Investigation population
into the cleanliness
of dentures
in an elderly
Gillian Hoad-Reddick, M.Sc., B.D.S.,* Alan A. Grant, D.D.Sc., M.Sc.,** and Christopher S. Griffiths, B.D.S.*** University Dental Hospital of Manchester, Manchester and Halewood Health Centre, Cheshire, England During a survey of 233 elderly people of whom 89.9% were edentulous, attitudes toward denture cleaning were investigated. Questioning revealed the frequency of cleaning and methods used. Examination showed which dentures were clean, types and amounts of stain present, and comparison of clean dentures directly with dirty ones. Comparison of different residential groups highlighted problems particular to a group, so that recommendations for improvements could be made. Only 40% of dentures were properly clean. Subjects resident in the long-stay hospitals had the cleanest dentures and those in the elderly persons’ homes the dirtiest. One quarter of the dentures examined were over 30 years old. They tended to be dirtier than the newer ones and related to a higher incidence of denture stomatitis. Wearers of cleaner dentures were more satisfied with their cleansing methods and more likely to use a propietary cleanser regularly than those with dirty dentures. (J PROSTHET DENT 1990;64:48-62.)
M
any denture wearers find denture cleaning a problem. Surveys of United Kingdom elderly persons report patients wearing dirty dentures. Investigating 1000 denture wearers, MacCallum et al1 found 17.5% were dissatisfied with the method they were using, although on examination 69.8% had stained dentures. After surveying 300 hospital patients, Ritchie2 found only 27 % of dentures were clean although 65 % to 68 % of patients claimed to use a proprietary cleanser. Ettinger and Manderson3 found 65% of elderly denture wearers in Edinburgh’s residential institutions had staining, calculus, or soft debris on their dentures. Smith and Sheiham: investigating elderly residents in the community, found 51% had hard deposits and 8% soft deposits on their dentures. Of these residents, 20% had difficulty moving their hands, but only 9 % claimed to have difficulty cleaning dentures or teeth. MacCallum et al.’ suggested that the public does not associate staining with “dirt” on a denture and accepts that denture cleansers neither affect nor control staining. The Adult Dental Health Survey5 reported that 65 % of denture wearers cleaned their dentures once daily, and soaking in a proprietary cleanser was the most popular method. Household bleach was used by 16 % of Bates and Smith’s patients,s ’ 7 % of Neill’s patients,s and 19.3% of
*Lecturer, Department of Prosthetic Dentistry, University Dental Hospital of Manchester. **Professor,Departmentof Prosthetic Dentistry, University Dental Hospital of Manchester. ***District Dental Officer, Halewood Health Centre. 10/l/19460
48
Hamilton’s.g Hamilton9 found 60 % soaked their dentures and concluded that the method of cleaning bore no significant relation to cleanliness.
THE SURVEY A survey was made of 233 elderly patients in the Halton Health Authority (Cheshire) on the cleanliness of their dentures. Specific questions were asked about age of dentures, methods and frequency of cleaning, satisfaction with the method used, and if they had ever been shown how to clean their dentures. Any relationship between age of denture and cleansing problems, or specific types of staining and any cleansing process was sought so that recommendations could be forwarded to any agency that could assist elderly people.
MATERIAL
AND METHODS
Patients were selected from four residential groups so that comparisons could be made and problems specific to any particular group identified. They were: (1) long-stay hospital patients (LSH), (2) residents of elderly people’s homes (EPH), (3) people resident in the community with assistance from Social Services, Home Helps, or Meals on Wheels (CWA), and (4) people resident in the community with no assistance from outside agencies (NAC). Patients were selected at random so that there were similar numbers in each group and so that ratios of men to women and those 65 to 74 years of age and those more than 75 years were in the ratios found in the local population (Table I). An examiner undertook the survey from October 1984 to January 1985. Interview questions were based on previous survey questions (especially the Hampshire surveyi and
JULY
1990
VOLUME
64
NUMBER
1
CLEANLINESS
OF DENTURES
IN ELDERLY
POPULATION
the Adult Dental Health Surveys) for comparison or new questions were formulated. Examinations were made in the patient’s home or the Halton Hospital Day Center. Illumination was by a hand-held light; patients sat where they were most comfortable, and not in a dental chair. Since the sampling was random, not all patients were edentulous and not all edentulous patients had dentures (21 had lost them, and two had never worn them). Patients were assessedon their ability to answer questions using a four-point scale of: (1) totally alert and able to answer all questions easily, (2) muddled but able to answer most questions satisfactorily, (3) great difficulty in answering many questions, and (4) totally unable to answer any questions. This division would identify patients most receptive to oral hygiene instruction and care of dentures (Table I).
Table I. Distribution of patients between four residential groups and assessedability of each group Sex
Total
Male
Female Total
LSH
EPH
CWA
NAC
24 29 53 51
93
18
23
140
37
39
233
55
62
28 35 63
8 13 15 19
26 25 9 2
53 7 3 0
Ability 1 2 3 4
1
0 1
For the statistical analysis of ability, groups 1 and 2 and 3 and 4 were pooled: x2 in 3’ freedom, 77.2; p < 0.01, result is significant. LSH, Long-stay hospital patients; EPH, elderly people’s home residents; CWA, people living in community with assistance; NAC, people living in community with no assistance.
