Original article

Effects of complete dentures on respiratory performance:

spirometric evaluation

Bulent Piskin1, Cumhur Sipahi1, Omer Karakoc2, Arzu Atay3, Faruk Ciftci4, Canturk Tasci5,
Hakan Akin6,*, Volkan Arisan7, Haldun Sevketbeyoglu8 and Turker Turker9
1
Department of Prosthodontics, Gulhane Military Medical Academy, Ankara, Turkey; 2Department of Otolaryngology, Head and Neck
Surgery, Gulhane Military Medical Academy, Ankara, Turkey; 3Department of Prosthodontics, Gulhane Military Medical Academy
Haydarpasa Training Hospital, Istanbul, Turkey; 4Department of Chest Disease, Gulhane Military Medical Academy Haydarpasa Training
Hospital, Istanbul, Turkey; 5Faculty of Dentistry, Department of Chest Disease, Gulhane Military Medical Academy, Ankara, Turkey;
6
Department of Prosthodontics, Faculty of Dentistry, Cumhuriyet University, Sivas, Turkey; 7Department of Oral Implantology, Faculty of
Dentistry, University of Istanbul, Istanbul, Turkey; 8Department of Chest Disease, Konya Military Hospital, Konya, Turkey; 9Faculty of
Dentistry, Public Health, Gulhane Military Medical Academy, Ankara, Turkey

doi: 10.1111/j.1741-2358.2012.00687.x
Effects of complete dentures on respiratory performance: spirometric evaluation
Objectives: There is a lack of data regarding whether edentulous subjects should remove dentures dur-
ing spirometric measurements or not. The purpose of this study is to determine influences of complete
dentures on spirometric parameters in edentulous subjects.
Materials and methods: A total of 46 complete denture wearers were included in this study.
Respiratory functions of the subjects were evaluated by spirometric tests that were performed in four
different oral conditions: without dentures (WOD), with dentures, lower denture only and upper
denture only. Forced vital capacity (FVC), peak expiratory flow, forced expiratory volume in 1 s and
forced expiratory flow between 25% and 75% were evaluated. The data were analyzed with Friedman,
Wilcoxon and paired-samples t tests (a = 0.05).
Results: Significant differences were found between spirometric parameters in different oral conditions
(p < 0.05). In all spirometric parameters, the most important significant differences were found between
conditions WOD, FVC and with lower dentures (FVC), and WOD (forced expiratory volume in 1 s) and
with upper dentures (forced expiratory volume in 1 s) (p < 0.001).
Conclusion: It was observed that complete dentures may unfavourably affect spirometric values of
edentulous subjects. However, current findings need to be confirmed with advanced respiratory function
tests.

Keywords: edentulism, complete dentures, spirometric evaluation.

Accepted 8 May 2012

offered to the edentulous patient worldwide2,3. To

Introduction
The proportion of elderly people in the population
has increased throughout the course of the 20th
century, particularly in developed countries. As
might be expected, age is one of the most impor-
tant factors in edentulousness. Although ageing
itself does not cause tooth loss, the frequency of
dental and general diseases and functional disabili-
ties increase with advancing age, which may
predispose older people to edentulousness1. There-
fore, total edentulism is a widespread, intraoral
condition among the aged population; complete
dentures are still the most common treatment
ensure sufficient retention and stability, complete
dentures must extend up to the soft palate in the
maxilla and to retromolar tissues in the mandible36.
Thus, the volume of the oral cavity may decrease
and some crucial functions may be disturbed, such
as speech production and chewing efficiency79.
Respiration is one of the most vital functions,
and it can be described as the exchange of gases
between the living organism and the atmosphere
to meet the metabolic demands of the body10. In
the course of oral respiration, oral tissues and
existing dentures are the first contacting structures
of the air passing through upper airways. It has

