Denture Stomatitis Literature Review: Classification, Causes, Treatment

Denture Stomatitis: A
Literature Review
INDIAN DENTAL ACADEMY
Leader in continuing Dental
Education
www.indiandentalacademy.com

LEARNING OBJECTIVES
At the end of the presentation the learner
should be able to;
 Define Denture stomatitis.
 Describe the classification and aetiology of
Denture stomatitis.
 Describe the preventive measures and
treatment for Denture stomatitis.

INTRODUCTION
The word stomatitis means
inflammation of oral mucosa.
Denture stomatitis is a term used in the
literature to indicate an inflammatory
state of the denture bearing mucosa.
Denture stomatitis is also known as
denture-induced stomatitis, denture
sore mouth, inflammatory papillary
hyperplasia and chronic atrophic
candidiasis.

 It is one of the common problems in elders
wearing complete or partial dentures.
Incidence of occurrence is 11-67% complete
denture wearers and is more common in
women than men.
 Palatal mucosa is the most common site for
the fungi to grow where it is covered by the
denture base.
 There are many literatures relating to the
classification, causes of denture stomatitis
and treatment, which are discussed in the
following sections.

CLASSIFICATION
It was first classified by Newton (1962) according to its clinical
appearance as:
Type 1: A localized simple inflammation or pinpoint hyperemia
(Fig. 1).
Type 2: An erythematous or generalized simple type seen as
more diffuse erythema involving a part or the entire denturecovered
mucosa (Fig. 2).
Type 3: A granular type (inflammatory papillary hyperplasia)
commonly involving the central part of the hard palate and the
alveolar ridges (Fig. 3).
• Type III often is seen in association with type I or type II.
• Type III denture stomatitis involves the epithelial response to
chronic inflammatory stimulation secondary to yeast

ETIOLOGY
Multifactorial Findings
 The etiology of denture stomatitis remains controversial
as it is of multifactorial nature.
 Denture trauma, night time denture wearing, denture
cleanliness, dietary factors, Candida infections and
predisposing systemic conditions have been proposed
as associated factors in denture stomatitis.

Trauma
 Denture trauma due to ill-fitting dentures is believed as
one of the etiological factors of denture stomatitis.
 According to Nyquist; trauma caused by dentures was
the dominant factor in denture stomatitis.
 Cawson; concluded that the trauma and candidal
infection are significant causes of denture stomatitis.
 Immunohistochemical analysis of the mucosal tissue
also has demonstrated a possible role of trauma in
denture stomatitis.

 Incorrect vertical dimension of occlusion has also
been suggested as a contributing factor in the
occurrence of denture stomatitis.
 The results of the studies by Emami E et
al..,research suggest traumatic occlusion results
in an inflammatory reaction which may create an
environment favourable to microorganisms found
in denture stomatitis.
 According to some recent evidence, nocturnal
wear of dentures and smoking are suggested as
other significant risk factors for denture stomatitis.

Micro-organisms
 Although some earlier investigators linked denture stomatitis
with trauma or bacterial infection, others had isolated the
strains of the genus Candida, in particular Candida albicans
from the mouths of patients with this condition.
 It has been recently shown that the presence of Candida
albicans in denture stomatitis is probably related to an
extensive degree of inflammation and that denture stomatitis
is usually associated with the detection of Candida species
while other factors such as denture hygiene habits and
trauma are important to the development of the disease.

 The severity of the denture stomatitis has been
corelated with the presence of yeast colonizing
the denture surface.
 Denture induced stomatitis or chronic atrophic
Candidiasis is the commonest form of oral
Candidiasis and is present in 24- 60 percent of
denture wearers.
 Denture stomatitis has been associated with
angular cheilitis, atrophic glossitis, acute
pseudomembranous Candidiasis and chronic
hyperplastic Candidiasis, and has been found to
be more common in females than males.

Denture Lining Materials
 For the prosthodontic treatment and management of
traumatized oral mucosa, denture lining materials, which
include tissue conditioners and soft denture liners, are
widely used.
 Denture lining materials are most commonly used in
association with the mandibular denture. Recently
materials which are available are either silicone
elastomers, plasticized higher methacrylate polymers,
hydrophilic polymethacrylates or fluoropolymers.
 Candidal growth has been associated with mandibular
dentures relined with soft liner. The most commonly
detected yeasts were strains of the genus Candida, in
paticular C. albicans, C. glabrata and C. tropicalis.