Questionnaire Questions relating to denture cleanliness and use were: When do you wear your dentures? Do you clean your dentures yourself? How do you clean your dentures? When (how frequently) do you clean your dentures? Do you feel you can clean your dentures properly? Has a dentist or his staff ever shown you or told you how to clean your dentures? Patients were also asked how often they visited their dentist, and if they were satisfied with the appearance of their dentures and the age of their dentures. For the age analysis, three groups were selected because it seemed from the pilot survey that they would be numerically similar. Four patients had dentures 0 to 5 years old, 77 patients had dentures 6 to 30 years old, and 44 had dentures over 31 years old. For the analysis of cleansing methods, results were pooled so that the four groups finally compared were those who (1) brush regularly, (2) soak regularly, (3) perform a satisfactory combination, and (4) use a regimen that would not maintain a satisfactory state of denture cleanliness. 1. 2. 3. 4. 5. 6.
Examination The oral cavity was examined. Criteria for examination of dentures has been described elsewhere.11,12The oral mucosal examination covered the same headings as Smith and Sheiham,4 who based their criteria on World Health Organization guidelines.13 The cosmetic appearance of the denture was observed with the denture in the patient’s mouth and while facing the patient. It was considered to be unsatisfactory if the denture was very dirty or broken, if there was unsatisfactory lip support, or if the midlines were not satisfactorily aligned. The cleanliness of the denture was noted when removed from the mouth and placed in a small dish. Scoring for cleanliness was undertaken as follows.
THE
JOURNAL
OF PROSTHETIC
DENTISTRY
Soft debris. Soft debris was scored as present if it was packed between the teeth and over the tissue surface of the denture. Hard debris. Hard debris was scored as mild if it was present around gingival margins and lingual to the lower central incisors and buccal to the upper first molars. It was scored as severe if it covered the teeth, flanges, and tissue surface. Staining. Staining was scored as mild if it covered the gingival margins and as severe if it covered teeth, flanges, and palate. For statistical analysis, values for soft debris, mild hard debris, and mild staining were pooled, as were hard debris and severe staining. Patients, or those caring for them, could remove the mild deposits, whereas professional help would be necessary for the severe deposits.
RESULTS Denture examination The level of edentulousness was very high. Only 28 patients had any remaining teeth and 179 had some form of denture. There were 142 sets of complete upper and lower dentures, 28 complete upper dentures, three complete lower dentures, and three mandibular and six maxillary removable partial dentures.
Questionnaire Dentures were worn by 39.7 % of the patients for the full 24 hours, 51.4 % during the daytime only, and 8.8 % for either eating or social reasons. No significant differences were found between residential groups, although the proportion in the community with no assistance who wore their dentures for the full 24 hours (46.8%) was slightly higher than in the other three groups (LSH, 34.6 % ; EPH, 37.3 % ; CWA, 38.2%). This might be related to the fact that 84% of those in the community lived with their spouses. Most
49
HOAD-REDDICH
Table
II.
ET AL.
Response to question, “who cleans your dentures?” (residential group) Total
Who cleans the denture?
No.
Never cleaned Self Somebody else
LSH
EPH
CWA
NAC
%
No.
%
No
%
No.
%
No.
%
6.0 84.2
3.9 90.2 5.9
3 51 3
89.5
1 46 1
2.1 95.8
9.8
2 46 3
5.3
42.9
18
5 12 11
17.9
155
11
39.3
5.3
2.1
Statistical analysis: Figures for “never cleaned” or “cleaned by someone else” pooled for analysis: x2 in 4’ freedom, 43.51; p < 0.01, highly significant.
Table
III.
Cleansing methods used (residential group) Total
Cleaning
regimen
Brush regularly Soak regularly Satisfactory combination Not satisfactory
EPH
LSH
No.
%
No.
38 38 72
21.2 21.1 40.2
31
17.3
5 14 6 2
%
CWA
NAC
No
%
No.
%
No.
%
24.0 32.0 26.0 18.0
7 6 29 13
.12.7
14 2 24 7
29.8 4.3 51.1
18.5
12
51.9
16
22.2 7.4
13 9
10.9 52.7 23.6
14.9
Statistical analysis: Brushing and soaking regularly were pooled with satisfactory combination for analysis: x2 in 3’ freedom, 4.2, p > 0.05, not significant.
Table
IV.
