of each ear to a depth of 3 mm. The needles
are manipulated for 30 seconds prior to carrying out dental treatment. The needles
remain in Situ throughout treatment and are removed before the patient is discharged.

Acupressure- stimulate the points with gentle finger pressure rather than fine
needles and therefore is a less invasive technique.
To make use of it locate the REN24 point.[ Chengjiang (REN-24)
is an effective acupressure point for controlling the gag reflex during
impression making. ]
It is situated in the horizontal mentolabial groove. Approximately
midway between the chin and the lower lip. Apply light finger pressure with the
index finger progressively increase the finger pressure until the patient feels
discomfort and distension.
The acupressure should start at least 5 min before impression making, continue
through the impression procedure, and be terminated only after the impression has
been removed from the patients mouth. Pressure can be applied by the patient,
dental assistant, or dentist.

Placebo effect
The placebo or suggestive effect of treatment can be very powerful. A recent
systematic review has confirmed that the placebo effect is mediated via
endogenous opioids.

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COMPLETE DENTURE THEORY AND PRACTICE

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b) Clinical techniques

Marble technique- Singers marble technique is a method by which the gag reflex
can be exhausted. It consist of seven steps at Ist visit- no oral examination of any kind was made at the first office visit.
Five rounded, multicolored, glass marbles approximately inch in diameter were
placed on a tray in front of the patient. The patient was told to put the marbles in
his mouth, one at a time at his leisure, until all five marbles were in his mouth.

Since the fear of swallowing the foreign object can induce a gag reflex, the patient
was assured that if he swallows the marble, it could not harm him. Continual
assurance that he would be able to wear dentures was given to the patient at each
weakly visit. He was urged to keep five marbles in his mouth continuously for one
week, except when eating and sleeping.

Roofless Denture- maxillary denture can be reduced to a U-shaped border


situated approximately 10mm from the dental arch.

Matte finish denture : a smooth highly polished surface which is coated with
saliva may produce a slimy sensation which is sufficient to cause gagging in
some patients; a matte finish has been advocated as more acceptable in this
situation.

Training bases- patient is supplied with a series of small to full sized denture
bases. A thin acrylic denture base without teeth is fabricated and the patient is
asked to wear it at home, gradually increasing the length of the time the
training base is worn. Initially 5 min once each day, then twice each day and
so on. After 1 week; 3 min each day, then 15 min, 30 min & 1 hr. anterior
teeth are added and when the patient is able to tolerate it, posterior teeth are
added.

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COMPLETE DENTURE THEORY AND PRACTICE

Progressive desensitization:

IMPRESSION MAKING 4

As sensitive patients will experience the same

difficulty at each succeeding visit and as the wearing of the finished denture
will be difficult, it is advisable to construct a fitting base plate in acrylic on
the first impression and give it to the patient with instructions to practice
wearing it for increasingly longer periods each day until it can be worn for at
least an hour without discomfort.

Modification of edentulous maxillary custom tray- to prevent gagging-attach


a disposable saliva ejector to the base plate in the midline of the tray. It is
easy to fabricate these trays using disposable saliva ejectors at their distal
aspects so that the excess impression materials flow through these ejectors
without triggering the soft palate area.

Increasing the interocclusal distance by either remounting and grinding the


teeth or remaking the denture when the discrepancy was gross.

the

interocclusal distance was inadequate in patients with serious gagging


problems.

Teaching the patient to swallow with their mouth open- it has been
suggested that all patient who gag characteristically swallow with their teeth
clenched, using the teeth, lips and cheeks as a buttress for the tongue to push
against. Teaching the patient to swallow with teeth apart, the tip of the tongue
placed anteriorly on the hard palate, and orbicularis oris relaxed, has been
advocated.

soft blow down splint can be used both in dentate and edentulous patients. It
can be fabricated and adjusted very easily. It guides the tongue to more
favourable position rather than pharyngeal guarding posture.

Soft swallow method by asking the patient to hold the tip of the tongue
behind the upper anterior teeth and undulate the tip back and forth and then do
swallowing with the teeth apart is also found successful to prevent gagging.

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COMPLETE DENTURE THEORY AND PRACTICE

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c) Pharmacological management
1. Locally acting- peripherally acting drugs/ local anesthesia:
They may apply in the form of sprays, gells or lozenges or by injection. The
effectiveness of these agents is limited. When mucosal surface is desensitized, the
patient is less likely to gag.
The deposition of LA around the posterior palatine foramen has been used for patient
who gags.
However, the administration of a local injection may not be possible and may itself
provoke gagging. Further more injection of LA solution may distend the tissue
resulting in an inaccurate impression, which may compromise retention of prosthesis.
A topical anesthetic containing benzocaine (14%), butyl aminobenzoate(2%0 and
tetracaine hydrochloride (2%) can be sprayed on a gauze pad and placed on the back
of the upper arch until the area is obtained.
LA solution and impression material mix : Dispense 1 capsule of LA solution 8ml
of 2% lidocaine with 1 part in 100,000 epinephrine to the plastic measuring cylinder
and then add water to the correct volume. Now to this solution add impression
material, mix thoroughly. Insert the loaded tray gently in the patients mouth and
press until set.
2. Centrally acting drug- it is only a short term solution for severe gagging problem and
should not be used routinely
1. Tranquilizers like chlorpromazine are useful in patient under strain/tension 25100mg
2. Semi hypnotic, antihistamines, parasympatholytics.

