| Abstract|| |
Context: Conventional complete dentures still remain a viable method of treatment for many patients in this era of fixed prosthesis like dental implants. All patients undergoing complete denture treatment need nonsurgical preprosthetic treatment for the preparation of healthy denture bearing mucosa as well-keratinized healthy mucosa is desirable for a complete denture. Aims: To evaluate and compare the keratinization before and after denture insertion at intervals of 1 week and 1 month. Settings and Design: The present study was conducted on 24 completely edentulous male subjects divided into control and study groups. Each patient in study group was asked to massage with astringent on the denture bearing mucosa over a 4-week period. Subjects and Methods: Exfoliative cytology was used to collect the surface cells from the palatal mucosa and buccal mucosa. The first smear was taken before the denture insertion. The second and third smears were taken after the stimulation treatment with astringent gel for each patient after 1 week and after 4 weeks. Each smear was stained with the Papanicolaou's technique. The number of basal cells, intermediate cells, and superficial cells were recorded to calculate the degree of keratinization. Statistical Analysis Used: Descriptive statistics, paired samples t-test, independent t-test, and repeated-measures analysis of variance. Results: The result showed statistically significant increase in the keratinization of palatal mucosa after 4 weeks of astringent therapy and no effect was noted in the keratinization of buccal mucosa. Conclusions: Astringent has shown to increase keratinization of palatal mucosa, and so it can be used to increase the quality of the denture bearing mucosa; moreover, the astringent stimulation has no effect on the keratinization of buccal mucosa.
Keywords: Astringent, complete denture, keratinization, oral mucosa
|How to cite this article:|
Menon RS, Dhakshaini M R, Gujjari AK, Hegde U. A clinical evaluation on the effect of astringent on keratinization of oral mucosa before and after the insertion of complete denture. Indian J Dent Res 2019;30:347-51
|How to cite this URL:|
Menon RS, Dhakshaini M R, Gujjari AK, Hegde U. A clinical evaluation on the effect of astringent on keratinization of oral mucosa before and after the insertion of complete denture. Indian J Dent Res [serial online] 2019 [cited 2020 Jan 29];30:347-51. Available from: http://www.ijdr.in/text.asp?2019/30/3/347/264125
| Introduction|| |
Conventional complete dentures still remain a viable method of treatment for many patients in this era of preventive dentistry and sophisticated methods of replacing teeth, such as with dental implants. One critical aspect of complete denture treatment, which is often confusing and poorly understood, is the proper preparation of the denture bearing areas.
The denture bearing area preparation involving surgical or nonsurgical approach should be done depending on the needs of the patient. On many occasions, both forms of treatment are needed to return the denture-bearing tissues to a state of optimal health and form. The success of removable prosthesis depends on the health of denture bearing mucosa. A well-keratinized healthy mucosa is desirable for a complete denture. As the life expectancy of human life is increasing, it is the prime duty of the prosthodontist to extend the complete denture service over many years of an individual's life. Many contradictory results were found in studies which were done to examine the denture-bearing mucosa. Some studies suggested that the denture-bearing epithelium becomes more keratinized while others found that there is not only a quantitative reduction of keratinization but also acanthosis as the time passes.,,,,,
To keep the denture-bearing mucosa in a good physiologic condition, this study was conducted to evaluate the effect of astringent on denture-bearing palatal mucosa and also buccal mucosa. Tissue sampling was done by exofoliative cytology technique as it has been proved more appropriate for examining the keratinization of the oral mucosa.
| Subjects and Methods|| |
An in-vivo study was conducted on 24 completely edentulous subjects who had reported to the Department of Prosthodontics, JSS Dental College and Hospital, Jagadguru Sri Shivarathreeswara University, Mysuru. Ethical approval was obtained from Institutional Ethical Committee.
Inclusion criteria: Male subjects in the age group of 40–60 years who gave informed consent and completely edentulous patients undergoing complete denture treatment for the first time were included in the study.
