375
Australian Dental Journal, October, 1976
Volume 21 ::Number 5
Denture sore mouth. Aetiological aspects and treatment Ross J. Bastiaan, Y.D.Sc. Aesmcr-Seventy-four patients wearing full upper and lower dentures were examined in the study; 37 exhibited varying degrees of denture sore mouth (DSM)while the remaining 37 patients acted as controls. Denture trauma was more common in the DSM group. Candida was grown from 73 per cent of patients with DSM but only from 22 per cent of controls. Control patients had better denture hygiene than DSM patients. One year later 22 of the original IXSM patients wearing newly made dentures were re-examined. Nine out of 22 still exhibited varying degrees of DSM. In the 9 cases persisting, a nystatin-chlorhexidine treatment plan was prescribed, resulting in resolution of 7 further cases. The cases that failed to resolve were wearing unstable traumatogenic new dentures. (Received for publication May, 1975)
Introduction
Denture sore mouth (DSM) is a term used to describe the inflamed mucous membrane sometimes seen on the palate under a maxillary denture. It may appear as a simple localized red inflamed area or a more generalized reddening involving the whole palatal area beneath the denture. Occasionally this later form presents areas with a granular surface more commonly known as papillary hyperplasia. Denture sore mouth is a symptom-complex that may arise from a variety of local and systemic factors. There have been Seven main aetiological factors implicated:(i) traumatogenic dentures;
(ii) candidiasis; (iii) allergy to the denture base material; (iv) heat accumulation beneath the appliance (v) restriction of blood circulation and saliva secretions by the appliance; (vi) changes in the autonomic nervous system with altered salivary Secretions; (vii) putrefaction of foods and glandular discharge beneath the appliance. One of the earliest reliable studies relating to the aetiology of denture sore mouth appears to have been performed by Wright'. He attributed damage to the oral mucosa under full dentures 1 Wright, W. H.-The importance of tissue changes under artificial dentures. J.A.D.A., 16:6. 1027-1031 (June) 1929.
Australian Dental Journal, October, 1976
376 to mechanical factors. Hechtz, Landa3, Nyquist4, Kim, Ringsdorf, and Cheraskins and Love, Goska, and Mixson6 found that an unbalanced occlusion and poor fit of the denture could be associated with denture sore mouth. Landas and Nyquist4 reported a significant resolution of the condition after adjusting the dentures. Nyquist4 considered traumatogenic dentures were responsible for only localized areas of inflammation which rarely affected more than half of the palate. BudtzJorgensen and Bertram? examined 58 DSM patients and an equal number of controls. They showed that trauma alone gave rise to simple, well-localized inflammation and in rare instances to a more generalized inflammation of the palatal tissues; however they were unable to define clearly the role of trauma as an aetiological agent. The possibility of candidiasis being involved in DSM was first mentioned by Cahns in 1936. Little interest was shown in this factor until Lyon and Chicks found that candida organisms were isolated more often from inflamed palates than from healthy palates of denture wearers. Later studies by Cawsonlo and Davenport" lend support to these findings. In these studies Candida albicans was demonstrated in 66 per cent and 70 per cent respectively of DSM patients. Davenport's" study found only 20 per cent of control patients had C. albicans colonies whereas Cawson's10 swabbing technique failed to isolate C. albicans in the control group.
2
Hecht, S . S.-Chronic irritation of the epithelial tissues of the mouth associated with dentures. Am. J. Orthodont. and Oral Surg., 25: 574-585 (June) 1939.
3 Landa. J. .$.-Burning mouth and dry mouth. Prosthodontist's view. D. Items Interest, 6 7 5 , 470.478 (May) 1945.
study of denture sore mouth. An investigation of traumatic, allergic and toxic lesions of the oral mucosa arising from the use of full dentures. Acta Odont. Scand., 10, Suppl., 9: 11-154, 1952.
4 Nyquist, G.-A
5 Kim, M. S., Ringsdorf, W. M., and Cheraskin, E.-
Factors in denture tolerance. P.D.M., 3-64 (Jan.) 1962.
6 Love, W. D., Goska, F. A , , and Mixson, R. J.-The
etiology of mucosal inflammation associated with dentures. J. Prosthet. D . , 18:6, 515-527 (Dec.) 1967.
