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 Table of Contents  
RESEARCH
Year : 2022  |  Volume : 22  |  Issue : 3  |  Page : 256-261

Comparative evaluation of efficacy of three different denture cleansing methods in reducing Candida albicans count in removable partial denture wearers: A randomized controlled trial


1 Department of Prosthodontics and Crown and Bridge, KMCT Dental College, Mukkam, Calicut, Kerala, India
2 Department of Prosthodontics and Crown and Bridge, Government Dental College, Kottayam, Kerala, India

Date of Submission17-Dec-2021
Date of Decision16-May-2022
Date of Acceptance19-May-2022
Date of Web Publication18-Jul-2022

Correspondence Address:
Roshy George
Department of Prosthodontics and Crown and Bridge, Government Dental College, Kottayam, Gandhinagar P. O., Kottayam - 686 008, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jips.jips_553_21

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  Abstract 


Aims: The study aims to find out the best possible method of cleaning the removable partial denture (RPD) by evaluating the Candida count limiting ability in RPD users using three different cleaning methods.
Settings and Design: The present study is randomized controlled trial. Three groups were formed with 20 participants in each. The groups were Group 1 RPD cleansing done using sterile saline and denture brush (negative control group), Group 2 RPD cleansing done using soap and denture brush and Group 3 RPD cleansing done using denture cleansing tablet and denture brush.
Materials and Methods: A baseline data and 15 days' postinsertion data of Candida count was recorded using swab collection, from the RPDs given. The swab was collected, cultured, and incubated using standard methods. Once Candida was identified using Sabouraud's dextrose agar, Candida albicans was further confirmed using germ tube test and cornmeal agar.
Statistical Analysis Used: The analysis was done using SPSS software (IBM Corp. Released 2010. IBM SPSS Statistics for Windows, Version 19.0. Armonk, NY: IBM Corp.). Paired t-test, was used to compare the number of colonies pre and postintervention. The difference between the groups was analyzed using one-way analysis of variance (ANOVA) and Tukey's post hoc analysis.
Results: The comparison of baseline data and postintervention data within each group using paired t test demonstrated statistically significant values; P = 0.046 and 0.000 in Group 2 and 3 respectively. The difference between the Candida colonies in three different groups after the intervention (15 Days) was analyzed using analysis of variance and found to be statistically significant with P = 0.004. Tukey's post hoc analysis was used to analyze the difference between the groups. It was concurred that there was a statistically significant difference between all three groups, but the difference in the mean was highest between the Group 1 and 3 (1210.99).
Conclusion: Within the limitations of the study, it is concluded that the use of denture cleansers and brush on a daily basis would actively reduce the number of C. albicans colony formation in RPD and thereby improve the overall health of denture wearer.

Keywords: Candida associated denture stomatitis, Candida colony, denture cleansers, denture cleansing methods, removable partial denture


How to cite this article:
Rajendran A, George R, Mathew N, Ranjith M, Nazar N A. Comparative evaluation of efficacy of three different denture cleansing methods in reducing Candida albicans count in removable partial denture wearers: A randomized controlled trial. J Indian Prosthodont Soc 2022;22:256-61

How to cite this URL:
Rajendran A, George R, Mathew N, Ranjith M, Nazar N A. Comparative evaluation of efficacy of three different denture cleansing methods in reducing Candida albicans count in removable partial denture wearers: A randomized controlled trial. J Indian Prosthodont Soc [serial online] 2022 [cited 2022 Aug 12];22:256-61. Available from: https://www.j-ips.org/text.asp?2022/22/3/256/351287




  Introduction Top


Removable partial denture (RPD) is one of the most common treatment options which patient would select for the replacement of one or more missing tooth/teeth. The RPD is most commonly made with Polymethylmethacrylate (PMMA) type resin material.[1] Proper maintenance of denture is essential to avoid the accumulation of biofilm and plaque on the denture surface. Various factors that result in these accumulations are improperly polished RPDs, denture porosity, salivary constitution of the patient, dietary constituents, inadequate maintenance due to poor dexterity or reluctance in cleaning, abrasion due to use of brushes, duration of denture wearing, inappropriate patient education and unsuitable materials for cleaning.[2],[3],[4]

Background and objectives

Poor oral hygiene, resulting in biofilm accumulation on RPDs can increase the incidence of tissue inflammation, Candida-associated denture stomatitis and caries on abutment teeth and some important systemic infections.[5],[6] Hence, proper maintenance and cleaning of RPD are inevitable for the best outcome.

