brought to you by
Rationale for Adhesives in
Complete Denture Therapy
Joseph J. Massad, DDS; William J. Davis, DMD, MS;
Richard June, DDS; William A. Lobel, DMD;
Joseph Thornton, DDS; David R. Cagna, DMD, MS
The number of people in the United States requiring removable prosthodontic therapy
has increased dramatically over the past twenty years.1-3 Current predictions suggest
that over the next two decades, the declining incidence of edentulism4,5 will be more than
compensated by a 79% increase in adults over 55 years of age.6 In the United States
alone, the number of adults requiring complete denture therapy is expected to increase
from 33.6 million in 1991 to 37.9 million in 2020.6 Considering the projected decrease in
edentulism, the expected increase in the number of older individuals, and the need for
both maxillary and mandibular complete denture by many patients, it has been estimated
that the 56.5 million complete dentures made in the United States in 2000 will increase
to more than 61 million dentures in 2020.6
Marked atrophy of alveolar bone following tooth loss7-9 complicates prosthodontic
rehabilitation. This phenomenon has been termed “reduction of residual ridges” by
Atwood7, who considered it a major oral disease entity. Although consensus regarding
etiology is lacking,10-16 alveolar bone and oral soft tissue changes observed in denture
wearers may be an inevitable consequence of the loss of natural teeth, tissue
remodelling, occlusal factors, and/or prolonged denture wear.16-26 Alveolar bone loss
subsequent to long term edentulism may be severe and the process may progress
throughout life.19,20,25,27,28 Although generally more pronounced in the mandible and
characterized by individual variability in volume and rate,7,15,20,21,24,26,29,30 advanced reduction
of residual ridges presents a significant restorative challenge.
Edentulous patients encountered in dental practice may have been wearing complete
dentures for decades. Significant atrophy of alveolar processes following the loss of
natural teeth is an all too familiar consequence of long term edentulism. This oral
condition complicates both the dentists’ ability to considered as an etiologic factor in alveolar
construct adequate complete dentures, and the resorption. Though difficult to substantiate, an
patients’ ability to successfully manage their new association may exist between residual ridge
prostheses. reduction and osteoporosis.7,37-39
More than 50 years ago it was suggested Complete Denture Stability & Retention
that local factors were primarily responsible For edentulous patients, successful denture
for edentulous ridge resorption. Schlosser31 therapy is influenced by the biomechanical phe-
implicated ill-fitting dentures and associated nomena of support, stability, and retention.40-42
trauma to oral tissues as the primary causes Retention, or the resistance to movement of the
of rapid destruction of the denture bearing denture away from the supporting tissues, is criti-
structures. He lists faulty impressions, excessive cal. Unfortunately, the physical, physiological,
occlusal vertical dimension, inaccurate centric jaw and mechanical factors associated with denture
relationships, and occlusal disharmony as major retention are not completely understood. Physical
contributing factors. Lammie32 suggested that a forces influencing denture retention are believed
detrimental external molding force may adversely to include adhesion, cohesion, capillary attraction,
impact the residual bony ridges as overlying oral surface tension, fluid viscosity, atmospheric
soft tissues contract or atrophy with time. This pressure, and external forces originating from
molding force may, in turn, accelerate resorption the oral-facial musculature.43-49 Of these, the
of the edentulous ridges. interfacial surface tension developed as a result
of the saliva layer between the denture base and
In a review of 18 complete denture patients, the supporting soft tissues is quite important.
Atwood33 suggests that the deterioration of This is particularly true for maxillary prostheses.
