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THE PREVALENCE AND AETIOLOGY OF DENTURE RELATED STOMATITIS IN PATIENTS WEARING REMOVABLE DENTURES

Summary

Introduction

Denture related stomatitis (DRS) was determined as the most frequently encountered lesion associated with denture wearing and is most often seen under full upper dentures 1, 5, 21, 23, 26 . There are opposite opinions considering the DRS and its predisposing factors. While some of the investigators have found an association between the prevalence of DRS with the rising age of patients 22 , others found no association 17, 23 . A number of investigators have suggested that females have more DRS in comparison to males 4, 21, 23, , whereas others did not 2, 15, 17 and MacEntee 1998 even found that DRS was seen more often in male gender 19 .

A lot of investigators speculated that denture age 13, 22 , denture hygiene 3, 12 and continuous use of dentures 10, 16 have a stimulating effect on the development of DRS . But there are also investigations denying such a causal relationship between those factors and DRS. Considering the large number of contradictory results on clinical parameters in previous investigations, focus should be directed to pathogenesis of DRS as well as epidemiologic aspect of findings on denture wearers. Therefore, a series of studies have been planned to conduct which will investigate the clinical epidemiologic findings through pathogenesis of DRS.

This study is the first of the planning series of investigations focused more on epidemiologic parameters by assessing the prevalence of DRS in patients with various type of dentures and to evaluate the importance of denture wearing habits as predisposing factors in the development of DRS.

Material and Methods

363 edentulous and partially dentate patients attending the Department of Removable Prosthodontics of Istanbul University, for a new denture, were examined and interviewed. A total of 274 patients who were wearing removable dentures longer than 6 months were selected to include in our study group.

The patients age, gender, existence of a denture actually being used, denture age, frequency and method of denture cleaning and dental history were recorded. Clinical examination was performed by the same investigator for standardization reasons. The type of dentures, presence and localization of denture induced lesions such as ulceration, stomatitis, angular cheilitis, inflammatory papillary hyperplasia, epulis fissuratum, flabby ridge, and the cleanliness of the dentures was noted.

In the case of DRS, the erythema was scored by using Newton 's classification index (1962) 27 :

1- Slight inflammation (Localized slight hyperaemia)

2- Moderate inflammation (generalized erythema)

3- Severe inflammation (Diffuse and papillary hyperplasia)

For DRS cases, additionally a mycological test for Candida albicans was made.

Mycological testing:

In order to provide standardization for collected samples the overall investigation was carried out at midmorning and at least 2 hours after eating, drinking or any hygiene procedure. Smear samples were taken from a triangular area of the palate and samples from saliva were initially cultured in Saubauroud's medium at 37°C for 48 hours and subsequently the count of Candida colony-forming units was recorded.

A subjective denture hygiene index was used to score the plaque at the intaglio surface in three groups.

1- Good : No or very little plaque

2- Fair : Less than half of the denture base covered by plaque

3- Poor : More than half of the denture base covered by plaque

All patients showing one or more oral lesions received proper praeprosthetic treatment.

The relationship between DRS and denture age and patient age was analyzed by using Whitney-Mann-U test.

The relationship between other denture related factors and DRS was investigated by the use of Chi-square test.

Results

One hundred and forty (51.1 %) of 274 patients (average age 61.2 ± 10.3) came with their first, 79 (28.8 %) with their second, 39 (14.2 %) with their third and 16 (5.9 %) with their fourth or more dentures. The average denture age was 9.8 ± 7.9 years. More than half of all patients were performing denture cleaning more than once a day and by the use of toothbrush and toothpaste (Table 1-2). Besides DRS, several patients showed one or more denture related oral lesions (Table 3, Figure 1), whereby the distribution of DRS is shown in Table 4. Out of 121 patients who were diagnosed with signs of DRS only 74 were evaluated microbiologically, 47 patients refused any further examination. Furthermore, candidal growth showed no statistically significant differences within the three stomatitis types, although a pronounced number of DRS cases (55 cases, 74.3 %) showed candida albicans growth (Figure 2) .

The prevalence of DRS was found statistically significant higher in women (p = 0.05) (Table 5, Figure 3) and in continuous (24h) denture wearing patients (p = 0.001) (Table 6, Figure 4). However, there was no statistically significant evidence that continuous denture wearing habits in females were more pronounced (p = 0.71) (Table 7). The denture age was statistically significant higher in patients with DRS (11.02 ± 7.99) in comparison to the denture age of patients without DRS (8.80 ± 7.80) (p = 0.008). There was also a statistically significant association between the prevalence of DRS and denture cleanliness (p = 0.02) (Table 8, Figure 5). The prevalence of DRS was lower in patients with good denture hygiene (35.6 %).

DRS lesions were mainly detected in the palatal region under maxillary dentures (p< 0.001). In patients with maxillary and mandibular complete dentures, 47 % of the cases had DRS, whereby patients with maxillary and mandibular removable partial dentures only had 22 % of DRS prevalence. The difference of DRS prevalence between complete and partial dentures was statistically significant (p= 0.01) (Table 9). There was no statistically significant relationship between prevalence of DRS and other factors such as denture cleaning habits (p = 0.43), frequency of denture cleaning (p = 0.21), patient age (p = 0.66) and renewal frequency of dentures (p = 0.12).

