Aaa

Volume 25, Number 2, 2012 113
Identifying the pathologic determinants as well as
monitoring and preventing oral diseases remains
paramount to the general health and well-being of
populations worldwide. Denture stomatitis (DS) is a
prevalent and chronic problem in individuals wearing
complete removable dental prostheses (RDPs).1,2 It is
generally considered to be the most frequent lesion
affecting the oral mucosa.3,4 The prevalence of DS
varies between 6.5% and 75.0% according to the
populations and characteristics of the studies.3,5 DS
is an inflammatory reaction of the denture-bearing
mucosa and has three different clinical manifesta-
tions: type 1, localized inflammation or hyperemic
spots; type 2, diffuse erythema; and type 3, papillary
hyperplasia of the palate.6 According to the literature,
this condition has a multifactorial etiology.1,7 Several
factors have been proposed as predisposing fac-
tors in DS, ie, trauma, bacterial and fungal infections
(particularly Candida albicans), hygienic habits (poor
oral hygiene, nocturnal wear of the prosthesis), age
of denture, smoking, systemic conditions, as well as
allergic reactions to denture base materials.5,8–10
Although the definitive etiology of DS remains
undetermined, an association between the occur-
rence of DS and wearing of a complete RDP has been
widely accepted.7,11 However, there are differences
between partial and complete RDPs in terms of sup-
port, retention, and fabrication materials, and their
aAssistant Professor, Oral Health and Rehabilitation Research Unit,
Faculté de Médecine Dentaire, Université de Montréal, Montréal,
Canada.
bResearch Trainee, Oral Health and Rehabilitation Research Unit,
Canada.
cFull Professor, Oral Health and Rehabilitation Research Unit,
Canada.
dAssociate Professor, Oral Health and Rehabilitation Research Unit,
Canada.
eAssistant Professor, Department of Dental Materials and Prosth-
odontics, Ribeirão Preto Dental School, University of São Paulo,
Ribeirão Preto, Brazil.
Correspondence to: Dr Elham Emami, Faculté de Médecine
Dentaire, Université de Montréal, C.P. 6128, Succursale Centre-ville,
Montréal, Québec, Canada H3C 3J7. Email: elham.emami@
umontreal.ca
The Association of Denture Stomatitis and Partial Removable
Dental Prostheses: A Systematic Review
Elham Emami, DDS, MSc, PhDa/Hanan Taraf, DMDb/Pierre de Grandmont, DDS, MScc/
Gilles Gauthier, DMD, MScd/Louis de Koninck, DMD, MScd/Claude Lamarche, DMD, MScc/
Raphael F. de Souza, DMD, MSc, PhDe
Purpose: The aim of this systematic review was to analyze the evidence on the
occurrence of denture stomatitis (DS) and potential risk factors in patients wearing
partial removable dental prostheses (RDPs). Materials and Methods: MEDLINE,
EMBASE, the Cochrane Central Register of Controlled Trials, and the Cochrane
Database of Systematic Reviews were searched and complemented by manual
searching. Outcome measures were the presence of DS in patients wearing partial
RDPs and an assessment of associated risk factors. All types of experimental and
observational studies investigating an association between DS and the wearing of
partial RDPs were included. Methodologic quality and level of evidence were assessed
using valid scales. Two authors performed study selection, data extraction, and quality
assessment independently. Results: A total of eight studies met the inclusion criteria.
The prevalence of DS in partial RDP wearers ranged from 1.1% to 36.7%. Data on the
potential risk factors were not consistent. Despite the heterogeneity and methodologic
quality of included studies, an association between DS and the wearing of partial
RDPs was found. Conclusions: There is some evidence that the presence of DS
is associated with the wearing of partial RDPs. However, because of methodologic
limitations and cross-sectional designs of research studies, no cause-effect relationship
could be inferred. Future research should provide higher levels of evidence to confirm
the etiology of DS in partial RDP wearers. Int J Prosthodont 2012;25:113–119.
© 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

114 The International Journal of Prosthodontics
Association of Denture Stomatitis and Partial RDPs
role in the etiology of DS is still unclear.12 Therefore, a
systematic review might clarify this topic and provide
directions for future studies. To the authors’ knowl-
edge, this is the first systematic review that aimed
to examine the published data on the occurrence of
DS and its potential risks in partial RDP wearers. This
study focused on the question: Is wearing a remov-
able denture associated with a high prevalence of DS
in partially edentulous individuals?