edentulous ridges is a complex biophysical Retention is realized as the saliva layer maxi-
process involving functional factors (i.e., the mizes contact with approximating prosthetic and
intensity and duration of applied forces), mucosal surfaces. Therefore, xerostomic patients
prosthetic factors (i.e., techniques and materials who experience a quantitative or qualitative
used in denture construction), and metabolic reduction in saliva may have reduced complete
factors (i.e., systemic influences on bone denture retention due to decreased interfacial
formation and resorption). For example, occlusal surface tension.50,51
parafunction may adversely affect the denture
bearing tissues. It is likely that many complete In the maxilla, alveolar resorption may obscure
denture wearers limit both separation of the anatomic landmarks needed to identify the
denture teeth and mandibular movement in order postpalatal seal area. An ineffective or improperly
to avoid unintentional prosthesis movement.34 If located postpalatal seal may compromise
this clenching habit occurs over extended periods denture retention.52 Therefore, reduced vertical
of time and with sufficient force, damage to the alveolar height in a severely atrophic edentulous
denture bearing hard and soft tissues may result. maxilla may result in poor denture stability and
inadequate denture retention.53,54
Others35,36 support Atwood’s conclusions by
suggesting that despite careful prosthodontic The typical pattern of residual ridge resorption
management and apparent short-term successful results in the medial-lateral and anterior-posterior
outcomes, aggressive reduction of residual narrowing the maxillary denture foundation
edentulous ridges may still occur. Consequently, and a widening of the mandibular denture
systemic disease or systemic factors must be foundation.55-59 Resultant changes in horizontal
maxillomandibular ridge relationships may Complete denture retention is, in part, influenced
necessitate setting the posterior denture teeth in by denture occlusion. Most denture wearers
cross-bite. This arrangement may complicate consciously or subconsciously perform random,
force distribution to the denture bearing tissues. empty-mouth occlusal contacts throughout the
If cross-bite posterior denture occlusion is not day. These contacts may result from functional
carefully developed and managed in patients activity (e.g., swallowing) or parafunction (e.g.,
with severe residual ridge resorption, denture bruxism or clenching). A bilaterally balanced
instability may result.60 denture occlusion will minimize the adverse
consequences of functional and parafunctional
The objective of complete denture therapy for loading by widely distributing these forces on the
patients with severe reduction of residual ridges denture bearing structures. Therefore, a properly
is not solely the replacement of missing teeth. balanced denture occlusion may serve to dampen
Rather, complete dentures must be designed to potentially detrimental occlusal forces acting to
replace both the missing dentition and associated disrupt denture stability. A balanced occlusion
supporting structures. In doing so, the denture is dependent on effective clinical and laboratory
base may occupy a substantial volume. Since procedures. Accurate and precise registration
denture base coverage of the hard palate is of maxillomandibular relationships, meticulous
necessary to satisfy mechanical requirements articulation of master casts, careful positioning of
of the prosthesis, and not to replace missing denture teeth, and correct processing of denture
anatomic structures, care must be taken to bases must be accomplished. Both laboratory
limit denture base thickness in this area. In and clinical remount procedures are essential if
addition to replacing missing oral tissues, optimal occlusal balance is to be achieved prior to
complete dentures structurally redefine potential delivery of the prostheses. Finally, periodic recall
spaces within the oral cavity. Inappropriate of all edentulous patients allows reevaluation of
denture tooth positioning and physiologically the denture occlusion; a clinical remount can be
unacceptable denture base contour or volume performed when correction is indicated.
may result in compromised phonetics,61
inefficient tongue posture and function,56,62 and Complete maxillary and mandibular dentures
hyperactive gagging.63-66 Carefully designed have long been considered the standard of care
external denture contours (i.e., cameo or polished for treating edentulous patients. While most
denture surfaces) may contribute substantially edentulous patients express relative satisfaction
to prosthesis stability and retention. Successful with their maxillary complete dentures, many do
denture wearers display patterns of oral-facial not enjoy equally successful mandibular denture
muscular activity that serve to retain, rather comfort and function.69,70 The use of endosseous
than displace, the prostheses. When optimally dental implants to assist in the support, stability,
contoured, complete dentures occupy space in and retention of removable prostheses is now
the oral cavity defined by the physiologic limits considered an effective treatment modality for the
of acceptable muscular function, thus acquiring edentulous patient. Individuals wearing implant-
stability and retention during mastication, assisted overdentures typically report improved
deglutition, and phonation.67,68 Conversely, oral comfort and function when compared to
poorly designed prostheses that do not conventional, mucosa-supported prostheses.71-76
accommodate anticipated muscular function Except when contraindicated due to financial or
may yield compromised denture stability and surgical considerations, implant-assisted over-
reduced retention. dentures are usually the treatment of choice.
Recently, a symposium held at McGill University layer, particularly in saliva-deficient patients, and
addressed the efficacy of implant-assisted over- (2) eliminating voids occurring in the interfacial
dentures for treatment of edentulism. After space in the absence of absolute adaptation of
thorough, evidence-based review of existing the denture base to the bearing tissues.49
information, the following consensus statement In addition to improved retention and stability,
was formulated: “The evidence currently available denture adhesives have been shown to reduce
suggests that the restoration of the edentulous mucosal irritation, reduce food impaction beneath
mandible with a conventional denture is no longer the denture base, improve chewing efficiency,
the most appropriate first choice prosthodontic increase bite force, improve functional load
treatment. There is now overwhelming evidence distribution across the denture-bearing tissues,
that a two-implant overdenture should become and facilitate the psychological well-being of the
the first choice of treatment for the edentulous patient. 49,78,80-85 For patients with xerostomia, the
mandible.” 77 use of a well-hydrated denture adhesive provides
a cushioning or lubricating effect, reducing
The Use of Adhesives as Part of Complete frictional irritation of the supporting soft tissues
Denture Therapy and preventing further tissue dehydration.