Denture Plaque
 Poor denture hygiene is considered to be one
of the etiologic factors for denture stomatitis.
 Various factors stimulating yeast proliferation,
such as poor oral hygiene, high carbohydrate
intake, reduced salivary flow, composition of
saliva, design of the prosthesis and
continuous denture wearing can also enhance
the pathogenicity of denture plaque.

Surface Texture and Permeability of Denture
Base
The tissue surface of the dentures usually shows
micropits and microporosities.
Microorganisms harboring in these areas are
difficult to remove mechanically or by chemical
cleansing.
According to several in vitro studies, the microbial
contamination of denture acrylic resin occurs very
quickly, and yeasts seem to adhere well to denture
base materials.
Surface roughness may facilitate microbial retention
and infection.

 The porosity and surface texture of acrylic resin
were investigated,and it was found that the
denture surface with a fine texture with an
absence of porosity did not allow attachment of
plaque by penetration of surface defects or by
mechanical fixation to surface irregularities.
 In vitro study, Van Reenen.., showed that C.
albicans penetrated the commonly used acrylic
resin; penetration of the unpolished surface that is
in contact with the mucosa was greater than that
of the polished surface.
 It was further confirmed with the use of a
fluorescent dye.

Allergic Condition/Reaction
Toxicity is usually manifested by the release of
several chemical constituents from the material,
which can induces an allergic response in terms
of localized or generalized stomatitis/ dermatitis,
severe toxicological reactions or carcinogenic/
mutagenic effects.
An allergic reaction to constituents of the
denture material in the form of contact mucositis
is also suggested.

 This reaction may be related to the presence of
resin monomer, hydroquinone peroxide, dimethyl-
p-toluidine, or methacrylate in the denture.
 Furthermore, contact sensitivities are more
common to occur with cold or autopolymerized
resins than with heat-cured denture-base
materials.
 Several forms of allergies including type IV
hypersensitivity, urticaria, allergic stomatitis,
dermatitis and psoriasis have been reported in
literature from different polymer components.

Systemic Factors
In cases that fail to respond to the usual treatments,
consider the role of systemic disease and its impact
on oral function.
Certain systemic conditions such as diabetes
mellitus, nutritional deficiencies (iron, folate, or
vitamin B12), hypothyroidism, Immunocompromised
conditions (HIV infection), malignancies (acute
leukemia, agranulocytosis), iatrogenic
immunosuppressive drugs, e.g. Corticosteroids, may
also predispose the host to candida-associated
denture stomatitis.

Treatment of Denture Stomatitis and Preventive Measures
Due to its multifactorial etiology, the management of
Candidaassociated denture stomatitis is complex. Several
treatment procedures can be used, including the use of
antifungal therapy,in addition to the removal of dentures at night
and efficient plaque control.
Recent research has suggested the use of denture lining
materials containing antifungals, antiseptic mouth rinses
microwave irradiation,as factors to be considered in the
treatment of Candida-associated denture stomatitis.
There have been several reviews concerning the treatment of
denture stomatitis in the literature.
Their conclusions vary and cover findings about different
treatment regimens.

Correction of Ill-fitting Dentures
Ill-fitting dentures were considered to be the main
predisposing factor for the occurrence of denture
stomatitis.
Therefore, improving adaptation of the denture should be
considered for the management of denture stomatitis.
Correction of ill-fitting denture is considered important for
the treatment of denture
stomatitis.
Discontinuous denture wearing are also
considered important for the treatment of denture
stomatitis.

Antifungal Agents
These act by inhibiting pathways (enzymes, substrates,
transport) necessary for cell membrane synthesis or altering
the permeability of the cell membrane (polyenes) of the fungal cell.
It may also alter RNA and DNA metabolism or an
intracellular accumulation of peroxide that is toxic to the fungal cell.
The effect of the antifungal agent depends on its
concentration, susceptibility of the strain and the source of the mucosal
surface.
Some advocate the use of antifungals such as nystatin and
amphotericin B for the treatment of denture stomatitis and consider it
effective, While others believe that the use of antimycotic drugs seems
unnecessary.
It is also observed commonly that the disease recurs if the appropriate
therapy is stopped.