7 Budtz-Jorgensen, E., and Bertram, U.-Denture
stomatitis I. The etiology in relation to trauma and infection. Acta Odont. Scand., 28:1, 71-92 (Mar.) 1970.
OCahn, L. R.-The denture sore mouth. Ann. Dent.. 3 : l . 33-36 (Mar.) 1936. 9Lvon. D -. G.. and Chick. A. 0.-Denture , -
sore mouth and angular cheilitis. ~A-preliminary-investigation into their possible association with candida infection. Dent. Practit. Dent. Record, 7:8, 212-217 (April) 1957.
R A.-Symposium on denture sore mouth. 11. The rble bf Candida. Dent. Practit. Dent. Record, 16:4, 138-142 (Dec.) 1965.
10 Cawson
oral distribution of Candida in denture 6tomatitis. Brit. D. J., 129:4, 151-156 (Aug.) 1970.
11 Davenport, J. C.-The
According to Holti12 C. albicans is one of the most allergenic micro-organism known, and delayed hypersensitivity to it is very common in the adult population; Kozinn and Taschdjianl3 believe that C. albicuns in the mycelial phase is a pathogen but a saprophyte in the yeast phase. The isolation of hyphal structures in smears may indicate a possible candidiasis whereas the mere isolation of the organisms by cultivation is considered unreliable proof of infection. In the study conducted by Budtz-Jorgensen and Bertram? trauma from the denture was thought to predispose to growth of candida but growth and infection may still be present even when the dentures cause no trauma to underlying tissues. They also found that the number of yeast colonies isolated on an impression of a DSM palate could be related to the severity of the inflammation on the mucosal surface. Budtz-Jorgensen and Bertram? suggested that both the more generalized simple inflammation and inflammatory papillary hyperplasia of the palate could be caused by candidiasis. By using antifungal therapy they were able to resolve generalized simple inflammation and inflammatory papillary hyperplasia without modifying the dentures. However, both these lesions did not resolve when only the dentures were modified and no anti-fungal therapy provided. On the other hand the only way to remove localized simple inflammation was by denture modification; anti-fungals had little effect. Williamson14 showed that patients who wore their dentures at night as well as during the day had a tenfold increase in the number of candida colonies compared to patients who wore dentures only during the day. Lyon and Chick9 and Davenport" found that there was a far higher yield of candida from the denture surface itself than from the oral mucosa beneath the denture. Evidence of the significance of C. albicans in the aetiology of DSM was produced by Lehner15 who, using a quantitive immunofluorescent antibody technique demonstrated a significantly higher incidence of raised antibody titres to the organ-
Holti, G.-Candida allergy. In. Symposium on Candida infections, Edit. Winner, H.I., and Hurley, R. Edinburgh. S. Livinnstone Ltd., 1966 (P.73). 13 Kozinn, P. J., and Taschdjian, C. L.-Enteric Candidisis. Diagnosis and clinical considerations. Pediatrics, 301, 71-85 (July) 1962. 14 Williamson J . J.-Diurnal variation of Cundida albicum counts in'saliva. Austral. D. J., 17:l. 54-60 (Feb.) 1972. 15Lehner, T.-Symposium on denture sore mouth. 111. Immunofluorescent investigation of Candida. Dent. Practit. Dent. Record, 16:4, 142-146 (Dec.) 1965. 12
Australian Dental Journal, October, 1976 isms in DSM patients when compared with control patients. Van Reenan16 in a detailed microbiological study showed that in an area of DSM the predominant organisms isolated were Gram-positive cocci, many of which were Diplococcus pneumoniae. A few Gram-negative cocci and other bacterial forms were found. Yeast cells or hyphae were occasionally observed but provided only a minor fraction of the total microbial population. Van Reenan believes that a number of organisms participate in the infection and Grampositive organisms play a prominent part. Fisher and Rashid'? and others6 found certain trends towards a poorer denture cleanliness being associated with DSM however Nyquist4 could find no such correlation. Budtz-Jorgensen and Bertram7 found that the correlation between poor denture cleanliness and severely inflamed mucosa of the palate was statistically significant. The purpose of this study was to investigate further the role that trauma and candidiasis play in the development of denture sore mouth and the effect on this condition after removal of these possible aetiological factors. Materials and methods section 1