Exclusion criteria: Subjects with systemic disorders of long duration or even recent past; on antibiotic therapy for the last 1 month; and with habits like smoking, tobacco, and betel nut chewing were excluded from the study.
Subjects were randomly divided into two groups based on the application of astringent gel. Control group consisting of 8 subjects to whom no astringent application was done, and 16 subjects were included in the study group to whom commercially available astringent gel (Hiora GA astringent gel manufactured by The Himalaya Drug Company) was provided. Subjects were explained to massage the edentulous ridge by using thumb and index finger with astringent gel. Smears were taken from palatal and buccal mucosa three times in all the subjects [Figure 1]. The first smear was taken from the palatal mucosa and buccal mucosa before denture insertion. Second and third smears were taken from the same sites 1 week and 4 weeks after denture insertion from both the groups. After the collection, smears were labeled, stained with Papanicolou's stain, and viewed under low power (10 × 10) microscope (Binocular Research Microscope with digital camera attachment Carl Zeiss- Axicalb) [Figure 2] in the Department of Oral Pathology and Microbiology, JSS Dental College and Hospital, Jagadguru Sri Shivarathreeswara University, Mysuru. The slides were studied under the low power (10 × 10) objective lens of a microscope. One hundred cells were counted for each slide from the selected field depending on the coloring and morphology of cells. These cells were divided into three groups as pink staining superficial cells, blue staining intermediate cells, and green staining basal cells. Pyknotic nuclei and normal nuclei were not differentiated as it was not essential for the present study.
|Figure 2: Binocular Research Microscope with digital camera attachment Carl Zeiss- Axicalb|
Click here to view
Statistical analysis was carried out using Statistical Package for the Social Sciences (SPSS) version 22 developed by IBM corporation in 2015.
| Results|| |
In the palatal mucosa, control group, and study group, after 1 week of stimulation treatment, there was a moderate increase in the number of superficial cells (hyperkeratinized) compared to the first smear. In the study group, after 4 weeks, the count of superficial cells had significantly increased compared to the first smear whereas in the control group there was a moderate increase in the number of superficial cells after 4 weeks compared to first smear [Figure 3]. During the 4-week period of stimulation treatment, there was a statistically significant decrease in the number of basal cells in both the study and control groups. There was a statistically significant decrease in the number of intermediate cells in the study group. However, no statistically significant effect was noted in the control group. All these observations revealed a gradual increase in the keratinization of cells of edentulous palatal mucosa after 1 and 4 weeks treatment of astringent gel application. This finding was found to be statistically significant.
In the buccal mucosa, in the control group and study group, after 1 week of stimulation treatment, there was no statistically significant effect in number of superficial cells compared to the first smear. In the study group and control group, after 4 weeks, the number of superficial cells showed no statistically significant effect compared to the first smear [Figure 4]. During the 4-week period of stimulation treatment, there was a statistically significant decrease in the number of basal cells in both the study and control groups. There was no statistically significant effect in the number of intermediate cells in the study and control groups. All these observations revealed that there is no effect on keratinization of buccal mucosa by astringent gel application at 1 and 4 weeks interval.
| Discussion|| |
Keratinization, also termed as cornification, is a process of cytodifferentiation which the keratinocytes undergo when proceeding from their post germinative state (stratum basale) to finally differentiated, hardened cell filled with protein, constituting a structurally and functionally distinct keratin containing surface layer such as stratum corneum. Oral epithelium is classified into three types based on their morphology and specific pattern of differentiation: keratinized stratified squamous epithelium (masticatory mucosa distributed in hard palate and gingiva), nonkeratinized stratified squamous epithelium (buccal mucosa, labial mucosa), and specialized mucosa (dorsal surface of the tongue). Masticatory mucosa covers the gingiva and hard palate, regions that are subject to mechanical forces of mastication, causing abrasion and shearing. It consists of a keratinized epithelium that closely resembles the epidermis of the skin in its pattern of maturation, and is usually tightly attached to underlying structures by a collagenous connective tissue.