Results of examination of denture
cleanliness* Total numbers
Upper denture Clean Mild debris Severe debris Lower denture Clean Mild debris Severe debris
LSH (%)
EPH (%)
CWA (%)
NAC (%)
community 69 48
63.3 20.0
30.9
39.6 24.9
29.5
51
16.7
32.6
35.5
31.8
58 33
54.5 4.5
55
40.9
26.2 40.5 33.3
47.5 10.0 42.5
38.1 26.2 35.7
30.4
38.6
Statistical analysis: Upper denture, x2 in 6” freedom, 9.49; p > 0.05, not significant; lower denture, x2 in 6” freedom, 16.51; p < 0.05, significant. *Soft debris, mild hard debris, and mild staining are combined, as are severe hard debris and severe staining.
patients (155 or 84.2%) claimed to clean their dentures themselves. Eleven said they never cleaned them, and 18 said someone other than themselves performed the cleaning. At the time of the survey, nurses in the long-stay hospitals collected patients’ dentures and soaked them overnight. Only 42.9% of this group (LSH) claimed to clean their dentures themselves compared with over 89.5% in the other three groups. These differences were highly significant (Table II). Investigation into cleaning methods showed that the regimen considered most satisfactory by the examiner (a combination of soaking and brushing) was used by more than 50% of both community groups but only 26% of el-
50
derly home residents and 22% of long-stay hospital patients. The method described did not maintain denture cleanliness in 23.6% of the community-assisted group, 18% of elderly persons home residents, and 14.9% of the without-assistance
group.
In the long-stay
hospital, however, only 7.4% of patients described a regimen that was patently inadequate. Although statistically insignificant,
these results suggest that the cleansing meth-
ods in the long-stay hospitals are generally the most satisfactory (Table III). Dentures were cleaned daily by 79.1% of the patients, five times weekly by 4.5%, thrice weekly by 7.9%) and 8.4 % claimed either never to clean them or could not remember how frequently they did clean them. When long-term hospital patients were asked if they believed they could clean their dentures properly, 34.6% were not happy with the method used, whereas the overall level of dissatisfaction was only 14.6% (EPH, 10%; CWA, 18.2%; NAC, 4.3%). Thus, in spite of having the cleanest dentures, long-stay hospital patients were dissatisfied, suggesting unhappiness with their inability
to be responsible
for their own lives.
Most patients (86.3%) thought they had never been shown how to clean dentures either by their dentist or his staff. There was little variation swers to this question.
Examination
between the groups’ an-
for cleanliness
The examiner was not satisfied with the appearance of 25.3% of the dentures examined while they were being worn, whereas only 6.7 % of the patients were dissatisfied.
Although not all appearance problems were caused by the
JULY
1990
VOLUME
64
NUMBER
1
CLEANLINESS
OF DENTURES
IN ELDERLY
a.
Clean
POPULATlON
b. Severe hard debris and stain
Dentures
75
Lower
Lower
Upper
Upper
t
.,... ..,... ..,.. .... ...,... ._... ...I . ~1 Denture
Age
0-Syrs.
6-30yrs.
Over
31yrs.
Fig. 1. Relationship between age of denture and cleanliness. Statistical analysis: x2 on 4’ freedom: Upper denture, 16.58; lower denture, 31.05; p < 0.01, highly significant.
presence of dirt on the dentures, it suggests that denture wearers are either not self-critical, or do not have high expectations of their appearance when wearing dentures. Results of denture cleanliness are shown in Table IV. Overall, only 41.1% of upper dentures and 39.7% of lower dentures were properly cleaned. Severe hard debris was present on 11.3% of upper and 19.9% of lower dentures. The cleanest dentures were found in the long-stay hospitals and the dirtiest in the elderly persons’ homes. Differences between the residential groups were significant for the lower denture (p < 0.05) but not for the upper (Table IV). When the relationship between age of denture and cleanliness was investigated (Fig. l), 55.3% of dentures 0 to 5 years old were clean compared with only 30.6% of dentures more than 31 years old. None of the newer dentures had soft deposits, but in the old dentures their level was 8.3%. Severe staining rose from 5.3% in the 0- to 5-year-old dentures to 25% in dentures 6 to 30 years old, whereas levels of mild staining dropped: 0 to 5 years, 23.7%; 6 to 30 years, 12.5%; and 31+ years, 5.6%. Percentages of both mild and severe hard debris rose from 15.8% in the 0- to 5-year-old group to 36.2% in the older group. This relationship between age of denture and level of cleanliness was found to be highly significant and may be related to degeneration of the material from which the dentures were made, caused by wear, discoloration, or general use.
THE
JOURNAL
OF PROSTHETIC
DENTISTRY
Further analysis of the clean and dirty dentures revealed that 27.9 % of clean dentures were soaked regularly, whereas only 15.8% of dirty denture wearers claimed to soak them. Denture cleaners were used by 71.7% of clean denture wearers and by only 55.8% of dirty denture wearers. Daily cleaning was performed by 90.2 % of clean and 76.6 % of dirty denture wearers. Wearers of clean dentures were more likely to want a dental checkup, with 36.7% wanting a checkup compared with 18.1% of those wearing dirty dentures. Denture stomatitis and angular cheilitis were twice as prevalent (14.5 % ) in patients with di.rty dentures as in the clean-denture group (7.8 % ).
