Preventing Denture Stomatitis Essay
Preventing Denture Stomatitis Essay
Ghani F and colleages20 did a study on 50 denture wearers and 50 non denture wearers assessing candida activity through recording pH changes in candida selective medium. Results showed pathological candida activity was significantly higher in denture wearers.
While in a study by Yilmaz HH78 27 patients with denture stomatitis and 23 patients without clinical signs of denture stomatitis were compared. They found that there was a relationship between poor denture hygiene and denture stomatitis and the relationship between denture stomatitis and candidal hyphae was not significant. Therefore proper hygiene is important to prevent denture stomatitis and antifungal drugs should not be prescribed without mycological investigation. Preventing Denture Stomatitis Essay.
Opportunistic growth of pathogenic yeasts such as candida is promoted by constant denture wearing which maintains anaerobic and low pH conditions between the denture and mucosa.18. It was revealed in different studies that nearly one third of the patients evaluated slept with their dentures 19,22,89.
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Similarly other studies have found significant association between denture related stomatitis with denture age and continuous denture wearing88moreover candida albicans hyphae and lactobacillus was also found in the saliva and palate of denture stomatitis patients89
SURFACE TEXTURE AND PERMEABILITY OF DENTURE BASE:
Highly polished surfaces are important not only for aesthetics and patient's comfort but also for low plaque adherence, oral hygiene and denture longevity84.
In an in vitro study Van Reenen79 demonstrated that penetration of the unpolished surface which is in contact with the mucosa with candida albicans was greater than that of polished surface. It was confirmed further with the use of fluorescent dye.
Another study18 confirmed that surface roughness and cracks facilitate development of biofilm and adherence of plaque.
The authors also noted that prolonged brushing of acrylic denture with toothbrush and abrasive dentrifices create scratches that can enhance bacterial attachment and biofilm growth22.
DENTURE LINING MATERIALS AND ADHESIVES:
In a study by Sato Y and colleagues90 it was found that denture adhesives enhance retention and stability of both ill fitting and well fitting dentures.
AL et al 91 suggested that denture adhesives contribute to mucosal inflammation in denture wearers as they are commonly used throughout the day. Preventing Denture Stomatitis Essay.
While in an assessment of 24 denture wearing patients Oliveira and colleagues92 evaluated the number of colony forming units(CFUs) and Candida species in saliva samples which were collected at denture placement, 7 day and 14 day intervals from patients using an adhesive denture strip. 12 patients using the adhesive were compared with 12 patients not using the adhesive. There was no statistical difference between the groups at the 2 weeks analysis.
MANAGEMENT OF DENTURE STOMATITIS:
Placebo-controlled studies reported that treatment with either oral fluconazole (50mg/day for 2 weeks) or topical miconazole (2% gel applied to fitting surface of the denture 3 times daily for 2 weeks) significantly reduced the presence of candida on oral mucosa and decreased inflammation in denture stomatitis93 .
Cross LJ et al94 reported capsule and liquid formulations of itraconazole ( 100 mg 4 times a day for 15 days), fluconazole alone ( 50 mg orally for 14 days) or in combination with chlorhexidine applied to fitting surface of the denture 2 times
a day for 2 weeks and amphotericin ( 40mg oral dissolving lozenges 4 times daily and topical cream applied to fitting surface of denture) all to be effective in the treatment of denture stomatitis.
In a study by Mililla L et al95 amorophiline antifungal varnish was applied once or twice a week for 6 months in patients affected by nystatin resistant denture stomatitis. Results showed significant decrease in candidal count and improvement in symptoms of denture stomatitis. Preventing Denture Stomatitis Essay.
In a study photodynamic therapy was found to be an effective method for resolving candida spp. on dentures96
In a study by Webb et al97 nursing home patients with denture stomatitis were randomized to maintain their usual hygiene procedures or had their dentures cleaned daily with overnight soaking in sodium hypochlorite and microwaving. Relative to control group both cleaning techniques showed 100% reduction in candida colonization and clinical improvement in denture stomatitis.
In another study 10% vinegar solution was used for the immersion of dentures and was found to be effective in decreasing the quantity of candida spp in saliva and the presence of denture stomatitis 98 .
Cryosurgery is the treatment of choice in patients with Type III denture stomatitis along with prosthesis substitution34.
