Denture stomatitis. II. The effect of antifungal and prosthetic treatment

Strategies for Preventing and Treating Oral Mucosal Infections Associated with Removable Dentures: A Scoping Review

Oral infections occur due to contact between biofilm rich in Candida albicans formed on the inner surface of complete dentures and the mucosa. This study investigated historical advances in the prevention and treatment of oral mucosal infection and identified gaps in the literature. Bibliographic research was conducted, looking at PubMed, Embase, Web of Science, and Scopus, where 935 articles were found. After removing duplicates and excluding articles by reading the title and abstract, 131 articles were selected for full reading and 104 articles were included. Another 38 articles were added from the gray literature. This review followed the PRISMA-ScR guidelines. The historical period described ranges from 1969 to 2023, in which, during the 21st century, in vitro and in vivo studies became more common and, from 2010 to 2023, the number of randomized controlled trials increased. Among the various approaches tested are the incorporation of antimicrobial products into prosthetic materials, the improvement of oral and denture hygiene protocols, the development of synthetic and natural products for the chemical control of microorganisms, and intervention with local or systemic antimicrobial agents. Studies report good results with brushing combined with sodium hypochlorite, and new disinfectant solutions and products incorporated into prosthetic materials are promising.

Therapeutic Role of Nystatin Added to Tissue Conditioners for Treating Denture-Induced Stomatitis: A Systematic Review

Denture-induced stomatitis (DIS) represents a pathological condition caused by ill-fitting dentures trauma, manifested as inflammation of the palatal tissue beneath the denture. The fungal infections are the principal contributory factors to DIS. Although the aetiology of DIS is multifactorial, the Candida albicans fungal infection remains the main cause. The objective of the present systematic review was to evaluate the latest literature on the addition of nystatin into the tissue conditioners (TCs) in the management of DIS. To search the published literature about “the addition of nystatin in TCs for treating DIS”, electronic databases (PubMed (National library of medicine) and Cochrane Library (Wiley)) were searched (from 1975 until December 2020) using different keywords. Various studies described the effectiveness and efficacy of incorporating nystatin into several TCs. The present systematic review reported that the addition of nystatin is beneficial, with slight or no consequences on both the mechanical and physical features of TCs. Adding nystatin to various TCs for treating DIS can be suggested.

Antifungal activity, biofilm-controlling effect, and biocompatibility of poly(N-vinyl-2-pyrrolidinone)-grafted denture materials

Colonization and biofilm-formation of Candida species on denture surfaces cause Candida-associated denture stomatitis (CADS), a common, recurring disease affecting up to 67% of denture wearers. We developed poly(N-vinyl-2-pyrrolidinone)-grafted denture materials that can be repeatedly recharged with various antifungal drugs to achieve long-term antifungal and biofilm-controlling effects. The monomer, N-vinyl-2-pyrrolidinone (NVP), was grafted onto poly(methyl methacrylate) denture resins through plasma-initiated grafting polymerization. The physical properties and biocompatibility of the resulting resins were not negatively affected by the presence of up to 7.92% of grafted poly (N-vinyl-2-pyrrolidinone) (PNVP). Miconazole and chlorhexidine digluconate (CD) were used as model antifungal drugs. PNVP grafting significantly increased the drug absorption capability of the resulting denture materials. Further, the new materials showed sustained drug release and provided antifungal effects for weeks (in the case of CD) to months (in the case of miconazole). The drug-depleted resins could be recharged with the same or a different class of antifungal drug to further extend antifungal duration. If needed, drugs on the PNVP-grafted denture materials could be "washed out" (quenched) by treating with PNVP aqueous solutions to stop drug release. These results point to great potentials of the new materials in controlling biofilm-formation in a wide range of device-related applications.

Does the presence of anterior mandibular teeth increase the incidence of denture stomatitis?

PURPOSE

To compare the frequency of denture stomatitis (DS) under maxillary complete dentures (CDs) in patients with opposing mandibular distal extension removable partial dentures (RPDs) and CDs.

MATERIALS AND METHODS

Participants included 365 maxillary CD wearers (241 women, mean age 70.5 ± 13.2 years; 124 men, mean age 71.5 ± 10.4 years) from 7 rest homes in Istanbul. A total of 268 had mandibular CDs; 97 had mandibular distal extension RPDs. Two independent, calibrated examiners performed oral examinations. Presence of maxillary denture-related stomatitis and the effect of risk factors on DS were evaluated and recorded.

RESULTS

The frequency of palatal DS (Newton I-III) was 45.1% (n = 121) in the mandibular CD group and 49.5% (n = 48) in the mandibular distal extension RPD group, a statistically insignificant difference (p= 0.4). Factors significantly associated with palatal DS were maxillary denture age (p= 0.02), reduced occlusal vertical dimension (p= 0.04), and nocturnal denture wear (p= 0.03).