Astringents are substances that precipitate proteins but do not penetrate cells, thus affecting the superficial layer of mucosa only. They toughen the surface by making it mechanically stronger and decrease exudation. Gum paints are a combination of antiseptics and tanning agents which precipitate proteins but do not penetrate cells, thereby affecting only the superficial layer making it mechanically stronger and decreases exudation. They have germicidal, fungicidal, anesthetic, and healing properties. The patient is advised to apply 3–4 drops on finger and massage 3–4 times a day.
The oral mucous membrane coming in intimate contact with complete dentures is highly keratinized. This keratinized stratified squamous epithelium undergoes continual replacement by an orderly process involving cell migration and differentiation through four discrete morphologic stages of development. The superficial keratin layer of mucosa is generally thought to be a protective barrier. Several studies had been done in the past to assess the keratinization of mucosa beneath the complete denture. However, in reality, there remains a controversy within the literature.
Kapur (1963) concluded that histologic examination of biopsy specimens prior to the insertion of dentures, and following the wearing of dentures for 3 months, revealed healthy tissue with minimal inflammatory infiltration and increased keratinization. The dentures appeared to stimulate keratinization. Jani (1976) found that there is an increase in the thickness of palatal mucosa after insertion of complete denture for 3 months. Complete dentures increased the keratinization of palatal mucosa. Markov (1968) in his cytological study found increase in keratinization of palatal mucosa under complete denture. Watson (1982) in his study of complete dentures concluded that complete dentures tend to reduce the quantity and quality of the keratin layer with a decrease in keratinization.
For the success of prosthetic treatment, health of the denture bearing area should be given primary importance. For that, the soft tissue beneath the denture should be properly prepared before denture construction. Markov (1969) stated that better keratinization represents a better functional adaptation of the mouth to an artificial appliance. Massage of the denture-bearing area in completely edentulous ridges has been recommended for the problems of ridge soreness by the use of dentures. Kapur and Shklar (1962) undertook a study to determine the effect of stimulation with an automatic toothbrush on the edentulous ridge and gingivae, where they found increased keratinization of the edentulous mucosa and gingiva.
Radke (2014) conducted a study to evaluate the effect of stimulation of edentulous mucosa with the use of astringent gum massage. However, there is no experimental evidence in available literature demonstrating the effect of astringent on keratinization of oral mucosa before and after denture insertion.
In this study, a total of 24 completely edentulous subjects were selected based on the inclusion criteria. They were divided into two groups as control group consisting of 8 subjects who were not given astringent gel for massage and study group consisting of 16 subjects who were given astringent gel for massage.
Only males were selected as subjects. Female subjects were not included because of changes in the oral mucous membrane and its association with menstrual cycle, pregnancy and menopause has been a subject of controversy., Subjects between the age group of 40 and 60 years were selected, as subjects with higher age can show senile tissue changes. In addition, subjects free from habits like smoking, tobacco, and betel nut chewing were only selected as these habits have shown to affect the keratinization of oral epithelium. Subjects who were first time and recent complete denture wearer were also selected as there will not be any changes in keratinization due to frictional keratosis.
