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ORIGINAL RESEARCH Table of Contents   
Year : 2010  |  Volume : 21  |  Issue : 3  |  Page : 353-356
A microbiological evaluation of the use of denture cleansers in combination with an oral rinse in complete denture patients


1 Department of Advanced Dentistry and Implantology, Jebel Ali Hospital, Dubai, United Arab Emirates
2 Department of Accident and Emergency, Gulf Medical College and Hospitals, Ajman, United Arab Emirates

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Date of Submission28-Aug-2009
Date of Decision21-Oct-2009
Date of Acceptance21-May-2010
Date of Web Publication29-Sep-2010
 

   Abstract 

Background and Aim : Patients with complete dentures more occasionally neglect their denture and oral health by improper maintenance of dentures, resulting in bad oral and denture hygiene. This may lead to a host of multiple local and systemic problems such as stomatitis, bacterial and fungal infections, reservoirs for distant infections, denture stains and bad breath. Most denture wearers maintain their dentures with simple manual cleansing methods, which are not adequate to effectively sanitize the reservoir of microorganisms inhabiting the denture surfaces. The aim of this study was to compare the efficacy of the use of a denture cleanser and compare it with an adjunct use of chlorhexidine mouth rinse along with the denture cleanser and possibly suggest it as a suitable protocol.
Materials and Methods : Two groups of complete denture patients were selected for the study. The total number of patients in each group was 12 and the total period of the study was 21 days. Three sets of microbiological samples were collected from each patient: before the start of the study, on day 8 and on day 21 of the study. The first sample was collected after an initial washover period (7 days) with plain water before the start of the study and the second set after 1 week of study initiation, where group-1 followed protocol-I (denture cleanser only) and group-2 followed protocol-II (denture cleanser and mouth rinse). A second washout period of 7 days followed and a crossover of the protocol was performed for the groups and followed for 1 week. Then, a third set of samples were collected. The colony-forming units were calculated for each patient for each sample and statistically analyzed. Friedman test for non-parametric analysis was employed for the comparison within the groups and a Mann-Whitney test was used for the statistical comparison between the groups.
Results : There was a definite reduction in the bacterial numbers and a significant statistical difference after administering the protocols in both the groups (P<0.001). However, there was little significance on comparing the samples between the groups (P=0.026) in the initial study period, and there was no statistical significance when comparing the groups after the crossover (P=0.140).
Conclusion : The use of denture cleansers definitely reduced the microbial numbers as compared to plain manual cleansing methods in complete dentures. Although there was a substantial decrease in the bacterial colonies after the use of the mouthwash, it was not statistically significant.

Keywords: Chlorhexidine mouthwash, denture cleansers, denture hygiene

How to cite this article:
Srinivasan M, Gulabani M. A microbiological evaluation of the use of denture cleansers in combination with an oral rinse in complete denture patients. Indian J Dent Res 2010;21:353-6

How to cite this URL:
Srinivasan M, Gulabani M. A microbiological evaluation of the use of denture cleansers in combination with an oral rinse in complete denture patients. Indian J Dent Res [serial online] 2010 [cited 2019 Dec 10];21:353-6. Available from: http://www.ijdr.in/text.asp?2010/21/3/353/70799
Poor denture hygiene is a seemingly common problem encountered by restorative dentists with their numerous complete denture patients. Elderly patients, particularly those who are in a compromised state, are not able to maintain good denture hygiene due to some physical and/or mental handicap. [1],[2],[3] However, the maintenance of hygiene in dentures is not just with compromised geriatric patients but also with normal healthy denture wearers. [4] This can be attributed to a definite lack of motivation, basic knowledge, clinical importance or, simply, carelessness and neglect. It is absolutely essential to ensure that the patient is trained or instructed about the importance of maintenance of denture hygiene and that the patient is recalled at regular intervals to ensure that the hygiene is maintained.

Research indicates that inadequately maintained dentures contribute to a host of infections in denture patients and also compromise the physical condition of the denture itself and, regardless of the cleansing methods employed, food debris, bacterial plaque, calculus, etc. have all been demonstrated on denture surfaces. [1],[5] Poor denture hygiene precipitates tissue response, which are direct sequels to accumulation of food debris, tartar, stains and proliferation of micoorganisms. [1] Frequently, Candida albicans infection is a common finding in persons with poor denture hygiene. [6] Other distant infections such as pulmonary infections and infections of the gastrointestinal tract have also been observed. [7] Particles of food entrapped between the denture and the denture-bearing tissues allow multiplication of microorganisms, resulting in denture stomatitis and multiple papillomatosis. [6],[8]

The denture cleansing and plaque elimination methods commonly employed by a vast majority of patients are merely restricted to either rinsing under running water or brushing with a normal tooth paste. These simple forms of manual plaque elimination are relatively insufficient and may not satisfactorily eliminate the accumulation of microorganisms or the fungal colonies from the denture surfaces. [9] Hence, more definitive cleansing methods or protocols are recommended and need to be adhered to in order to effectively maintain a disease-free oral environment. To achieve this, the use of commercially prepared denture cleansing tablets, powders or pastes is highly recommended for use in adjunct with regular manual cleansing methods. [9],[10] Studies indicate that the use of these chemical denture-cleansing products maintain and manage overall hygiene in denture wearers. [1],[10] In spite of the use of denture cleansers, it is observed that a majority of denture wearers exhibit poorly maintained dentures or infection, suggesting a definite need for motivation/education and a protocol.