 An effective topical agent, amphotericin B is also a drug of
choice for intravenous treatment of progressive and
potentially fatal candidal infections.
 Amphotericin B Lotion 3% is applied topically twice daily.
Nystatin, which is useful as a topical agent in oral and
pharyngeal candidosis, most of the drug passes unchanged
through the gastrointestinal tract as it is poorly absorbed
when ingested.
 A nystatin suspension 100,000 unit per ml is prescribed. Both
amphotericin B and nystatin have an unpleasant taste, and
sometimes its oral use may lead to gastrointestinal side
effects such as nausea, vomiting and diarrhoea.

 The imidazole compounds such as clotrimazole,
miconazole, econazole and ketoconazole, are broad-
spectrum antifungal agents which affect permeability of
Candida membrane by interfering with the synthesis of
ergosterol; they also bind more strongly to Candida
enzymes than to mammalian enzymes.
 Clotrimazole (1% cream) is only used topically,
because of gastrointestinal and neurological toxicity;
Econazole exists in topical form only; miconazole (2-
4% cream) and ketoconazole (200-400 mg, orally once
daily) can be used both topically and systemically.

 To test the efficacy of denture lining materials
containing antifungals in the treatment of denture
stomatitis, a number of studies have been carried out.
Douglas and Walker, in their in vivo investigation
confirmed the inhibitory effect of tissue conditioners
incorporated with Nystatin.
 According to Thomas and Nut, Tissue conditioner
combined with Nystatin powder was successful in
inhibiting the growth of Candida albicans, Candida
tropicalis, Candida krusei.

Efficient Plaque Control
 Lacopino and Wathen noted the presence of C.
albicans in microbial denture plaque and
emphasized the importance of oral hygiene.
 Therefore, it was recommended that by simple
denture hygiene measures such as careful
brushing and overnight denture soak in 0.1%
aqueous chlorhexidine is efficient to remove
microbial plaque on the denture.

Antiseptics and Disinfecting Agents
 The use of disinfecting agents, such as sodium
hypochlorite and chlorhexidine aimed to eliminate
denture plaque and to control colonization of the fitting
denture surface by candida.
 Schwartz et al .., compared antiseptic (Listerine),
Nystatin Oral Suspension (100,000 units/mL) and
control (5% hydroalcoholic) mouth rinses three times
per day for 30 percent over a 28-day period.
 The authors also suggested that the denture may be a
reservoir of infection and recommended that treatment
should include antimicrobial therapy of the denture and
removal of the denture for a period of time in every 24
hours.

 In another study a 0.2% chlorhexidine gluconate mouth rinse
used three times daily significantly reduced plaque, but there
was no significant effect on the number of Candida
organisms.
 However in one study, it was concluded that in the absence of
other mechanical denture hygiene measures, the antiseptic
rinses and relines were equally effective in reducing denture
stomatitis.
 Some studies showed that the sodium hypochlorite eliminate
denture plaque effectively in vitro even after denture soaked
for short period exposures.

MICROWAVE IRRADIATION
 There are many evidences showing a new
alternatives, such as the use of microwave
irradiation at a specified setting and exposure
time, are bactericidal and fungicidal.
 But so far, there has been only few studies
reported the use of microwave irradiation to
sterilize microorganisms on denture surfaces.
 Rohrer and Bulard showed that microwaving at
high setting for eight minutes would sterilize
acrylic dentures contaminated with C. albicans
suspension.

 Ribeiro D et al47 in there study evaluated the
clinical effectiveness of two exposure times (2 and
3 minutes) of microwave irradiation on the
disinfection of complete dentures and concluded
that microwave irradiation for 3 minutes may be a
potential treatment to prevent crosscontamination.
 Thomas and Webb48 demonstrated that
microwaving of dentures at medium setting (350
W, 2450 MHz) for six minutes caused minimal
change which was considered to be harmless in
the long-term.

Surgical Treatment
In mild cases , antifungal treatment without
surgery might be an alternative before the
dentures are relined or replaced. In severe e
papillary hyperplasia of palate, cryosurgery or
excision can be considered.

Recent Study
 Recent study showed that the prevalence of
denture stomatitis is reduced when
mandibular dentures are stabilized by
implants and concluded that implant
overdentures could be an effective in
controlling denture stomatitis by preventing
trauma to the oral mucosa in edentulous
elders.
 Better maxillary oral mucosal health may
result when mandibular dentures are
supported by a minimum of 2 implants.