Successful complete denture therapy must involve Two currently available denture adhesives
both technical excellence during prosthesis that function well in this regard are Fixodent
fabrication and effective patient management (Procter & Gamble) and Denture Grip (Laclede
once the dentures are placed. Satisfying the Research Laboratories).
expectations of many patients for optimal denture
retention and stability is often beyond the The composition of most modern denture
technical skills of even the most accomplished adhesives includes constituents that promote
practitioners. Discussing and implementing the bioadhesion via carboxyl groups once the
judicious use of denture adhesives may satisfy adhesive is hydrated. Two commonly employed
patients’ expectations and achieve the intended active ingredients in denture adhesives
treatment goals. are poly[vinyl methyl ether maleate] and
carboxymethylcellulose. The physical chemistry
It is appropriate to prescribe a denture adhesive of these adhesive constituents is discussed in
to augment retention and stability of conventional detail elsewhere.49,78,86 Once placed on the intaglio
complete dentures. Adhesives are indicated surface of the denture, the adhesive material
for routine use when appropriately constructed must be substantially hydrated in order to achieve
complete dentures do not satisfy stability and optimal performance.
retention expectations of the patient.49 Denture
adhesives may also prove psychologically Following complete denture fabrication and
beneficial78,79 when the patient requires prior to definitive placement of the prostheses,
supplemental retention and stability, particularly it is prudent to reemphasize to the patient the
during times of public interaction. Denture anticipated outcome of therapy. For patients
adhesives are not indicated to provide retention with favorable anatomic, physiologic, and
for ill-fitting prostheses. psychological factors, including extensive
denture wearing experience, the anticipated
When properly managed, adhesives enhance outcome of complete denture therapy is
the interfacial surface tension occurring between favorable. Conversely, for individuals who display
the denture base and supporting soft tissues compromised anatomic oral conditions, poor
by (1) improving the adhesive, cohesive, and muscular control, psychological indifference, or
viscosity characteristics of the interfacial film a lack of successful denture experience, a fair or
guarded prognosis is more realistic. Discussing Most denture wearers, at one time or another,
reasonable expectations with the patient prior to have attempted to use adhesive to facilitate
placing complete dentures may prepare them for comfortable denture function. Unfortunately,
an otherwise disappointing experience. the concept that “more is better” does not hold
true for denture adhesives. Table 1 presents the
It is appropriate to prescribe adhesive to augment approach used by the authors when presenting to
retention and stability of conventional complete the patient the appropriate method for application
dentures. Anticipating suboptimal stability and of denture adhesive. It is equally important to
retention in the presence of compromised patient make certain that patients are informed about
factors, e.g., xerostomia, is sound therapy. removal of adhesive from both denture surfaces
Informing patients that the proper use of a limited and oral tissues on a regular basis. Appropriate
amount of denture adhesive can supplement denture and oral hygiene should be accomplished
existing denture stability and retention is by edentulous patients at least two times each
both clinically acceptable and prudent patient day. Table 2 presents an effective technique for
management. The need for denture adhesive denture adhesive removal.
is not necessarily an indication of suboptimal
therapy, or admission of failure by either to dentist
Appropriate Application of Denture Adhesive
1. Inform the patient that, due to existing
conditions, achieving optimal complete
denture retention and stability may not be
possible. Also suggest that the proper
use of denture adhesive is an acceptable
means of augmenting the stability and
retention of a new prosthesis. Honest and
realistic communication of the anticipated
results of therapy may ease future patient
2. The use of small amounts of hydrated
paste adhesives (e.g., Fixodent, Procter
& Gamble) works well due to favorable
adhesive, cohesive, and viscosity
Table 1. (continued)
Appropriate Application of Denture Adhesive
3. A small amount of the paste should be Figure 1.
dispensed onto the clean and dry intaglio Adhesive
surface of the denture. The use of to maxillary
excessive adhesive will likely interfere with denture.
proper placement of the denture on the
bearing tissues. For the maxillary denture,
adhesive should be dispensed in the
midpalatal region (Figure 1), while for the
mandibular denture very small amounts can Figure 2.
be placed in two or three locations along the Adhesive
ridge crest (Figure 2). mandibular
4. Once dispensed onto the dentures, the Figure 3.
patient should evenly disperse the paste Adhesive
over the entire intaglio surface of the over intaglio
prosthesis with a clean, dry finger surface.
(Figure 3). This will result in a thin,
even layer of adhesive.
5. The denture is submersed in a container Figure 4.
of cool water to maximally hydrate Denture
the adhesive (Figure 4). The denture submersed
in cool water
should remain submersed in water for to hydrate
approximately 20 to 30 seconds. adhesive.
6. The denture is then placed in the mouth Figure 5.
and firmly seated with finger pressure Denture
for approximately 10 seconds (Figure 5). firmly seated.
