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Revista Facultad de Odontología Universidad de Antioquia

Print version ISSN 0121-246X

Rev Fac Odontol Univ Antioq vol.25 no.1 Medellín July/Dec. 2013

 

TOPIC REVIEW

 

SALIVA AND ALTERNATIVE ADHESIVE SYSTEMS FOR COMPLETE DENTURES1

 

 

Javier Enrique Méndez Silva2; Cristhian Camilo Madrid Troconis3; Lesbia Rosa Tirado Amador4

 

1 This study was financed by Universidad de Cartagena, which supplied databases to access scientific articles

2 Dentist. Universidad de Cartagena. Oral Rehabilitator, Universidad de Buenos Aires. Implantologist, Universidad Católica de Argentina

3 Dentist. Universidad de Cartagena. Associated Researcher, Madefouc Research Group on Dental Materials

4 Rural Dentist at the Research Depratment of Universidad de Cartagena School of Dentistry. Associated Researcher, Madefouc Research Group on Dental Materials. E-mail address: lesbiarosa_tiradoamador@hotmail.com

 

SUMBITTED: FEBRUARY 19/2013-ACCEPTED: AUGUST 13/2013

 

Méndez JE, Madrid CC, Tirado LR. Saliva and alternative adhesive systems for complete dentures. Rev Fac Odontol Univ Antioq 2013; 25(1): 208-218.

 

 


ABSTRACT

Complete dentures may present biomechanical problems related to retention and stability, which can arise from professional errors during functional tissue impression, as well as during prostheses design and manufacturing, in addition to errors during the laboratory phase by technicians or simply by biological changes of adjacent tissues, such as bone resorption, maxillaries atrophy, and decreased salivary flow. The latter is a circumstance of major concern because saliva plays an important role in prosthesis retention as a "natural adhesive"; therefore, various alternative retention methods have been suggested over time, especially in terms of complementary adhesive systems whose properties have been improved by including other compounds such as synthetic polymers, antimicrobial agents, colorants, additives, and preservatives, which are available in different commercial presentations. The goal of this review is to highlight the properties of saliva as a natural adhesive and the possibility of improving denture retention when it lacks the ability to guarantee the desired results by additional adhesive systems, which are a safe and effective alternative, provided that the dentist is responsible and competent enough to prescribe the right adhesive in relation to specific patient conditions to avoid undesirable situations such as systemic effects due to prolonged excessive intake of zinc salts included in some commercial presentations of denture adhesives.

Key words complete denture, adhesives for complete denture, retention, stability, saliva, sodium carboxymethylcellulose (DeCS Bireme).


 

 

INTRODUCTION

Despite the existence of oral health promotion and prevention programs, periodontal treatments, and restorative dentistry for preserving teeth in the mouth, there are still completely edentulous patients in our population, who require prosthetic treatments to provide them with solutions for specific needs such as esthetics and self-esteem.1 However, choosing a treatment plan requires certain conditions; for instance, making implant-supported prosthesis requires sufficient remnant bone and absence of systemic conditions.2 There are other influencing factors such as increased treatment costs, which prevents all patients from being candidates for this option, so complete denture is still an affordable option among a range of rehabilitation treatments. Although complete dentures are conventionally used, they present some biomechanical problems related to retention and stability since the bone and connective tissue underlying the denture base changes constantly,2 which in the mid-run may cause instability and lack of denture retention, directly affecting comfort3 and the patients' psychological condition, reducing confidence when smiling, eating or talking for fear of accidentally dislodging the prosthesis.4, 5 Saliva is another key factor to achieve prosthetic retention since it is the patients' natural adhesive; however, in some circumstances it is not sufficient and adhesive systems are needed to satisfactorily complement the action of saliva.6

AN OVERVIEW OF SALIVA

The human body produces various fluids in charge of several functions in organs and tissues. In the oral cavity, saliva plays an important role due to its many properties and functions in oral mucosa and dental structures.6 Saliva is produced by three pairs of major salivary glands (parotid, submandibular, and sublingual) by 93%, plus numerous minor salivary glands that produce the remaining 7%.7 Salivary gland secretion may vary; parotid and submandibular glands produce serous saliva while smaller and sublingual glands located on the surface of the oral, palatine, and sublingual mucosa of the oral cavity (approximately 300-400) are responsible for the production of mucous saliva.8 Salivary glands are formed by a specialized cell epithelium containing two segments with defined function and morphology; these structures are interspersed acini and ducts coupled with a glandular system of ducts of varying complexity.9