The study was based on a clinical survey of 74 patients attending the Royal Dental Hospital of Melbourne over a five month period. All wore full dentures and desired new ones. The 7 4 patients were placed in one of two groups:(a) a control group comprising 37 patients randomly chosen with apparently clinically normal mucosa over the maxillary denturebearing area; and (b) a denture sore mouth group comprising 37 patients with either localized or diffuse inflammation of the maxillary denture beariug area. A history of each patient was taken and a clinical examination made by the author and four other examiners all of whom had been carefully instructed regarding parameters and clinical techniques to be used. The history recorded information related to:(i) medical history, allergies, and current medication; (ii) edentulous history - present and past denture history, relines and rebases, J. F.-Microbiologic studies on denture stomatitis. J . Prosthet. D.. 30:4, 493-505 (Oct.) 1973. 17 Fisher, A. K., and Rashid, P. J.-Inflammatory papillary hyprplasia of the palatal mucosa. Oral. Surg., Oral Med., and Oral Path.. 5 2 , 191-198 (Feb.) 1952. 16 Van Reenan,
377
methods of cleaning, frequency of cleaning, and hours dentures worn. The examination recorded:(i) the alveolar ridge quality related to the stability and retention of the dentures and classified according to Budtz-Jorgensen and Bertram':satisfactory - well developed alveolar processes covered by a non-compressible mucosa; moderately unsatisfactory - moderately developed alveolar processes (a), moderately compressible alveolar mucosa (b), or both; totally unsatisfactory - completely atrophied alveolar processes (a), extremely mobile alveolar ridge mucosa (b), or both. (ii) angular cheilitis or traumatic ulceration. (iii) the condition of the maxillary denture (examined out of the mouth) noting the following:(a) texture of the tissue bearing surface; (b) relief areas; (c) tooth material and areas of abrasion. (iv) the functioning of the dentures when inserted with respect to:(a) retention and stability, assessed by trying to dislodge the denture by alternating finger pressure across the premolar region; (b) freeway space using a Willis gauge; (c) tooth contacts in centric relation; (d) eccentric excursions, demonstrated with articulating paper. Before the articulation was considered balanced, complete stability and freedom to move without cuspal interference was required. On the basis of the examination within and outside the mouth the upper denture was classed as either traumatogenic or not. The former group was further graded. Grade I - where one of the following three defects was present:(a) instability; (b) traumatogenic centric occlusion; (c) traumatogenic articulation. Grade ZZ - where only two of these occurred. Grade 111 - where all three defects were present. (v) denture cleanliness, assessed by swabbing the fitting surface with a two per cent erythrocine dye, rinsing and examining for any plaque deposits; calculus was noted. Denture cleanliness was then classified as:excellent: none, or only a few spots of plaque: fair: plaque more extended, but covering less
378 than one third of the denture base, small quantities of calculus. poor: plaque covering greater than one third of the denture base,. large areas of calculus. (vi) microbiological samples were collected by taking a swab from the entire upper ridge and palate and inoculating on candida medium. slopes, incubated at 38°C for three days in a closed container, and examined for raised metallic black colonies indicating growth of three possible species of organismms, viz., C . albicans, Candida krusii, or Candida parakrusii. (vii) for DSM patients only - the topography of the inflammation was plotted on a diagram of the maxillary denture-bearing area and clinical photographs were taken. The degree of severity of DSM was classified:slightly inflamed - localized slight erythema where scraping with a spatula produced no reaction; moderately inflamed - distinct erythema either localized or generalized, where scraping with a spatula produced no reaction; severely inflamed - generalized fiery red mucosa where scraping with a spatula may produce a reaction of pain and bleeding. The chi-square test was used for testing the agreement between the values observed and the values expected.