Materials and Methods
Inclusion Criteria
Eligible studies in this review were clinical trials
and observational studies such as cross-sectional,
case-control, and cohort studies. Only studies that
had assessed at least one group of partial RDP
wearers in adults (18 years or older) were included.
All types of partial RDP designs were considered.
Excluded studiesdealt exclusively with other intraoral
appliances,ie, complete RDPs, fixed rehabilitations,
or orthodontic appliances. Studies with a sample
population composed of partially and completely
edentulous patients were considered only if separate
data were provided for partial RDP wearers. The main
study outcome was the prevalence of DS. The sec-
ondary outcome was the associated risk factors.
Search Methods
For the identification of studies, the following data
bases were searched: EMBASE (1980 to 2010 week
39), Cochrane Central Register of Controlled Trials
(3rd Quarter 2010), Cochrane Database of Systematic
Reviews (2005 to September 2010), and Ovid
MEDLINE (1950 to September 2010 week 4). No lan-
guage restriction was considered.
A search strategy (Table 1) was developed for
MEDLINE and adapted to the other databases by
incorporating two groups of words combined by the
Boolean term “OR.” The first group included terms
associated with DS (1 to 6), whereas the second
group included words related to RDPs (8 to 15). Both
groups were combined by the Boolean term “AND.”
Further search methods involved the identification of
additional studies from the reference lists of articles
retrieved electronically and a manual search of all is-
sues of the core dental journals related to prostho
dontics or oral diseases that were published over the
past 5 years, as well as abstracts from international
dental research meetings.
Two reviewers independently screened the titles
and abstracts identified by the search and noted cita-
tions for full review if there was any possibility that the
study matched the inclusion criteria. Intraexaminer
calibration at the beginning of the systematic review
and duplicate examinations throughout the study
were carried out using a kappa test. The kappa value
was 0.83, indicating good agreement between the
reviewers. The existing disagreements were dis-
cussed and resolved by consensus. The full copy of all
possibly or definitely relevant studies was retained for
further assessment by three reviewers. A flow chart
showing the study protocol is presented in Fig 1.
Data Extraction and Outcomes
From each study, the following data were collected:
authors, year and country of the study, characteristics
of sample population, materials used in partial RDP,
and presence and prevalence of DS. Collected data
also included information regarding the potential risk
factors of DS. An attempt to contact corresponding
authors was done by email to request any missing
information. However, no additional information was
received.
Quality of Reports and Level of Evidence
Included studies were reviewed and assessed
according to the Strengthening the Reporting of
Observational Studies in Epidemiology (STROBE)
Table 1 Search Strategy Used for MEDLINE
Search no. Keywords involved
1 exp Candidiasis, Oral/
2 exp Stomatitis, Denture/
3 *Stomatitis/
4 *cheilitis/
5 exp Candida/
6 *candida albicans/
7 or/1–6
8 exp Denture, Partial, Removable/
9 *Denture, Partial/
10 *Denture, Overlay/
11 exp Denture Bases/
12 *Denture, Partial, Temporary/
13 *Denture, Partial, Removable/
14 *Denture, Partial, Immediate/
15 Denture/ae
16 or/8–15
17 7 and 16

Emami et al
statement.13 STROBE provides a checklist with 22
items that should be described in reports of observa-
tional studies, such as prespecified hypotheses, sam-
ple size estimation, and reasons for nonparticipation.14
Two independent reviewers carried out this assess-
ment. After that, studies were classified according to
the three categories established by Olmos et al15:
(1) the study is in agreement with more than 80% of
the STROBE criteria, (2) 50% to 80% of STROBE cri-
teria were fulfilled, and (3) less than 50% of criteria
could be achieved.
The level of evidence was assessed based on
the American Association of Critical Care Nurses’
(AACN) new evidence-leveling system.16 This system
was used to identify the best available evidence on
the topic (Table 2).
Results
Results of the Search and Characteristics of
Studies
In total, 1,152 nonduplicate articles were identified
from database searches, of which 22 were eligible for
full-text searching (Fig 1). Twenty-one studies were
published in English, and 1 study was in Spanish.
Among the 22 studies, 14 were excluded because
they referred only to complete RDPs, they did not
have specific results related to the partial removable
prosthesis, or they did not report on DS. Two studies
had 2 published manuscripts, and the necessary data
from these articles without overlapping the sample
population were retrieved.17–20
A total of eight studies were included in the pres-
ent review. The details of the characteristics of
each study are shown in Table 3. The last study was
conducted in 2010, the earliest in 1984. All stud-
ies were observational in design with descriptive or
analytic approaches. Data from these studies were
obtained from national health surveys,20,21 retrospec-
tively using dental records,17 from individuals par-
ticipating in clinical studies,22–25 or from a screening
program.26 The total number of participants wear-
ing partial RDPs within the eight studies was 2,813.