Saliva has a mixed composition: 99% of it is made of water and the remaining 1% is comprised of organic and inorganic molecules10 including mucin, glycoproteins rich in proline, lysozyme, lactoferrin, lactoperoxides, cystine, histatins, immunoglobulins, IgA, bicarbonate, phosphate, calcium, fluoride, amylase, lipase, ribonucleases, and proteases.11 It is considered to perform multiple actions including lubrication, maintenance of mucosal integrity, antimicrobial activity, cleaning, food preparation for swallowing, digestion, taste, and speech.12-14

SALIVA AS A NATURAL ADHESIVE SYSTEM

Patients with removable prosthesis need the presence of saliva to increase retention, since the mechanics of salivary moistening creates cohesion, adhesion and tension between surfaces.15 Cohesion refers to the junction between surfaces, bodies or particles of the same nature.16 The mouth requires interaction among salivary flow particles in order to facilitate adhesion, which is defined as the bonding between materials or bodies of different nature; in the case of oral environments with prostheses, saliva promotes adhesion by acting as an interface between the oral mucosa epithelium and the denture's base, by creating vacuum pressure on the region where the denture rests.17 While it is true that dentures move inside the mouth, especially during certain functions, the alternating activity of the presence of saliva and its swallowing facilitates prosthetic retention.15-17

The adhesive effect of saliva may be explained by one of its components: mucins, a group of glycoproteins which intersect structurally through hydrogen bonding, hydrophobic electrostatic interactions, and van der Waals forces to generate high viscosity and to produce mucinous substance that facilitates gelling of the surrounding structures and that depends on the number of these molecules in saliva.18 During sol-gel transitions, the amount of polymer molecules of viscous solutions is the determining factor for saliva having viscoelastic properties18 that help maintain the interactions between mucosa and the denture's base. But often saliva does not adequately fulfill its natural adhesive functions, causing retention difficulties as some systemic conditions can decrease salivary flow.20 These include physiological conditions such as age, the number of teeth in the mouth, gender, body weight, or time of the day, systemic diseases such as hypertension, depression, malnutrition, dehydration, diabetes, immune disorders such as Sjögren syndrome,21-23 and salivary flow disorders due to use of drugs, such as tricyclic antidepressants, sedatives, tranquilizers, antihistamines, antihypertensive agents, cytotoxic agents, antiparkinsonian, and anticonvulsants.24-26 When the natural adhesive system offered by saliva is not enough, a complementary adhesive system may be used.

ADHESIVES FOR COMPLETE DENTURES

Commercial adhesives are substances intended to improve the relationship between the denture's base and underlying tissue, as well as stability and functionality. Some studies show that about 15 to 33% of the edentulous population with complete prosthesis use complementary adhesive systems.27, 28 Although the geriatric population is the one that most uses these products, dentists tend to avoid prescribing these alternative systems since they think it implies an inability to perform good overall prosthodontic rehabilitation; it is even common to find dissatisfied patients who may need to use these complementary systems even after undergoing previous required adjustments.27 Although prosthetic adhesives provide edentulous patients with great advantages, the earlier literature mentions unfavorable characteristics such as vertical dimension increase, mucosa hypersensitivity reactions, and altered oral flora.28-30 The results of more recent studies have changed this paradigm and instead they maintain that adhesives offer more advantages, such as improved prosthesis stability, increased retention and strength to dislocation—which can be calculated by instruments such as gnatodinamometers or gnatometers—, and reduction in discomfort in the mucosa; other advantages include reduction in the frequency with which the clinician should adjust the structure, as well as in the frequency of mucosa irritation and ulceration as adhesives act as a resilient agents and prevent direct contact with surfaces.31-35 Similarly, they help improve patients' phonation, as they favor bonding to the mucosa and therefore patients can pronounce with much more energy without experiencing prosthesis movements.36

THE HISTORY OF DENTURE ADHESIVES

The history of denture adhesives dates back to the eighteenth century, although the literature reports few studies on the field, and research has been limited to manufacturing companies. The first studies and publications date from the nineteenth century in the United States of America, home of the leading manufacturers of adhesives in their commercial presentations. These products used to be combined with various plant-based resins such as karaya, acacia, tragacanth, and acemannan, which in contact with saliva or water become a mucinous gel that adheres to the denture's base and the underlying mucosa. The first patent was obtained in 1913 in the United States and the American Dental Association referred to it in 1935.37, 38