Section 2 One year later, 22 of the original 37 patients with DSM were examined by the author. These 22 patients had new dentures made at least three months prior to the second examination. Note was made of:(i) any change in the medical history or alterations in drug medication; (ii) patient’s ability to chew foods satisfactorily and degree of comfort with new dentures. New dentures were classified as either traumatogenic or not according t o criteria described. Cleanliness of dentures and freeway space were again measured, and DSM was deemed to be either present or absent. In patients who still had DSM, comparison was made with earlier clinical photographs and topographical draftings to determine whether DSM had increased or decreased. Microbiological examinations for candida were made from swabs * Oxoid.
to which was added l o ~ g l m ychloramphenicol, to suppress bacterial growth.
Australian Dental Journal, October, 1976 taken from the palate and from samples of saliva from each patient. Clinical photographs were taken when denture sore mouth was still present. TABLE 1
Average age according t o the sex distribution of 37 patients with denture sore mouths (DSM)and 37 control patients (Cont) DSM (years)
Women .......................................... 59 Men ............................ ................. 64 All patients ............................. 61 ~
Cont (years)
64 69 66
TABLE 2
Average time in years dentures worn by two groups of patients
Men ...................................... Women ................................ All patients .....................
DSM (years)
Cont (years)
11.7
16.1 19.6 17.2
21.5
19.0
When DSM was still evident, nystatin* ointment was applied liberally to the palatal surface of the upper denture three times daily and the denture was worn continuously until the next ointment application. The dentures were not worn at night but were soaked in 5 per cent chlorhexidine solution**t and a further exarnination was performed two weeks later to determine whether resolution of the condition had occurred after this treatment. Results
Section 1 There was a predominance of women to men
(2:l) in each group, and the control group was an average of five years older. This age difference also applied between the sexes of both groups (Table 1). The degrees of severity of DSM in these patients were classified as 23 slight, 12 moderate, and two severe cases. The control group had a longer experience wearing full dentures than the DSM group, but the dentures worn by the control group were generally not as old as those of the patients with DSM (Table 2). Thirty-four (92 per cent) of the DSM group wore their dentures both day and night com** Mycostatin (Squibb) t Hibitane (1.C.I.)
100,000
U/G.
379
Australian Dental Journal, October, 1976 pared with 27 (73 per cent) of the control group. The majority of well-developed alveolar ridges with a relatively non-compressible mucosa were found in the control group. In contrast, the DSM group exhibited alveolar ridges which provided
I
loo
loo
UNSAT I SFACTOW
5
0
MOD. SATISFACTOW
50
W
2z w
V b(
SAT I SFACTDRV
. c w
i i iI i i i i i
0
59%
32%
i . POOR I I
FAIR EXCELLENT DEMURE CLEANLINESS
QUALITY OF DENTURE BEARING TISSUES
Fig. 1.-Percentage incidence of denture nore mouth as related to the quality of the Bupporting alveolar tissues.
poor support for the dentures and in many cases consisted of extremely mobile alveolar ridge mucosa. It will be noted from Fig. 1 that the prevalence of DSM declines as the quality of the supporting ridges improves. Only 15 of the 74 patients examined were wearing non-traumatogenic dentures. Denture sore mouth was found in only two of these 15 patients. It became evident that as the degree of trauma increased, so did the prevalence of DSM. Within the two groups of 37 patients, 35 (95 per cent) DSM patients had traumatogenic dentures whereas only 24 (65 per cent) of the control patients wore traumatic dentures (PPercentage incidence of denture sore mouth as related to the degree of denture cleanliness.
loo
I
i !
71%
4
1
2
>2
FREQUEWY OF CLEANIffiIMY
Fig. 3.-Percentage incidence of denture sore mouth as related to the frequency of cleaning the dentures per day.