The age range of participants in these studies varied
between 23 and 80 years. All studies except one23
elected a mixed sample composed of partial and
complete RDP wearers. The material used in the de-
sign of the RDPs, when specified, consisted of acrylic
resin or an association of acrylic resin and metal.
Obtained data were analyzed cross-sectionally using
descriptive, univariate,17,22,23,25 or multivariate statisti-
cal approaches.20,21,24,26
1,152 nonduplicate citations identified
Title and abstract screening:
• 1,131 abstracts excluded because of
failure to meet inclusion criteria
22 potentially eligible publications identified
14 publications excluded:
• Not meeting the inclusion criteria
• Outcomes of no interest for review
8 publications included in the systematic review
Fig 1 Systematic review flow diagram.
Table 2 Levels of Evidence According to the AACN’s
New Evidence-Leveling System
Level Description
A Meta-analysis of multiple controlled studies or
meta-synthesis of qualitative studies with results that
consistently support a specific action, intervention, or
treatment
B Well-designed controlled studies, both randomized
and nonrandomized, that consistently support a
specific action, intervention, or treatment
C Qualitative studies, descriptive or correlation studies,
integrative reviews, systematic reviews, or random-
ized trials with inconsistent results
D Peer-reviewed professional organizational standards
with clinical studies to support recommendations
E Theory-based evidence from expert opinion or mul-
tiple case reports
M Manufacturers’ recommendations

Quality of Reports and Level of Evidence
The reports presented a moderate to low level of the
information that should be described for observational
studies. None of them was allotted a grade A in
terms of quality (Table 2). The level of evidence for all
included studies was ranked as C according to study
design (Table 2).
Prevalence of DS and Risk Factors
Prevalence of DS in partial RDP wearers varied
between 1.1% and 36.7%.21,22 Only a few studies re-
ported the frequency of DS based on the type of in-
flammation21,22,25 or jaw location.20,21,25 According to
these studies, DS was more prevalent in the maxilla
than mandible. DS type I and II were more prevalent
than type III in individuals with maxillary partial RDPs
(Table 3).
Partial RDP wearers were less affected by DS than
those who wore complete dentures in most studies
with a mixed sample of removable prosthesis wear-
ers.19,20,22,25,26 According to Celic´ et al,25 there was
a stronger correlation between denture plaque and
DS in maxillary complete denture wearers than in
those with partial RDPs (Spearman correlation: 0.85
versus 0.45, respectively). Only in two studies was DS
more common in partial RDP wearers.17,24 This dif-
ference was statistically significant in the study by
Jainkittivong et al (P = .006).17 In one study, which
was designed to screen for the prevalence of oral
mucosal lesions in Spain,26 wearing a partial RDP
was a strong risk factor for developing hemangioma
(odds ratio [OR]: 5, 95% confidence interval [CI]: 11.2
to 21.4) but not DS.
There was heterogeneity between studies in terms
of risk factors contributing to DS in partial RDP wear-
ers. In terms of demographic factors, DS prevalence
decreased with age in two studies.20,21 Although these
two studies reported that women were more affected
by DS,20,21 there was no significant sex-related differ-
ence for DS in several other studies.17,21,22,24,25
The effect of material and type of denture sup-
port was assessed only in one clinical study.25 It was
reported that wearing acrylic resin and mucosa-
supported partial RDPs had a significant influence
on DS (P ≤ .05). Stability of the prosthesis appears
to be related to DS. Individuals with unstable max-
illary partial RDPs (unclear measurement method)
had two times more risk of DS than those with stable
prostheses (adjusted OR: 2.12, 95% CI: 1.15 to 3.91).21
Smoking, prosthesis wearing, hygienic habits, and
denture cleanliness were investigated by some stud-
ies.19–22,24,25 Heavy smoking has been associated
Table 3 Characteristics of Included Studies and Prevalence of DS
Publication, country
No. of participants
with RDPs
Age of
participants (y) % male RDP material
Abaci et al,22 Turkey 30 Range: 41–70 53.3 NA
Jainkittivong et al,17 Thailand 225 Mean: 62.8 ± 8.4 31.1 NA
Dundar and Ilhan Kal,24 Turkey 142 > 60 61.4 NA
Shulman et al,21 USA 1,606 Mean: 59.2 ± 0.5 57.7 NA
Vallejo et al,26 Spain 39 Mean: 54.3 ± 13.5 NA NA
Celic´ et al,25 Croatia 100 Range: 45–83 33 Metal: 60.6%
Acrylic resin: 39.4%
Yeung et al,23 Hong Kong 87 Mean: 58 NA Chromium-cobalt
Mikkonen et al,20 Finland 884 > 30 NA Metal: 8.1%
Acrylic resin: 91.9%
NA = not applicable; SE = standard error; CI = confidence interval.
