KEYWORDS: partial removable dental prosthesis, mucosal pain, pain sensitivity, anxiety, awake bruxism, oral dryness. Accepted for publication 22 May 2016.
Journal of
Oral Rehabilitation
Journal of Oral Rehabilitation 2016 43; 683–691
Factors associated with mucosal pain in patients with partial removable dental prostheses H. KUMAGAI, K. FUEKI, E. YOSHIDA-KOHNO & N. WAKABAYASHI
Tokyo Medical and
Dental University – Removable Partial Prosthodontics, Tokyo, Japan
SUMMARY The aim of this study was to investigate factors associated with mucosal pain in patients with partial removable dental prostheses (PRDPs). In this hospital-based cross-sectional study, 333 patients wearing 500 PRDPs (mean age 714 years, men 333%) were consecutively recruited from prosthetic clinic of a dental hospital in Japan. Subjects rated pain intensity and frequency of denture-bearing mucosa. An examiner recorded age, gender and systemic diseases as well as dental, mucosa, denture, sensory, behavioural- and psychological-related characteristics that were possibly associated with the mucosal pain. Multivariate analyses were performed to analyse factors related to mucosal pain. Pain intensity was rated as more than score 0 (presence) in 342% (171/ 500) PRDPs, and pain was experienced after denture delivery in 428% (214/500) PRDPs. Logistic regression analyses showed that younger age,
Introduction Recently, the proportion of the elderly population has increased rapidly in many developed countries, and the prevalence of edentulous jaw and the number of missing teeth is decreasing (1). Dental implants are becoming more popular in prosthodontic treatment. However, partial removable dental prostheses (PRDPs) will continue to be provided widely as a treatment option for replacing missing teeth owing to socioeconomic reasons (2). Patients with oral prosthetics have a variety of oral healthrelated problems related to masticatory function, speech, aesthetics, pain and discomfort with denture wear as well as psychological problems (3). Pain at © 2016 John Wiley & Sons Ltd
mucosal damage, poor mucosal condition, bone prominence, poor residual ridge, higher pain sensitivity, presence of awake bruxism, perception of oral dryness, interim denture wear and high number of missing teeth were significant independent predictors for the presence of the mucosal pain intensity and/or frequency (P < 005). Multiple factors are associated with mucosal pain in patients with PRDPs. Oral mucosal characteristics, age, pain sensitivity and behavioural factors seem to be more critical for mucosal pain than distribution of missing teeth and number of abutment teeth. KEYWORDS: partial removable dental prosthesis, mucosal pain, pain sensitivity, anxiety, awake bruxism, oral dryness Accepted for publication 22 May 2016
the denture-bearing mucosa is one of the most frequent problems in patients with removable dentures (4, 5). For example, 21% of PRDP wearers reported soreness on the denture-bearing mucosa while chewing (6), 30% of complete removable dental prostheses (CRDPs) or PRDP wearers experienced pain when using dentures (7) and 51% of patients with CRDPs or PRDPs experienced aching spots while chewing (8). Furthermore, mucosal pain during denture wear was associated with impairment of chewing ability (7). Thus, the relief of mucosal pain is important for improving oral function and oral health quality of life in denture wearers. A number of cross-sectional studies have reported factors associated with mucosal pain (5, 6, 8–13). In doi: 10.1111/joor.12417
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H . K U M A G A I et al. patients with CRDPs, denture base shape (9); imbalanced occlusion (9); mucosal damage such as redness, abrasion and traumatic ulcer (5, 10); residual ridge resorption (11); thin oral mucosa (12); bone prominence (12); wearing time (13); chewing hard foods (13); and oral dryness (6, 8) were associated with mucosal pain. On the other hand, the information in patients with PRDPs is limited to traumatic ulcer (10) and oral dryness (6, 8). Furthermore, most of the above-cited studies did not analyse data using multivariate analysis; thus, relative importance of factors related to mucosal pain is not well documented. In addition, sensory characteristic such as pain sensitivity (pressure pain threshold; PPT) and psychological factor such as anxiety level are known to be associated with pain (14, 15). Therefore, we hypothesised that multiple factors such as patient, dental, mucosal, denture, sensory, behavioural and psychological characteristics could be associated with mucosal pain in PRDP wearers. The aim of this study was to elucidate factors associated with mucosal pain in patients with PRDPs.
Materials and methods Study sample Patients with PRDPs who had undergone prosthodontic treatment with new dentures or presented for denture adjustment or oral maintenance care at the prosthetic clinic at the dental hospital of Tokyo Medical and Dental University in Japan were consecutively recruited. Patients with acute dental pain or oro-facial pain were excluded from the study. Each subject received a written and oral description of the experimental procedures and provided informed consent prior to enrolment into the study. All experimental procedures were approved by the Institutional Review Board (#1034). Rating of mucosal pain Subjects were asked to rate pain intensity (PI) on denture-bearing mucosa while wearing dentures on an 11-point numerical scale (0: no pain – 10: worst pain imaginable) and pain frequency (PF) between the setting of the denture to the day of data collection on a 5-point Likert scale (0: absence, 1: few, 2: often, 3: very often and 4: always).