DISCUSSION The findings of this survey are similar to those of earlier workers in that most elderly people do not know how to keep dentures clean. Yet, by comparing different residential groups, it is clear that where an adequate cleaning regimen is instituted, dentures can be kept clean. In the longstay hospitals where the dentures are routinely soaked overnight in a proprietary cleaner, dentures were significantly cleaner than in the other groups. The dirtiest dentures were in the elderly persons’s homes where residents are expected to clean their dentures themselves. As more people are cared for in residential homes, it is important that dental awareness and the need for oral hygiene, even in the edentulous, be publicized. Older dentures were dirtier than newer ones, more in 51
HOAD-REDDICK
need of replacement, and related to a higher level of denture stomatitis or angular cheilitis. Other workers have shown a direct relationship between denture stomatitis and denture hygiene.14-17 It is thus clearly incumbent upon the dental profession, at a time when the number of elderly is rapidly rising, to ensure that the denture-wearing public know how to clean dentures properly. The media should be contacted and encouraged to assist educating those caring for the elderly about denture hygiene and oral health care. Which magazine I8 has shown the way. Their comparison of denture cleaners distinguishes between the different types of cleaners and lists the advantages and disadvantages of brush-on or soaking tvnes of cleaners. There is also a discussion on the importance of regular denture cleaning, the need to follow manufacturers’ instructions, and the importance of avoidance of substances such as household bleach or scouring powder, which may damage dentures. Other organizations must be encouraged to assist in this education nrocess. Manufacturers of cleansers should be encouraged to provide more information about their products, such as explaining that the acid-based cleansers assist in removal of tartar/calculus and that the hypochlorite cleansers are more helpful in the removal of stains. At present, little information about the specific cleaning action of denture cleansers is given on their packaging. Crawford et al.lg have already suggested to manufacturers of one cleanser that current usage instructions need reinforcement so that the use of hot water and resultant bleaching of dentures is discouraged. It has been shown elsewhere that dentures should be checked regularly and on average replaced every 10 years.l’ If the dental profession were to become more active in promoting oral health for elderly people, denture cleanliness could be one of the easier ways of alerting elderly to their dental problems.
CONCLUSION This survey has shown that only 40% of dentures worn by the elderly are properly clean. Dental health education must be directed to this problem by dentists, the media, and manufacturers of denture cleansing products. Since the dirtiest dentures were found in the elderly peoples’ homes, education must be directed toward the care-givers as well as the elderly persons themselves. The dental profession must encourage denture wearers to have regular checkups so that old, ill-fitting dentures, which tend to be
52
ET AL.
dirtiest and are related to a higher incidence of denture stomatitis, can be detected and remedial procedures advised. Education of the denture-wearing public and also those caring for them is urgently needed. Dentists must be assisted by other organizations if oral hygiene of the elderly is to be improved. REFERENCES 1. MacCallum M, Stafford GD, MacCulloch WT, Comhe EC. Which cleanser? Dent Pratt Dent Ret 196&19:83-g. 2. Ritchie GM. A report of dental findings in a survey of geriatric patients. J Dent 19’73;1:106-12. 3. Ettinger RL, Manderson RD. Geriatric dental services and facilities in Edinburgh. Modern Geriatrics 1975;5:22-8. 4. Smith JM, Sheiham A. How dental conditions handicap the elderly. Community Dent Oral Epidemiol 1979;7:305-10. 5. Todd JE, Walker AM. Adult dental health. Vol 1. England and Wales 1968-78. London: Her Majesty’s Stationery Office. 6. Bates JF, Smith DC. Evaluation of indirect resilient liners for dentures. J Am Dent Assoc 1965;70:344-53. 7. Smith DC. The cleaning of dentures. Dent Pratt Dent Ret 1966;17:3943. 8. Neil1 DJ. A study of materials and methods employed in cleaning den-
tures. Br Dent J 1968;124:107-15. 9. Hamilton F. The dental health care problems of the elderly living at home with particular reference to care by general dental practitioners [M.D.S. Thesis]. 1986. 10. Osborne J, Maddick I, Gould A, Ward D. Dental demands of old people in Hampshire. Br Dent J 1979;146:351-5. 11. Hoad-Reddick G. A survey into the dental needs of the elderly with special reference to their treatment needs [M.Sc. Thesis] 1985. 12. Hoad-Reddick G, Grant AA. A system of examination of prosthetic status: the formation of a schedule. J PROSTHET DENT 1988;59:105-9. 13. World Health Organization. Oral health surveys, basic methods. 2nd ed. Geneva: World Health Organization, 1977. 14. Fisher AK, Rashid PJ. Inflammatory papillary hyperplasia of the palatal mucosa. Oral Surg Oral Med Oral Path 1952;5:191-8. 15. Love WD, Goska FA, Mixon RJ. The aetiology of mucosal inflammation associated with dentures. J PROSTHET DENT 1967;18:515-27. 16. Budtz-Jorgenson E. Clinical aspects of candidal infection in denture wearers. J Am Dent Assoc 1978;96:474-9. 17. Olsen I. Denture stomatitis, relapse tendency and removal of acquired discolorations in longterm denture disinfection with chorhexidine. Acta Odontol Stand 1975;33:111-4. 18. Anon: Denture cleaners and fixatives. “Which” Consumers Association 1983;Jan:29-31. 19. Crawford CA, Lloyd CH, Newton JP, Yemm R. Denture bleaching: a laboratory simulation of patients’ cleaning procedures. J Dent 1986;14:258-61. Reprint requests to: DR. G. HOAD-REDDICK UNIVERSITY DENTAL HOSPITAL OF MANCHESTER HIGHER CAMBRIDGE ST. MANCHESTER Ml5 6FH ENGLAND
JULY
1990
VOLUME
64
NUMBER
1
into the cleanliness
of dentures
in an elderly
Gillian Hoad-Reddick, M.Sc., B.D.S.,* Alan A. Grant, D.D.Sc., M.Sc.,** and Christopher S. Griffiths, B.D.S.*** University Dental Hospital of Manchester, Manchester and Halewood Health Centre, Cheshire, England During a survey of 233 elderly people of whom 89.9% were edentulous, attitudes toward denture cleaning were investigated. Questioning revealed the frequency of cleaning and methods used. Examination showed which dentures were clean, types and amounts of stain present, and comparison of clean dentures directly with dirty ones. Comparison of different residential groups highlighted problems particular to a group, so that recommendations for improvements could be made. Only 40% of dentures were properly clean. Subjects resident in the long-stay hospitals had the cleanest dentures and those in the elderly persons’ homes the dirtiest. One quarter of the dentures examined were over 30 years old. They tended to be dirtier than the newer ones and related to a higher incidence of denture stomatitis. Wearers of cleaner dentures were more satisfied with their cleansing methods and more likely to use a propietary cleanser regularly than those with dirty dentures. (J PROSTHET DENT 1990;64:48-62.)
