From Volume 43, Issue 2, March 2016 | Pages 159-166
Dealing with patients who are unable to tolerate dentures can present a challenge to the general dental practitioner (GDP). Careful assessment of patients and their dentures will identify any causes of the intolerance to dentures. Training plates are a useful technique that can be used to allow patients to become accustomed to removable prosthesis but will inevitably lengthen the treatment process.
There are a number of treatment options available to replace missing teeth. This can include implant-retained prostheses, fixed prostheses and removable prostheses. One of the most straightforward is the removable option, providing either complete or partial dentures. The majority of patients that are provided with a removable prosthesis cope well but there are some patients that struggle to tolerate them.
The demographics of the UK adult population is changing. People are living longer, with the population of over 65-year-olds estimated at 17%,1 but predicted to increase by approximately 30% over the next 25 years, and it is also predicted that the number of patients in the over 85 years age group will rise even more dramatically.2 The Adult Dental Health Survey in 2009 showed that 19% of adults wore dentures, of these 13% wore partial dentures and 6% complete dentures.3 The Adult Dental Health Surveys also show that the incidence of edentulism in England and Wales has decreased from 37% in 1968 to 6% in 2009 and that elderly patients are retaining their natural teeth into their older age and fewer are becoming edentate.3 It is often stated that the need for complete denture treatment will decline as the elderly retain teeth for longer, but many elderly patients still require prosthodontic replacement.2,4,5
It has been shown that elderly patients find it more difficult to accommodate dentures, particularly patients that are being provided with complete dentures for the first time.4,6 It has also been stated that successful provision of dentures in the elderly individual is arguably more of a challenge now than it was a few decades ago.2,5 It has also been shown that there is a link between denture provision and gagging in some patients.7,8,9,10,11,12,13,14,15,16,17,18,19,20,21
The aim of this article is to provide the clinician with an understanding of training plates, the clinical process involved in their fabrication and delivery to a patient and the subsequent management.
Training plates are prosthodontic appliances that are used to prepare the patient for prosthodontic treatment. This appliance has the effect of acclimatizing the patient to the feel of the denture in the mouth prior to definitive denture construction.4 There are many descriptors, including training bases, training plates, training dentures, treatment dentures, conditioning appliance, rehabilitation devices and transitional prostheses.6,7,15,16,17 The British Society of Prosthodontics (BSSPD) have defined ‘training bases’ as ‘A denture base, usually made of heat-cured acrylic resin, provided for a patient who has difficulty in tolerating the bulk of a denture, with the intention of promoting its acceptance. Once the base is tolerated additions to it can be made to facilitate progression to a denture.'22
These appliances have predominantly been used in patients that suffer from a prominent gag reflex. They can also be used in patients acclimatizing to dentures. Training plates can be used in partially dentate or edentate patients and can be made of a variety of materials and be in a number of designs.16,23
Training plates have a role in the management of the gagging patient. Treating patients who gag may be unpleasant and dealing with such a situation is something all dentists have experienced at some point. Gagging can hinder and often prevent procedures being performed, and may also lead patients to being unable to tolerate appliances within the mouth. The majority of patients cope well with appliances within the mouth and are able to adapt, but some do not and it can be difficult to identify the cause of such reactions in patients.
The gag reflex is a normal, defence mechanism controlled by the parasympathetic division of the autonomic system. Its function is to prevent foreign bodies from entering the trachea.17 The prevalence of gagging within the general population is unknown, but is not uncommon.20 Patients who suffer from these problems can be divided into two groups:
Dickinson and Fiske20 devised a gagging severity index to define a patient's level of gagging (Table 1). The majority of gaggers will be mild/moderate and the most amenable group to treat. The severe/very severe category of gaggers are a difficult group to treat and, in some cases, a solution may not be possible. Also note from Table 1 how reassurance and good communication forms part of the management in these patients and is an important adjunct to treatment in ‘gaggers’. This reflex disappears in most cases as the patient adapts to the dentures. However, some patients may not be able to tolerate the denture.
| Normal gagging | Very mild, occasional and controlled by the patient |
| Mild gagging | Control is required by the patient with reassurance from the dental team |
| Moderate gagging | Consistent and limits treatment options. Gagging prevention measures are usually required |
| Severe gagging | Gagging occurs with all forms of treatment including simple visual examination. Treatment is limited |
| Very severe gagging | Affecting patient behaviour and dental attendance and making treatment impossible without specific treatment for control of gagging |
When examining a patient, a detailed assessment of the patient's dentures, in order to identify any faults that could be causing or exacerbating a patient to gag, is required (Table 2). If no clinical faults can be identified, it may be a consideration to provide the patient with a training plate, and this needs to be discussed with the patient.4,7,21 Once constructed, it is advised that it be worn at home to help desensitize the patient to stop him/her gagging and assist in toleration of the denture. Instructions are given to the patient about how this will take time and will inevitably slow the process of denture delivery.