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COMPLETE DENTURE THEORY AND PRACTICE

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3. General anesthesia- a minority of patient does not respond to any form of sedation
or behavioral therapy and dental treatment under GA may be appropriate as a last
resort.
3. Conscious sedation-. The use of conscious sedation with inhalation, oral or intravenous
agents may temporarily eliminate gagging during treatment while maintaining reflexes that
protect the patients airway.
Oral sedation may be useful in mild gagging
Intravenous sedation is often much more predictable than oral sedation, and can be
of use in patient were inhalation sedation is ineffective.
1. Desensitize the surface of the mucous membrane with:
a- Phenol mouth washes of one part phenol to eighty parts of cold water.
b- Sucking a tablet made for this purpose.
c-The application of a surface type of local anaesthetic either in the form of cream or
spray. the hard palate, soft palate, cheeks, lips and tongue were swabbed with 2%
pentocaine solution in order to produce topical anesthesia.

d) Surgical technique

Leslie advocated an operation to shorten and tighten the soft palate on healing
the removal of the uvula, This solution has not been accepted.

e) Prosthodontic Management
Reduction of stimuli
The patient should blow the nose to clear any nasal obstruction and then
encouraged in deep, nasal breathing.

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COMPLETE DENTURE THEORY AND PRACTICE

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Explain to the patient that, as soon as the impression is seated, the head may
be brought well forward over the lap and that a bowl will be provided to hold
under the chin to catch any saliva that may run out of the mouth.
Carry out the impression technique using as little material as possible. Avoid
touching the dorsum of the tongue with the back of the tray and seat the
impression as quickly as possible.
Avoid using impression material of thin consistency.
Select appropriate size of the impression tray. Over extensions should be carefully
avoided.
Use fast set material
Use saliva ejector to remove excess saliva
Have the patient sit in upright position with the head tilted slightly downward to
prevent material running to throat
Patients dislike plaster of Paris more than any other material, even when it is flavoured, the
alginates are tolerated slightly better; composition is usually tolerated well, probably owing to its
putty-like consistency and its heat; zinc oxide paste seems to be disliked least of any but this may
be largely due to its only being used in a tray which already fits, though its flavour of cloves
undoubtly helps in some cases.

Distraction maneuvers

Talking to the patient and engaging him in some topics of special interest to distract him

Asking him to breath deeply and audibly through the nose

Asking the patient to raise his hand or foot

Asking the patient to tap his foot rhythmically on the floor

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COMPLETE DENTURE THEORY AND PRACTICE

IMPRESSION MAKING 4

Progressive desensitization:

Construct a fitting base plate in acrylic on the first impression and give it to the
patient with instructions to practice wearing it for increasingly longer periods each day
until it can be worn for at least an hour without discomfort.

Singers marble technique: the patient is asked to practice with marble in his mouth,
gradually the number of marble increased

Patient is allowed to take the tray home and practice insert tray in the mouth every day

Patient is instructed to make presuure on the palate by tooth brush witout making
himself rech.

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COMPLETE DENTURE THEORY AND PRACTICE

IMPRESSION MAKING 4

Summary
Procedures that will help to prevent gagging include:
1. The dentist should:
a) Not mention the subject of gagging
b) Ask whether the patient has had impressions made previously.
2. Before the impression is made:
a) Ask the patient to use astringent mouth rinse and cold-water rinses
b) Seat the patient in an upright position with the occlusal plane parallel with the floor.
c) Ask the patient to take a deep breath and hold the breath while the dentist quickly
checks the size and fit of the tray.
d) Correct the maxillary tray with modeling plastic and leaving sufficient unrelieved
modelling plastic at the posterior border.
3. The impression material must:
a) Have the consistency of thick whipped cream
b) Fast-setting alginate.
c) Set up to a rubbery consistency in few minutes.
4. During the impression procedure:
a) Not overfill the tray with impression material.
b) Seat the posterior part of the tray first and then rotate the tray into position.
c) Force excess alginate in an anterior direction.
d) Ask the patient to: Keep the eyes opened and focused on some small object.
Breathe through the nose.
5. The leg lift procedure is used before and during the making of the impression.
6. Giving all instructions to the patient in a firm, controlled manner.
7. The use of an anesthetic spray is usually contraindicated.
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