Journal of Oral Rehabilitation, 1978, Volume 5, pages 35-39
A 3-months' study of enzymes as denture cleansers
E. B U D T Z - J O R G E N S E N Royal Dental College, Arhus
Department of Prosthetic Dentistry,
Summary
It was the purpose of the study to test the efficacy of dissolvent tablets containing mutanase and protease in removing denture plaque. The study group consisted of forty institutionalized geriatric denture wearers, who were assigned randomly into an enzyme group and a placebo group. Enzyme tablets and placebo for denture soaking were administered by the nurses. The dentures were immersed for 15 min once daily for three months. The amount of denture plaque, the clinical condition of the palatal mucosa, and the concentration of yeasts and bacteria in mucosal and denture smears were recorded before, during, and after the experimental period. The study was designed and carried out as a double-blind study. After denture soaking for six weeks a significant reduction of the amount of denture plaque and improvement of the clinical condition of the palatal mucosa was recorded. After denture soaking for twelve weeks the conditions had improved further when comparing the enzyme group with the placebo group. Introduction
Infection by Candida species is a significant cause of denture stomatitis (BudtzJorgensen, 1974). The condition, which has been found in about 60% of denture wearers, is due primarily to an extensive plaque accumulation on the fitting surface of the dentures (Budtz-Jorgensen & Bertram, 1970; Davenport, 1970; Budtz-Jorgensen, Stenderup & Grabowski, 1975). Healing of the lesions has been reported subsequent to meticulous denture hygiene by mechanical plaque control (Lindquist, Andrup & Hedegard, 1975) or disinfection of the dentures by chlorhexidine (Budtz-Jorgensen & Loe, 1972; Olsen, 1975). In order to improve denture cleanliness, commercial solution cleansers have been recommended as an adjunct to mechanical cleansing (Neill, 1968; Herrmann, 1971). Some of these products were efficient when the immersion period was 8 h. However, in studies using a 10-15 min immersion period commercial solution cleansers were found to be no more efficient than water or placebo (Nicholson, Stark & Scott, 1968; Glantz, Hansson, Nyquist, Rundcrantz & Rundcrantz, 1975; Budtz-Jorgensen & Kelstrup, 1977). Recently, we have studied the efficiency of enzymes in removing denture plaque Correspondence: Dr E. Budtz-Jorgensen, Institut for Protetik, Royal Dental College DK 8000 Arhus C, Denmark.
35
36
E. Budtz-Jorgensen
(Budtz-Jorgensen & Kelstrup, 1977). It was found that dissolvent tablets containing mutanase and protease during an immersion period of 15 min daily for 2 weeks caused a significant reduction of the amount of denture plaque to an extent which improved the clinical condition of the palatal mucosa. However, in these experiments the concentration of the enzymes was relatively high. It was the purpose of the present study to test the long-term effect of dissolvent tablets with economically more realistic enzyme concentrations. Material and methods The study group consisted of forty institutionalized old people (> 70 years of age) wearing complete dentures. The patients were assigned randomly to either an enzyme group (Group E) or a placebo group (Group P). It was reported that the ordinary, routine denture cleansing was performed by nurses once daily using brush and soap; commercial denture cleansers were not used. Forty percent of the patients kept their dentures in water during the night. The nurses were instructed to dissolve one tablet in 150 ml luke-warm water (37°C) and to soak the dentures for 15 min in a freshly prepared solution once daily for three months. No change of the usual denture cleansing regimen was intended. During the course of the experiment the patients were asked whether they had observed any change (improvement) of denture cleanliness. After the experiment, the nurses were asked for their opinion of the tablets. The study was carried out double-blind, the composition of the tablets not being known by the participants, the nurses, or the examiners. Methods of examination The patients were examined by dental hygienists and were calibrated prior to the start of the experiment (plaque index, presence or absence of denture stomatitis). Examinations were performed before the start of the experiment and after denture immersion for two, six and twelve weeks. At each examination, the oral cavity was inspected using a torch to provide sufficient light. A distinction was made between clinically normal and inflamed palatal mucosa (denture stomatitis). An examination of denture cleanliness was made using a plaque detector (0-3 % aqueous solution of proflavinemonosulphate), and the