CONCLUSION

In this study, DS beneath maxillary CDs did not differ between mandibular distal extension RPD and CD wearers. The presence of mandibular anterior teeth did not influence the occurrence of palatal DS.

The etiology of inflammatory papillary hyperplasia

An investigation was carried out to evaluate some of the etiologic factors of inflammatory hyperplasia. The lesion was found in 97 out of 700 patients (13.9 per cent). It occurred in the palate and was always associated with the wearing of dentures, especially those which had relief areas in the palate. It was possible to associate the lesion with constant wearing of the dentures. The results indicate that the cause of inflammatory papillary hyperplasia is complex, and it seems to occur only in susceptible subjects when the tissues are irritated by local factors. The lesion is treated by reducing the inflammation and removing the papillae. The construction of new prostheses and the education of patients in oral hygiene and the care and maintenance of their dentures are essential.

Effectiveness of photodynamic therapy for the inactivation of Candida spp. on dentures: in vitro study

OBJECTIVE

This in vitro study evaluated the effectiveness of photodynamic therapy (PDT) for the inactivation of different species of Candida on maxillary complete dentures.

BACKGROUND DATA

The treatment of denture stomatitis requires the inactivation of Candida spp. on dentures. PDT has been reported as an effective method for Candida inactivation.

METHODS

Reference strains of C. albicans, C. glabrata, C. tropicalis, C. dubliniensis and C. krusei were tested. Thirty-four dentures were fabricated in a standardized procedure and subjected to ethylene oxide sterilization. The dentures were individually inoculated with one of the strains and incubated at 37°C for 24 h. Dentures submitted to PDT (P+L+) were individually sprayed with 50 mg/L of Photogem(®) (PS) and, after 30 min, illuminated by LED light for 26 min (37.5 J/cm(2)). Additional dentures were treated only with PS (P+L-) or light (P-L+) or neither (P-L-). Samples of serial dilutions were spread on Sabouraud dextrose agar and incubated at 37°C for 48 h. The colonies were counted and the values of log (cfu/mL) were analyzed by Kruskall-Wallis and Dunn tests (p<0.05).

RESULTS

For all species of Candida, PDT resulted in significant reduction (p<0.05) of cfu/mL values from dentures when compared with P-L- (reductions from 1.73 to 3.99 log(10)). Significant differences (p<0.05), but lower reductions, were also observed for P+L- and P-L+when compared with P-L- for some species of Candida.

CONCLUSIONS

PDT was an effective method for reducing Candida spp. on dentures.

Candida-associated denture stomatitis in type 2 diabetes mellitus

OBJECTIVE

To describe the clinical appearance of Candida-associated denture stomatitis (DS) in subjects with type 2 diabetes (T2DM). The relationships between the types of DS, oral complaints and associated conditions were assessed in terms of glycemic control as determined by glycated hemoglobin (HbA1c) measurements.

MATERIALS AND METHODS

Demographic and clinical data were obtained from questionnaires and oral examinations of 110 edentulous patients with T2DM and 50 control subjects.

RESULTS

Type II DS commonly occurred in diabetics (57.3% vs 30%; p=0.002) together with DS related oral complaints (60.9% vs 24%; p<0.001) compared with controls. Burning sensation of the mouth (BS) was the most common complaint. Dryness of the oral mucosa (DOM) (50.9% vs 6%; p<0.001), angular cheilitis (26.4% vs 8%; p=0.01) and glossitis (27.3% vs 6%; p=0.003) occurred more frequently in diabetics. Oral complaints and associated conditions of DS coincided with elevated HbA1c levels (p<0.001). Diabetics with extensive type of inflammation had higher HbA1c levels than type I/III DS subjects (p<0.001).

CONCLUSIONS

Diffuse type of inflammation was associated with T2DM. BS and DOM were the most common oral complaints. Inadequately controlled diabetes with Candida-associated DS was linked to a high incidence of an extensive type of inflammation, oral complaints and associated conditions.

An immunohistochemical study of p53 and PCNA in inflammatory papillary hyperplasia of the palate: a dilemma of interpretation

OBJECTIVE

Inflammatory papillary hyperplasia of the palate (IPHP) or the granular type of denture stomatitis, is a non-neoplastic lesion characterized histologically by a significant epithelial hyperplasia and inflammatory infiltrate usually caused by trauma and Candida infection. p53 and proliferative cell nuclear antigen (PCNA) are cell-cycle regulators, that when overexpressed, are considered by many investigators as markers of malignant transformation. The objective of this study was to investigate the immunodetection of p53 and PCNA in IPHP, and to correlate these results with the degree of epithelial hyperplasia and inflammatory infiltrate.