2012 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd, 19
Gerodontology 2014; 31: 1924
20 B. Piskin et al.
been stated that edentulism produces a decrease in
size and tone of the pharyngeal musculature11,12.
However, it was reported that sleeping without
dentures(WOD) created an adverse effect on the
ApnoeaHypopnea Index, especially in edentulous
patients with respiratory deformation during sleep
support this idea13. Furthermore, Bucca et al.11
advocated that edentulism had an adverse effect
on spirometric measurement. Thus, on pulmonary
function testing (PFTs), there has been some
controversy about whether the edentulous subject
should remove dentures during spirometric
measurements14 or not15,16.
Pulmonary function tests are highly valuable
tools for physiologic evaluation of the respiratory
system, diagnosis of some pathologies, and clinical
case management17. PFTs include a large number
of tests, ranging from simple non-invasive oxime-
try to sophisticated invasive blood gas analysis.
Invasive tests display some implemental difficulties
in physiologic studies, even though they provide
precise results1820. Although reference values,
results, and interpretation may vary individually,
spirometry is widely used throughout general
medicine to assess the mechanical or bellows
properties of the respiratory system by measure-
ment of the dynamic or respired lung volumes
and capacities10,18,21. Thus, spirometric test has
been generally used for evaluating the respiratory
disorders including chronic obstructive lung
disease, pneumonia, and asthma. Compared with
other pulmonary function tests, the spirometric
test has some important advantages, including
being non-invasive and ease of use10,21,22.
The aim of this study was to determine the
effects of complete dentures on spirometric values.
The null hypothesis of the study was that wearing
dentures in edentulous subjects do not produce
significant changes in test results of spirometry.
Materials and methods
This study was approved by the Ethic Committee
of Gulhane Military Medical Academy (Ankara,
Turkey) and executed in accordance with the Hel-
sinki Declaration of 1975, as revised in 2008 in
Seoul, South Korea.
Inclusion criteria of participants
A total of 46 Caucasian volunteers were included
in this clinical study. Participation criteria were as
follows:
Fully edentulous,
Wears complete dentures,
2012 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd,
Wearing existing complete dentures <4 years,
Absence of any complaints from existing
dentures,
Absence of major fabrication faults on existing
dentures,
Having Malampatti Class I soft palatetongue
oropharynx relationship23,
Non-smoker,
Absence of any respiratory disorders such as
asthma or chronic obstructive pulmonary
disease (COPD),
No cardiovascular or other serious systemic
disorders.
Spirometric test procedure
The participants were warned about refraining
from intense physical activity such as walking,
running or climbing stairs 60 min or less before
the test, and about wearing loose-fitting clothes to
allow unrestrained physiologic respiratory move-
ments of the chest and abdomen. The height and
weight of the subjects were taken and recorded
before the test. All patients were informed about
how the test will be performed and the correct
technique was demonstrated. The subjects were
reposed at least 10 min before the tests. Spirome-
try was performed by an experienced technician
in accordance with the proposed standards of the
American Thoracic Society.24,25.
Tests were conducted using a Jaeger Flowscreen
spirometer (North Rhine, Westphalia, Germany) at
four stages for each participant. The first test was
carried out in the without dentures (WODs) oral
condition, and its values were accepted as the
control group. The second test was carried out
with both upper and lower dentures inserted
(WULDs), the third test only with lower dentures
inserted (WLD), and finally, the fourth test with
upper dentures inserted (WUD). All tests were
then carried out in four different oral statuses
(WODs, WULDs, WLD and WUD), and spirometric
parameters such as forced vital capacity (FVC),
peak expiratory flow (PEF), forced expiratory
volume in 1 s (FEV1) and forced expiratory flow
between 2575% (FEF2575) were measured at
each stage of the test. The results of the four
different oral statuses were compared with identify
the effect of complete dentures on selected
spirometric parameters.
Statistical analysis
Data were analyzed with the SPSS 15.0 soft-
ware program (SPSS, Inc., Chicago, IL, USA). The
Gerodontology 2014; 31: 1924
 Spirometric evaluation of edentulous patient 21