ness of the dentures improved (Fig. 2) and the frequency of cleaning the dentures per day increased (Fig. 3). More controls employed 4 chemical denture cleanser of some type, which
380
Australian Dental Journal, October, 1976 TABLE 3
Results of cultures for candida from 22 patients recalled f o r observation twelve months after treatment
Saliva positive ........................... Saliva negative ........................ Palatal mucosa positive Palatal mucosa negative
4 5
5
3 6
3 10
8
may explain the reduction in hours of wearing dentures in this group. Candida colonies were isolated from 27 (73 per cent) of the 37 DSM patients while in only 8 (22 per cent) of the 37 control patients could Candida be demonstrated (P
Australian Dental Journal, October, 1976
Volume 21 ::Number 5
Denture sore mouth. Aetiological aspects and treatment Ross J. Bastiaan, Y.D.Sc. Aesmcr-Seventy-four patients wearing full upper and lower dentures were examined in the study; 37 exhibited varying degrees of denture sore mouth (DSM)while the remaining 37 patients acted as controls. Denture trauma was more common in the DSM group. Candida was grown from 73 per cent of patients with DSM but only from 22 per cent of controls. Control patients had better denture hygiene than DSM patients. One year later 22 of the original IXSM patients wearing newly made dentures were re-examined. Nine out of 22 still exhibited varying degrees of DSM. In the 9 cases persisting, a nystatin-chlorhexidine treatment plan was prescribed, resulting in resolution of 7 further cases. The cases that failed to resolve were wearing unstable traumatogenic new dentures. (Received for publication May, 1975)
Introduction
Denture sore mouth (DSM) is a term used to describe the inflamed mucous membrane sometimes seen on the palate under a maxillary denture. It may appear as a simple localized red inflamed area or a more generalized reddening involving the whole palatal area beneath the denture. Occasionally this later form presents areas with a granular surface more commonly known as papillary hyperplasia. Denture sore mouth is a symptom-complex that may arise from a variety of local and systemic factors. There have been Seven main aetiological factors implicated:(i) traumatogenic dentures;
(ii) candidiasis; (iii) allergy to the denture base material; (iv) heat accumulation beneath the appliance (v) restriction of blood circulation and saliva secretions by the appliance; (vi) changes in the autonomic nervous system with altered salivary Secretions; (vii) putrefaction of foods and glandular discharge beneath the appliance. One of the earliest reliable studies relating to the aetiology of denture sore mouth appears to have been performed by Wright'. He attributed damage to the oral mucosa under full dentures 1 Wright, W. H.-The importance of tissue changes under artificial dentures. J.A.D.A., 16:6. 1027-1031 (June) 1929.
Australian Dental Journal, October, 1976
376 to mechanical factors. Hechtz, Landa3, Nyquist4, Kim, Ringsdorf, and Cheraskins and Love, Goska, and Mixson6 found that an unbalanced occlusion and poor fit of the denture could be associated with denture sore mouth. Landas and Nyquist4 reported a significant resolution of the condition after adjusting the dentures. Nyquist4 considered traumatogenic dentures were responsible for only localized areas of inflammation which rarely affected more than half of the palate. BudtzJorgensen and Bertram? examined 58 DSM patients and an equal number of controls. They showed that trauma alone gave rise to simple, well-localized inflammation and in rare instances to a more generalized inflammation of the palatal tissues; however they were unable to define clearly the role of trauma as an aetiological agent. The possibility of candidiasis being involved in DSM was first mentioned by Cahns in 1936. Little interest was shown in this factor until Lyon and Chicks found that candida organisms were isolated more often from inflamed palates than from healthy palates of denture wearers. Later studies by Cawsonlo and Davenport" lend support to these findings. In these studies Candida albicans was demonstrated in 66 per cent and 70 per cent respectively of DSM patients. Davenport's" study found only 20 per cent of control patients had C. albicans colonies whereas Cawson's10 swabbing technique failed to isolate C. albicans in the control group.
2
Hecht, S . S.-Chronic irritation of the epithelial tissues of the mouth associated with dentures. Am. J. Orthodont. and Oral Surg., 25: 574-585 (June) 1939.
3 Landa. J. .$.-Burning mouth and dry mouth. Prosthodontist's view. D. Items Interest, 6 7 5 , 470.478 (May) 1945.
study of denture sore mouth. An investigation of traumatic, allergic and toxic lesions of the oral mucosa arising from the use of full dentures. Acta Odont. Scand., 10, Suppl., 9: 11-154, 1952.
4 Nyquist, G.-A
5 Kim, M. S., Ringsdorf, W. M., and Cheraskin, E.-
Factors in denture tolerance. P.D.M., 3-64 (Jan.) 1962.
6 Love, W. D., Goska, F. A , , and Mixson, R. J.-The
etiology of mucosal inflammation associated with dentures. J. Prosthet. D . , 18:6, 515-527 (Dec.) 1967.