M
any denture wearers find denture cleaning a problem. Surveys of United Kingdom elderly persons report patients wearing dirty dentures. Investigating 1000 denture wearers, MacCallum et al1 found 17.5% were dissatisfied with the method they were using, although on examination 69.8% had stained dentures. After surveying 300 hospital patients, Ritchie2 found only 27 % of dentures were clean although 65 % to 68 % of patients claimed to use a proprietary cleanser. Ettinger and Manderson3 found 65% of elderly denture wearers in Edinburgh’s residential institutions had staining, calculus, or soft debris on their dentures. Smith and Sheiham: investigating elderly residents in the community, found 51% had hard deposits and 8% soft deposits on their dentures. Of these residents, 20% had difficulty moving their hands, but only 9 % claimed to have difficulty cleaning dentures or teeth. MacCallum et al.’ suggested that the public does not associate staining with “dirt” on a denture and accepts that denture cleansers neither affect nor control staining. The Adult Dental Health Survey5 reported that 65 % of denture wearers cleaned their dentures once daily, and soaking in a proprietary cleanser was the most popular method. Household bleach was used by 16 % of Bates and Smith’s patients,s ’ 7 % of Neill’s patients,s and 19.3% of
*Lecturer, Department of Prosthetic Dentistry, University Dental Hospital of Manchester. **Professor,Departmentof Prosthetic Dentistry, University Dental Hospital of Manchester. ***District Dental Officer, Halewood Health Centre. 10/l/19460
48
Hamilton’s.g Hamilton9 found 60 % soaked their dentures and concluded that the method of cleaning bore no significant relation to cleanliness.
THE SURVEY A survey was made of 233 elderly patients in the Halton Health Authority (Cheshire) on the cleanliness of their dentures. Specific questions were asked about age of dentures, methods and frequency of cleaning, satisfaction with the method used, and if they had ever been shown how to clean their dentures. Any relationship between age of denture and cleansing problems, or specific types of staining and any cleansing process was sought so that recommendations could be forwarded to any agency that could assist elderly people.
MATERIAL
AND METHODS
Patients were selected from four residential groups so that comparisons could be made and problems specific to any particular group identified. They were: (1) long-stay hospital patients (LSH), (2) residents of elderly people’s homes (EPH), (3) people resident in the community with assistance from Social Services, Home Helps, or Meals on Wheels (CWA), and (4) people resident in the community with no assistance from outside agencies (NAC). Patients were selected at random so that there were similar numbers in each group and so that ratios of men to women and those 65 to 74 years of age and those more than 75 years were in the ratios found in the local population (Table I). An examiner undertook the survey from October 1984 to January 1985. Interview questions were based on previous survey questions (especially the Hampshire surveyi and
JULY
1990
VOLUME
64
NUMBER
1
CLEANLINESS
OF DENTURES
IN ELDERLY
POPULATION
the Adult Dental Health Surveys) for comparison or new questions were formulated. Examinations were made in the patient’s home or the Halton Hospital Day Center. Illumination was by a hand-held light; patients sat where they were most comfortable, and not in a dental chair. Since the sampling was random, not all patients were edentulous and not all edentulous patients had dentures (21 had lost them, and two had never worn them). Patients were assessedon their ability to answer questions using a four-point scale of: (1) totally alert and able to answer all questions easily, (2) muddled but able to answer most questions satisfactorily, (3) great difficulty in answering many questions, and (4) totally unable to answer any questions. This division would identify patients most receptive to oral hygiene instruction and care of dentures (Table I).
Table I. Distribution of patients between four residential groups and assessedability of each group Sex
Total
Male
Female Total
LSH
EPH
CWA
NAC
24 29 53 51
93
18
23
140
37
39
233
55
62
28 35 63
8 13 15 19
26 25 9 2
53 7 3 0
Ability 1 2 3 4
1
0 1
For the statistical analysis of ability, groups 1 and 2 and 3 and 4 were pooled: x2 in 3’ freedom, 77.2; p < 0.01, result is significant. LSH, Long-stay hospital patients; EPH, elderly people’s home residents; CWA, people living in community with assistance; NAC, people living in community with no assistance.