| Poor retention/Rocking of the denture4,8,9,10,20,21 |
| Excessive thickness of the posterior border of the upper denture (particularly when it is placed forward of the vibrating line)10,15,20,21 |
| Over extension of posterior border of upper denture (placed beyond the vibrating |
| line)15,20 |
| Reduced posterior extension of upper denture4 |
| Narrow arch form that forces the lingual cusps of the upper posterior teeth to impinge on the dorsum of the tongue21 |
| Inadequate peripheral seal8,10,15,20 |
| Incorrect occlusal planes20 |
| Reduced or excessive freeway space9,10,20 |
| Incorrect denture tooth positions15,20 |
| Malocclusion10 |
| Restricted tongue space10,20 |
The process is known as systematic desensitization, a technique that consists of incremental exposure of the patient to the feared stimulus. The maladaptive thoughts and expectations of patients can be altered by positive experience and this forms the basis of re-education techniques. Behaviour that has been classically conditioned can be reversed essentially by reversing the process.13 This entails exposing the patient gradually to the stimulus by increasing the intensity, duration and frequency of the stimuli.11,12 There are a number of re-education techniques that have been described in which the patient is given an object to place in the mouth for a period of time.14 The size of the object and length of time for which it is held in the mouth is progressively increased until the patient is able to acclimatize.14,16,18 With reassurance and conditions of relaxation the patient is exposed to an aversive stimulus and learns to cope with this.14 The approach is to develop the necessary confidence to feel motivated to overcome the problem.7
A review of the literature on successful denture provision has suggested that a good relationship with the patient seems more important than technically perfect denture construction for achieving patient satisfaction, and is therefore a consideration in treatment delivery.24
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Training plates usually consist of a thin acrylic base (Figure 1) and can be fully extended and appropriately thinned at the posterior border with a correctly formed post dam. Therefore a good knowledge of dental anatomy is needed. There are some design features that can be incorporated, such as a finger grip, that may be provided so that the patient can control insertion and removal of the device. The baseplates can also be constructed with a small acrylic bead attached to the lingual polished surface. This is a further distraction ‘device’ to focus the attention. It also ‘trains’ the tongue to adopt a more favourable position and discourage it from taking up a ‘pharyngeal guarding’ posture.16,23 The surface finish of the training bases can form part of the technique and sandblasting the acrylic to create a dull, matte surface texture can be used.16,23 This was suggested by Jordan in 1954 with the reasoning behind it being that a smooth, highly polished surface which is coated with saliva may produce a slimy sensation, which is sufficient to cause gagging in some patients; a matte finish has been suggested as more acceptable.19 However, this may vary from patient to patient. A training plate is usually constructed without teeth and the patient is asked to wear it at home.11,15,16,21,23 The above features are more a personal preference of the clinician and patient rather than based on evidence.
Impression-taking needs to maximize the area from which a denture can gain support. An adequate impression needs to record the full denture-bearing area with close tissue adaptation and functional border moulding, which is important for both edentulous and partially dentate patients.25
The patient is given tailor-made instructions and asked to practise progressively increasing the length of time the training plate is worn. A suitable regimen may be 15 minutes once each day, then twice each day; after one week the patient is asked to increase this to 15 minutes 3 times each day, then 30 minutes and 1 hour, until the patient is happy to wear it for long periods of time. It is often best for patients to wear it when doing something distracting, such as watching television, or even wearing it at night so that they are not concentrating on what is in their mouth.11
Eventually the patient will be able to tolerate the training base for most of the day.18 The timing and rate of progress will vary between patients and the patient needs to be pre-warned of this.11 The patient is reviewed on a regular basis as problems may occur and encouragement and advice needed. It may be necessary to reduce the posterior border of the training plate. One approach is to place two post dams, one slightly more anterior, to allow some adjustment of the posterior edge, where necessary.4,11This will all take time, which can be difficult in a busy practice, and will also delay the provision of the final prosthesis, which the patient needs to understand.
Once tolerated, the bases can be used to fabricate the final dentures.12 The teeth can be set up gradually by placing anterior teeth (Figures 2, 3) and then posterior teeth (Figure 4, 5) as the patient gets accustomed to the denture or all the teeth placed at once. This can then be the patient's definitive denture or, via a copying technique, be used to achieve the final denture.21
Good denture construction is needed to optimize retention and stability of the prosthesis and this process is not an excuse for poor denture fabrication.11
An 84-year-old male patient was referred by his GDP for provision of complete dentures. The GDP had made a number of sets but the patient complained of being unable to wear the upper set due to gagging. On examination, it was noted that the patient was completely edentulous and had resorbed firm residual ridges with reasonable height and width (Figure 6). The current dentures had correct peripheral extension and the patient had a prominent gag reflex on palpation around the vibrating line. It was planned for the patient to be provided with an upper training plate (Figures 7, 8) with regular review and adjustments. Once the patient was able to tolerate the training plate, it was copied and used to construct his upper complete denture (Figure 9). This was carried out over a 5-month period and the patient is now able to tolerate and wear dentures (Figure 10). He was discharged back to his GDP.
A 75-year-old female patient was referred by her GDP who was struggling to provide an upper partial denture with which the patient could cope. This was due to the patient's medical condition of having a blepharospasm (facial muscle disorder) of the left side of the face which caused the denture to be readily dislodged. Examination revealed a partially dentate patient with severely resorbed residual ridges (Figure 11). It was planned for the patient to have an upper training plate of a Cunliffe design to assess tolerance (Figure 12). The patient was able to tolerate the training plate quickly and provided with an upper partial denture, and the patient has been subsequently discharged back to her GDP (Figures 13, 14).
A 67-year-old male patient had been referred by his GDP to provide an upper denture due to the patient being unable to tolerate a removable prosthesis. The patient had recently been provided with his first removable prosthesis and was unable to cope as it felt like it was ‘too bulky’ and ‘went too far back’. On examination, it was noted that the patient was partially dentate with firm residual ridges of reasonable height and width; it was also noted that the patient had a very prominent gag reflex. A training plate (Figure 15) was provided and extensively adjusted until the patient was able to tolerate it. The training plate was then copied to provide the definitive prosthesis (Figure 16). The patient was able to tolerate the dentures (Figure 17) and was discharged back to his GDP.
Patients are retaining teeth for longer and requiring prosthetic replacement later in life. Within this group there will be some people who are unable to tolerate dentures and will include ‘gaggers’. Training plates are a useful technique that can be used on edentulous and partially dentate patients to allow them to become accustomed to dentures. This technique is a useful tool but will inevitably slow the process of denture delivery.