7 Budtz-Jorgensen, E., and Bertram, U.-Denture
stomatitis I. The etiology in relation to trauma and infection. Acta Odont. Scand., 28:1, 71-92 (Mar.) 1970.
OCahn, L. R.-The denture sore mouth. Ann. Dent.. 3 : l . 33-36 (Mar.) 1936. 9Lvon. D -. G.. and Chick. A. 0.-Denture , -
sore mouth and angular cheilitis. ~A-preliminary-investigation into their possible association with candida infection. Dent. Practit. Dent. Record, 7:8, 212-217 (April) 1957.
R A.-Symposium on denture sore mouth. 11. The rble bf Candida. Dent. Practit. Dent. Record, 16:4, 138-142 (Dec.) 1965.
10 Cawson
oral distribution of Candida in denture 6tomatitis. Brit. D. J., 129:4, 151-156 (Aug.) 1970.
11 Davenport, J. C.-The
According to Holti12 C. albicans is one of the most allergenic micro-organism known, and delayed hypersensitivity to it is very common in the adult population; Kozinn and Taschdjianl3 believe that C. albicuns in the mycelial phase is a pathogen but a saprophyte in the yeast phase. The isolation of hyphal structures in smears may indicate a possible candidiasis whereas the mere isolation of the organisms by cultivation is considered unreliable proof of infection. In the study conducted by Budtz-Jorgensen and Bertram? trauma from the denture was thought to predispose to growth of candida but growth and infection may still be present even when the dentures cause no trauma to underlying tissues. They also found that the number of yeast colonies isolated on an impression of a DSM palate could be related to the severity of the inflammation on the mucosal surface. Budtz-Jorgensen and Bertram? suggested that both the more generalized simple inflammation and inflammatory papillary hyperplasia of the palate could be caused by candidiasis. By using antifungal therapy they were able to resolve generalized simple inflammation and inflammatory papillary hyperplasia without modifying the dentures. However, both these lesions did not resolve when only the dentures were modified and no anti-fungal therapy provided. On the other hand the only way to remove localized simple inflammation was by denture modification; anti-fungals had little effect. Williamson14 showed that patients who wore their dentures at night as well as during the day had a tenfold increase in the number of candida colonies compared to patients who wore dentures only during the day. Lyon and Chick9 and Davenport" found that there was a far higher yield of candida from the denture surface itself than from the oral mucosa beneath the denture. Evidence of the significance of C. albicans in the aetiology of DSM was produced by Lehner15 who, using a quantitive immunofluorescent antibody technique demonstrated a significantly higher incidence of raised antibody titres to the organ-
Holti, G.-Candida allergy. In. Symposium on Candida infections, Edit. Winner, H.I., and Hurley, R. Edinburgh. S. Livinnstone Ltd., 1966 (P.73). 13 Kozinn, P. J., and Taschdjian, C. L.-Enteric Candidisis. Diagnosis and clinical considerations. Pediatrics, 301, 71-85 (July) 1962. 14 Williamson J . J.-Diurnal variation of Cundida albicum counts in'saliva. Austral. D. J., 17:l. 54-60 (Feb.) 1972. 15Lehner, T.-Symposium on denture sore mouth. 111. Immunofluorescent investigation of Candida. Dent. Practit. Dent. Record, 16:4, 142-146 (Dec.) 1965. 12
Australian Dental Journal, October, 1976 isms in DSM patients when compared with control patients. Van Reenan16 in a detailed microbiological study showed that in an area of DSM the predominant organisms isolated were Gram-positive cocci, many of which were Diplococcus pneumoniae. A few Gram-negative cocci and other bacterial forms were found. Yeast cells or hyphae were occasionally observed but provided only a minor fraction of the total microbial population. Van Reenan believes that a number of organisms participate in the infection and Grampositive organisms play a prominent part. Fisher and Rashid'? and others6 found certain trends towards a poorer denture cleanliness being associated with DSM however Nyquist4 could find no such correlation. Budtz-Jorgensen and Bertram7 found that the correlation between poor denture cleanliness and severely inflamed mucosa of the palate was statistically significant. The purpose of this study was to investigate further the role that trauma and candidiasis play in the development of denture sore mouth and the effect on this condition after removal of these possible aetiological factors. Materials and methods section 1
