journal club of complete denture for patient with stroke

1. JOURNAL CLUB PRESENTATION
Complete dentures for a patient after a stroke by
means of orofacial myofunctional therapy.
A clinical report
PRESENTED BY :
DR. DHANANJAY D SHETH.
1ST YEAR MDS
DEPARTMENT OF PROSTHODONTICS AND CROWN AND BRIDGE.

2. Stroke:The sudden death of brain cells due to lack of oxygen, caused
by blockage of blood flow or rupture of an artery to the brain.
Sudden loss of speech, weakness, or paralysis of one side of the body
can be symptoms.
After a stroke, patients frequently show compromised swallowing,
mastication, and speech, as well as unfavorable motion and
deviation of the tongue and mandible.

3.  What is that a dentist can do in such case/ why is it
important to us?
 The dentist can improve the oral rehabilitation of a
patient with deteriorated facial and oral muscles
after a stroke by incorporating orofacial
myofunctional therapy.
 Dysphagia in stroke is usually considered to indicate
a brain stem lesion caused by vertebrobasilar disease
or bilateral corticobulbar fibre damage, but it has
also been reported in unilateral hemisphere lesions,
including stroke.

4.  On the basis of clinical and radiographic studies, 76% of
patients after an acute stroke suffer from dysphagia
that can be associated with a higher incidence of
aspiration, eating dependency, decreased rehabilitation
results, pneumonia, dehydration, and even death.
 Additionally, a hemiparesis may also result in mandible
deviation, which can make it difficult for edentulous
patients to retrude their mandible into centric relation
(CR), an issue that arises even in healthy individuals.
 Dysphagia, or swallowing dysfunction, is studied
with keen interest because it frequently affects
elderly people, who constitute an increasing
percentage of the population.

5.  Robbins et al reported positive changes in lingual strength
after progressive resistance exercises for the tongue in
healthy men and women over 70 years.
 These findings also included improvements in maximum
lingual strength measured during the act of swallowing,
suggesting direct carryover of isometric strength gains to
functional swallowing outcomes.
 Examples of OMT include resistance lingual exercises (with
the Iowa Oral Performance Instrument), oral screen
exercises, palatal plate stimulation , and palatal
augmentation prostheses.
 This article describes a straightforward and effective
approach to restoring tongue function by correcting
mandibular deviation for an edentulous patient after a
stroke.

6.  The treatment uses a modified maxillary denture with a
pearl located over a stainless wire in the anteriomedian
palatal part and incorporated orofacial myofunctional
therapy
CLINICAL REPORT
 A 70-year-old white man with edentulism was referred
to KA-Dent Dental Clinic, Wschowa, Poland, for
maxillary and mandibular complete dentures
 He had experienced a unilateral hemispheric stroke 2
years previously, for which he had received motor and
sensory rehabilitation.
 During the visit, the patient complained of
compromised tongue movements and difficulty in
mastication.
 An extraoral examination revealed competent lips with
normal mouth opening, a concave facial profile, and
mild right facial hemiparesis.

8.  Intraorally, mandible deviation toward the right side
and protrusion were observed, as well as limited
movement of the tongue.
 Signs and symptoms of temporomandibular joint
dysfunction were detected (right joint early opening
and late closing click)
 The patient could touch the anterior and median
part of the hard palate with slight deviation to the
right and touching the posterior part of the palate
was difficult, and he could not touch the right buccal
mucosa.
 After maneuvering the tongue to the anterior part
of the palate, he exhibited improved facial features
and no right joint clicks; however, after a few
minutes, he returned to his habitual position.
 The treatment plan was to fabricate a maxillary
denture with a pearl over a wire in the palatal part
to guide the mandible to CR and for OMT

10.  The definitive dentures were evaluated intraorally,
still, the patient exhibited mandibular deviation and
protrusion in his habitual mandible position.
 A lateral cephalometric radiograph (CS 9000 3D;
Carestream Health Inc) confirmed class III skeletal
profile
 To guide the mandible to CR, a stainless wire
(round, ø 0.9 mm, spring hard, Remanium,
Dentaurum GmbH & Co. KG) with an
autopolymerizing acrylic resin pearl (ø 5 mm;
Premacryl Plus, SpofaDental a.s.) was placed in the
most posterior palatal part of the maxillary denture
that the patient was able to reach with his tongue
(anteriomedian part) by using an autopolymerizing
acrylic resin material.

11. • Posterior bends in the wire were made to keep
the pearl in the midline.
• Second radiographic examination demonstrated
correct mandibular position when the patient
touched the pearl.
• The patient was advised to use the prostheses
except when asleep and to perform tongue
exercises for at least 15 minutes 3 times a day,
which involved touching the pearl, turning it
around its axis from the anterior to the posterior
part of the denture and back, and moving it from
left to right and right to left.