MATERIALS AND METHODS

In 12 cases diagnosed clinically as IPHP, Candida was cultured from the denture base and the palatal mucosa. Lesions were biopsied and stained with H&E for histomorphometric analysis of the epithelial width and inflammatory infiltrate. PAS and Gram stains were used for screening of Candida. Sections were immunostained with DO-7 for p53 and PC-10 for PCNA. Fifteen palatal biopsies obtained from autopsies of edentulous subjects with normal palatal mucosa served as controls.

RESULTS

All cultures of swabs from both the palatal mucosa and denture base were positive for Candida. Candidal hyphae could not be identified in PAS stained sections. Small foci of Gram-positive organisms were found in two cases of IPHP. Epithelial width and inflammation were significantly higher in IPHP than in controls (P < 0.001). A three-fold increase in positively stained cells for p53 and a two-fold increase in positively stained cells for PCNA were seen in IPHP compared with controls (P < 0.001).

CONCLUSIONS

Although a significant increase in the immunodetection of p53 and PCNA may indicate a malignant potential, IPHP has never been reported to undergo malignant transformation nor is it associated with cytologic signs of dysplasia. The increase in the epithelial width and inflammation degree is probably associated with the colonization of the denture bases with Candida organisms. The increased detection of p53 and PCNA can be a secondary effect of cytokines originating from both the inflammatory cells and the keratinocytes. Thus, immunodetection of p53 and PCNA by current immunohistochemical methods on archival tissues is neither specific nor sensitive enough to be used as indicators for malignant potential in the absence of cytological dysplastic changes or genetic proof of mutated cell cycle genes.

The association of yeasts and denture stomatitis with behavioral and biologic factors

OBJECTIVES

This study describes the association of yeasts and denture stomatitis with behavioral and biologic factors.

STUDY DESIGN

Seven hundred eighty 55-year-old citizens of Oulu, Finland, were examined clinically; 452 of them had complete dentures. Salivary yeasts and lactobacillus counts were detected through the use of Oricult-N and Dentocult-LB dip-slide techniques. Lifestyle factors were measured by means of questions concerning physical activity, tobacco smoking, alcohol consumption, and dietary habits. Other background variables used in cross-tabulations and logistic regression analysis were unstimulated salivary secretion rate, retention of denture, oral hygiene, gender, and socioeconomic status.

RESULTS

The prevalence of denture stomatitis was greater among subjects with an unhealthy lifestyle, subjects with higher lactobacillus counts, and subjects with poor oral hygiene. Salivary secretion rate and smoking were associated with the presence of yeasts, but general lifestyle measures were not.

CONCLUSION

The presence of yeasts tended to be associated with biologic factors, but behavioral factors reflecting lifestyle may be more important in the development of denture stomatitis.

Effect of treatment of palatal inflammatory papillary hyperplasia with local and systemic antifungal agents accompanied by renewal of complete dentures

The aim of this study was to estimate the effect of local and systemic antifungal treatment, accompanied by renewal of complete dentures, on palatal inflammatory papillary hyperplasia (PIPH). The treatment groups consisted of 26 subjects treated with a local antifungal agent (miconazole, 2% gel) for 4 weeks and 13 subjects treated with a systemic antifungal agent (fluconazole, 50 mg) for 2 weeks (test groups). Ten subjects fitted with new complete dentures served as a control group. Variables examined before antifungal and prosthetic treatment included estimation of the size and color of the affected palatal area, measurements of the lengths of the papillae, and salivary variables. Six months after the completion of prosthetic treatment healing was determined as disappearance or marked reduction of the redness of the PIPH. Healing was more often observed in test groups (64%) than in the control group (20%) (p = 0.012). Fifty-eight per cent of the subjects treated with a local (miconazole, 2%) and 77% of those treated with a systemic (fluconazole, 50 mg) antifungal agent were healed. Even though papillary hyperplastic tissue did not disappear, the treatment of PIPH with an antifungal agent without surgery before renewal of dentures might be an alternative treatment in mild cases.

Comparison of different treatment methods for localized and generalized simple denture stomatitis

The purpose of this study was to compare the treatment effects of fluconazole, fluconazole plus chlorhexidine and the fitting of new dentures upon the treatment of denture stomatitis and 15 subjects with clinical evidence of localized simple denture stomatitis were investigated clinically and mycologically. Patients with clinical evidence of generalized simple denture stomatitis were divided into three treatment groups. The first group was given 50 mg of fluconazole tablets daily for 2 weeks. The second group were instructed to apply chlorhexidine solution to the inner surface of the denture twice a day in addition to fluconazole treatment for 2 weeks. New dentures were constructed for the third group. Patients with clinical evidence of localized simple denture stomatitis were fitted new dentures without antifungal therapy. Palatal swabs were taken from each subject before, immediately after, and 2 weeks after the end of treatment, and the samples were examined mycologically in order to identify yeast colonies. It was found that for generalized simple denture stomatitis, treatment with fluconazole plus chlorhexidine resulted in better improvement of palatal inflammation than that by either fluconazole or the fitting of new dentures without medication. Whereas fitting new dentures did not reduce inflammation in patients with generalized simple denture stomatitis, the beneficial effects of prosthetic treatment were seen in patients with localized simple denture stomatitis.