fitting surface of the denture was photographed. The amount of denture plaque was graded as: 0, none visible; 1, less than | of the fitting surface of the denture; 2, covering ^-f of the fitting surface; 3, covering more than f of the fitting surface; 4, heavy accumulations on all surfaces. Smears were prepared from scrapings from the fitting surface of the maxillary denture and from the palatal mucosa (Budtz-Jorgensen & Loe, 1972). The smears were stained with periodic acid Schiff, and counterstained with hematoxylin. Occurrence of Candida cells (blastospores and hyphae) and bacteria was recorded. A measure of the concentration of hyphae was obtained using Davenport's index (Davenport, 1970); the same index was used for quantification of the number of bacteria:
Enzymes as denture cleaners
37
0, no hyphae (bacteria) seen in the smear; 1, a few scattered hyphae (bacteria) present; 2, large numbers of hyphae (bacteria) present in a few fields; 3, large numbers of hyphae (bacteria) present in most fields. Enzymes The enzymes tested were a combination of protease and mutanase the latter being a-1,3 glucan glucanohydrolase (Budtz-Jorgensen & Kelstrup, 1977). Two types of dissolvent tablets were prepared (A/S Novo, Bagsvaerd, Denmark), one with a mixture of the enzymes and one without enzymes (placebo). The content of the enzymes per tablet was 0-2 g mutanase and 0-5 g protease. Both types of dissolvent tablets contained citrate buffer, sodium bicarbonate, and magnesium stearate. Statistical analyses Data obtained in the enzyme group and the placebo group were compared by means of the Chi-square test (Yate's correction). Results
Five patients (two in Group E and three in the Group P) did not complete the study. Of these, one had died and four did not want to co-operate. Denture stomatitis was detected in 60 % of the patients in Group E and 70 % in Group P before the experiment and in 30 % and 65 %, respectively, after the experiment. The mean denture plaque scores are recorded in Fig. 1. After denture soaking for two weeks both groups showed decreased plaque scores; however, during the following weeks mean plaque scores decreased in Group E but showed increased values in Group P. After 5 weeks the plaque scores were significantly reduced in Group E as compared with Group P (x^ = 3-3, P
A 3-months' study of enzymes as denture cleansers
E. B U D T Z - J O R G E N S E N Royal Dental College, Arhus
Department of Prosthetic Dentistry,
Summary
It was the purpose of the study to test the efficacy of dissolvent tablets containing mutanase and protease in removing denture plaque. The study group consisted of forty institutionalized geriatric denture wearers, who were assigned randomly into an enzyme group and a placebo group. Enzyme tablets and placebo for denture soaking were administered by the nurses. The dentures were immersed for 15 min once daily for three months. The amount of denture plaque, the clinical condition of the palatal mucosa, and the concentration of yeasts and bacteria in mucosal and denture smears were recorded before, during, and after the experimental period. The study was designed and carried out as a double-blind study. After denture soaking for six weeks a significant reduction of the amount of denture plaque and improvement of the clinical condition of the palatal mucosa was recorded. After denture soaking for twelve weeks the conditions had improved further when comparing the enzyme group with the placebo group. Introduction
Infection by Candida species is a significant cause of denture stomatitis (BudtzJorgensen, 1974). The condition, which has been found in about 60% of denture wearers, is due primarily to an extensive plaque accumulation on the fitting surface of the dentures (Budtz-Jorgensen & Bertram, 1970; Davenport, 1970; Budtz-Jorgensen, Stenderup & Grabowski, 1975). Healing of the lesions has been reported subsequent to meticulous denture hygiene by mechanical plaque control (Lindquist, Andrup & Hedegard, 1975) or disinfection of the dentures by chlorhexidine (Budtz-Jorgensen & Loe, 1972; Olsen, 1975). In order to improve denture cleanliness, commercial solution cleansers have been recommended as an adjunct to mechanical cleansing (Neill, 1968; Herrmann, 1971). Some of these products were efficient when the immersion period was 8 h. However, in studies using a 10-15 min immersion period commercial solution cleansers were found to be no more efficient than water or placebo (Nicholson, Stark & Scott, 1968; Glantz, Hansson, Nyquist, Rundcrantz & Rundcrantz, 1975; Budtz-Jorgensen & Kelstrup, 1977). Recently, we have studied the efficiency of enzymes in removing denture plaque Correspondence: Dr E. Budtz-Jorgensen, Institut for Protetik, Royal Dental College DK 8000 Arhus C, Denmark.