*Risk ratio for location of the prosthesis (maxilla versus mandible, controlling for sex and type of prosthesis).

Emami et al
with DS in partial RDP wearers.21 Long-term use of
the denture and hygienic habits were found to be
associated with DS in a mixed population of RDP
wearers.19 Nocturnal wear, poor oral hygiene, the
frequency of denture cleaning, and age of the pros-
thesis seem to have little influence on the occurrence
of DS.20,22,24,25 The role of C albicans in DS has been
investigated in two studies.21,22 Although C albicans
has been reported as a main species in the palatal
mucosa and saliva of individuals who wore partial re-
movable prostheses and developed DS in the study
by Abaci et al,22 Shulman et al21 reported that only
7.2% of individuals with DS had a positive smear of
C albicans.
The main systemic factors predisposing to DS
advocated by the studies were vitamin A defi-
ciency and diabetes mellitus.21,24 Data from a large
US sample from the National Health and Nutrition
Examination Survey suggest that individuals wearing
maxillary or mandibular partial RDPs with lack of vita-
min A had 5 (adjusted OR: 5.67, 95% CI: 1.59 to 20.29)
and 24 (adjusted OR: 24.42, 95% CI: 5.77 to 103.33)
times the chance of having DS than those with nor-
mal vitamin A levels, respectively.21 According to
Dundar and Ilhan Kal,24 diabetes mellitus was a sig-
nificant risk factor for DS (OR: 3.51, P = .001) in RDP
wearers whether completely or partially edentulous.
Discussion
The main finding of this systematic review is a wide-
ranging prevalence of DS in partial RDP wearers.
Prevalence of DS varied from 1.1% to 36.7%. Previous
reports on the prevalence of DS in complete denture
wearers suggested a variaton of 6.5% to 75.0%.27 The
lower rate of DS prevalence in partial compared to
complete RDP wearers could be explained by the dis-
tinct characteristics of different types of prostheses,
the difference in materials (acrylic resin versus metal),
the amount of tissue coverage, and compliance in oral
health care.
The substantial variation in the considered out-
come variable of this study can be explained by the
role of predisposing factors in different populations
and the characteristics of sample populations. One of
the two studies with the lowest values of prevalence
in this review enrolled participants who were wearing
mandibular partial RDPs with less surface contact
with the subjacent mucosa.21 Another study with low
values assessed participants who received regular
dental recall visits, which may prevent the occurrence
of DS.20
Trauma has been suggested to be an important
risk factor in DS,28 and the results of this systematic
review support these findings. One of the included
studies in this systematic review evaluated a group of
partial RDP wearers whose acrylic resin–based pros-
theses were defective or unstable.17 For that group,
the prevalence of DS was higher than that for com-
plete denture wearers.
These results suggest that rather than the amount
of tissue coverage, other factors such as prosthesis
base material (acrylic resin versus metal), prosthetic
support, and instability may play a role in develop-
ment of DS in partial RDP wearers. A smaller area
of supporting mucosa is covered by partial rather
than complete RDPs; thus, factors such as instability
in the case of acrylic resin–based or free-end eden-
tulous spaces may be more important, whereas its
potential biofilm coverage area is smaller. It would
be interestingto assess how traumatic forces could
predispose RPD wearers to DS. To clarify this, fur-
ther clinical studies comparing different categories of
edentulous arches should be encouraged.
The literature considers Candida carriage and
hygienic habits as important factors predisposing RPD
wearers to DS.9,29,30 The results of studies included in
this review suggest that these risk factors may have
less influence on the occurrence of DS in partial RDP
wearers compared to those with complete dentures.
However, these results should be investigated further
because of limited and inconsistent evidence.