Comparison of three different treatment methods for generalized denture stomatitis

This study compared the effects of fluconazole, fluconazole plus chlorhexidine, and placing new dentures for the treatment of generalized simple denture stomatitis. Subjects with clinical evidence of generalized simple denture stomatitis were investigated clinically and myocologically. These 45 patients were divided into three groups. The first group was given 50 mg of fluconazole in tablet form once a day for 2 weeks. The second groups were instructed to apply chlorhexidine solution to the inner surface of the denture twice a day in addition to the fluconazole treatment for 2 weeks. New dentures were made for the third group. Palatal swabs and smears were taken from each subject before, immediately after, and 2 weeks after treatment and these samples were examined myocologically. It was found that for generalized simple denture stomatitis, treatment with fluconazole in conjunction with chlorhexidine resulted in greater improvement of palatal inflammation and a decrease in candidal colonization than that with fluconazole alone or making new dentures without medication.

Comparative trial of fluconazole and amphotericin in the treatment of denture stomatitis

The efficacy of fluconazole and amphotericin in the management of denture stomatitis was investigated in a comparative trial. Patients were assessed clinically, hematologically, and mycologically at the time of entry into the study and at 1, 4, and 12 weeks thereafter. A total of 29 patients were selected at random to receive 50 mg of fluconazole daily for 14 days; 30 patients were selected to receive amphotericin lozenges and cream for 28 days. Clinical response rates were similar in both treatment groups throughout the study. The best mycologic response was noted after 1 week whereas the best clinical response was observed after 4 weeks. Clinical evidence of relapse and recurrence at 12 weeks was a common finding irrespective of treatment. Side effects were uncommon in both groups.

Human submandibular-sublingual saliva promotes adhesion of Candida albicans to polymethylmethacrylate

The purpose of this study was to identify components of saliva that interact with Candida albicans in solution and that may modulate adhesion to dental acrylic (polymethylmethacrylate [PMMA]) surfaces. Saliva-derived pellicles extracted from C. albicans blastoconidia and hyphal-form cells mixed with fresh human submandibular-sublingual saliva (HSMSL) contained predominantly high- and low-molecular-weight mucins (MG1 and MG2, respectively). In contrast, few components from fresh human parotid saliva were adsorbed to yeast cells. Coating PMMA beads with HSMSL significantly enhanced (10-fold) adhesion of both growth forms of C. albicans compared with human parotid saliva (2-fold), suggesting a role for mucins in adhesion. HSMSL-enhanced adhesion was completely abolished by preadsorbing HSMSL with either blastoconidia or hyphal-form cells prior to coating PMMA. However, coating PMMA with purified salivary mucins or the addition of mucin to preadsorbed saliva did not enhance or restore adhesion to levels found with fresh HSMSL. Adhesion assays employing guanidine-treated fresh HSMSL showed a complete lack of Candida binding, suggesting that subjecting HSMSL to dissociating conditions may alter a property of salivary mucins crucial for C. albicans adhesion. Protease and glycosidase treatment of yeast cells significantly reduced adhesion to HSMSL-coated PMMA. In addition, preincubation of C. albicans with mannose and galactose inhibited adhesion to HSMSL-coated PMMA. These results suggest that mucins may play a role in C. albicans adhesion to saliva-coated PMMA and that a glycoprotein on the yeast surface may be involved in these events.

Denture stomatitis--a review of the aetiology, diagnosis and management

Denture stomatitis is a common recurring problem of the denture wearers. The aetiology of the disease includes infection, trauma and probably a defect in the host defence mechanism. Current thinking suggests an interplay of most of these factors in the pathogenesis of the disease. The extent of interplay of these factors is still a controversy. Candida albicans has been implicated as the causative organism. However, in the light of recent research it is debatable if it is the only causative organism. Recently, cases resistant to antifungal therapy have been reported. In such cases other micro-organisms have been isolated. At the moment, comprehensive management includes meticulous denture hygiene together with anti-fungal or antibacterial therapy and correction of denture faults.