Friedman test was used for multiple comparisons Table 2 The mean, maximum and minimum values of
into groups. To perform dual comparisons into spirometric parameters obtained from 46 patients in
groups, the Bonferroni-corrected paired-samples t four different oral conditions.
test was used for regularly distributed variables,
and the Bonferroni-corrected Wilcoxon test was Oral status Mean (SD) Median (MinMax)
used for irregularly distributed variables. The
WODs-FVC 3.05 (0.8) 3.18 (1.524.83)
Pearson test was performed for regularly distrib- WULDs-FVC 2.98 (0.9) 3.14 (1.394.8)
uted variables, and the Spearman correlation test WLD-FVC 2.93 (0.89) 3 (1.34.62)
was used for irregularly distributed variables. The WUD-FVC 2.91 (0.93) 2.96 (1.494.61)
confidence level was set at p < 0.05. WODs-PEF 5.73 (2.38) 5.01 (1.2711.78)
WULDs-PEF 5.51 (2.44) 4.9 (1.3910.86)
WLD-PEF 5.36 (2.19) 4.76 (1.279.77)
Results WUD-PEF 5.41 (2.16) 5.02 (1.59.03)
Sex, age distribution and body mass index (BMI) WODs-FEV1 2.35 (0.82) 2.33 (0.954.02)
of participants are shown in Table 1. The mean, WULDs-FEV1 2.31 (0.81) 2.21 (0.983.9)
WLD-FEV1 2.29 (0.82) 2.16 (0.723.87)
median, minimum, maximum and standard
WUD-FEV1 2.28 (0.82) 2.2 (13.91)
deviation values of spirometric parameters in four
WODs-FEF2575 2.7 (1.4) 2.44 (0.675.33)
different oral conditions are presented in Table 2. WULDs-FEF2575 2.56 (1.41) 2.14 (0.575.34)
The highest mean value was found in the WLD-FEF2575 2.62 (1.47) 2.3 (0.66.3)
WODs condition for each spirometric parameter WUD-FEF2575 2.6 (1.51) 2.2 (0.56.65)
(Table 2). Moreover, the lowest mean value was
seen in the WUD condition for FVC and FEV1. WODs; without dentures FVC; forced vital capacity;
Furthermore, the lowest mean values were WULDs; with both upper and lower dentures PEF; peak
expiratory flow; WLD; with lower denture FEV1; forced
obtained in the WLD condition for PEF, and in
expiratory volume in 1 s; WUD; with upper denture.
the WULDs condition for FEF2575 (Table 2).
FEF2575 ; forced expiratory flow between 25 and 75%.
For FVC and FEV1, WODs values were signifi-
cantly higher than those of WDs, WLD and WUD
values (p < 0.05). No significant difference was
found between WODs and WULDs values for
PEF. However, WODs values were significantly
Table 3 Comparison of spirometric values between
higher than those of WUD and WLD values without dentures (WODs) and three different oral
(p < 0.05). In addition, WODs values were signifi- conditions (WULDs, WLD and WUD).
cantly higher than those of WUD and WLD for
FEF2575 (p < 0.005). There was no significant
Comparisons of spirometric values p
difference between WODs and WLD conditions
(p > 0.05). Comparisons of spirometric values WODs-FVC & WULDs-FVC 0.018a
between WODs and three different oral conditions WODs-FVC & WLD-FVC 0.001a
are presented in Table 3. WODs-FVC & WUD-FVC 0.003a
In all spirometric parameters, the most impor- WODs-PEF & WULDs-PEF 0.321b
tant significant difference was found between WODs-PEF & WLD-PEF 0.003b
WODs-PEF & WUD-PEF 0.024b
WODs-FVC and WLD-FVC (p < 0.001), and
WODs-FEV1 & WULDs-FEV1 0.042*
WODs-FEV1 and WUD-FEV1 (p < 0.001) WODs-FEV1 & WLD-FEV1 0.009a
(Table 3). WODs-FEV1 & WUD-FEV1 0.001a
In all spirometric parameters, high correlation WODs-FEF2575 & WULDs-FEF2575 0.009b
values were found between WODs and WULD, WODs-FEF2575 & WLD-FEF2575 0.057b
WODs-FEF2575 & WUD-FEF2575 0.003b
Table 1 Distribution of the participants according to a
sex, age and Body Mass Index (BMI). Bonferroni-corrected paired-samples t test.
b
Bonferroni-corrected Wilcoxon test.
WODs, without dentures FVC, forced vital capacity.
Number of WULDs, with both upper and lower dentures PEF, peak
participants Age (Mean) BMI (Mean) expiratory flow.
Female 19 59.3 30.6 WLD, with lower denture FEV1; forced expiratory
Male 27 61.6 29.7 volume in 1 s.
Total 46 60.6 30.1 WUD, with upper denture FEF2575, forced expiratory
flow between 2575%.