Emphasis on hygiene in complete denture wearers has predominantly focused mainly in the care and maintenance of the dentures. However, a definitive procedural protocol is needed in the care and maintenance of the oral cavity itself for obvious reasons. Most complete denture patients tend to think that being in the state of edentulism does not require any specific oral hygiene measures, and that a thorough rinsing of the oral cavity with water is sufficient enough. Although this may be sufficient for a certain period, it may however not be very adequate for the long-term maintenance of overall hygiene. [11] Use of a suitable oral rinse regularly as a standard protocol in denture wearers in combination with a recommended denture cleanser may satisfactorily achieve an excellent hygiene in the dentures and the oral cavity.

Chlorhexidine (CHX) gluconate has always been considered to be an efficient antibacterial and therapeutic mouth rinse and is recommended by a vast majority of the dentists globally. [12] It is commonly used, but not limited to, as a therapeutic oral rinse in the treatment of gingivitis and is advocated in the inhibition of dental plaque, as an adjunct to supportive periodontal care, antiseptic oral rinse following dental extractions, minor oral surgical procedures, prevention of alveolar osteitis, treatment of halitosis and the prevention of oral candidiasis. [13],[14],[15],[16],[17] Few dentists have even recommended it in the use of disinfection of root canals, [18] while others strongly recommend it for cancer-irradiated patients and for geriatric patients in long-term care. [19]

The use of a suitable mouth rinse along with a denture cleanser for the denture would probably maintain an overall oral and denture hygiene. Therefore, the purpose and target of this study was to evaluate the effectiveness of a simple cleansing protocol for denture wearers, which advocate the use of a commonly recommended commercially available denture-cleansing tablet in combination with a 0.2% CHX oral rinse. The study aims to assess quantitatively the microbial colonial numbers cultured from the denture surfaces prior to and after using the suggested protocol and to recommend it as a standard protocol if found to be statistically significant.


   Materials and Methods Top


Study group

A group of 24 non-smoking complete denture patients were invited to participate in this clinical study. The group consisted of 16 men and eight women, with the mean age of the entire study group being 65.9 years. Subjects were assigned at random to either of the two divided groups - 1 and 2 - independent of any other factors (e.g., age, sex). The groups had equal numbers of subjects.

The cases were selected on the basis of following criteria:

  • Subjects must be completely edentulous in both jaws and should have been rehabilitated with complete dentures for at least a period of 1 year or more
  • Subject has not adopted any definite special regime in maintaining the dentures during the last 1 year, except for manual cleansing methods
  • Subject has not used any mouthwashes during the last 1 year period
  • Subjects had no immunocompromising or any debilitating pre-existing systemic condition
  • Subject did not have any pernicious oral habits


Patients with partial dentures and with only single complete dentures were not considered in the study. The eligible cases were selected by a single dentist working in the dental department. Each patient was explained the purpose of the study and was asked to sign a consent form and questionnaire before undergoing a full oral examination. All examinations were performed by the same dentist.

Study protocol

This randomized crossover study involved two groups - group-1 and group-2. Three sets of swabs (samples I, II and III) were collected from the tissue surface of the dentures from each of the subjects at different periods during the study. Both groups were asked to use only water to clean their dentures for a period of 1 week (washout period) before the study began and, in the second washout period, during the study, before the crossover. [1],[20] Subjects of group-1 were allotted only a denture cleanser (protocol-I) while group-2 subjects were allotted a CHX mouthwash in adjunct to the denture cleanser (protocol-II) during the first week. A washout period of 1 week followed, during which time only water was used by both groups. Then, a crossover was performed. Group-1 subjects were instructed to use protocol-II while group-2 subjects were instructed to discontinue protocol-II and proceed with protocol-I for the final 1-week period. The total study period was 21 days (excluding the initial washout period of 7 days): two 7-day study periods and one washout period of 7 days before the crossover.