Although cleaning of RPDs is commonly done by brushing, the dexterity limitations and complexities in RPD design, can impair complete biofilm removal.[7] The American College of Prosthodontists recommended soaking of dentures in an effective, nonabrasive denture cleansing solution and daily brushing to reduce the levels of potentially harmful biofilm.[8]

Routine use of denture cleansers by RPD wearers could improve biofilm control and effectively limit Candida levels.[9] Some clinical studies were reported toward the effectiveness of denture cleansers in controlling the Candida biofilm in complete denture wearers.[10],[11] In vitro studies that provided evidence regarding its effect on physical and mechanical properties of resin teeth, acrylic, and metallic framework were also published.[12],[13],[14],[15] While most of the studies were concentrated toward complete denture, only very few studies have been published regarding denture cleansing habits and the effect on Candida species in RPD users.[16],[17],[18] Some studies had shown that there were differences in the quantity of Candida biofilm in complete denture wearers as compared to RPD wearers.[19],[20] Hence, the effect of different denture cleansing methods, and its effect in controlling Candida biofilm in RPD patients should be studied separately.

The present study is a randomized controlled trial (RCT) that aims to evaluate the effectiveness of common denture cleansing methods followed by the patients in reducing the Candida counts in RPD wearers.


  Materials and Methods Top


Trial design

Randomized parallel-arm controlled trial.

Participants

Participants were selected based on satisfaction of inclusion criteria.

Inclusion criteria

  1. Subjects with good oral and systemic health conditions irrespective of age and sex
  2. Subjects who were fresh denture wearer because baseline data is collected on the day of insertion
  3. Subjects who were willing to continuously use the RPD and to follow the instructions.


Exclusion criteria

  1. Subjects whose consent to participate was not obtained
  2. Subjects who underwent antimicrobial therapy in the past 3 months
  3. Subjects who reported with denture stomatitis or any other oral inflammatory conditions.


The study was conducted in the department of Prosthodontics at a dental college in South India. It was approved by the Institutional Ethics Committee with reference number-KIDS/IEC/05-2014/11 and was conducted according to the instructions from the institutional ethical committee and with the Helsinky declaration of 1975 as revised in 2000. The study was conducted from April to June 2014.

The sample size was derived to be 20 in each group. Since the study design consisted of three groups, one negative control group and two study groups, a total of 60 participants with twenty subjects in each group were planned. The participants were selected from those subjects who were rehabilitated with RPDs in the department of prosthodontics. Sixty participants, who satisfied all the inclusion criteria, were selected after examining 84 new RPD wearers. The selected participants signed the informed consent. Study subjects were randomly selected and allocated using lottery method of randomization. There were no dropouts among the participants.

  • Group 1: Subjects who cleaned their RPD using sterile water and denture cleaning brush. This group acted as a negative control group
  • Group 2: Subjects who cleaned their RPD using soap and denture cleaning brush
  • Group 3: Subjects who cleaned their RPD using denture cleansing tablet and denture cleaning brush.


Group allocation was double-blinded. Normal saline (Albert David Ltd, Kolkata), Lifebuoy bath soap (Hindustan Unilever Limited, Mumbai), Fittydent Denture Cleansing Tablets (Dr. Reddy's Laboratories Ltd., Hyderabad), and Clinsodent denture cleansing brush (ICPA Health products Ltd, Mumbai) were used in the study. All the participants were provided with the materials for cleaning the denture, based on the study group they were involved. Oral hygiene measures were done for all the participants before starting with the impression procedures.

Sample collection: Baseline data (first denture biofilm) was collected on the day of insertion of RPD. 1 h postinsertion, RPDs were removed, debris and saliva were removed by gentle washing with sterile distilled water and then a sterile swab was rubbed onto the whole denture-both inner and outer surfaces in the following sequence-clasps, teeth and acrylic denture base.