2012 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd,
Gerodontology 2014; 31: 1924
22 B. Piskin et al.
WLD and WUD (p < 0.001, r > 0.8). All correla-
tive p values were lower than 0.001. Correlation
values are given in Table 4.
Discussion
According the findings from this study, spiromet-
ric values for pulmonary function testing were
affected by wearing complete dentures. Therefore,
the hypothesis was rejected. Indeed, previous
studies2631 showed that there is a strict relation-
ship between orofacial conditions and the upper
airway. However, until the end of the 20th
century, clinical findings were not used for the
evaluation of respiratory functions in different
dental conditions such as partial or total edentu-
lism. The most significant clinical evidence about
the relationship between oral conditions and
respiratory functions emerged in the late 1990s.
Bucca et al.32 reported that Apnoea-Hypopnea
Index (AHI) scores almost doubled during sleep
WOD in a 44-year-old COPS and OSA patient
who began to wear complete dentures because of
total tooth loss after extractions. Cephalometric
analysis of the patient revealed significant nar-
rowing in the anteroposterior oropharyngeal dis-
tance from 1.5 to 0.6 cm. After these striking
findings, they extended their study to six edentu-
lous male OSA patients, and authors observed
that removal of complete dentures significantly
decreased retropharyngeal space and that sleeping
WOD was associated with a decrease in mean and
lowest arterial blood saturation while increasing
AHI scores32. The authors concluded that the
Table 4 The correlations of the results obtained from
spirometric measurements of edentulous patients with-
out dentures (WODs) and three different oral condi-
tions (WULDs, WLD and WUD) with dentures.
WDs WLD
r r
WODs-FVC 0.984 0.976
WODs-PEF 0.947 0.959
WODs-FEV1 0.987 0.978
WODs-FEF2575 0.970 0.966
r, correlation coefficient.
WODs; without dentures FVC; forced vital capacity.
WULDs; with both upper and lower dentures PEF; peak
expiratory flow.
WLD; with lower denture FEV1; forced expiratory
volume in 1 s.
WUD; with upper denture FEF2575 ; forced expiratory
flow between 25 and 75%.
2012 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd,
removal of complete dentures significantly
decreased the retropharyngeal distance in OSA
patients during sleep, and they advised them to
not remove their complete dentures while sleep-
ing to avoid the risk of upper airway collapse13,32.
Likewise, in a study evaluating the effect of
complete dentures on AHI scores carried out on
34 OSA patients, Arisaka et al.33 determined that
wearing complete dentures decreased AHI scores
in 19 patients while increasing the scores in eight
patients during sleep. Interestingly, the improve-
ment of AHI scores did not originate from the
decrease in apnoea scores, but from the reduction
in hypopnea scores. Moreover, there was no
significant difference between different prosthetic
conditions (with and WOD in the mouth) in
regard to mean, the lowest SpO2 indexes and the
desaturation index.
In another study, Bucca et al.11 performed
spirometric tests on 76 edentulous patients [36
asymptomatic patients, 22 chronic obstructive pul-
monary disease (COPD) patients, and 18 interstitial
lung disease (ILD) patients] to determine the effect
of complete dentures on respiratory functions. In
addition, they reported that in asymptomatic and
ILD patients, the pulmonary performance slightly
improved when complete dentures were in the
mouth. The authors added that no significant dif-
ference was found in COPD patients with or with-
out wearing complete dentures. According to
Bucca et al.32, PEFR, FIF50 and FEF50 values
increased in asymptomatic patients and PEFR and
FEF50 values increased in ILD patients. No signifi-
cant difference was determined for FVC and FEV1
values in any patient groups.
Contrarily to the previous studies, Almeida
et al.34 performed polysomnographic evaluation on
23 edentulous patients with OSA. They observed
that wearing complete dentures during sleep was
significantly increased AHI scores in mild cases.
The result of this study was in accordance with that
WUD of Almeida et al. Nevertheless, if it is compared
r with spirometric test, it should be considered that
0.963 subjects have different sleeping positions during
0.962 polysomnography contrary to sitting at upright
0.829 position of the standard spirometry.
0.973 Complete dentures are large devices and may
cause narrowing of the oral cavity. Furthermore,
the thickness of the complete denture (with
artificial teeth) may shift the tongue posteriorly,
causing collapse of the pharyngeal airway space9.
Indeed, the results of this study may be
interpreted as the oropharyngeal airflow being
unfavourably affected by the large coverage of
complete dentures. In this regard, findings of our
Gerodontology 2014; 31: 1924

