Relationship of Removable

Partial Denture Use to

Root Caries in an
Older Population
Paul S, Wright, PhD, BDS, FDSRCS'
Paul H. Hellyer, MSc, BDS"
David Beighton, PhD'"
Robin Heath, PhD, BDS, fDSRCS"
Edward lynch, BA, BDentSc, FDSRCS"
The London Hospital Medical College
The pattern and severity of root caries in a selected older
popul at i on, living in the communi t y and attending a general
dental practice in Bexhill, East Sussex, England, is repotted.
A total of 146 patients were examined to determine the
relationship among removable partial dentures, their design,
and root caries. Of those patients, 57% wore removable
dentures and had a higher prevalence of exposed root
surfaces and root caries, particularly on abutment teeth. In
addi ti on, root caries lesions on abutment surfaces were
f ound t o be larger and more active than those on
nonabutment surfaces, int] Prosthodont ]992;5:39-46.
R
oot caries may be defined as dental caries that
is either totally confined to the anatomic tooth
root or, while involving the undermining of enamel
at the cementoenamel junction, appears to have
been initiated on the root,' The prevalence of root
caries has been shown to increase with age^-" and
the prevalence of root caries in a selected older
population, living in the community and attending
a general dental practice in Bexhill, East Sussex,
England, has recently been reported,^ In this pop-
ulation, those having removable partial dentures
(RPDs) demonstrated a higher prevalence of
exposed root surfaces and of root caries.
Earlier studies of the effect of RPDs on the
remaining natural teeth demonstrated an increased
prevalence of dental caries in the absence of ade-
quate oral hygiene,'' Later, careful oral mainte-
Department of Prosthetic Dentistry. The London Hospital
Medicai College, Turner Street, London El 2AD. England.
"Department of Prosthetic Dentistry.
'"Hunterlan Dental Research Unit.
''"Department of Conservative Dentistry.
Presented to The British Society for tbe Study of Prosthetic
Dentistry Annuai Conference, Durbsm, 1991.
Supported by the Soutb East Tbames Regionai Health Author-
ity (LORS Project 88/05).
nance was shown to prevent the detrimental
effects associated with RPDs,' More recently, in a
study of 58-year-old men in Finland, those using
RPDs demonstrated less dental caries than those
without a prosthesis, in spite of the rather high
levels of dental plaque and calculus in both
groups,^ None of these studies, however, differ-
entiated between coronal or root caries.
The investigation of the selected older popula-
tion in this study was designed to include infor-
mation about the relationship of RPDs to the
remaining teeth. The purpose was to analyze the
data acquired to determine both the pattern and
severity of root caries in removable partial denture
wearers as well as the relationship of these param-
eters to removable partial denture design.
Materials and Methods
A total of 146 persons (49 males, 97 females)
ranging in age from 56 to 88 years, with a mean of
69,3 years, were examined. All subjects lived inde-
pendently in the community and had a minimum
of 12 teeth. Plaque was removed and the teeth
were dried prior to examination. Each root sur-
facemesial, distal, buccal, and lingualwas
recorded as either exposed, if the cementoenamel
junction was clearly visible above the gingival mar-
gin, or absent. Each exposed root was then coded
as either sound or decayed. Root caries was
k/olume 5, Number ! , 1992
39 The International Journal of PrOilhodontics
ut RPD Use and Root Ca Wright et al
IB 17 16 IE 14 13 12 11 21 23 2i 5 26 27 2
i 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Mandibular Teeth
MESIAL 0 DISTAL BUCCAL 0 PALATALf LINGUAL
Fig 1 Abutment surfaces con-
tacted by ttie denture.
defined as an area of exposed root, at or below
tbe cementoenamel junction, where the colour
and/or texture of the root differed from the norm.