CONCLUSION
 In this article, denture-stomatitis was reviewed.
 It has multifactorial etiology.
 Trauma, microorganism (Candida albicans), denture plaque,
denture lining material, surface texture and permeability of
denture base, allergic conditions and systemic factors are
some of the proposed associated factors in the denture
stomatitis.
 Treatment of denture induced stomatitis differs, depending on
the causes of the disease.
 In most of the patient, the elimination of mechanical and
traumatic factors, the consistent use of oral hygiene
measures, and the administration of local antimycotic therapy
usually enables the inflammatory lesions to heal rapidly.

1ST CROSS REFERENCE
Effect of Denture Base Acrylic Resin,
Denture Adhesive Material, and Denture
Liner on Denture Stomatitis (A Longituidinal
Study).
Khaled Ahmed Arafa ;
J Am Sci 2012;8(9):578-581]. (ISSN: 1545-
1003)

Introduction
 Denture stomatitis (DS) is an inflammatory lesion,
in which there is redness of the oral mucosa
underneath a complete denture.
 Although Candida albicans is a component of
normal microbial flora, local and systemic factors
can cause opportunistic infections.
 Poorly fitting or unhygienic dentures leads to the
presence of yeasts attached to it., and
cause inflammation.
 Treatment procedures include correction of ill-
fitting dentures, plaque control, and topical and
systemic antifungal therapy.

 Although the dominant etiologic factor now
appears to be fungal infection, other factors
must be considered; these include the
prosthetic device itself and also local and
systemic factors in patients who are aging
and edentulous.

Material and Methods:
A sample of sixty edentulous patients was used,
and was divided into three equal groups each
consisted of twenty patients:
Group 1: patients wearing complete dentures.
Group 2: patients wearing complete denture with
adhesive material (Coriga, USA)
Group 3: patients wearing complete dentures with
soft lining material (Mollosil M, Detax, GmbH,
Germany)

 Each group was Subdivided into two
subgroups, one was wearing the denture only
during the day, and the other was wearing the
denture during day and night.
 Candida colonies were detected by taking a
palatal swaps and were stained with KOH stain and
examined by optical microscope (Olympus, Japan)
at X400 magnification.
 These swaps were taken after nine months of
wearing the dentures according to the
and calculated in each patient then the results
were tabulated as expressed in cells/mm2.

RESULTS

Discussion:
 Candida albicans can produce biofilms on
natural surfaces, such as teeth, and foreign
surfaces, such as prostheses. These biofilms are
normally resistant to common antimicrobial therapy,
an increasing problem in clinics.
 Candida species are generally ubiquitous
commensal microorganisms that are part of the
normal mucosa microflora.
 If, however, the balance of the normal flora is
disrupted or the immune defenses are
compromised, Candida yeasts can invade
mucosal surfaces and cause diseases, such as
Candida-associated denture stomatitis.www.indiandentalacademy.com

 In vivo, such surface defects would provide an ideal
protective area for microorganisms and the potential for a
focus from which outgrowth and infection might proceed.
 Materials with rough surfaces make the cleaning of the
prosthesis and mechanical removal of the microorganisms
difficult, also, they cause discoloration of the denture base
materials.
 Another study stated that the differences in surface
topography affects the attachment of microorganisms to a
surface, with higher number of cells retained on rough
surfaces and surface irregularities would increase the
likelihood of microorganisms remaining on the surface.
 In this longitudinal study, the number of
candida albicans differred according to the time of wearing
the denture, day time only or all day and night time.

An examination of the denture cleanliness was made
using a plaque detector to disclose the plaque on the
fitting surface of the denture with 1% of fuchsin.
According to the quantity of plaque on dentures, patients
could be divided into three groups using the following
index of denture cleanliness [4]:
Excellent: none or only few spots of plaque.
Fair: more extended plaque, less than half of the
denture base covered by plaque.
Poor: more than half of the denture base covered by
plaque

Conclusions:
1-Denture fitting surface of the complete denture is a
dominant cause for stomatitis.
2-Wearing the denture with adhesive material
decrease the amount of candida albicans to the
least number.
3-Using liner decrease the possibility of stomatitis
along time.
4-Wearing the denture at night, during sleep, inceases
the possibility of stomatitis and increase number
of Candida albicans.