Clinical interview and examination Subjects were interviewed using questionnaire including questions on demographic information such as age, sex, anamnesis, prescribed drugs, smoking habits, awareness of awake bruxism (0: absence – 3: frequently) and oral dryness while eating (0: absence – 4: always). The residual ridge shape was scored depending on section shape (0: narrow and low – 3: wide and high), area (0: small – 3: large), strike (0: concave – 3: flat) and position of attached gingiva (0: shallow – 3: deep), and the sum of the four scores was indicated as residual ridge score (0: worst – 12: good). Mucosal condition under the denture base was rated on a 4-point scale (0: flabby – 3: firm). Residual ridge and mucosal condition of the overall denturebearing area in the examined arch were evaluated for each subject. If a subject had multiple denture-bearing areas in each examined arch, the worst score was employed for statistical analyses. Presence/absence of mucosal damage (redness, abrasion and traumatic ulcer) and bone prominence (maxillary/mandibular torus) at the denture-bearing area were recorded. The redness was defined as a local hyperaemia, abrasion as a local hyperkeratosis and traumatic ulcer as a round or oval epidermis defected lesion. All clinical examination was performed by a single examiner calibrated prior to the examination. Pain sensitivity For evaluating individual pain sensitivity on oral mucosa, pressure pain threshold (PPT) was measured by a single examiner using a dial tension gauge* . The subjects sat on a dental chair with his/her head supported by the headrest in a quiet room. The examiner set the tip of the dial tension gauge on the surface of attached mucosa in the median of maxillary central incisors (remote region from denture-bearing mucosa) and then applied load perpendicularly to the mucosal surface. In subjects with missing maxillary central incisors, the load was applied at a point below 3 mm from a labial maxillary fraenum. The load was increased gradually at a constant rate of 50 N/s calibrated prior to the measurement, and the load when the subject felt an initial pain was recorded as the PPT. The load rate influenced PPT, and the most
*Teclock, Nagano, Japan © 2016 John Wiley & Sons Ltd
MUCOSAL PAIN IN DENTURE WEARERS reliable measures could be obtained at 50 N/s (14). The PPT measurement was performed three times with a 3-min interval, and the minimum PPT in the last two trials was used for statistical analysis. The lower PPT indicates higher pain sensitivity. Assessment of anxiety level Anxiety was assessed using a validated self-administrate inventory, Japanese version of the State-Trait Anxiety Inventory (STAI) Form X (Sankyobo) (16). The STAI has two series of questionnaires consisting of 20 items that are designed to assess response to specific anxious situations (state anxiety) and a general aspect of anxiety-related personality (trait anxiety), respectively. Subjects responded to each item (1: absence, 4: always), and total scores of each questionnaires are calculated for state and trait anxiety score (20: lowest anxiety – 80: highest anxiety) (17). Statistical analyses Bivariate and multivariate analyses were performed to identify factors related to PI and PF scores. As the PI and PF scores were skewed, score ≥1 was dichotomised as (1) presence and (0) as no pain for PI and absence for PF in multivariate logistic regression analyses. Associations between PI and PF scores and between PPT and state/trait anxiety scores were analysed using Spearman’s rank correlation coefficient (q). SPSS ver. 16.0 (IBM Japan Inc, Tokyo, Japan) was used for statistical analyses. P-values of 2 Denture type Interim PRDP (reference) Definitive PRDP Residual ridge score (0: poor – 12: good) Mucosa condition score (0: poor – 3: good) Mucosa damage Absence (reference) Presence Bone prominence Absence (reference) Presence Pressure pain threshold (N/10) Oral dryness (0: absence – 4: very often) Awake bruxism (0: absence – 3: frequently) State anxiety score Constant
Pain P
Odds (95% CI)
Beta (SE)
P
Odds (95% CI)
0.44 (0.15)
0.004
0.65 (0.48–0.87)
0.28 (0.14)
0.041
0.76 (0.58–0.99)
0.00 0.54 (0.28)
– 0.053
1.00 1.72 (0.99–2.97)
0.00 0.16 (0.25)
– 0.525
1.00 1.17 (0.72–1.92)
0.00 0.51 (0.27)
–
0.059
1.00 0.60 (0.36–1.02)
0.00 0.38 (0.24)
0.107
1.00 0.68 (0.43–1.09)
0.00 0.04 (0.49)
0.944
1.00 0.97 (0.37–2.54)
0.00 0.65 (0.46)
0.159
1.00 1.91 (0.78–4.70)
0.00 0.15 (0.33) 0.10 (0.04)
– 0.649 0.020
1.00 1.16 (0.61–2.21) 1.11 (1.02–1.20)
0.00 0.05 (0.30) 0.09 (0.04)
– 0.858 0.022
1.00 0.95 (0.53–1.70) 1.09 (1.01–1.18)
0.00 0.61 (0.40)
– 0.129
1.00 0.54 (0.25–1.20)
0.00 0.06 (0.34)
– 0.856
1.00 1.06 (0.55–2.05)
0.00 0.27 (0.29)
– 0.359
1.00 0.76 (0.43–1.36)
0.00 0.10 (0.26)
– 0.713
1.00 0.91 (0.54–1.52)
0.00 0.51 (0.28) 0.01 (0.06) 1.29 (0.25)
– 0.072 0.932