The individual characteristics of each root caries
lesion were recorded. The colour (yeliow, light
brown, dark brown, or black) was assessed against
a colour guide prepared from photographs of root
caries. The depth of cavitation, the vertical and
horizontal dimensions, and the distance of the
iower border of the lesion from the gingival margin
were recorded to the nearest millimetre, using a
periodontal probe. Texture was recorded as either
bard (as hard as surrounding tooth tissue), soft (if
tbe lesion had the spongy texture of actively car-
ious dentine), or leathery (if the lesion was not
obviously soft, but displayed resistance to with-
drawal on probing witb an Ash no. 6 probe). The
presence or absence of removable partial dentures
in each arch was recorded and the relationship of
the prosthesis to each tooth surface was noted.
Surfaces of the teeth were classified as abutment
surfaces if eitber the denture base or a clasp cov-
ered tbat surface.
Means and standard deviations of values were
calculated and compared using the appropriate t
test. Cross tabulations of variables were examined
using the cbi-square test of independence.
Results
There was a range of 12 to 29 teeth with a mean
of 20.16 ( 4,45) teeth per person. Of the? 11,816
tooth surfaces examined, 415 were recorded as
having root caries.
The International lournal of Prosthodontii
40 5, Number 1, 1992
Wright Et al
Relationship of RPD Use and Root Caries
Fig 2 Exposed root surfaces
present on abutment teeth.
18 17 16 15 ia 13 12 11 J1 2 2 2 3 2 i 25 6 27 21
Maxillary Teeth
Mandibular Teeth
DISTAL D BUCCAL PALATAL/LINGUAL
Removable partial dentures were worn by 81
persons (55.5%) and maxillary complete dentures
were worn by 2 persons (1.4%). A total of 52
(35.6%) persons wore one denture and 31 (21.2%)
wore both maxillary and mandibular prostheses.
The majority of the dentures (87) were fabricated
using polyimethyl methacrylate), with or without
stainless steel clasps; 16 RPDs were fabricated
using cobalt-chromium plates; and 9 RPDs utilised
cobalt-chronnium bar designs.
Denture wearers generally had fewer teeth than
non-denture wearers. Mandibular anterior teeth
were present in similar numbers in both groups but
mandibuiar posterior teetb and all maxillary teeth
were more frequently absent in the denture wear-
ers. Tbe number of exposed root surfaces present,
expressed as a percentage of tbe number of
retained tooth surfaces by tootb, clearly demon-
strated tbe greater prevalence of exposed root sur-
faces in those using RPDs.
The most common abutment surface contacted
by the denture was tbe lingual or palatal surface
(Fig 1), Facial abutment surfaces, contacted by
clasps, were mainly the maxillary posterior teeth
and mandibuiar canines and premolars. Because
only those surfaces associated with the denture
were recorded, some surfaces are not represented
(eg, facial surfaces of incisor teeth). The promi-
nence of the maxillary canines in Fig 1 is accen-
tuated by the number of RPDs that contact three
or four surfaces of these teeth. The pattern of
exposed root surfaces on abutment teeth (Fig 2) is
closely related to tbe pattern of abutment surfaces
present.
5, Number 1, 1992 41
The International Journal of Proithodontics
Reladonsliip of RPO Use and Root Cari
Wright et al
18 IT 16 15 14 13 IS 11 !1 22 13 2i 5 26 27 2
Mandibular Teeth
MESIAL 0 DISTAL D BUCCAL
PALATALfLIKGLIAL
Fig 3 Root caries in denture
wearers.
Table 1 Exposed Root Surfaces and Root Caries Expressed
as a Percentage of all Root Surfaces, Exposed and
Unexposed, by Person
Non-
denture Denture
% wearers wearers
Denture wearers
Nonabutments Abutments
Exposed
root
surfaces
Root
27.0
(15.9)
2.1
(2.4)
48.0
(24.5)
5.6
(4.9)
Standard deviation in perenttieses.
" P < .0001.