POST INSERTION INSTRUCTIONS REGARDING MAINTENANCE OF THE PROSTHESIS:
To decrease the levels of biofilm and harmful micro organisms , patients who wear dentures must do the following:
- Dentures must be immersed and brushed with an effective and non abrasive denture cleanser everyday18.
- Denture cleanser must only be used to clean dentures outside the mouth62.
- Dentures must be rinsed thoroughly after immersion and brushing with denture cleansing solution before reinsertion in the oral cavity16.
- Dentures should be cleaned annually by a dentist using ultrasonic cleanser to minimize biofilm coverage overtime27.
- Dentures must never be placed in boiling water77. Preventing Denture Stomatitis Essay.
- Dentures must never be soaked in sodium hypochlorite bleach for periods greater than 10 minutes because it may damage the dentures28.
- Dentures should be immersed in water after cleaning, when not inserted in oral cavity to avoid warping16.
MECHANICAL METHODS OF DENTURE CLEANING:
Brushing with tooth brush, denture brush and pastes:
Scanning electron microscopic images and microbiologic essays have demonstrated that cleaning the dentures with water and tooth brushes is ineffective at removing microorganisms62.
While in a study by Nishi Y and colleagues 25 it was found that the quantity of micro organisms was significantly reduced in the outpatients who used a denture brush for cleaning the prosthesis.
Salles AES and Macedo LD99 found in a study that brushing with a denture paste|(Corega Brite) was the most effective method of disinfecting dentures followed by brushing with neutral soap and brushing with water only was the least effective method.
It was found by Lira AF et al100 that tooth brushing promoted higher levels of surface roughness when compared to chemical disinfection while boiled resins were found to be more prone to surface roughness and biofilm accumulation than microwaved resins.
Pisani MX and Bruhn JP et al101 analyzed surface roughness and weight loss in acrylic caused by dentrifices. They found that the conventional dentrifice containing sodium bicarbonate produced greatest weight loss and surface roughness while dentrifices containing chloramine T and fluorosurfactant produced less weight loss and surface roughness. Preventing Denture Stomatitis Essay.
While in another study it was found that dentrifices containing 1% chloramine T and 0.01% fluorosurfactant decreased biofilm coverage but were ineffective against candida102.
Ultrasonic cleaning:
Ultrasonic devices are helpful in removing the plaque adhering to dentures by producing microscopic cavities that grow and burst creating voids that result in localized areas of suction 16.
Gwinnet et al103 showed in different ways effective disinfection of inoculated dentures using ultrasonic treatment in a water bath as well as in various baths of antiseptic and detergent agents.
In another study it was found that ultrasonic cleaning when combined with immersion in a peroxide based cleanser solution effectively reduces the quantity of micro organisms surviving on dentures25. Hence may be a suitable method for elderly who find brushing their dentures difficult.Preventing Denture Stomatitis Essay.
Studies have found that ultrasonic cleaning is not completely bactericidal but improves the killing of bacteria16.
Chemical Methods:
Soaking in household solution:
Sodium hypochlorite diluted 1:10 in tap water is adequate for killing adherent micro organisms but is ineffective against calculus buildup and stains. Metallic elements in the denture acquire a black stain after soaking in bleach for greater than 10 minutes daily62
In a study done by Dr. Roshan Khan 5.25% sodium hypochlorite was more effective in disinfecting dentures as compared to 0.2% chlorhexidine at a 5 minute immersion period28.
Surface roughness was evaluated by Paranhos HDO et al64 and they found that immersing the acrylic resin denture in 0.5% sodium hypochlorite solution every night for more than a year and a half resulted in increased surface roughness while no effect was noted regarding the flexural strength of the acrylic.
A major issue in immuno compromised and hospitalized patients is the emergence of methicillin resistant staphylococcus aureus(MRSA) which increases mortality rates significantly 16.
Lee and colleagues104 showed that MRSA can be killed effectively with sodium hypochlorite.
The use of vinegar (acetic acid) was evaluated by Basson et al105 and they found it effective at killing adherent micro organisms albeit less effective than sodium hypochlorite. Vinegar has an advantage over bleach and it is that inadequate rinsing after soaking in vinegar does not result in mucosal damage. Preventing Denture Stomatitis Essay.
In another study vinegar alone is found to be least effective at removing denture plaque but when used in combination with brushing its results were comparable with those of denture cleansers24
Soaking in a commercial solution:
Immersing the dentures in denture cleansers reduces the micro organisms and plaque and is found to be a suitable method for denture cleansing specially for geriatric patients106.