2nd cross reference:-
STOMATITIS PROSTHETICA-A
POLYETIOLOGIC
DISORDER
Hrizdana Hadjieva, Mariana Dimova, S.
Todorov;Department of Prosthetic Dentistry,
Faculty of Stomatology,;Medical University-
Sofia, Bulgaria
Journal of IMAB - Annual Proceeding
(Scientific Papers) 2006, book 2

Introduction
 The prosthetic stomatitis is a multietiological condition.
 The clinical manifestation could be the same
nevertheless what is the etiology and at the same time
one and the same reason could result in different
clinical manifestation.
 The purpose of this investigation is to establish the
frequency of denture stomatitis, its etiology, diagnosis and
treatment.

Materials and methods.
The authors have investigated 300 patients with removable
complete and partial dentures.
The patients with denture stomatitis were
54.
All of these 54 patients were subjected to microbiologic
tests and tests for allergy to pink and clear
polymethylmethacrylate.
The quality of the prosthetic treatment was checked: the
extension of the borders, the vertical occlusal distance, the
occlusion and the dentures’ fir to the underlying mucosa.

 A qualitative differentiation of the inflammatory
intensity were made by those with observed inflammation
of the mucosa, distinguishing between, slightly inflamed,
moderately inflamed and severely inflamed mucosa.
 Slightly inflamed: slight erythema, scraping with a
spatula does not produce any reaction of pain
 Moderately inflamed: distinct erythema, scraping
with a spatula produces a reaction of pain.
 Severely inflamed: the mucosa is fiery red, scraping
with a spatula produces a reaction of pain and bleeding
of the mucosa involved.

Fig1- slight inflammation
fig2- moderate inflammation

Fig 3- Angulus oriswww.indiandentalacademy.com

 On all the patients with established denture
stomatitis the mouth was examined for Candida
infections.
 Dermal “patch tests” to pink and clear PMMA were
performed by patients with denture stomatitis.
 All patients with inflamed mucosa were checked
for occlusion, vertical dimensions and fit of the
dentures to the palatal mucosa.
 The occlusion was controlled by articulation
paper, the vertical dimension by measuring the
interocclusal distance and the fit of the denture by
pressure indicating paste

RESULTS AND
DISCUSSION:
 From all 300 patients we observed 54 patients with
denture stomatitis (18%), 39 women (72,22%) and 15
men (27,78%).
 Only 6 women (11,11%) with denture stomatitis
complained of slight burning and itching sensation,
especially provoked by intake of hot and spicy food.
 Four women and two men (11,11%) had severe
inflammation of the palate , with marked papillomatosis
and angulus oris. /Fig.4 and Fig 3/.
 Twelve women and six men were with moderate stomatitis
(33,33%) / Fig 2/ 19 women and 11 men were with slight
inflammation (55,56%).

Allergy to modern denture base materials is very
rare.
Residual monomer of methyl methacrylate is known
to be an irritant to mucosal tissues, but the residual
monomer content in properly processed denture base is so
small that it would be unlikely to cause problems and would
leach out of the dentures soon after it was first inserted.
Our results show that 12 patients (22,22%) had
positive patch test for pink polymethylmethacrylate
(PMMA), 10 with one plus measured at the 48h and two
patients with tree plusses.
All patients showed negative
patch test to clear PMMA.

CONCLUSION
 Although denture stomatitis is usually asymptomatic,
and patients often unaware they have this condition, an
inflamed edematous palatal mucosa is not healthy.
 If left untreated it may progress to papillary hyperplasia, which
can only be resolved surgically.
 Every effort should be made to restore the healthy palate,
especially if this can be achieved by simple modifications to the
denture and patient’s wearing habits.
 Also it would be unwise to make a new denture with denture
stomatitis present as not only may the fit of the denture be
compromised but also the new denture would propagate the
condition.

Summary:
 The observed frequency of denture stomatitis by us is 18%.
 Women suffer more often than man, twice more in our
observation.
 The evidence for the etiology of denture stomatitis is inconclusive
and often contradictory.
 The etiology is probably multifactorial, and there may be as yet
undiscovered mechanisms operating, which predispose
towards this condition.
 Provisional diagnosis of denture stomatitis is based on clinical
signs, as symptoms are rare. The treatment should begin with
thorough examination of the dentures and corrections of the
faults if possible.

 If a new denture is needed first the
inflammation must be treated.
 Patch tests should be made by patients with
allergic history and by those, whose other
treatment gives no reliable results and there
are frequent recoveries of the condition

THANKYOU

Denture Stomatitis Literature Review: Classification, Causes, Treatment

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Denture Stomatitis Literature Review: Classification, Causes, Treatment