Angular cheilitis in a group of Sri Lankan adults: a clinical and microbiologic study

The relative importance of various factors in the pathogenesis of angular cheilitis in a population of Sri Lankan adults was studied. Forty-nine patients with cheilitis were examined clinically and microbiologically. Only 5 of 49 patients were full denture wearers. The clinical presentation of the lesions could be categorized as mild (Type I), moderate (Type II) or severe (Type III) and the duration of the lesions ranged from 1 month to more than 4 yr. Hematologic investigations revealed 18 patients with low hemoglobin 8 of whom had hypochromic, microcytic anaemia. Pathogenic organisms were isolated from 59% of the lesions; Candida spp. in 24 patients and Staph. aureus in 11 patients. A significant positive relationship between commissural leukoplakia and an infective etiology of angles was noted. This study confirms the multifactorial etiology of angular cheilitis while highlighting the varied clinical presentation of the lesions in an Asian population.

Etiology, pathogenesis, therapy, and prophylaxis of oral yeast infections

Etiologic factors in oral candidosis are immature antimicrobial host defenses, acquired suppression of immune defense mechanisms (AIDS, immunosuppressive or radiation therapy), or changes of the environmental conditions of the oral cavity (antibiotics, dentures, epithelial changes). After colonization and adhesion of Candida to the epithelial surface the subsequent mucosal lesion is due to tissue destruction by potent proteolytic enzymes or toxins and an inflammatory response to Candida antigens. Topical antimycotic treatment with nystatin, amphotericin B, or miconazole is important especially to prevent spread of the infection. Chronic Candida infections require long-term antifungal therapy, and patient compliance may be difficult to obtain. In denture stomatitis colonization of the fitting denture surface by Candida should be controlled by, for example, using a chlorhexidine solution as a denture disinfectant. However, recurrences are frequent if the local or the systemic predisposing conditions are not corrected. Fluconazole, a new bis-triazole, may be important for long-term treatment of immunocompromised patients.

Effect of nystatin and chlorhexidine digluconate on Candida albicans

Polyene antibiotics such as nystatin and amphotericin B are among the most widely recommended drugs for use against oral candidiasis. It is also generally accepted that chlorhexidine gluconate is an appropriate adjunct or an alternative to specific antimycotic drugs. The aim of the present study was to examine the effect of the combination of nystatin and chlorhexidine digluconate on Candida albicans in vitro. The minimum inhibitory concentration (MIC) value for the combination of the two drugs was found to be significantly higher than the values for each of the drugs alone, approximately 33 times the MIC value for the nystatin solution and 4 times the value for chlorhexidine digluconate. The results of the MIC study and the presence of a precipitate in all combinations of nystatin and chlorhexidine digluconate showed that the combination of the drugs is not effective in vitro against Candida albicans. The most likely reason is that a low solubility chlorhexidine-nystatin salt is formed, thus rendering the combined drug complex ineffective as an antibiotic agent.

Model system for the in vitro testing of a synthetic histidine peptide against Candida species grown directly on the denture surface of patients with denture stomatitis

The denture surface provides a nidus for the growth of microbial species that act to initiate, aggravate, and maintain clinical disease. The present investigation describes the development of a model system for the testing of the effectiveness of agents against these microbial species inhabiting the denture surface. It was observed through in vitro growth patterns that the model permitted the testing of representative samples of the microbial flora. Poly-L-histidine was observed to inhibit both Candida albicans and C. glabrata from growing from the denture surface into nutrient broth. Scanning electron microscopy of control and treated denture disks revealed that poly-L-histidine had either eliminated most microbial flora from the denture surface or had effected a noticeable distortion of those Candida blastospores still present on the surface. From microbiologic studies, it appeared that poly-L-histidine had inflicted direct but not lethal damage to the still-attached distorted blastospores because the latter were still able to promote growth in agent-free broth. The antifungal effects of poly-L-histidine were observed to be dependent on the concentration of the polypeptide. The data obtained were consistent for all of the patients regardless of their denture stomatitis classification.

Sanitization of dentures by several denture hygiene methods

Denture sanitization is an important element in the treatment of denture stomatitis and should be emphasized in instructions to patients. A two-part study was designed to compare the efficacy of eight denture-cleaning methods in removing and/or killing aerobes, anaerobes, and yeasts on dentures. Part I tested the effectiveness of the cleaners on a pure yeast culture of C. albicans. Part II tested the various denture sanitization techniques under actual clinical conditions. The following conclusions were made from the information obtained in this study: Miller's and Kleenite were the most effective sanitizing agents. Brushing the denture with soap and water and soaking the denture in the cleaner Mersene were effective to a lesser degree. Although Clorox and Calgon was effective at killing yeast under in vitro conditions, it was not effective under clinical conditions. The other denture cleaners were not found to be effective under the clinical conditions of this study for the removal and/or killing of any of the three microorganism groups cultured. In the past, the function of denture cleaners has been to remove deposits and stains from dentures. With the present knowledge of the role of microorganisms in the etiology of denture stomatitis, more emphasis should be placed on the ability of denture cleaners to sanitize dentures.