It was found that soaking in alkaline peroxide every night for more than a year resulted in color alteration of the resin64.
In a study it was found that the combination of brushing and peroxide cleansers was the most efficacious method to remove denture plaque24.
It was found in a study by de Andrade IM and colleagues107 that the effervescent tablets are effective in reducing streptococci mutans and total aerobes from denture biofilm. However, they were not as effective against C. albicans
Mc Cabe and colleagues108 reported that effects of alkaline peroxide solution were enhanced using water at a temperature of 50 centigrade.
In a study done to investigate the relationship between the frequency of use of denture cleanser and the quantity of micro organisms adhering to dentures it was found that patients who used denture cleansers daily or 3-4 times a week had significantly lower amount of micro organisms than the patients who used the denture cleanser once or less per month25.
While in a study by Jose A and colleagues23 it was concluded that denture cleansers were effective against Candida albicans activity both in terms of removal and disinfection but residual biofilm retention that could lead to re growth and denture colonization was seen. Hence alternate mechanical cleaning methods are required to enhance biofilm removal..
New materials for denture immersion contain silicon polymer that provides a protective coating on denture as a final step in cleaning process. Coating helps to minimize adhesion of debris throughout the day until the next cleaning27.
MICROWAVE RADIATION
Effectiveness of microwaving depends on solution in which the dentures are immersed, the time of exposure, the level of power of microwave oven and the types of micro organisms adhering the denture109.
Senno P and colleagues110 found that putting the dentures in denture cleanser and then microwaving was efficient in disinfecting dentures with lower irradiation time and temperature than the use of microwave irradiation alone therefore avoiding denture distortion. While in another study it was concluded that immersing the denture in a cup of water to transfer heat uniformly during microwave sterilization was more effective111.
While Kaskin et al112 showed that independent of solution used irradiation for 15 minutes at 500 watt achieved complete sterilization of acrylic resin base materials contaminated by Staphylococcus aureus, Escherichia coli, candida albicans and streptococcus mutans.Preventing Denture Stomatitis Essay.
It was concluded by Brondani MA et al109 that irradiation time above 15minutes and voltage greater than 850 watts may cause distortion and surface roughness of the denture while not affecting the hardness of the material.
While in another study 50 seconds of exposure at 850 watt seemed to be sufficient to disinfect the acrylic denture without any adverse effect on the material113.
ALTERNATE DENTURE CLEANSING METHODS:
Chlorhexidine destroys bacteria by breaking their membranes and inducing cytoplasmic precipitation114.
In a study by de Andrade IM and colleagues 107 60 CD wearers participated in a trial for 21 days after getting brushing instructions. They found that the biofilm coverage area after treatment with immersion in 2% chlorhexidine for 5 minutes was the lowest when compared to immersion in water and in 0.12% chlorhexdine for 20 minutes.
While in a study by Uludamar A and colleagues26 it was found that patients whose upper dentures were sprayed with mouthwashes on palatal surface showed decreased candida count when compared to patients who used effervescent type denture cleansers for soaking and cleaning.Preventing Denture Stomatitis Essay. It can be concluded that mouthwashes can be used as effective denture disinfectants.
Tissue cleansing and massage is often neglected part of complete denture care. Brushing the tongue and residual ridges will improve the circulation and remove plaque and debris that may cause irritation of soft tissue and offensive odors 115. In a study by Marchini L116 it was found that 68% of the complete denture wearers didn't clean their tongue.
PERIODIC RECALL FOR ORAL EXAMINATION:
Patient recall must be a tool to help prevention, allow early intervention and ensure long term dental health117. In a study by Peracini A 51`% of the patients interviewed were not informed about their recall visits.118 An evidence based, patient centered approach taking into account multiple risk categories must be implemented in designing recall visits.119
The American College of Prosthodontists recommends that patients wearing complete dentures must be checked every year for assessment of oral health status, denture fit and function and for evaluation of bone loss as well as oral lesions such as denture stomatitis 16. This recommendation is based on the evidence regarding the relationship between proper complete denture oral hygiene and overall systemic health particularly in dependant elderly45.