35
36
E. Budtz-Jorgensen
(Budtz-Jorgensen & Kelstrup, 1977). It was found that dissolvent tablets containing mutanase and protease during an immersion period of 15 min daily for 2 weeks caused a significant reduction of the amount of denture plaque to an extent which improved the clinical condition of the palatal mucosa. However, in these experiments the concentration of the enzymes was relatively high. It was the purpose of the present study to test the long-term effect of dissolvent tablets with economically more realistic enzyme concentrations. Material and methods The study group consisted of forty institutionalized old people (> 70 years of age) wearing complete dentures. The patients were assigned randomly to either an enzyme group (Group E) or a placebo group (Group P). It was reported that the ordinary, routine denture cleansing was performed by nurses once daily using brush and soap; commercial denture cleansers were not used. Forty percent of the patients kept their dentures in water during the night. The nurses were instructed to dissolve one tablet in 150 ml luke-warm water (37°C) and to soak the dentures for 15 min in a freshly prepared solution once daily for three months. No change of the usual denture cleansing regimen was intended. During the course of the experiment the patients were asked whether they had observed any change (improvement) of denture cleanliness. After the experiment, the nurses were asked for their opinion of the tablets. The study was carried out double-blind, the composition of the tablets not being known by the participants, the nurses, or the examiners. Methods of examination The patients were examined by dental hygienists and were calibrated prior to the start of the experiment (plaque index, presence or absence of denture stomatitis). Examinations were performed before the start of the experiment and after denture immersion for two, six and twelve weeks. At each examination, the oral cavity was inspected using a torch to provide sufficient light. A distinction was made between clinically normal and inflamed palatal mucosa (denture stomatitis). An examination of denture cleanliness was made using a plaque detector (0-3 % aqueous solution of proflavinemonosulphate), and the fitting surface of the denture was photographed. The amount of denture plaque was graded as: 0, none visible; 1, less than | of the fitting surface of the denture; 2, covering ^-f of the fitting surface; 3, covering more than f of the fitting surface; 4, heavy accumulations on all surfaces. Smears were prepared from scrapings from the fitting surface of the maxillary denture and from the palatal mucosa (Budtz-Jorgensen & Loe, 1972). The smears were stained with periodic acid Schiff, and counterstained with hematoxylin. Occurrence of Candida cells (blastospores and hyphae) and bacteria was recorded. A measure of the concentration of hyphae was obtained using Davenport's index (Davenport, 1970); the same index was used for quantification of the number of bacteria:
Enzymes as denture cleaners
37
0, no hyphae (bacteria) seen in the smear; 1, a few scattered hyphae (bacteria) present; 2, large numbers of hyphae (bacteria) present in a few fields; 3, large numbers of hyphae (bacteria) present in most fields. Enzymes The enzymes tested were a combination of protease and mutanase the latter being a-1,3 glucan glucanohydrolase (Budtz-Jorgensen & Kelstrup, 1977). Two types of dissolvent tablets were prepared (A/S Novo, Bagsvaerd, Denmark), one with a mixture of the enzymes and one without enzymes (placebo). The content of the enzymes per tablet was 0-2 g mutanase and 0-5 g protease. Both types of dissolvent tablets contained citrate buffer, sodium bicarbonate, and magnesium stearate. Statistical analyses Data obtained in the enzyme group and the placebo group were compared by means of the Chi-square test (Yate's correction). Results
Five patients (two in Group E and three in the Group P) did not complete the study. Of these, one had died and four did not want to co-operate. Denture stomatitis was detected in 60 % of the patients in Group E and 70 % in Group P before the experiment and in 30 % and 65 %, respectively, after the experiment. The mean denture plaque scores are recorded in Fig. 1. After denture soaking for two weeks both groups showed decreased plaque scores; however, during the following weeks mean plaque scores decreased in Group E but showed increased values in Group P. After 5 weeks the plaque scores were significantly reduced in Group E as compared with Group P (x^ = 3-3, P