Questionnaire Questions relating to denture cleanliness and use were: When do you wear your dentures? Do you clean your dentures yourself? How do you clean your dentures? When (how frequently) do you clean your dentures? Do you feel you can clean your dentures properly? Has a dentist or his staff ever shown you or told you how to clean your dentures? Patients were also asked how often they visited their dentist, and if they were satisfied with the appearance of their dentures and the age of their dentures. For the age analysis, three groups were selected because it seemed from the pilot survey that they would be numerically similar. Four patients had dentures 0 to 5 years old, 77 patients had dentures 6 to 30 years old, and 44 had dentures over 31 years old. For the analysis of cleansing methods, results were pooled so that the four groups finally compared were those who (1) brush regularly, (2) soak regularly, (3) perform a satisfactory combination, and (4) use a regimen that would not maintain a satisfactory state of denture cleanliness. 1. 2. 3. 4. 5. 6.
Examination The oral cavity was examined. Criteria for examination of dentures has been described elsewhere.11,12The oral mucosal examination covered the same headings as Smith and Sheiham,4 who based their criteria on World Health Organization guidelines.13 The cosmetic appearance of the denture was observed with the denture in the patient’s mouth and while facing the patient. It was considered to be unsatisfactory if the denture was very dirty or broken, if there was unsatisfactory lip support, or if the midlines were not satisfactorily aligned. The cleanliness of the denture was noted when removed from the mouth and placed in a small dish. Scoring for cleanliness was undertaken as follows.
THE
JOURNAL
OF PROSTHETIC
DENTISTRY
Soft debris. Soft debris was scored as present if it was packed between the teeth and over the tissue surface of the denture. Hard debris. Hard debris was scored as mild if it was present around gingival margins and lingual to the lower central incisors and buccal to the upper first molars. It was scored as severe if it covered the teeth, flanges, and tissue surface. Staining. Staining was scored as mild if it covered the gingival margins and as severe if it covered teeth, flanges, and palate. For statistical analysis, values for soft debris, mild hard debris, and mild staining were pooled, as were hard debris and severe staining. Patients, or those caring for them, could remove the mild deposits, whereas professional help would be necessary for the severe deposits.
RESULTS Denture examination The level of edentulousness was very high. Only 28 patients had any remaining teeth and 179 had some form of denture. There were 142 sets of complete upper and lower dentures, 28 complete upper dentures, three complete lower dentures, and three mandibular and six maxillary removable partial dentures.
Questionnaire Dentures were worn by 39.7 % of the patients for the full 24 hours, 51.4 % during the daytime only, and 8.8 % for either eating or social reasons. No significant differences were found between residential groups, although the proportion in the community with no assistance who wore their dentures for the full 24 hours (46.8%) was slightly higher than in the other three groups (LSH, 34.6 % ; EPH, 37.3 % ; CWA, 38.2%). This might be related to the fact that 84% of those in the community lived with their spouses. Most
49
HOAD-REDDICH
Table
II.
ET AL.
Response to question, “who cleans your dentures?” (residential group) Total
Who cleans the denture?
No.
Never cleaned Self Somebody else
LSH
EPH
CWA
NAC
%
No.
%
No
%
No.
%
No.
%
6.0 84.2
3.9 90.2 5.9
3 51 3
89.5
1 46 1
2.1 95.8
9.8
2 46 3
5.3
42.9
18
5 12 11
17.9
155
11
39.3
5.3
2.1
Statistical analysis: Figures for “never cleaned” or “cleaned by someone else” pooled for analysis: x2 in 4’ freedom, 43.51; p < 0.01, highly significant.
Table
III.
Cleansing methods used (residential group) Total
Cleaning
regimen
Brush regularly Soak regularly Satisfactory combination Not satisfactory
EPH
LSH
No.
%
No.
38 38 72
21.2 21.1 40.2
31
17.3
5 14 6 2
%
CWA
NAC
No
%
No.
%
No.
%
24.0 32.0 26.0 18.0
7 6 29 13
.12.7
14 2 24 7
29.8 4.3 51.1
18.5
12
51.9
16
22.2 7.4
13 9
10.9 52.7 23.6
14.9
Statistical analysis: Brushing and soaking regularly were pooled with satisfactory combination for analysis: x2 in 3’ freedom, 4.2, p > 0.05, not significant.
Table
IV.