Most studies related to effect of astringent on oral mucosa were done using biopsy. This study was done using exfoliative cytological method. Exfoliative cytology is the microscopic examination and measurements of shed or desquamated cells from the surface epithelium, usually the mucous membrane. Even though exfoliative cytology is not 100% accurate, it has its own potential value in cases where biopsy is contraindicated, for example, in systemically compromised patients, inaccessible areas, recurrent malignancies, and in mass screening. The smear obtained by exfoliative cytology can be analyzed quantitatively and qualitatively. With advancements in the field of quantitative oral exfoliative cytology, various parameters such as nuclear size, cell size, nuclear-to-cytoplasmic ratio, nuclear shape, nuclear discontinuity, optical density, and nuclear texture can be evaluated collectively to confirm the diagnosis. Of these parameters, the nuclear size, cytoplasmic size, and their ratio have been shown to be significant in the evaluation of oral lesions.,
In this study, a portion of the hard palate immediately posterior to the rugae zone was selected as the site for obtaining cells from the surface of the oral mucosa. The presence of mucous secretions in the posterior half of the hard palate and the corrugated nature of the surface in the rugae zone would make these two areas less suitable for obtaining a smear. The material was obtained by scrapping with wooden spatula. Also portion of the buccal mucosa opposite to the second premolar and molar region was taken as a site for smear collection.
The first smear was taken from the palatal mucosa and buccal mucosa before the denture insertion from both the groups. The patients were provided with the astringent gel (Hiora GA astringent gel manufactured by The Himalaya Drug Company), in which the main ingredient is tannic acid and they were asked to massage with the help of index finger on the denture-bearing areas three times a day for 10 minutes. This was done in accordance to a study on gingiva, which concluded that use of Jenocin gum massage (tannic acid) thrice daily with the index finger resulted in an increase in the thickness of the keratin layer. They were recalled after 1 week for second smear and after 4 weeks for the third smear from the same area.
The results from the present study demonstrated a statistically significant (P < 0.05) increase in the superficial cells of palatal mucosa in the study group from 73.1250 (mean number of superficial cells) before denture insertion to 82.1250 (mean number of superficial cells) 1 month after denture insertion with application of astringent gel. The results were similar to the study conducted by Radke et al. There was statistically significant (P < 0.05) decrease in 17.50 (mean number of basal cells) before denture insertion and 12.37 (mean number of basal cells) after four weeks of stimulation of astringent gel. Further, there was a statistically significant (P < 0.05) decrease in 10.50 (number of intermediate cells) before insertion and 5.43 (number of intermediate cells) 4 weeks after insertion and stimulation with astringent. Their study was conducted to evaluate the effect of stimulation of edentulous mucosa with the use of astringent massage. However, evaluation of keratinization before and after denture insertion with or without astringent application was not done in their study. Moreover, evaluation of keratinization of buccal mucosa was also not done.
In this study, no statistically significant change (P > 0.05) was noted in the number of superficial cells of buccal mucosa in both study group and control group, which was a similar result as the study by Suad (1966). It was stated that the lack of significant changes in the buccal mucosa can be ascribed to its flexibility and the presence of abundant amounts of saliva.
The results thus obtained were in agreement with the hypothesis that there is an increase in the keratinization of palatal mucosa with application of astringent gel. The normal turnover rate of gingival epithelium is approximately 41–57 days. In this study, the keratinization process in palatal mucosa gradually increased after astringent massage over 30 days in the study group. This increase in keratinization process is beneficial for the health of edentulous mucosa under denture base. However, there was no statistically significant effect in keratinization of buccal mucosa with application of astringent.
The limitation of our study is limited sample size. The prolonged effect of astringent on the keratinization of palatal and buccal mucosa was not studied, and further studies should be carried out to evaluate this effect.
| Conclusion|| |
Hence, it may be concluded that the stimulation of denture bearing mucosa with gum astringent has been shown to increase keratinization of palatal mucosa, and hence can be used as a preprosthetic nonsurgical treatment measure to increase the quality of the denture bearing mucosa, and also the astringent stimulation has no effect on the keratinization of buccal mucosa.
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Conflicts of interest
There are no conflicts of interest.
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Dr. M R Dhakshaini
Department of Prosthodontics and Crown and Bridge, JSS Dental College and Hospital (Constituent College) Jagadguru Sri Shivarathreeswara University, JSS Medical Institutions Campus, Sri Shivarathreeswara Nagar, Mysuru - 570 015, Karnataka
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4]