Discussion

The patients in this study were drawn from a population of people having complaints of their old dentures and thus seeking a new set of dentures. Therefore, this sample group may not be representative of the population wearing removable dentures on a whole.

Some investigators found no statistically significant association between DRS and denture age 16, 17 or continuous denture wearing 17 . In contrast, our results agreed with previous reports which indicated that DRS is in statistically significant association between both denture age 13, 22 and continuous denture wearing 9, 10, 16 . Due to the deterioration of the dentures in time, such as the polished surfaces, fit to the underlying tissues and the occlusion, dentures could become more irritant to the mucosa and more open to candidal and bacterial colonization.

It is reported that the prevalence is higher in women than in men 21, 23, 30 . The results of our study also showed a higher predisposition in females. Several explanations including iron-deficiency anemia, vaginal carriage and endocrine deficiency 9 have been offered, but the cause of this phenomenon is not well known. The idea that females prefer to wear dentures 24 hours and promote DRS, was not supported by our findings. There are authors reporting of the gender as not being a predisposing factor 2, 20 and MacEntee et al. (1998) even found that the prevalence in males was higher than in females 19 .

A significant number of DRS cases were encountered especially among patients wearing maxillary complete dentures: the palate is the most frequently affected region and is more susceptible to yeast colonization 24, 30 . This finding was usually reported in similar investigative studies 21, 23 , which is also confirmed by our results. This fact can be explained by the greater area which is covered by the denture base and thus prevented from contacting saliva, thus being subject to anaerobic conditions 26 . Continuous denture wearing could be an attribute, strengthening this effect, as observed in our study, too.

Budtz-Jorgensen & Bertram (1970) suggested that the denture plaque on tissue surfaces of dentures must have an irritating effect on mucosa 3 . Catalan et al., 1987, have reported that denture plaque in patients with DRS mostly show a considerable thickness 8 . The toxic effects of plaque masses in contact with oral mucosa for extended periods of time, are predictable and similar as in the periodontal patient. Candida albicans and other related species are the most common type of bacteria found in oral candidal infections 30 . Denture plaque is mainly composed of Candida albicans, which is the main cause of DRS 6, 8, 25 . The importance of Candida species, especially Candida albicans, in provoking DRS was also confirmed by several other investigators 6, 7, 9, 14, 18, 25, 28 . The denture cleanliness, according to numerous studies 3, 7, 12, 16, 17, 18, 19 is an important factor in the development of DRS. Similarly, in Kulak & Arikan's study (1993) the results showed a significant association between DRS and denture hygiene and candidal colonization 17 . Our results indicated a significant association between DRS and denture cleanliness and a tendencial relation to Candida albicans growth, too, because 55 out of 74 DRS patients showed a high yeast colonization. The results of our study showed no statistically significant differences in yeast colonization between the various stages of DRS.

There seem to be contradictory opinions about the effect of patient age on DRS. While some investigations point out on the importance of patient age 11, 15, 22 , others reject that 17, 23, 29 . The results of our study showed no correlation between patient age and DRS.

Some studies have shown that denture hygiene habits (frequency and method) are important factors in the development of DRS 16 , however, in accordance to our findings, others found no relationship 17, 18, 23 . The reason for these controversial findings could be the fact that many patients are not properly informed about the brushing and cleaning methods and the frequency, and believe that their habits are adequate.

Epidemiological facts about DRS, such as gender, age of patients, the type and localization of dentures are factors, which are not possible to manipulate, whereas denture-wearing habits can be easily changed and thus the prevalence of DRS dramatically reduced. It should be concentrated on patient information and motivation on hygiene, for prophylactic purposes. Future studies will be a series of studies which have already been planned in our department to conduct the clinical epidemiologic findings through pathogenesis of DRS.

References:

Figure Legend:

Fig. 1. The distribution of the denture related oral lesions

CDRL: Combination of denture related lesions

AS: Asymptomatic

EF: Epulis Fissuratum

DCU: Denture Caused Ulcerations

FR: Flabby Ridge

DRS: Denture Related Stomatitis

Fig. 2. Distribution of candidal growth in patients with DRS

Fig. 3. The relationship between DRS and gender (p= 0.05)

Fig. 4. The effect of continuous denture wearing (CDW) on DRS (p= 0.01);

(+): performed CDW; (-): no CDW

Fig. 5. The relationship between DRS and denture cleanliness (p= 0.02)

Table Legend:

Table 1 The frequency of denture cleaning

Table 2 Distribution of denture cleaning methods

Table 3 Distribution of denture related oral lesions

Table 4 Distribution of DRS types ( Newton classification)

Table 5 Cross tabulation table demonstrating the distribution of DRS in male and female (p= 0.05)

Table 6 Cross tabulation table demonstrating the effect of continuous denture wearing on DRS (p= 0.001)

Table 7 Cross tabulation table demonstrating the relationship of continuous denture wearing and gender (p= 0.71)

Table 8 Cross tabulation table demonstrating the effect of denture cleanliness on DRS (p= 0.02)

Table 9 Cross tabulation table demonstrating the distribution of DRS in different types of dentures (p= 0.01)