Results of examination of denture
cleanliness* Total numbers
Upper denture Clean Mild debris Severe debris Lower denture Clean Mild debris Severe debris
LSH (%)
EPH (%)
CWA (%)
NAC (%)
community 69 48
63.3 20.0
30.9
39.6 24.9
29.5
51
16.7
32.6
35.5
31.8
58 33
54.5 4.5
55
40.9
26.2 40.5 33.3
47.5 10.0 42.5
38.1 26.2 35.7
30.4
38.6
Statistical analysis: Upper denture, x2 in 6” freedom, 9.49; p > 0.05, not significant; lower denture, x2 in 6” freedom, 16.51; p < 0.05, significant. *Soft debris, mild hard debris, and mild staining are combined, as are severe hard debris and severe staining.
patients (155 or 84.2%) claimed to clean their dentures themselves. Eleven said they never cleaned them, and 18 said someone other than themselves performed the cleaning. At the time of the survey, nurses in the long-stay hospitals collected patients’ dentures and soaked them overnight. Only 42.9% of this group (LSH) claimed to clean their dentures themselves compared with over 89.5% in the other three groups. These differences were highly significant (Table II). Investigation into cleaning methods showed that the regimen considered most satisfactory by the examiner (a combination of soaking and brushing) was used by more than 50% of both community groups but only 26% of el-
50
derly home residents and 22% of long-stay hospital patients. The method described did not maintain denture cleanliness in 23.6% of the community-assisted group, 18% of elderly persons home residents, and 14.9% of the without-assistance
group.
In the long-stay
hospital, however, only 7.4% of patients described a regimen that was patently inadequate. Although statistically insignificant,
these results suggest that the cleansing meth-
ods in the long-stay hospitals are generally the most satisfactory (Table III). Dentures were cleaned daily by 79.1% of the patients, five times weekly by 4.5%, thrice weekly by 7.9%) and 8.4 % claimed either never to clean them or could not remember how frequently they did clean them. When long-term hospital patients were asked if they believed they could clean their dentures properly, 34.6% were not happy with the method used, whereas the overall level of dissatisfaction was only 14.6% (EPH, 10%; CWA, 18.2%; NAC, 4.3%). Thus, in spite of having the cleanest dentures, long-stay hospital patients were dissatisfied, suggesting unhappiness with their inability
to be responsible
for their own lives.
Most patients (86.3%) thought they had never been shown how to clean dentures either by their dentist or his staff. There was little variation swers to this question.
Examination
between the groups’ an-
for cleanliness
The examiner was not satisfied with the appearance of 25.3% of the dentures examined while they were being worn, whereas only 6.7 % of the patients were dissatisfied.
Although not all appearance problems were caused by the
JULY
1990
VOLUME
64
NUMBER
1
CLEANLINESS
OF DENTURES
IN ELDERLY
a.
Clean
POPULATlON
b. Severe hard debris and stain
Dentures
75
Lower
Lower
Upper
Upper
t
.,... ..,... ..,.. .... ...,... ._... ...I . ~1 Denture
Age
0-Syrs.
6-30yrs.
Over
31yrs.
Fig. 1. Relationship between age of denture and cleanliness. Statistical analysis: x2 on 4’ freedom: Upper denture, 16.58; lower denture, 31.05; p < 0.01, highly significant.
presence of dirt on the dentures, it suggests that denture wearers are either not self-critical, or do not have high expectations of their appearance when wearing dentures. Results of denture cleanliness are shown in Table IV. Overall, only 41.1% of upper dentures and 39.7% of lower dentures were properly cleaned. Severe hard debris was present on 11.3% of upper and 19.9% of lower dentures. The cleanest dentures were found in the long-stay hospitals and the dirtiest in the elderly persons’ homes. Differences between the residential groups were significant for the lower denture (p < 0.05) but not for the upper (Table IV). When the relationship between age of denture and cleanliness was investigated (Fig. l), 55.3% of dentures 0 to 5 years old were clean compared with only 30.6% of dentures more than 31 years old. None of the newer dentures had soft deposits, but in the old dentures their level was 8.3%. Severe staining rose from 5.3% in the 0- to 5-year-old dentures to 25% in dentures 6 to 30 years old, whereas levels of mild staining dropped: 0 to 5 years, 23.7%; 6 to 30 years, 12.5%; and 31+ years, 5.6%. Percentages of both mild and severe hard debris rose from 15.8% in the 0- to 5-year-old group to 36.2% in the older group. This relationship between age of denture and level of cleanliness was found to be highly significant and may be related to degeneration of the material from which the dentures were made, caused by wear, discoloration, or general use.
THE
JOURNAL
OF PROSTHETIC
DENTISTRY
Further analysis of the clean and dirty dentures revealed that 27.9 % of clean dentures were soaked regularly, whereas only 15.8% of dirty denture wearers claimed to soak them. Denture cleaners were used by 71.7% of clean denture wearers and by only 55.8% of dirty denture wearers. Daily cleaning was performed by 90.2 % of clean and 76.6 % of dirty denture wearers. Wearers of clean dentures were more likely to want a dental checkup, with 36.7% wanting a checkup compared with 18.1% of those wearing dirty dentures. Denture stomatitis and angular cheilitis were twice as prevalent (14.5 % ) in patients with di.rty dentures as in the clean-denture group (7.8 % ).