The swab was immediately placed in a polypropylene tube containing 3 mL of sterile saline solution (0.9% Sodium Chloride) and then sonicated at 7 Watts for 30 seconds. The resulting suspension containing biofilm was diluted 10-fold and then it was inoculated by the spread plate technique in Sabouraud's Dextrose Agar (SDA) culture media with 10% Chloramphenicol (Himedia, India). The plates were incubated for 48 h at 37°C in aerobic condition and the number of colony-forming units was quantified using a stereomicroscope.

Candida was preliminarily identified by the characteristic creamy convex yeast colonies on SDA. Gram staining of the smear revealed Gram-positive budding cells. Germ tube test and cornmeal agar formed germ tube and chlamydospores, respectively, which further confirmed Candida albicans.

Once swab collection was completed, the dentures were given back to the respective patients for use. They were instructed to rinse the RPD once in plain water before the cleaning procedure. The cleaning was done once a day, after their routine nocturnal brushing using the method they were asked to follow. The brushing time of RPD was kept as 3 min for all. No additional hygiene instructions were provided to avoid any bias.

The participants in Group 1 were asked to brush the denture using sterile water and brush provided. The participants in Group 2 used soap before they brush the denture. Those participants who were included in Group 3 were instructed to dissolve one denture cleansing tablet in 200 ml warm water and soak the denture for 10 min in it followed by brushing. A reminder message for following the instructions was sent every night to subject's registered mobile number at 9:00 pm and a printed checklist was also given to tick mark on a daily basis after performing the cleaning of denture in instructed manner.

Fifteen days' postinsertion, the study subjects turned back for the posttreatment sample collection. Checklists were evaluated for confirming that the subjects followed the instructions properly. Patients were given instruction to wear the RPD at least 1 h before the sample collection. The same procedures were followed as done for the baseline sample collection. The dentures were given back to the participants after sample collection.

Statistical methods

The analysis was done using SPSS software (IBM Corp. Released 2010. IBM SPSS Statistics for Windows, Version 19.0. Armonk, NY: IBM Corp.). Paired t-test, was used to compare the number of colonies pre and postintervention. The difference between the groups was analyzed using one-way analysis of variance (ANOVA) and Tukey's post hoc analysis.


  Results Top


A final sample consisted of 20 subjects in each group. Group 1 comprised of 12 males and 8 females with a mean age of 45 ± 8.6 years; Group 2 comprised of 13 males and 7 females with mean age of 47 ± 5.6 years: Group 3 comprised of 11 males and 9 females with mean age of 42 ± 5.88 years. [Graph 1] shows the distribution of C. albicans counts. The figure also shows the P values of paired t-test, which was used to compare the number of colonies pre and postintervention. It was seen that there was a statistically significant difference in the mean colony in Group 2 and 3 with P = 0.046 and 0.000 respectively.



[Table 1] shows the difference between the Candida counts in three different groups after the intervention (15 days). The difference between the groups was analyzed using one-way ANOVA. It was seen that there was a statistically significant difference within the groups. Tukey's post hoc analysis was used to analyze the difference between the groups. It was concurred that there was a statistically significant difference between all the three groups, but, the difference in the mean was highest between the Group 1 and 3 (1210.99). A subset of alpha scores showed that the highest scores were of Group 1 and lowest of Group 3 [Table 2].
Table 1: Difference between the Candida colonies in three different groups after the intervention (15 days)

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Table 2: Distribution of the subsets

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  Discussion Top


The efficacy of different methods of cleaning the RPD is not well documented. The present study evaluated the efficacy of three commonly used methods of cleaning the denture. Micro-porosities in dentures made from PMMA can cause easy adherence and colonization of Candida. Since C. albicans is the main causative organism of denture stomatitis, the count of C. albicans colony was used to assess the effectiveness of various denture cleansing methods.[10]

The RPD is less studied when compared to complete denture regarding the effectiveness of cleansing agents. Hence, RPD was studied in the present RCT. It is demonstrated in some studies that the Candida biofilm formed is less in RPD as compared to complete denture. This was because of the reduced surface area of PMMA and the highly polished surface of metallic framework in RPD that reduces the colonization of Candida species.[19],[20] The present study involve RPDs fabricated with PMMA without any metal framework.