DS prevalence
Classification
of report
Level of
evidence
36.7% C C
22.7% C C
14.7% C C
Maxillary: 33.2%
Maxilla (n = 503): 33.7%
(type I and II: 22.2%, SE: 3.77%;
type III: 11.5%, SE: 2.14%)
Mandibular: 1.1%
Mandible (n = 197): 2.6%
(type I and II: 0.6%, SE: 0.59;
type III: 2.0%, SE: 1.48%)
B C
2.6% C C
Maxilla: 30.5% (type I: 20.9%,
type II: 9.6%)
Mandible: 13.7% (type I: 11.3%,
type II: 2.4%)
C C
12.6% C C
18.6%
RR*= 43.02
90% CI: 20.8 to 88.9
B C

Regarding the systemic factors, recent clinical
studies suggest that DS commonly occurs in dia-
betic patients wearing complete dentures.31 This may
be a result of decreased tissue resistance, tissue
regeneration, or reduced thickness of the oral epithe-
lium in these individuals. These characteristics may
also favor the inflammatory reaction of the mucosa
caused by trauma from the instable prosthesis. This
evidence supports the findings of Dundar and Ilhan
Kal24 included in this systematic review.
The results from Shulman et al21 suggest that
vitamin A deficiency is a strong risk factor for DS in
partial RDP wearers. Although the preventive role of
vitamin A in maintaining the integrity of epithelial tis-
sue is justified through several mechanisms, the great
difference of its influence in the maxilla and mandible
as reported by this study was not explainable. These
results have to be interpreted with caution because of
possible confounders.
The quality assessment and assessment of the
level of evidence can be challenging during a sys-
tematic review, especially if included studies present
different designs. In this study, the AACN updated
evidence-leveling hierarchy was used as a tool to
identify the best evidence. This new leveling system
has some advantages compared to other tools used
in evidence-based practice.32 First, in this level of
evidence system, additional research designs such as
qualitative research and meta-syntheses are included.
Secondly, this system represents the level of evidence
by letter. The lowest level (M, manufacturers’ recom-
mendations) is intentionally separated from tradi-
tional standards of evidence to allow practitioners to
realize the low-level strength of this evidence. Finally,
peer-reviewed professional organizational standards
are also added, which are widely used by clinicians
who do not have enough background and education
on evidence-based dentistry. This system allows the
assessment of studies with a cross-sectional design
as well as randomized controlled trials (RCTs) with
inconsistent results. Surveys based on large, repre-
sentative samples and robust statistical analyses pro-
vided valuable information despite their limitations in
terms of study design.21
The accepted gold standard for the evaluation of
a therapeutic or preventive intervention is the RCT.
The RCT has a distinct advantage over observational
studies in terms of its potential to avoid selection
bias.33 However, it is not always feasible to study
questions about risk factors or infrequent events by
means of an RCT.34 This study aimed to evaluate the
quality of included studies according to standard-
ized criteria in accordance with what is proposed
for systematic reviews of observational studies.13,14
Although STROBE was not developed for quality
assessment, it could determine if important aspects
were adequatelyapproached. This way, the method
employed by Olmos et al15 can provide an overview
for how well included studies were reported and how
transparent that evidence is. However, the extent
of absent information associated with the levels of
evidence was a major concern and raised questions
about the methodologic quality of the included stud-
ies. Although in this study the level of evidence was
based on valid classification,32 great differences were
found between studies in terms of validity. The prin-
cipal limitation of this study was the fact that most of
the studies included in this systematic review were
conducted with the aim of screening for oral mucosal
lesions and not assessing the role of different pros-
thetic designs or their materials in terms of oral
health. Indeed, the absence of prospective cohort
studies limits us from reaching reliable conclusions
concerning the association of DS and the wearing
of partial RDPs. However, this is the first systematic
review on this topic, and present results can serve
as a guideline for future research on the influence
of design and the type of prosthesis on oral health.
Well-designed prospective studies are still necessary
to determine the causal association between DS and
possible risk factors. Moreover, the employment of
multivariate statistical methods may disclose the rel-
ative importance of different risk factors and adjust
them for possible confounders. Different designs of
prostheses could also be tested by RCTs in partially
edentulous populations, considering the health of
the supporting mucosa as an outcome.
Conclusions
This systematic review suggests that the occurrence
of DS is inconsistent within partial RDP wearers.
This type of prosthesis may be considered as a risk
factor for DS. A preventive approach based on well-
conducted randomized controlled trials should be
developed and implemented in this population.
Acknowledgments
The authors are grateful to Monique Clar for her generous assis-
tance on the search strategy. Dr Emami is supported by a stipend
from the CIHR Clinician Scientist Award.

Emami et al
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