44.3
(25.6)
4.1
(4.3)
50.3
(25.9)
8.7
(9.2)
The InlernlionaL Journal o Pro^thodontk 42 Volume 5, Number I , 1992
Relalionship of RPD Use and Root Caries
Fig 4 Root caries in non-
denture wearers.
18 17 t6 IS 14 13 1J 11 21 22 23 2S 26 27 2
Removable partial denture wearers may also be
compared to non-denture wearers by calculating
the mean of the percentage of all root surfaces that
are exposed in each individual for each group.
Those having RPDs had almost twice as many root
surfaces exposed. This difference was highly sig-
nificant (Table 1 ), Comparisons between abutment
surfaces and nonabutment surfaces show a smaller
btit still significant difference, with abutnnent sur-
faces more likely to show gingival recession.
The differences in the percentage frequency of
root caries were even more dramatic. Root caries
was 2.6 times as likely to be present in denture
wearers as in non-denture wearers. Among den-
ture wearers, root caries was twice as likely to occur
on abutment surfaces as on nonabutment surfaces;
nearly 9% of the abutment surfaces demonstrated
root caries.
The pattems of the occurrence of root caries
were compared between those having RPDs and
those without. Those having RPDs experienced a
higher prevalence of mesial, distal, and lingual root
caries than did non-denture wearers, whose root
caries was predominantly buccal or palatal on the
maxillary posterior teeth (Figs 3 and 4), The pat-
terns of lesions on abutment surfaces and of
exposed root surfaces were similar.
Characteristics of the root caries lesions were
5, Nun^ber 1, 1992
43 The International lournal of Pmsthodontii
Rel.iliorship of RPD Use and Root Caries
Table 2
Carious
lesions
(mm)
<2
Totals
Vertical Dimension of Lesion
Non-
denture
wearers
91
27
118
Denture wearers
Nonabutments
106
52
160
Abutments
66
52
118
Totals
265
131
396
Table 3
Carious
lesions
(mm
<2
Totals
Horizontal
Non-
denture
wearers
44
73
117
Dimension of Lesion
Denture wearers
Nonabutments
35
125
160
Abutments
16
102
118
Totals
95
300
395
Table 4 Distance from Lower Border of Lesion to Gingival
Margin
Distance
(mm)
<3
Totals
Non-
denture
wearers
117
7
124
Denture wearers
Nonabutments
146
22
168
Abutments
97
21
118
Totals
360
50
410
Table 5 Texture of Root Canes
Texture
Inactive
(hard)
Active
(soft or
leathery)
Totals
Non-
denture
wearers
87
37
124
Denture wearers
Nonabutments
97
76
173
Abutments
58
60
118
Totals
242
173
415
compared between those without RPDs and those
with RPDs, In denture wearers, the abutment sur-
faces had lesions with greater vertical and hori-
zontal dimensions than did the nonabutment
surfaces. Lesions on the nonabutment surfaces in
denture wearers were, in turn, larger than those in
non-denture wearers. These differences were
emphasised by di vi di ng the lesions into two
groups, the smaller lesions measuring < 2 mm and
the larger measuring >: 2 mm (Tables 2 and 3),
Similarly, the distances from the lower border of
the lesion to the gingival margin progressively
increased from root surfaces in non-denture wear-
ers, to nonabutment surfaces in those having RPDs,
to abutment surfaces. More of the lesions in the
latter two groups measured at least 3 mm from the
gingival margin (Table 4).
A greater proportion of lesions in the denture
wearer groups were leathery or soft. If these lesions
are regarded as active lesions and hard lesions are
Tlie International lournai of Prostliodorlii
1 Volun
Wright et al Relationship of RPD Use and Root Caries
considered to be inactive, then the differences are
even more apparent (Table 5). More than half of
tbe lesions on abutment surfaces were active while
only one third of lesions in non-denture wearers
were active. No significant relationship could be
shown between the colour of tbe lesion or the
depth of cavitation and the various groups studied.