study are not in accordance with those of Bucca
et al.11 In this study, the highest mean value for
all spirometric parameters was obtained in the
WODs condition. This difference may be due to
different methodological approaches.
One of the most important differences in terms
of methodology is the selection of subject type.
Contrary to Bucca et al.11, only healthy subjects
with a Malampatti Class 1 soft palatetongue
pharynx relationship and no systemic disorders
were selected for this study. Hence, such a
standardisation of subjects provided a homoge-
nous experimental population with a larger
oropharyngeal volume with least airway diffi-
culty35. Another difference between two studies
was the evaluation criteria of the existing
dentures. In this study, the complete dentures of
the subjects were carefully examined by two
experienced prosthodontists in accordance with
Nevalainen36 criteria, being aware that any fabri-
cation error that could lead to the renewal of the
dentures may affect the test results37. Subjects
using their dentures without any complaint, with
an accurate occlusion, articulation and vertical
dimension, and with a satisfying retention and
stability were included in the tests. Owing to the
fact that complete dentures must be renewed
within periods of 5 years, only 4-year wearers
were included in this study38. Therefore, more
coherent test results were obtained. As is apparent
in Tables 3 and 4, this coherence manifested in
strong positive correlations between the results
obtained in four different oral conditions. This
may be interpreted as appropriate completion of
spirometric tests by the subjects.
Although the WOD group had the highest
spirometric values, an idea that oropharyngeal air-
way volume was reduced when dentures were not
in the mouth was generally accepted in the litera-
ture. Spirometric test values can optionally be var-
ied at the same patients during test. Therefore, we
are aware that confirmation of the results of this
study by using polysomnography evaluation is
needed. Invasive respiratory function tests can also
be used as a confirmation method.
The inherent difficulty of determining the
effects of taking the spirometry mouth-piece into
the mouth is another disadvantage of the spirom-
etry test. It was also impossible to determine the
effect on test values of personal talent for taking
the spirometry mouth-piece into the mouth.
We think that patients with dentures took the
spirometry mouth-piece into the mouth better
than patients WOD. Furthermore, it is observed
that patients compliance for spirometry was
2012 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd,
Gerodontology 2014; 31: 1924
Spirometric evaluation of edentulous patient 23
different in all prosthetic conditions from the con-
dition without prostheses, especially during the
expiration phase of the test, since they were
anxious if their dentures would remove from
their mouths when they were performing test.
This observation is supported by the best determi-
nation parameters of the expiration, since
WOD-FEV1 values were significantly higher than
WLD-FEV1, WUD-FEV1 and WULD -FEV1 values.
Conclusion
Within the limitations of this clinical study, it is
observed that complete denture wearing in edentu-
lous subjects with a Mallampati Class I soft palate
tongue relationship may affect FVC, PEF, FEV1 and
FEF2575 spirometric parameters. Although the
many advantages of spirometric test, reference val-
ues, results, and also the interpretations of the test
may vary, the results of this study regarding the
effects of complete dentures on the respiratory per-
formance should be verified with the other
advanced tests. So, this study may lead prosth-
odontists to make new researches on the effect of
dentures on respiratory functions and parameters.
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Correspondence to:
Dr Hakan Akin, Department of Prosthodontics,
Cumhuriyet University, Faculty of Dentistry,
58140 Sivas, Turkey.
Tel.: +903462191010 2794
Fax: +90 3462191237
E-mail: drhknkn@hotmail.com
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