MECHANISM OF ACTION OF ADHESIVE SYSTEMS

Despite the scarce documentation available in the literature on complementary systems for denture retention, in 1991 Shay26 described the actual mechanism by which peripheral seal increases producing denture retention. For him, the adhesive components increase their volume when undergoing volumetric growth of a hygroscopic nature, due to the hydrophilic nature of some components, producing increases ranging from 50 to 150% and thus solving the discrepancies between the underlying mucosa and the denture's base; at the same time they decrease odors, bad tastes and food retention, so common in denture maladaptation.sup 39, 40

TYPES OF ADHESIVES AND THEIR CHEMICAL COMPOSITIONS

Currently there are various presentations that are now optimized compared to the initial products, by improving their organoleptic and mechanical properties. Adhesive creams, pads or strips and powders are used in different cases. However, creams are the patients' favorites because of their effectiveness and ease of application. 41 According to the American Dental Association (ADA), the common components of adhesive systems are classified in three groups: 1) those responsible for adhesion, such as pectin, cellulose and its byproducts, and synthetic polymers such as polyvinyl acetic acid and polyethylene oxide, 2) antimicrobial compounds like hexachlorophene and sodium tetraborate, and 3) additives, colorings and flavorings.42

Another classification may be established according to the components' solubility in the oral environment (soluble-insoluble).

The active ingredients of soluble adhesives generally include short-term action polymers such as sodium carboxymethylcellulose (CMC) and long-term action polymers such as methyl cellulose polyvinyl ether (PVM-MA), which are responsible for the hygroscopic growth of the product and the adhesive properties during the initial hydration process. On the other hand, insoluble components are polypropylene and cellulose, which have a long-term effect and may last between 6 and 12 hours.43

 

INDICATIONS

It is important for the dentist to prescribe the accurate adhesive system depending on each case, to educate and to monitor the overall prosthodontic treatment. These systems may be indicated for well adapted prosthesis to improve patient comfort, and in prosthetic remodeling due to the post-surgery difficulties to hold dentures in place. They are also useful for psychological reinforcement since patients usually lack confidence to talk, eat, laugh, and to perform any activity involving social interaction, even when their dentures are well adapted; therefore, small amounts of adhesive help control this situation in limited economic conditions since not all patients can afford treatments that offer greater biomechanical stability such as implant-supported prostheses.44-46

 

CONTRAINDICATIONS

Some situations are contraindicated for complementary adhesive systems and therefore they require dentist's supervision. Such cases include broken or poorly made dentures, or patients with disorders such as tissue hyperplasia, allergy to any of the components, poor oral hygiene, or in specific cases in which the clinician is not able to monitor the patient.44-46

 

CYTOTOXICITY OF DENTURE ADHESIVES

AWhile the adhesive systems available in the market are very effective for solving complete denture retention problems and to improve their stability providing patient comfort, some of their presentations include chemical compositions with zinc salt content, which have been reported by several studies to be harmful at high levels. One undesired effect is bone marrow suppression and polyneuropathy, with sensation of paresthesia and numbness of the extremities; other signs include loss of balance and difficulty in walking.47 In hypocupremia patients, denture adhesives have been identified as a source of zinc due to indiscriminate use of commercial products with high levels of zinc salts.48

Clinical conditions with prolonged copper deficiency in blood may cause motion and sensory problems due to high concentrations of zinc in some commercial presentations of denture adhesives.48 Geriatric patients with complete dentures and concomitant use of adhesives containing zinc are prone to maintain high concentrations of this metal in the small intestine, which triggers increased expression of the so-called metallothionein proteins, which tend to attach to zinc ions in order to prevent excessive absorption in the body; however, these proteins also show affinities with copper ions.49 Thus copper ingested in the diet cannot be absorbed by the body and is released through feces, aggravating the condition of hypocupremia patients;47 it is therefore important to maintain a balance between normal serum levels of copper (100-200 g/100 ml ) and zinc (75-120 g/100 ml) in order to maintain the functions related to bone marrow and neuronal activity.50

 

CONCLUSIONS

 

It is important to understand that denture retention depends on many conditions, such as patient's local and systemic status, the prosthesis design and manufacture, and the natural adhesion system that saliva offers; however, the latter often fails to supply the functional and aesthetic requirements that are obtained with proper apparel only. Saliva does not guarantee retention on bone bases, so it is necessary to use additional adhesive systems available in various commercial presentations that should be indicated depending on each particular case. The professional providing care must know the different alternatives of adhesive systems, as well as their advantages and disadvantages, in order to properly advice and educate the patient seeking the maximum possible treatment success.

 

CONFLICT OF INTEREST STATEMENT

The authors declare that this study does not have any conflict of interest. The resources used for this topic review consist of databases of which Universidad de Cartagena is a member, in order to access the consulted articles.

 

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