Discussion
The study sample in this report was chosen
because of a particular interest in patients attending
general dental practice in a seaside town, with a
large retirement population, in England. It is not a
random sample of an elderly population. In partic-
ular, the selection of persons with a minimum of
12 retained teeth strongly influenced the pattern
of tooth loss demonstrated. Nevertheless, consid-
erations of the characteristics of the sample suggest
that it is very similar to other samples obtained by
random sampling of dentate persons in defined
geographic areas,^
The design of tbe dentures worn by most of the
persons in this study was representative of a partial
denture design commonly used in general dental
practice. The oral and denture hygiene measures
recommended to these patients were not specially
modified or monitored for the study.
These data indicate that denture wearers are
more likely to have exposed root surfaces and
root caries than persons without dentures. How-
ever, whether this represents an effect of the pres-
ence of tbe dentures or a fundamental difference
between the two groups of persons is not estab-
lished. The need for a denture indicates a greater
level of tooth loss, which may indicate a lower
level of dental motivation or even a greater sus-
ceptibility to root caries caused by some unde-
fined factors. The effect of denture wearing in
accentuating the accumulation of plaque is, bow-
ever, well known, ^" In this population, denture
wearers harboured significantly higher salivary
levels of mutans streptococci, lactobacilii, and
yeasts.'^
The increase in the percentage of exposed root
surfaces on abutment surfaces might be expected
where the dentures are predominantly mucosa
supported. The assumption that exposure of the
root surface is necessary for the development of
root caries has not been proven and the root car-
ies pattern is not closely related to recession,^
except for abutment surfaces. However, tbe
increased prevalence of root caries on abutment
surfaces is difficult to attribute to any cause other
than to the presence of tbe denture. No previous
studies have examined the prevalence of root car-
ies specifically related to denture wearing.
In general, root caries lesions were clearly larg-
est on the abutment surfaces and more of those
lesions tended to be active. These findings would
support the hypothesis that covering the surface
of an exposed root with a denture significantly
increases the risk of root caries.
The tendency of lesions to be further from the
gingival margin on the abutment surfaces may be
related to either tbe denture's covering that sur-
face up to its maximum height of contour or the
progressive nature of the gingival recession on
these surfaces. Eurther study is planned on this
aspect.
Conclusions
1. Those using removable dentures have a
greater prevalence of exposed root surfaces
and root caries,
2. Abutment surfaces are more likely to have
exposed roots than nonabutment surfaces
when a removable partial denture is present
and they are twice as likely to have root caries,
3. In denture wearers, root caries lesions on
abutment surfaces are generally larger and are
more likely to be active than those on non-
abutment surfaces. Likewise, lesions on non-
abutment surfaces in denture wearers are
generally larger and are more likely to be
active than those in persons who do not wear
dentures.
References
1. Hellyer Ph), Lynch E: Root caries-diagnosis, epidemiol-
ogy, aetiology and prediction, in Tay WM, Rear S (eds|:
Genersi Dental treatment. London, Kluwer Publishing,
1989;4,1.8:1-18,
2. Kalz RV, Hazen SP, Chilton N, Mumma RD: Prevalence
and intra-oral distrihution of root caries in an adult pop-
ulation. Caries Res 1982;16:265-a71.
3. Miller A|, Brunelle |A, Carlos |P, Brown L|, Loe H: Oral
Heaith of United States Adults, publication No, 87/2868,
Bethe5ds, National Institute for Dental Research, 1987,
4. Vehkdlahli M: Occurrence of root caries and factors relat-
ing to it, Proc Finn Denf Soc1987;83:l-99,
5. Hellyer PH, Beighton D, Heath MR, Lynch E: Root caries
in older people attending a general dental practice in East
Sussex. rDenf/1990;169:201-206.
6. Carlsson GE, Hedegard B, Kolvumaa KK; The current
place of removable partial dentures in restorative den-
tistry. Dent Clin Nortfi Am 1970;14:553-569.