The study was based on a clinical survey of 74 patients attending the Royal Dental Hospital of Melbourne over a five month period. All wore full dentures and desired new ones. The 7 4 patients were placed in one of two groups:(a) a control group comprising 37 patients randomly chosen with apparently clinically normal mucosa over the maxillary denturebearing area; and (b) a denture sore mouth group comprising 37 patients with either localized or diffuse inflammation of the maxillary denture beariug area. A history of each patient was taken and a clinical examination made by the author and four other examiners all of whom had been carefully instructed regarding parameters and clinical techniques to be used. The history recorded information related to:(i) medical history, allergies, and current medication; (ii) edentulous history - present and past denture history, relines and rebases, J. F.-Microbiologic studies on denture stomatitis. J . Prosthet. D.. 30:4, 493-505 (Oct.) 1973. 17 Fisher, A. K., and Rashid, P. J.-Inflammatory papillary hyprplasia of the palatal mucosa. Oral. Surg., Oral Med., and Oral Path.. 5 2 , 191-198 (Feb.) 1952. 16 Van Reenan,
377
methods of cleaning, frequency of cleaning, and hours dentures worn. The examination recorded:(i) the alveolar ridge quality related to the stability and retention of the dentures and classified according to Budtz-Jorgensen and Bertram':satisfactory - well developed alveolar processes covered by a non-compressible mucosa; moderately unsatisfactory - moderately developed alveolar processes (a), moderately compressible alveolar mucosa (b), or both; totally unsatisfactory - completely atrophied alveolar processes (a), extremely mobile alveolar ridge mucosa (b), or both. (ii) angular cheilitis or traumatic ulceration. (iii) the condition of the maxillary denture (examined out of the mouth) noting the following:(a) texture of the tissue bearing surface; (b) relief areas; (c) tooth material and areas of abrasion. (iv) the functioning of the dentures when inserted with respect to:(a) retention and stability, assessed by trying to dislodge the denture by alternating finger pressure across the premolar region; (b) freeway space using a Willis gauge; (c) tooth contacts in centric relation; (d) eccentric excursions, demonstrated with articulating paper. Before the articulation was considered balanced, complete stability and freedom to move without cuspal interference was required. On the basis of the examination within and outside the mouth the upper denture was classed as either traumatogenic or not. The former group was further graded. Grade I - where one of the following three defects was present:(a) instability; (b) traumatogenic centric occlusion; (c) traumatogenic articulation. Grade ZZ - where only two of these occurred. Grade 111 - where all three defects were present. (v) denture cleanliness, assessed by swabbing the fitting surface with a two per cent erythrocine dye, rinsing and examining for any plaque deposits; calculus was noted. Denture cleanliness was then classified as:excellent: none, or only a few spots of plaque: fair: plaque more extended, but covering less
378 than one third of the denture base, small quantities of calculus. poor: plaque covering greater than one third of the denture base,. large areas of calculus. (vi) microbiological samples were collected by taking a swab from the entire upper ridge and palate and inoculating on candida medium. slopes, incubated at 38°C for three days in a closed container, and examined for raised metallic black colonies indicating growth of three possible species of organismms, viz., C . albicans, Candida krusii, or Candida parakrusii. (vii) for DSM patients only - the topography of the inflammation was plotted on a diagram of the maxillary denture-bearing area and clinical photographs were taken. The degree of severity of DSM was classified:slightly inflamed - localized slight erythema where scraping with a spatula produced no reaction; moderately inflamed - distinct erythema either localized or generalized, where scraping with a spatula produced no reaction; severely inflamed - generalized fiery red mucosa where scraping with a spatula may produce a reaction of pain and bleeding. The chi-square test was used for testing the agreement between the values observed and the values expected.