DISCUSSION The findings of this survey are similar to those of earlier workers in that most elderly people do not know how to keep dentures clean. Yet, by comparing different residential groups, it is clear that where an adequate cleaning regimen is instituted, dentures can be kept clean. In the longstay hospitals where the dentures are routinely soaked overnight in a proprietary cleaner, dentures were significantly cleaner than in the other groups. The dirtiest dentures were in the elderly persons’s homes where residents are expected to clean their dentures themselves. As more people are cared for in residential homes, it is important that dental awareness and the need for oral hygiene, even in the edentulous, be publicized. Older dentures were dirtier than newer ones, more in 51
HOAD-REDDICK
need of replacement, and related to a higher level of denture stomatitis or angular cheilitis. Other workers have shown a direct relationship between denture stomatitis and denture hygiene.14-17 It is thus clearly incumbent upon the dental profession, at a time when the number of elderly is rapidly rising, to ensure that the denture-wearing public know how to clean dentures properly. The media should be contacted and encouraged to assist educating those caring for the elderly about denture hygiene and oral health care. Which magazine I8 has shown the way. Their comparison of denture cleaners distinguishes between the different types of cleaners and lists the advantages and disadvantages of brush-on or soaking tvnes of cleaners. There is also a discussion on the importance of regular denture cleaning, the need to follow manufacturers’ instructions, and the importance of avoidance of substances such as household bleach or scouring powder, which may damage dentures. Other organizations must be encouraged to assist in this education nrocess. Manufacturers of cleansers should be encouraged to provide more information about their products, such as explaining that the acid-based cleansers assist in removal of tartar/calculus and that the hypochlorite cleansers are more helpful in the removal of stains. At present, little information about the specific cleaning action of denture cleansers is given on their packaging. Crawford et al.lg have already suggested to manufacturers of one cleanser that current usage instructions need reinforcement so that the use of hot water and resultant bleaching of dentures is discouraged. It has been shown elsewhere that dentures should be checked regularly and on average replaced every 10 years.l’ If the dental profession were to become more active in promoting oral health for elderly people, denture cleanliness could be one of the easier ways of alerting elderly to their dental problems.
CONCLUSION This survey has shown that only 40% of dentures worn by the elderly are properly clean. Dental health education must be directed to this problem by dentists, the media, and manufacturers of denture cleansing products. Since the dirtiest dentures were found in the elderly peoples’ homes, education must be directed toward the care-givers as well as the elderly persons themselves. The dental profession must encourage denture wearers to have regular checkups so that old, ill-fitting dentures, which tend to be
52
ET AL.
dirtiest and are related to a higher incidence of denture stomatitis, can be detected and remedial procedures advised. Education of the denture-wearing public and also those caring for them is urgently needed. Dentists must be assisted by other organizations if oral hygiene of the elderly is to be improved. REFERENCES 1. MacCallum M, Stafford GD, MacCulloch WT, Comhe EC. Which cleanser? Dent Pratt Dent Ret 196&19:83-g. 2. Ritchie GM. A report of dental findings in a survey of geriatric patients. J Dent 19’73;1:106-12. 3. Ettinger RL, Manderson RD. Geriatric dental services and facilities in Edinburgh. Modern Geriatrics 1975;5:22-8. 4. Smith JM, Sheiham A. How dental conditions handicap the elderly. Community Dent Oral Epidemiol 1979;7:305-10. 5. Todd JE, Walker AM. Adult dental health. Vol 1. England and Wales 1968-78. London: Her Majesty’s Stationery Office. 6. Bates JF, Smith DC. Evaluation of indirect resilient liners for dentures. J Am Dent Assoc 1965;70:344-53. 7. Smith DC. The cleaning of dentures. Dent Pratt Dent Ret 1966;17:3943. 8. Neil1 DJ. A study of materials and methods employed in cleaning den-
tures. Br Dent J 1968;124:107-15. 9. Hamilton F. The dental health care problems of the elderly living at home with particular reference to care by general dental practitioners [M.D.S. Thesis]. 1986. 10. Osborne J, Maddick I, Gould A, Ward D. Dental demands of old people in Hampshire. Br Dent J 1979;146:351-5. 11. Hoad-Reddick G. A survey into the dental needs of the elderly with special reference to their treatment needs [M.Sc. Thesis] 1985. 12. Hoad-Reddick G, Grant AA. A system of examination of prosthetic status: the formation of a schedule. J PROSTHET DENT 1988;59:105-9. 13. World Health Organization. Oral health surveys, basic methods. 2nd ed. Geneva: World Health Organization, 1977. 14. Fisher AK, Rashid PJ. Inflammatory papillary hyperplasia of the palatal mucosa. Oral Surg Oral Med Oral Path 1952;5:191-8. 15. Love WD, Goska FA, Mixon RJ. The aetiology of mucosal inflammation associated with dentures. J PROSTHET DENT 1967;18:515-27. 16. Budtz-Jorgenson E. Clinical aspects of candidal infection in denture wearers. J Am Dent Assoc 1978;96:474-9. 17. Olsen I. Denture stomatitis, relapse tendency and removal of acquired discolorations in longterm denture disinfection with chorhexidine. Acta Odontol Stand 1975;33:111-4. 18. Anon: Denture cleaners and fixatives. “Which” Consumers Association 1983;Jan:29-31. 19. Crawford CA, Lloyd CH, Newton JP, Yemm R. Denture bleaching: a laboratory simulation of patients’ cleaning procedures. J Dent 1986;14:258-61. Reprint requests to: DR. G. HOAD-REDDICK UNIVERSITY DENTAL HOSPITAL OF MANCHESTER HIGHER CAMBRIDGE ST. MANCHESTER Ml5 6FH ENGLAND
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1990
VOLUME
64
NUMBER
1