The precise etiology of the condition is unknown but is likely to involve at least one of the following factors: mucosal trauma from poorly fitting dentures, poor oral and deficient denture hygiene, nighttime wear of removable dentures and bacterial and yeast infection with Candida albicans (Gendreau 2011; Wilson 1998). Dentures may produce a micro‐environment conducive to the growth of Candida. This may be due to the enhanced adherence of Candidato the acrylic, reduced saliva flow under the surface of the denture fitting and poor oral hygiene (Epstein 1990; Guida 1988; Shulman 2012). Preventing Denture Stomatitis Essay. Long‐term and continuous use of a denture along with poor denture and oral hygiene promote the development of a biofilm (plaque) on the surface of the prosthesis (Gendreau 2011; Salerno 2011). The biofilm colonises the surface and penetrates into the cracks and imperfections of the denture material (Ramage 2004). The mucosa in contact with the denture then becomes inflamed.
The problem may be compounded by physical disabilities that reduce an individual’s ability to maintain good oral hygiene, and also by illnesses such as diabetes mellitus, immunosuppression and medications (e.g. antibiotics and corticosteroids), all of which can disturb the balance of the oral flora, leading to an increase in Candida as an opportunistic infection (candidiasis) (Dorocka‐Bobkowska 2010; Kulak‐Ozkan 2002; Webb 1988; Wilson 1998). Other risk factors have been associated with oral candidiasis and denture stomatitis such as vitamin A and folate deficiency and tobacco use (Shulman 2012).
Symptoms of denture stomatitis vary in their severity, from asymptomatic to pain and irritation (Altarawneh 2013). Occasionally, the overgrowth of Candida can be very severe and lead to discomfort, altered taste, dysphagia and a burning sensation in the mouth (Maciag 2014). Some authors believe that the chronic inflammation may increase the patient’s risk for systemic infection dissemination, and increase the risk of cardiovascular disease, diabetes and pulmonary disease (Offenbacher 2012). However, there is a lack of consensus as to the role of systemic inflammation in denture stomatitis (Maciag 2014). Future approaches for treatment could involve targeting the inflammation as well as targeting the binding of Candida to the denture surfaces and oral mucosa (Offenbacher 2012). Preventing Denture Stomatitis Essay.
Reccurrence of the condition following treatment is common in the absence of successful decontamination of the denture, continued poor oral and denture hygiene (Cross 2004; Gendreau 2011), and poor denture retention.
Description of the intervention
Candidiasis is very common and an under diagnosed condition among the elderly (Akpan 2002). The correct diagnosis is important for the appropriate management and prevention of the condition. In most instances, it can be prevented with regular oral hygiene and, in the case of poor fitting dentures, can be eliminated with a new set of well‐adapted dentures. As the symptoms and the severity of the infection vary, infection most often may resolve with hygiene and topical antifungals in uncomplicated cases.
Good oral hygiene is extremely important and the removal of denture plaque is necessary for maintaining the health of oral soft tissues and for the prevention of denture stomatitis (Felton 2011; Sciubba 2015). Dentures act as a reservoir for Candida, the most common fungal species associated with denture stomatitis. Mechanical (brushing) and chemical cleaning is necessary to remove the plaque from the surfaces of the denture (Budtz‐Jörgensen 1990; Nalbant 2008). Daily denture cleaning and disinfection is claimed to be paramount for the prevention of disease (Felton 2011).
Thorough daily cleaning is required (although this can be problematic for individuals with limited physical ability) followed by disinfection, preferably through soaking (Hoad‐Reddick 1990; Kanli 2005). It has been suggested that the ideal denture cleaner should be antibacterial and antifungal, non‐toxic and compatible with the denture material and should not modify or degrade the surface of the denture.Preventing Denture Stomatitis Essay. Additionally, it should be easy to use for patients and caregivers alike and be cost effective (Felton 2011).
Over‐the‐counter denture cleaning solutions and prescription oral rinses, such as chlorhexidine, claim to be effective for treatment and better than brushing and rinsing alone (Dahlan 2011; de Andrade 2012). Oral rinses with chlorhexidine and disinfection of the dentures have been suggested for treatment, however chlorhexidine can discolour the denture and the remaining natural dentition (Bagis 2011; Olsen 1975), and requires a professional prescription in many countries.