Section 2 One year later, 22 of the original 37 patients with DSM were examined by the author. These 22 patients had new dentures made at least three months prior to the second examination. Note was made of:(i) any change in the medical history or alterations in drug medication; (ii) patient’s ability to chew foods satisfactorily and degree of comfort with new dentures. New dentures were classified as either traumatogenic or not according t o criteria described. Cleanliness of dentures and freeway space were again measured, and DSM was deemed to be either present or absent. In patients who still had DSM, comparison was made with earlier clinical photographs and topographical draftings to determine whether DSM had increased or decreased. Microbiological examinations for candida were made from swabs * Oxoid.
to which was added l o ~ g l m ychloramphenicol, to suppress bacterial growth.
Australian Dental Journal, October, 1976 taken from the palate and from samples of saliva from each patient. Clinical photographs were taken when denture sore mouth was still present. TABLE 1
Average age according t o the sex distribution of 37 patients with denture sore mouths (DSM)and 37 control patients (Cont) DSM (years)
Women .......................................... 59 Men ............................ ................. 64 All patients ............................. 61 ~
Cont (years)
64 69 66
TABLE 2
Average time in years dentures worn by two groups of patients
Men ...................................... Women ................................ All patients .....................
DSM (years)
Cont (years)
11.7
16.1 19.6 17.2
21.5
19.0
When DSM was still evident, nystatin* ointment was applied liberally to the palatal surface of the upper denture three times daily and the denture was worn continuously until the next ointment application. The dentures were not worn at night but were soaked in 5 per cent chlorhexidine solution**t and a further exarnination was performed two weeks later to determine whether resolution of the condition had occurred after this treatment. Results
Section 1 There was a predominance of women to men
(2:l) in each group, and the control group was an average of five years older. This age difference also applied between the sexes of both groups (Table 1). The degrees of severity of DSM in these patients were classified as 23 slight, 12 moderate, and two severe cases. The control group had a longer experience wearing full dentures than the DSM group, but the dentures worn by the control group were generally not as old as those of the patients with DSM (Table 2). Thirty-four (92 per cent) of the DSM group wore their dentures both day and night com** Mycostatin (Squibb) t Hibitane (1.C.I.)
100,000
U/G.
379
Australian Dental Journal, October, 1976 pared with 27 (73 per cent) of the control group. The majority of well-developed alveolar ridges with a relatively non-compressible mucosa were found in the control group. In contrast, the DSM group exhibited alveolar ridges which provided
I
loo
loo
UNSAT I SFACTOW
5
0
MOD. SATISFACTOW
50
W
2z w
V b(
SAT I SFACTDRV
. c w
i i iI i i i i i
0
59%
32%
i . POOR I I
FAIR EXCELLENT DEMURE CLEANLINESS
QUALITY OF DENTURE BEARING TISSUES
Fig. 1.-Percentage incidence of denture nore mouth as related to the quality of the Bupporting alveolar tissues.
poor support for the dentures and in many cases consisted of extremely mobile alveolar ridge mucosa. It will be noted from Fig. 1 that the prevalence of DSM declines as the quality of the supporting ridges improves. Only 15 of the 74 patients examined were wearing non-traumatogenic dentures. Denture sore mouth was found in only two of these 15 patients. It became evident that as the degree of trauma increased, so did the prevalence of DSM. Within the two groups of 37 patients, 35 (95 per cent) DSM patients had traumatogenic dentures whereas only 24 (65 per cent) of the control patients wore traumatic dentures (PPercentage incidence of denture sore mouth as related to the degree of denture cleanliness.
loo
I
i !
71%
4
1
2
>2
FREQUEWY OF CLEANIffiIMY
Fig. 3.-Percentage incidence of denture sore mouth as related to the frequency of cleaning the dentures per day.
ness of the dentures improved (Fig. 2) and the frequency of cleaning the dentures per day increased (Fig. 3). More controls employed 4 chemical denture cleanser of some type, which
380
Australian Dental Journal, October, 1976 TABLE 3
Results of cultures for candida from 22 patients recalled f o r observation twelve months after treatment
Saliva positive ........................... Saliva negative ........................ Palatal mucosa positive Palatal mucosa negative
4 5
5
3 6
3 10
8
may explain the reduction in hours of wearing dentures in this group. Candida colonies were isolated from 27 (73 per cent) of the 37 DSM patients while in only 8 (22 per cent) of the 37 control patients could Candida be demonstrated (P