Maintenance of seating pressure will cause
the adhesive to flow throughout the interfa-
cial space between the denture base and
the denture bearing soft tissues.
Table 1. (continued)
Appropriate Application of Denture Adhesive
7. The patient may be provided with the sample
container of adhesive used during the demon-
stration. Suggesting local stores that carry this
product will emphasize that adhesive use is a
component of regular denture use. The patient
should be told that the use of excessive adhesive
may indicate an inadequate fit, necessitating
denture reline or remake procedures.
Technique for Denture Adhesive Removal
1. Use of an electric toothbrush can enhance Figure 6.
thorough cleaning of both denture surfaces Battery
and denture bearing oral tissues (Figure 6). toothbrush
Inexpensive, battery powered brushes are and tooth
now widely available to consumers (e.g.,
Crest SpinBrush Pro, Procter & Gamble).
A small amount of toothpaste on the electric
toothbrush will serve to freshen the patient’s
breath and improved taste (Figure 7).
2. Remove the dentures from the mouth, and Figure 8.
thoroughly scrub the entire intaglio surface Initial scrubbing
of the denture.
of the dentures with the electric toothbrush
(Figure 8). This procedure is not intended
to eliminate adhesive from the dentures.
Rather, this initial scrubbing will loosen
residual adhesive material, facilitating
Table 2. (continued)
Technique for Denture Adhesive Removal
3. The denture is then held submerged in a Figure 9.
container of warm water and simultane- with denture
ously scrubbed using the electric toothbrush submerged in
(Figure 9). Firm pressure should be applied warm water.
to the brush in order to eliminate adhe-
sive from the denture surface. Particles or
clumps of adhesive material will be seen ris-
ing to the surface of the water (Figure 10).
This procedure is continued until the entire Particulate
denture surface is free of residual adhesive. debris
to surface of
4. To clean and stimulate the oral tissues, the Figure 11.
electric toothbrush may again be used. A Initial massaging
of oral tissues
small amount of toothpaste is applied to the with toothbrush.
brush. All denture bearing soft tissues and
tissues that contact the cameo surfaces of
the dentures, including the tongue, are gently
massaged (Figure 11). At first, this may
cause a tingling sensation for the patient. This
sensation will disappear with repeated use.
5. Following thorough massaging of the oral Figure 12.
soft tissues, warm water is introduced into of warm water
the patient’s mouth (Figure 12). Holding this into patient’s
water in the mouth, the electric toothbrush mouth.
is again used to massage all oral soft
tissues (Figure 13). The patient is then
instructed to expectorate the water and
residual debris into a sink, leaving the oral
tissue free of adhesive. With warm
The phenomenon of residual ridge reduction proper use of denture adhesive to supplement
following loss of the natural teeth, and its impact sound complete denture therapy should be
on successful complete denture therapy, have carefully presented to patients prior to delivery of
been reviewed. Anatomic, physiologic, and the prostheses. Denture adhesives can effectively
mechanical factors associated with the stability augment denture stability and retention to improve
and retention of complete dentures are important overall denture performance, and patient comfort
for achieving optimal therapeutic results. The and satisfaction.
Dr. Massad is Adjunct Associate Professor, Tufts University School of Dental Medicine, and Adjunct
Associate Professor, Department of Prosthodontics, University of Texas Health Science Center at San
Antonio, and Adjunct Associate Professor, Department of Forensic Sciences, Oklahoma State University
Center for Health Sciences, and Adjunct Associate Professor, University of Oklahoma College of
Dentistry. He is also Associate Faculty, The Pankey Institute.
Dr. Davis is Professor, Division of Dentistry, Department of Otolaryngology, Medical College of Ohio,
and Adjunct Associate Professor, University of Oklahoma College of Dentistry. Additionally he serves
as Director, General Practice Residency Program, and Director, Continuing Medical Education, Medical
College of Ohio. He is also Associate Faculty, The Pankey Institute.
Dr. June is Adjunct Associate Professor, University of Oklahoma College of Dentistry. He is also in
private practice, Peoria, Illinois.
Dr. Lobel is Assistant Clinical Professor, Department of Restorative Dentistry, Tufts University School of
Dental Medicine, and Adjunct Associate Professor, University of Oklahoma College of Dentistry.
Dr. Thornton is Adjunct Associate Professor, University of Oklahoma College of Dentistry. He is also in
private practice, Duluth, Georgia.
Dr. Cagna is Associate Professor, Department of Prosthodontics, University of Texas Health
Science Center at San Antonio, and Adjunct Associate Professor, University of Oklahoma College of
Dentistry. He is a Diplomate, American Board of Prosthodontics and a Fellow, American College of
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