Numerous antifungals exist for the treatment of oral candidiasis (e.g. nystatin, clotrimazole, fluconazole, miconazole) available as oral suspension, pastilles, lozenges, troches, gel, varnish and rinses (Gendreau 2011; Sciubba 2015). Adverse effects are associated with the long‐term use of the medications if they are ingested. Nystatin is the most commonly used topical antifungal agent for the treatment of oral candidiasis. The formulation is in oral rinses, pastilles and oral suspensions, but it can cause nausea, vomiting and diarrhoea. Another antifungal clotrimazole, similar to nystatin, has a high sucrose content and is a concern for caries in the remaining natural dentition and patients with associated diabetes and should not be prescribed. For patients who require systemic antifungal therapy, hepatotoxicity of the antifungals is a major concern, especially for the elderly (Akpan 2002).
Natural products have been also used for the treatment and prevention of denture stomatitis. These include garlic, tea tree oil, propolis, pomegranate and salt (Santos 2008). It has even been suggested that the placement of the dentures in the microwave can be used (Neppelenbroek 2008; Senna 2013), but this has a strong possibility of damage and destruction of the prosthesis and is therefore not recommended.
Also the repair or replacement of ill fitting dentures, and the application of soft denture lining along with the discontinuous use at nighttime have been studied as the complementary practices for the prevention and treatment of denture stomatitis (Arikan 1995; Pires 2002). Preventing Denture Stomatitis Essay.
How the intervention might work
Denture cleaning (with or without disinfection)
Removal of plaque and appropriate denture wearing habits (including removal of denture for nighttime) are advocated for the treatment and prevention of denture stomatitis (Sciubba 2015).
Denture cleaning without antiseptic agents through brushing using only a denture brush or a regular brush and tap water may work. However, studies have shown that brushing alone is insufficient to eliminate Candida and that the use of toothpaste or any paste may alter the quality of the denture (Felton 2011). Denture washing with cleanser products such as commercially available tablets to immerse the denture have also been proposed, however their effectiveness in removing fungi is questionable (Felton 2011).
Alternative disinfectants, such as sodium hypochlorite and chlorhexidine, have been investigated to decontaminate the denture and eliminate plaque (Budtz‐Jörgensen 1972; Dahlan 2011; Felton 2011; Ryalat 2011).
Antifungal agents
Pharmacological treatment includes the use of specific antifungal agents, applied locally or systemically, to halt the growth of yeast. These include nystatin, amphotericin B, miconazole or clotrimazole administered in creams, tablets, rinses or troches.Preventing Denture Stomatitis Essay. The incorporation of antifungals into soft denture liners has been suggested for the treatment for denture stomatitis (Urban 2015). The primary purpose of these antifungal agents is to inhibit yeast growth.
Physical therapy
With physical therapies, typically the agent adheres to the mucosal surface of mouth to form a protective coating.
Natural remedies
Alternative, natural remedies can also be used as denture cleansers. These can include citric acid (Faot 2014), apple cider vinegar (Mota 2015), and sodium bicarbonate (Sousa 2009), acting to impede the adherence of Candida to the denture surface.
Why it is important to do this review
The Cochrane Oral Health Group undertook an extensive prioritisation exercise in 2014 to identify a core portfolio of the most clinically important titles to maintain on the Cochrane Library. Consequently, this title was identified as a clinically important priority by the oral medicine expert panel for development, maintenance, and investment of resources by the editorial base.
As the elderly population increases, the incidence of denture stomatitis is also increasing. Complete dentures are still the most common prosthesis offered to edentulous people for replacing missing teeth (Roessler 2003). A large proportion of the worldwide population has some type of removable prosthetic restoration. The incidence and prevalence of tooth loss in the elderly population is declining in some countries (Slade 2014; The World Bank Group 2013; Wu 2012). However, edentulism still exists despite the global trend towards prevention of oral disease and advances in oral health care (Emami 2013). Preventing Denture Stomatitis Essay. The use of complete dentures remains the most popular modality for replacing missing teeth. The frequency of removable partial dentures among adults varies between 13% and 29%, with 3% to 13% of edentulous patients wearing complete dentures in both arches in the European countries. In the US, 23% of adults over 65 years of age are edentulous (Dye 2012), and analysis of completely edentulous persons from 18 to 74 years of age has shown that 89.6% wear complete dentures in both arches (Redford 1996). Wearing dentures predisposes an individual to infection, with candidiasis prevalent in as many as 65% of the elderly people wearing dentures (Singh 2014).
Denture stomatitis is usually asymptomatic but, if left unchecked, can become serious, resulting in inflammatory papillary epithelial hyperplasia (Newton classification Type III), requiring surgical incision before a denture can be replaced (Infante‐Cossio 2007; Sciubba 2015). Preventing Denture Stomatitis Essay.