Quantitative relationship between yeast and bacteria in denture-induced stomatitis

Quantitative cultural studies of yeasts and bacteria were made from 7-day-old denture plaque accumulate on pieces of self-adhesive tape stuck on the fitting surface of the maxillary denture in 17 edentulous subjects with healthy oral mucosa and in 27 patients affected with denture-induced stomatitis. Significantly higher numbers of yeasts and bacteria were cultured in the stomatitis patients than in the controls. This indicates that the rate of plaque formation is increased in patients with denture-induced stomatitis. Yeasts usually constituted less than 1% of the anaerobic bacterial counts, but the percentage of yeasts was significantly higher in the stomatitis patients than in the controls. There was a significant correlation between initially higher yeast counts and improvement of the clinical condition of the palatal mucosa following antimycotic treatment. In some patients only bacteria were grown and antimycotic treatment had no effect. The study supported the contention that yeast antigens and toxins of denture plaque are significant factors in initiation and maintenance of denture-induced stomatitis. However, bacteria may also be involved as pathogens.

A combined clinical, mycological and histological study of denture stomatitis

The clinical and histological appearance of the different types of denture stomatitis are in many respects very similar and confluent. In order to study the correlation between clinical and histological appearance and amount of yeasts, 48 patients with denture stomatitis and 24 with a healthy palatal mucosa were examined. The terms atrophic and hyperplastic denture stomatitis were introduced. The intensity of the palatal erythema and the growth of yeasts were most prominent among patients with hyperplastic lesions. Dryness and soreness of the mouth, angular cheilitis, spontaneous hemorrhage, glossitis and leukoplakias were found to a varying extent. No statistical evidence of correlation between the intensity of clinical erythema, amount of yeasts and grade of subepithelial inflammation could be found. The disease has most certainly a background other than solely increased growth of yeasts.

Status and treatment of denture stomatitis patients: a 1-year follow-up study

The material comprised 48 patients, 19 exhibiting atrophic and 29 hyperplastic denture stomatitis. Twenty-seven patients with healthy mucosa served as a reference group. Past history, resilience of the mucosa, denture function and scores of palatal erythema, plaque and yeasts were recorded. The therapeutic program included new dentures, surgical and nystatin treatment, hygienic instruction and nutritional advice. The result concerning past history showed significantly more smokers, more patients with recurrent urinary tract infections in combination with prolonged antibiotic therapy, and more patients wearing their dentures at night in the denture stomatitis group. Nystatin treatment did not affect the healing of palatal erythema evaluated after 1 year. The treatment program evaluated after 1 year resulted in complete healing of the mucosa in 50% of patients. The remaining 50% had persisting erythema of varying intensity. The unhealed cases showed significantly more yeasts and plaque on the denture bas compared to the healed patients and the reference group. An evaluation of factors common to failure of healing is presented.

Oral mucosal lesions associated with the wearing of removable dentures

Lesions of the oral mucosa associated with wearing of removable dentures may represent acute or chronic reactions to microbial denture plaque, a reaction to constituents of the denture base material, or a mechanical denture injury. The lesions constitute a heterogeneous group with regard to pathogenesis. They include denture stomatitis, angular cheilitis, traumatic ulcers, denture irritation hyperplasia, flabby ridges, and oral carcinomas. Denture stomatitis is the most common condition which affects the palatal mucosa in about 50% of wearers of complete or partial removable dentures. Most of the lesions caused by chronic infection (Candida albicans) or mechanical injury whereas allergic reactions to the denture base materials are uncommon. Angular cheilitis (lesions of the angles of the mouth) is characterized by maceration, erythema and crust formation. The prevalence is about 15% among wearers of complete dentures. The lesions have an infectious origin but several local, including prosthetic, or systemic predisposing conditions are usually present. Traumatic ulcers caused by dentures with overextended or unbalanced occlusion are seen in about 5% of denture wearers. Denture irritation hyperplasia, which is caused by chronic injury of the tissue in contact with the denture border, is present in about 12% of denture wearers. Flabby ridge, which is replacement of alveolar bone by fibrous tissue, is present in 10-20%. Finally, there is evidence that chronic injury of the oral mucosa by dentures in rare instances may predispose to development of carcinomas. Most types of lesions are benign and quite symptomless. However, diagnosis may be difficult and the more severe and dramatic tissue reactions to dentures may indicate underlying systemic diseases. In order to prevent or minimize the extent of the lesions, denture wearers should be recalled regularly for an examination of the oral cavity and the dentures. It is important that the examination is carried out by a person who has adequate medical knowledge.