Comparisons between different types of cleaning agents are available in literature. One study suggested that there were no significant differences in the efficiency of plaque removal of denture using toothpaste, liquid handwashing soap, and two different chemical-soak denture cleansers.[11] Another study revealed that removal of coffee stains was least effective while turmeric stains were easily removed by both sodium perborate and sodium hypochlorite-based denture cleansers.[12]

The reduction of Candida biofilm is always considered important. Hence, few studies were done to improve the antimicrobial property by incorporation of different types of materials into tissue conditioners. Some authors have suggested that few materials such as Azadirachta indica, Melaleuca alternifolia oil, and Cocos nucifera oil reduced the Candida colony formation if incorporated into the tissue conditioners.[21],[22]

Many studies which evaluated the change in physical and mechanical properties of denture while using denture cleansers were reported and found that the color stability was in the clinically acceptable range.[12] Other factors such as hardness, flexural strength, and surface roughness are seriously affected.[13],[14],[15]

Within the group, the present study shows that the Candida count was reduced to a statistically significant level when 15 days cleaning protocol was followed as compared to the baseline value in groups 2 and 3 (P = 0.046 and 0.000 respectively). The Group 1 was added as a negative control group which showed no statistically significant improvement in Candida control as compared to baseline. This proves that both soap and brush technique and denture cleanser and brush technique are effective in controlling Candida species in RPD.

The comparison between the groups reveals that both Group 2 and 3 shows statistically significant difference (P = 0.045 and 0.001 respectively) when compared to Group 1. This suggests that both soap and brush technique and denture cleanser and brush technique are more effective than saline and brush technique in controlling Candida species in RPD.

There is statistically significant difference (P = 0.013) while comparing Group 2 and 3 which shows that soap and brush technique is less effective when compared to denture cleanser and brush technique. The effectiveness of peroxide-effervescent denture cleansers is attributed to its immediate decomposition to Hydrogen Peroxide followed by release of nascent oxygen when dipped in water, which in turn cleanses the surface of denture by the effervescent action.[23]

Few studies reported the influence of denture cleansers on mechanical and physical properties such as flexural strength and adaptation of denture base. The use of medium power microwave heating method and Sodium hypochlorite solution (5.25% for 5 min) for denture disinfection showed better disinfection and dimensional stability as compared to Chlorhexidine gluconate (for 5 h) and effervescent tablets.[24] Another study stated that thyme essential oil showed better flexural strength along with good cleansing activity as compared to denture cleansing tablets.[25] Hence, judicious use of denture cleansers is important.

The patient education is also a key factor in good denture hygiene care. The patients need to be educated well by the dentist regarding the requirement of cleaning the denture on daily basis using an effective plaque control method. However, few studies analyzed that, the knowledge of dental practitioners themselves regarding the effectiveness of various denture cleansing methods and materials is compromised.[4],[26] One systematic review stated that the poor patient education is attributed to the poor guidance from the professional bodies and at the same time professional bodies are not able to guide because of a lack of research publications on effective methods of cleaning the denture.[27]

The study used the methods which are commonly recommended by the dentists. Hence, this study is clinically relevant and can be generalized. Although denture cleanser and brush method was the most effective cleaning method against C. albicans colony formation, none of the methods was able to completely remove it.

This study is limited to the use of only one type of denture cleansing tablet. More studies need to be done to evaluate the most effective denture cleanser in removing Candida colonies.


  Conclusion Top


The effect of antiplaque agents is unquestionable in reducing Candidal growth.[28] Within the limitations of the study, it is concluded that the use of denture cleansers and brush on a daily basis would actively reduce the number of C. albicans colony formation and thereby improve the overall health of denture wearer.

Financial support and sponsorship

The study received a grant from Indian Council of Medical Research (ICMR), department of Health Research, Ministry of Health and Family Welfare, Government of India as a part of Short Term Studentship in 2014 with reference no. 2014-03365.

Conflicts of interest

There are no conflicts of interest.



 
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