All manufacturers' instructions were strictly adhered to, with the use of the cleanser and mouthwash. The commercially available denture cleanser used in this study was a carbon dioxide-producing, alkaline denture cleanser available in a tablet form (Corega denture cleansing tablets; (GlaxoSmithKline, Waterford, Ireland). The subjects had to wash and rinse the denture with a soft brush to remove the debris and soak it in the cleanser in accordance to the manufacturer's guidelines; only one tablet per night for both dentures was to be used. The subjects were instructed to thoroughly rinse the dentures with running tap water the subsequent day before use.

The mouthwash solution allotted in this study is a 0.2% CHX gluconate preparation (Corsodyl, GlaxoSmithKline Consumer Healthcare, Brentford, UK), to be used for rinsing the mouth twice-daily in accordance to the manufacturer's instructions. Ten milliliters of undiluted mouthwash was used for rinsing the mouth for a period of 1 min. In the protocol followed, the subjects were asked to use the mouthwash solution once in the morning before wearing the denture and once at night before bedtime.

Sample collection

All swabs were made from the tissue surface of the dentures and from any visible plaque or calculus deposits present on the denture surface. Swabs for culture were collected by a single investigator. The swabs were sent directly after collection to the in-house hospital microbiology department. Swabs for cultures were collected at different periods of the study for each patient in each group and were labeled A1, B1, C1 for group-1 and A2, B2, C2 for group-2. The first set of swabs, samples A1 and A2, were collected from the dentures immediately after the initial washout period, just before the study protocol was administered. Samples B1 and B2 were collected immediately after the first study period and samples C1 and C2 were collected after the crossover 1-week period after the final study period. The swabs were then cultured for bacterial colonies under standard incubatory conditions on blood and chocolate agar, which are the most common culture media used for the culture of oropharyngeal bacteria. [21] Standardized streaking techniques were followed using a sterile loop of known volume (1/500 ml).

Estimation of bacterial numbers

The colonies were counted after 48 h of incubation. The total numbers of bacterial colonies were counted and multiplied using a factor based on the volume of the streaking loop. This procedure was standardized using quality control measures and followed on all the culture plates. [22],[23] The scoring pattern used in this study is as follows:

Score 0: No growth.

Score I: <1000 colony-forming units (CFU).

Score II: 1,000-10,000 CFU.

Score III: 10,000-100,000 CFU.

Score IV: >100,000 CFU.

Statistical analysis

The collected data were then analyzed for any statistical significance. Friedman test for non-parametric study was employed to determine the statistical correlation within the two groups (significance between A1, B1 and C1in group-1 and A2, B2 and C2 in group-2) and Mann-Whitney test for finding the statistical significance in comparing between the groups (significance between B1-B2 and C1-C2). SPSS software was used for this statistical analysis of the results.


   Results Top


The results of the colony counts for each individual patient are tabulated in [Table 1]. The mean scores calculated for A1, B1, C1, A2, B2 and C2 along with the results of statistical comparison (P-value) within the two groups in listed. There was a noticeable reduction in the mean values of CFUs of the cultured microorganisms in both the groups after following both protocols. Statistical analysis revealed a very high significance within the groups (P<0.001 for both groups), but very minor or no significance on comparing between the groups during different study periods. On comparing the first week data between the group using protocol-I and the group using protocol-II, there was a minor statistical significance (P=0.026).There was no statistical significance after the crossover period (P=0.140) between the groups.
Table 1 :Scores of the colony forming units for each patient during different study periods


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   Discussion Top


The study demonstrated that there was an overall significance in the use of the denture cleanser, which considerably reduced the bacterial colonies as compared to the use of only water and manual methods. Although there was a further reduction in the mean scores when an adjunct mouth rinse was added to the protocol, the difference was of little or no statistical significance. Adding the mouth rinse may have reduced the CFU number, but this cannot be considered to be overwhelming.

This study however had its limitations. The sample number used was rather small and the subjects were selected based on certain criteria that might limit the generalization of the results. It is doubtful whether patients strictly adhered to the set protocols, although they were personally instructed to do so. The analysis of the colonies was not qualitative and a fungal culture for the study was not performed. Finally, the prevalence of denture stomatitis or other mucosal irritations and allergies in complete denture wearers using denture cleansers or CHX have not been addressed in this study.


   Conclusion Top


The findings of this simple clinical study demonstrated that the use of denture cleansers can be considered a definite measure and a recommended protocol in maintaining overall oral and denture hygiene in complete denture patients, as supported by Gornitsky et al. [1] and Chan et al. [10] The use of an adjunct mouth rinse may be further beneficial in reducing the bacterial colony counts, but this use cannot be statistically justified. The use of denture cleansers alone may be suitable enough in hygiene in denture wearers and is absolutely essential; the use of just plain water or other manual cleansing methods is not adequate in maintaining overall hygiene in complete denture wearers.

 
   References Top

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Correspondence Address:
Murali Srinivasan
Department of Advanced Dentistry and Implantology, Jebel Ali Hospital, Dubai
United Arab Emirates
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.70799

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