Oral candidosis. Report of a case implicating Candida parapsilosis as a pathogen

This article deals with the etiology, pathogenesis, clinical manifestations, diagnosis, and treatment of oral candidosis. Emphasis is placed on drug therapy, and the literature reviewed indicates that although many drugs are available, amphotericin B (10 mg. lozenges) is favored as the drug of choice in the treatment of this condition. Attention is drawn to predisposing factors, particularly diabetes mellitus. A case in which the pathogen was identified as Candida parapsilosis is reported.

Effect of nystatin in the treatment of denture stomatitis

The effect of nystatin treatment on denture stomatitis subclassified as generalized simple inflammation and inflammatory papillary hyperplasia has been studied. Twenty-four patients were carefully instructed to apply a thin layer of nystatin dusting powder on the fitting surface of the maxillary denture three times a day for 14 d. Different parameters were studied on three occasions; at the beginning of experiment and after 14 and 28 d. An untreated group of 24 patients with the same types of denture stomatitis served as control. The effect of treatment was evaluated by changes in the clinical erythema, the yeast colonization obtained by mycologic sampling on the palatal mucosa and on the denture base, and changes in the histologic picture of the mucosa obtained by biopsy. Subepithelial inflammation, leukocyte penetration, edema and thickness of the epithelium were histologic parameters. After 14 d of treatment the experimental group compared with the control group showed a statistically significant decrease in palatal erythema and in the amount of yeast colonies. No significant changes were found microscopically. Twenty-eight days after start, i.e. 14 d after withdrawal of the nystatin, there still was a statistically significant improvement of the palatal erythema in the experimental group compared with the controls. However, no patient was totally cured. There were no significant changes in the number of yeast colonies and the histologic parameters.

Reactions to acrylic resin dental prostheses

A review of the pertinent literature concerning acrylic resin and its relation to allergic reactions and chemical injury has been presented. The relation of acrylic resin prostheses and materials to oral reactions and lesions is discussed and possible causes and means of evaluation are proposed. Examples of mucosal infection and mucosal disease are presented (which may mimic acrylic resin allergy) along with examples of direct chemical injury of the oral mucosa as a result of autopolymerizing prosthetic techniques.

The Langerhans cell density of palatal epithelium in denture and non-denture wearers, as correlated with other parameters of the palatal mucosa

A quantitative histological investigation was carried out on biopsy specimens taken from patients suffering from denture sore mouth. The results were compared with those obtained in investigations on denture and non-denture wearers. The sections were studied by standardized quantitative morphometric methods. After 4 years the denture bearing palatal epithelium from both groups, normal denture wearers and the patients suffering from denture sore mouth did not show changes in mean thickness of the epithelium as compared with the controls. The mitotic index in denture bearing epithelium from patients suffering from denture sore mouth was three times lower than in the epithelium of the normal denture wearers. The number of Langerhans cells correlated with the mitotic indices of the group of denture wearers and non-denture wearers. The group of denture sore mouth patients showing a low mitotic index showed a high number of Langerhans cells in their palatal epithelium. The three groups of patients investigated did not show differences in density of mast cells in the lamina propria of their palatal epithelium.

Mucosal temperature rises following long-term use of full dentures

Mucosal temperatures were studied in twenty-two subjects, who had worn full upper and lower dentures for at least 5 years. By comparing with a group of twenty-two fully dentate subjects, it was found that in the denture wearers, temperatures were increased significantly in the lower jaw, but not in the upper jaw.

Skin sensitivity to denture base materials in the burning mouth syndrome

The significance of sensitizing compounds in the denture base for the etiology of the burning mouth syndrome (BMS) has been studied in 53 denture-wearing persons, seven males and 46 females. Epicutaneous patch tests were performed with standard concentrations of benzoyl peroxide, dibutylphthalate, dimethyl-p-toluidine, formaldehyde, hydroquinone, methylmethacrylate, p-phenylendiamine and with cadmium sulfate, potassium dichromate, cobalt chloride and nickel sulfate. Furthermore, patch testing was performed with filings from the denture mixed with the patient's own saliva. In cases with an inflamed oral mucosa, the presence of hyphae of Candida albicans was assessed by a smear technique. Positive skin reactions were observed in 15 persons to dimethyl-p-toluidine, hydroquinone, formaldehyde, methylmethacrylate, p-phenylendiamine, potassium dichromate, cobalt chloride and nickel sulfate, including three cases with reactions to filings from their dentures, and one patient who after subsequent testing showed skin sensitivity to balsam of Peru. In 12 cases an etiological connection could be traced between the oral symptoms and the denture base, indicating that contact sensitivity to base materials or to allergens and microbial antigens on the denture plate plays a greater role in the pathogenesis of BMS in edentulous persons than previously suggested.