13.  After 3 months of rehabilitation, the patient
reported for a clinical evaluation visit during which
he demonstrated absence of mandibular deviation
and protrusion, increased mastication and
deglutition activity, and no symptoms of
temporomandibular disorder.The tongue
movements improved significantly (touching the
anterior and median part of the palate with no
deviation, and slight deviation to the right in
posterior part).
 At the end of the visit, the wire with the pearl was
removed. At the second recall, 6 months later, the
therapeutic effects had been maintained.The
patient subjectively indicated improved satisfaction
with his treatment.

15. DISCUSSION
 To retrude the mandible into CR, patients are usually asked
to elevate the tongue to the most posterior position of the
palate and close in the retruded position or to close while
swallowing.
 Therefore, the most posterior placement of a wire and a
pearl in the palatal part of the maxillary denture is best.
 Therefore, the most posterior placement of a wire and a
pearl in the palatal part of the maxillary denture is best.
 The success of therapy was defined by clinical evaluation of
the patient’s ability to masticate and swallow as well as
maintain the mandible in CR for longer periods.
 Compromised tongue function and mandibular deviation
could be controlled by relearning physiological movements.
The advantages of this method, besides the improvements
in swallowing, deglutition, and mastication, include
regaining CR, correction of mandibular deviation and
protrusion, improvement of facial features, strengthening of
tongue muscles, ease of incorporation into the prosthesis
and its easy removal, and low cost.

16.  Training with an oral screen can improve the LF ( lip
forces) and SC ( swallowing capacity) of stroke
patients with oropharyngeal dysphagia, irrespective
of the presence or absence of a central facial
paresis, or of the pretreatment duration of
dysphagia, age, or sex. It is more likely that the
treatment results are attributable to sensory motor
stimulation and the plasticity of the central nervous
system, rather than the training of the lip muscles
per se.
 Steele et al. also suggested that tongue resistance
training is an effective method for reducing
aspiration and penetration.Thus, increased tongue
strength has a positive effect on the swallowing-
related quality of life of stroke survivors.
 The effectiveness of resistance training for the
tongue results from both a central (neural) and
peripheral (muscle mass) effect.

18. • Study provides evidence supporting the inclusion of
resistance training of the tongue muscle in rehabilitation
programs for stroke patients with dysphagia.The
administration of this resistance training can improve
tongue strength and general swallowing function.
• Effect of wearing a palatal plate on swallowing function
• It was concluded that, as the palatal plate thickened, SI,
which is the index related with aspiration, increased, and
TCT, which is the index related with swallowing difficulty,
decreased.

19. IOPI measures maximum pressure in an air-filled bulb that is pressed with the tongue “as
hard as you can.”This pressure is interpreted as a measure of tongue strength.

22. REFERENCES :
Gordon C, Hewer RL,Wade DT. Dysphagia in acute stroke. Br Med J (Clin Res Ed)
1987;295:411-4.
2.Robbins J, Levin RL. Swallowing after unilateral stroke of the cerebral cortex: preliminary
experience. Dysphagia 1988;3:11-7.
3. Barer DH.The natural history and functional consequences of dysphagia after
hemispheric stroke. J Neurol Neurosurg Psychiatry 1989;52:236-41.
4. Katzan IL, Cebul RD, Husak BA, Dawson NV, Baker DW.The effect of pneumonia on
mortality among patients hospitalized for acute stroke. Neurology 2003;60:620-5.
5. Feinberg MJ, Ekberg O.Videofluoroscopy in elderly patients with aspiration: importance
of evaluating both oral and pharyngeal phases of deglutition.AJR Am J Roentgenol
1991;156:293-6.
6. OnoT, Hori K, NokubiT. Pattern of tongue pressure on hard palate during swallowing.
Dysphagia 2004;19:259-64.
7. Hori K, OnoT,Tamine K, Kondo J, Hamanaka S, MaedaY, et al. Newly developed sensor
sheet for measuring tongue pressure during swallowing. J Prosthodont Res 2009;53:28-32.
8. Hirota N, Konaka K, OnoT,Tamine K, Kondo J, Hori K, et al. Reduced tongue pressure
against the hard palate on the paralyzed side during swallowing predicts dysphagia in
patients with acute stroke. Stroke 2010;41: 2982-4.
9. Blonsky ER, Logemann JA, Boshes B, Fisher HB. Comparison of speech and swallowing
function in patients with tremor disorders and in normal geriatric patients: a
cinefluorographic study. J Gerontol 1975;30:299-303.
10.ToyoshitaY, Koshino H, HiraiT, MatsumiT. Effect of wearing a palatal plate on
swallowing function. J Prosthodont Res 2009;53:172-5.

23. THANKYOU