7. Bergman B, Hugoion A, Olsson CO: Caries and peri-
odontai status in patients fitted with removable partial
dentures, ; Clin Pefio<ontoM977;4:134-146,
5, Number 1, 1992
45
The Internationa i of Prosthodontics
Relationship of RPD Use and Root Carit
8. Lappaiainen R, Koskenranla-Wuorinen P, Markkanen H:
Periodonial and cariologital 5latus in relation to different
combinations of removable dentures in eiderly men. Ger-
Oont/es19e7;3;122-l24,
9. Brill N, Tryde G, Stoltze K, Ei Ghamrawy EA: Ecologie
changes in the oral cavity caused by removable partial
dentures.; Prosthet Dent 1977;3B: 138-148,
10. Addy M, Bates IF: The effect of partial dentures and chior-
hexidine gluconate gel on plaque accumulation in the
Wright et al
absence of oral hygiene. ; Clin Periodontol 1977;4:4I -47.
11. Stipho HDK, Murphy WM, Adams D: Effect of oral
prostheses on plaque accumul at i on. Br Dent I
1978;145:47-S0.
12. Beighton D, HellyerPH, Lynch E, Heath MR: Salivary lev-
els of mtitans streptococci, lactobaalli. yeasts and root
carie5 prevalence in non-institutionalised elderly dental
patients. Community Dent Oral Epidemiol 1991 ;19:302-
307.
Literature ADstracts .
Assessing Neck Extension-Flexion as a Basis for
Temporomandibuiar Joint Dysfunction
Extension-flexion injury of the muscles of the neck is a commoniy encountered consequence ot motor
vehicle accidents. Often, temporomandibuiar joint syndromes and myotascial pain are subsequentiy
reported with the extension-fiexion motion cited as the causative event. Tfie article assesses the
proposed mechanism of injury, points out misconceptions in the previously publisfied physical and
biochemicai analyses, and compares the magnitude and direction of actual forces in extension-flexion
events to those that would be expected to occur in routine nontraumatic events. The authors state
that normal physiologic activity of mastication possesses a greater potential to produce traumatic
injury to the temporomandibuiar joints, whether caused by mechanical force at the joint or induced
by myospasm, than does mild-to-moderate extension-flex i on motion of the cervical spine.
Howard HP, Benedict JV, Haddin JH, Smith HL. J OraJ MaiiHofac Surg 1991 ;49:1210-1213. Reterences: 6. Reprints:
Df Hicfiara P. Howara, Biodynamic Research Corporation. 9901 I H 10 West, Suite 1000, San Antonio, Texas
78239.Jon D. Wagner, MD. DOS. University o New Mexico Medical Center. Albuquerque, Wew Mexico
Repairs Wifh Visible Ligfit-Curing Denture Base
Materials
The strength of Traid VLC resin, used as a repair material, was examined. The results were compared
to a uto polymerizing acrylic resin. Sixty rectanguiar plates, fabricated from either Triad VLC or a heat-
activated denture base resin, were tractured and then were repaired with either Triad VLC or
autopoiymerizing acrylic resin. The highest mean transverse bending strength and mean fracture
toughness were obtained for heat-activated acrylic resin samples repaired with autopolymerizing
acryiic resin. The lowest strengths were found with Triad sampies that were repaired with Thad. it is
proposed that the low strength of the Triad repair specimens can be attributed to the high viscosity
and poor adhesive properties ot the material compared to autopoiymerizing acryiic resin.
Andreopouloa AG, Polyzois GL. Oemetriou PP. QuiVilessence ynn991;22(9 703-706. Reterences: 19. Reprints; Dr
G.L Poiyzois, 15 Msandrou Street, 1152B Atliens, Greece.-EsWer J. Penn, DOS, Department o Veterans Affairs,
Veterans Administration Medical Center, Maniiattan, New York
atonal Journal of Prostliodortic 46 5, Number I , 7992