VERIFIABLE CPD: CANDIDA-RELATED DENTURE STOMATITIS
By DTA | 29th November 2022 | News
By Dr Chris Turner MSc, BDS, MDS, FDSRCS
Dr Turner is a retired specialist in restorative dentistry
The following article will be of particular interest to all those who manufacture custom-made removable devices.
Aim: To gain a clinical overview of denture stomatitis (oral thrush)
CPC Outcome: To have an understanding of the ways dentures can affect oral health
Development Outcome: C
Denture stomatitis presents as a redness of the oral mucosa limited to the denture bearing area. It can affect 70 per cent of denture wearers and is more common with complete rather than partial dentures.
It may range in severity from slight colour change to a raw red obvious inflammation with thickened nodular epithelium that may show white patches.
There are three types:
Type 1. Localised inflammation or pinpoint hyperplasia.
Type 2. More diffuse erythema involving part or all of the denture bearing surface.
Type 3. Nodular hyperplasia especially involving the central hard palate or the alveolar ridge.
This latter change is called chronic hyperplastic candidiasis and requires referral ideally to your local hospital Dental Department who will have the specialist knowledge to look after this case.
More often, the changes are less severe and can be looked after in the dental practice. The most common area affected is the hard palate because patients with either missing anterior teeth or a complete denture can be reluctant to leave their prosthesis out at night.
Other factors are:
● Poor denture hygiene.
● Pre-existing angular cheilitis associated with loss of vertical dimension
● Dentures that move during function.
● Another sign is the fit surface of the denture changes from a pink to an orange colour.
Patients are at greater risk of developing this condition if:
● They are diabetic
● Have poor oral health
● Are taking steroids
● Are taking wide spectrum antibiotics
● Are having cancer treatment or are immunosuppressed.
● Have a diet high in sugars or carbohydrates
● Have nutritional or endocrine deficiencies
Diagnosis is by clinical appearance supplemented in more severe cases with swabbing for Candida. The construction of new dentures is contra-indicated until the infection is cleared up. Unfortunately, there are no quick fix answers to this condition and patients should be warned that it can take several months before their mouth is healthy enough for new dentures, although improvements are often seen in the first few weeks.
When it comes to treatment, the first, and sometimes the hardest challenge, is to persuade patients to leave out their dentures at night because they retain plaque and its micro-organisms. Various arguments include social ones such as their partner/spouse has never seen them without their teeth or if their denture is left out at night the next morning it is loose when refitted. The explanation for this sign is that the mucosa is losing some of the oedematous fluid and shrinking in size, only to be retraumatised when the ill-fitting denture is replaced on the following morning.
The second challenge is teaching denture hygiene by both brushing carefully to remove as much plaque as possible then overnight soaking in at least water to prevent the prosthesis drying out and thus shrinking - and preferably using a proprietary cleansing agent.
Candidal hyphae attach to the denture and are most probably entrapped in surface irregularities. This may be the cause of the orange colour change noted above. Treatment is sand blasting the fit surface until the normal pink colour of the denture base is revealed. This is an important and often omitted stage to help reduce the candida load.
Reline the dentures using a tissue conditioning agent such as Viscogel. This will harden and needs to be replaced fortnightly. This review interval gives an opportunity to access progress and to compare the condition of the mucosa with that at first presentation.
Clinical photographs are a very useful patient information aid. You should expect to see significant changes within two months. If there is no or little improvement we need to consider why. The most likely cause is that dentures are being worn all the time rather than being removed during sleep.
Other measures that can be taken include applying the antifungal cream nystatin to the fit surface. However, it is unpleasant to the taste and can be poorly tolerated. Newer options include amorlofine varnish but more reports of its efficacy are required. Low energy laser therapy is gaining in popularity as it may give quicker results.
Oral antifungals are a final option when prescribed by a medical practitioner. These drugs may affect liver function so testing is required before starting this therapy and need to be repeated after one month. There are many side-effects, some of them serious. Their prescription requires careful consideration and should be reserved only for intractable cases.
When the mucosa has healed new complete maxillary and mandibular dentures are indicated when the occlusal vertical dimension has been restored. Larger teeth might be used and set to copy the patient's appearance from an old photograph if they can provide one, which will help restore a more youthful aspect.
Denture patients, and complete denture wearers especially, may think they do not need to have follow-up appointments. They should be advised that an annual check is a good idea, although you should not be surprised if many decline the offer.
Development Outcome C - 30 minutes
Q1 According to the author, what percentage of denture wearers suffer from denture stomatitis?
Q2 What are the types of denture stomatitis?
A. Localised inflammation or pinpoint hyperplasia.
B. More diffuse erythema involving part or all of the denture bearing surface.
C. Nodular hyperplasia especially involving the central hard palate or the alveolar
D. All of the above
Q3 Why is the most commonly affected area the hard palate?
A. Because the patient is reluctant to take their prosthesis out at night
B. The hard palate is more prone to infection
C. It offers a broader surface for plaque candida to adhere to
D. The shallower mucosa allows a stronger anchor for infection
Q4 Which of the following will not create a greater risk of developing the condition?
A. They are diabetic
B. They are taking broad spectrum antibiotics
C. They are using steroids
D. They are using oral probiotics
Q5 What is the best treatment if the fit surface of the denture changes from a pink to an orange colour?
A. Scouring with a hard toothbrush
B. Soak overnight in a strong antiseptic solution
D. Gentle toothbrushing with a bicarbonate of soda paste
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