Oral mycoses and their treatment

Mycoses of the mouth and nearby areas can be caused by both yeasts and filamentous fungi. They may appear either independently or as part of a systemic infection. It is typical of many mycoses that they occur as a consequence of local factors operating in the mouth, or in patients debilitated by severe diseases. Yeasts that are part of the normal microbial flora of man, among them especially Candida species, are the most frequent causative agents. Some tropical or semitropical infections may occur in Scandinavia and Finland, but they are rare. Local therapy with antimycotics is often effective in acute infections, whereas some chronic ones may make systemic administration necessary. Some of these infections are treated surgically.

Oral candidosis--frequency, treatment and relapse tendency in a group of psychiatric inpatients

Candida fungi are frequent in the oral cavity, especially in denture wearers. The infection can cause serious complications in elderly or debilitated subject. The present experimental group consisted of 81 female psychiatric patients (35--91 years of age). In addition to a clinical examination, smears from the palate, tongue and dentures (when present) were cultured on Nickerson's medium. Patients with a positive clinical and/or microbiological diagnosis were treated for 35 days with one of two gels containing 1% chlorhexidine. Following the treatment period patients with full or partial dentures took part in a maintenance program, in which the dentures were either soaked in a 0.2% chlorhexidine solution or mechanically cleaned every day for a period of 35 days. Two thirds of the patients showed clinical signs of oral candidosis or had positive cultures preexperimentally. The treatment with chlorhexidine gels resulted in negative cultures in 71% and negative clinical diagnosis gels resulted in negative cultures in 71% and negative clinical diagnosis in 96% of the patients. Mucosal soreness occurred during the treatment period in 8 out of 28 patients wearing full dentures. Xerostomia was not influenced by the chlorhexidine treatment. The relapse tendency was low during the post-treatment period. No clearcut differences between the two maintenance methods could be detected.

The in vitro fungicidal properties of Visco-gel, alone and combined with nystatin and amphotericin B

The in vitro effect of the tissue conditioner Visco-gel, with or without the inclusion of nystatin and amphotericin B, upon Candida albicans, Candida krusei and Candida tropicalis, has been studied. Visco-gel alone was completely inert and would therefore not be used without nystatin in the treatment of a denture stomatitis where a yeast infection was present. Amphotericin B became completely ineffective when mixed with Visco-gel, but in control tests remained very active.

Histological features of the palatal mucosa in denture sore mouth. Densities of mast cells in the lamina propria and histological features in the epithelium of the denture bearing and non-denture bearing human palatal mucosa in comparison with patients suffering from denture sore mouth

A histological investigation was carried out on biopsy specimens taken from patients suffering from denture sore mouth. The results were compared with those obtained in previous investigations on denture and non-denture-wearers. The sections were studied by standardized quantitative morphometric methods. After 4 years the denture bearing palatal epithelium from both groups, the denture wearers and the patients suffering from a denture sore mouth did not show changes in mean thickness of the epithelium from both groups, the denture wearers and the patients suffering from a denture sore mouth did not show changes in mean thickness of the epithelium compared with the controls. The mitotic index in denture bearing epithelium from patients suffering from denture sore mouth was three times lower than in the epithelium of the normal denture wearers. The three groups of patients investigated did not show differences in density of mast cells in the lamina propria of their palatal epithelium.

Denture stomatitis. Effects of chlorhexidine and amphotericin B on the mycotic flora

In 100 patients with denture stomatitis cultures and direct smears were used to evaluate 5 treatments, including sucking of chlorhexidine, amphotericin B or placebo tablets combined with denture soaking in 0.2% chlorhexidine or water. After 14 days of treatment the amphotericin B lozenges had brought about a significant reduction in the quantity of fungus on the oral mucosa, whereas they barely affected the large amount present on the fitting surface of the upper denture. Denture immersion in chlorhexidine significantly reduced the number of organisms both on the mucous membrane and on the denture. It therefore seems at least as important to treat the denture as the patient in denture stomatitis. Fourteen days after withdrawal of the drugs the mycotic flora was largely re-established.

Denture stomatitis. Relapse tendency and removal of acquired discolourations in long-term denture disinfection with chlorhexidine

Five patients with denture stomatitis were initially treated for 14 days with a combination of amphotericin B lozenges and denture soaking in 0.2% chlorhexidine. To prevent recurrence the dentures were then kept overnight in 0.2% chlorhexidine during five months. No relapse occurred, but the dentures (all-acrylic) became heavily discoloured by chlorhexidine. During this period fungi could not be grown either on palatal or on maxillar denture agar models, and clinical signs and symptoms were reduced further. At the end of treatment hypochlorite was used to remove chlorhexidine-induced denture stain. Brushing and soaking (0.16%) proved more efficient than brushing alone, and when a 0.60% solution was used, the stains were generally eliminated in two hours. Hypochlorites in the prevention and removal of chlorhexidine discolourations deserve further attention.