The Diagnosis and Management of Denture Stomatitis

Complete dentures rely entirely on the health of the underlying mucosa and bone for their support. Thus, the health of the oral mucosa is of primary importance when fabricating complete dentures and in the appropriate maintenance of their function. For the best chance of denture success, the practitioner must be able to detect and manage aberrations in soft tissue health. A variety of denture-associated mucosal lesions are seen commonly in clinical practice, including traumatic ulcers, redundant tissue, hyperplastic lesions, and denture stomatitis.¹ This article discusses the diagnosis and management of denture stomatitis.¹

Removable tissue-borne prostheses require significant tissue coverage for sufficient retention, support, and stability. This extension makes oral hygiene more challenging while also increasing the probability that food debris will accumulate on the denture’s cameo surface and beneath the prosthesis’ intaglio surfaces. In this way, dentures can significantly modify the microbiome of the oral cavity and impact the loading of the mucosa.¹

Denture stomatitis is a chronic inflammatory condition that can be generalized or localized (Figures 1 and 2). Affecting the tissue beneath the denture-bearing area, denture stomatitis is common, impacting up to 65% of denture wearers.²

Etiology and Risk Factors

The etiology of denture stomatitis is multifactorial.³ It is seen more commonly in women than men and the prevalence increases with age.³ The incidence of denture stomatitis varies by the population examined. Population studies of older independent adults puts the incidence at approximately 50%.³

Multiple risk factors are reported within the dental literature. A significant and commonly cited risk factor is full-time prosthetic use.⁴ Full-time wearing of a prosthesis or nocturnal wear facilitates the development of a complex biofilm beneath the denture intaglio surface (Figures 3 and 4). Biofilm development on a prosthesis commences immediately upon insertion of the prosthesis.

^­­Various interaction forces facilitate the adherence of biofilm to the denture base.⁵ Over time, with minimal disturbance, the biofilm increases in size and changes in complexity. As the complexity increases, the microenvironment beneath the prosthesis changes. These microbial changes favor the establishment of an anaerobic environment in which certain microorganisms can thrive. Candida, a common commensal fungus within the oral cavity, is particularly known for rapid proliferation.⁶

Additionally, traumatic denture adaption can cause ulceration of the denture-supporting mucosa. Traumatic denture adaption can be pro-inflammatory and further favors the development of a denture biofilm.⁷ Dentures with a rough and, consequently, plaque-retentive surface increase the potential for biofilm adherence.⁸

Presentation and Diagnosis

Denture stomatitis is most commonly identified in the maxilla, particularly on the hard palate. The condition is usually painless and is frequently identified by the clinician upon examination.⁷

Occasionally, patients present symptomatically; common symptoms are burning sensations, oral malodor, and pruritis.⁹ Denture stomatitis is associated with other oral mucosal lesions, most notably median rhomboid glossitis and angular cheilitis.¹⁰ In older patients, denture stomatitis is also related to aspiration pneumonia.¹¹

Classification and Management

Many attempts have been made to classify denture stomatitis. Newton¹² proposed one of the most common classification systems in 1962 (Table 1, page 26). Bertram⁴ proposed another system of classification (Table 2, page 26). These systems help categorize the extent of the inflammation and inform the condition’s management.

The management of denture stomatitis is targeted toward biofilm removal and cleaning of the denture. Cleaning of the prosthesis should focus on chemical disinfection and mechanical removal of biofilm.

The American College of Prosthodontists produced evidence-based guidelines for the care and management of complete dentures.¹³ The guidelines recommend brushing the prosthesis with a soft-bristled brush and a nonabrasive cleaning agent or soap outside the mouth at least once daily.

Specific denture cleaning formulations are available, and many have supplemental effervescent properties that aid in the mechanical dislodgement and removal of the biofilm. Dentures can be soaked in sodium hypochlorite solutions for less than 10 minutes to further disinfect the surface. If dentures are soaked in sodium hypochlorite solutions for longer than 10 minutes, however, care must be taken as the polymethyl methacrylate (PMMA) surface can be damaged.¹³

Dentures should be removed while the patient is sleeping and never worn continuously. When not in the mouth, the dentures should be stored in water. Water storage reduces the risk of warping. Patients with dentures should be examined annually by a dental provider, during which time all prosthesis should be professionally cleaned, potentially utilizing an ultrasonic bath.¹³ Professional review is vitally important for older dentures as a traumatic fit can predispose a patient to denture stomatitis.¹

During this appointment, the fit of the prosthesis must be closely examined. If relines or rebases are clinically required, high-quality products should be used.² Traditional autopolymerizing reline materials are not the materials of choice because they may produce a porous surface that can become rapidly colonized by biofilms.³

Recent advances in manufacturing have allowed the use of high-density and high-strength PMMA. Dentures fabricated from these materials with acrylic blanks that are processed under high strength and temperature may provide superior hygienic outcomes vs conventionally pro­cessed dentures.^14,15 Additionally, industrially processed acrylic blanks have less residual monomer, which may improve the biocompatibility of the prosthesis. Other authors postulate that subtractive denture manufacturing could be a potential reservoir for microorganisms.^16,17 A complete review of novel manufacturing processes is beyond the scope of the article, however, judicious selection criteria for computer-aided design and computer-aided manufacturing processes and materials may influence the incidence of denture stomatitis.

When a patient presents with denture stomatitis, antifungal agents — while effective — are not the first line of care.⁷ Effective oral hygiene practices are of paramount importance. When antifungal agents are considered, azoles and polyene antifungals are frequently utilized.¹⁸ These target the cellular components of a fungal cell wall.⁴ These agents should be used as an adjunct to appropriate denture hygiene. In the short term, however, they can be helpful. Overuse of these medications may increase the risk that patients will develop resistance to their active ingredients.¹⁶

The presentation of denture stomatitis in patients with severely compromised health or debilitation is serious. The primary concern is visceral involvement, or in rare cases, sepsis secondary to the fungal infection.¹⁹ While it is beyond the scope of this article to discuss the management of patients with severe oral and/​or esophageal candidiasis in detail, candidiasis can impact a patient’s capacity to sufficiently ingest food. The use of an alkaline mouthrinse containing a nystatin suspension in combination with multivitamins may help this patient population manage symptoms.^20,21

Conclusion

Denture stomatitis is a commonly encountered inflammatory, infectious condition. It is associated with poor denture hygiene and full-time denture wear. Adequate and prompt treatment of denture stomatitis can bring about clinical resolution. Frequently, denture stomatitis presents asymptomatically and as an incidental finding during routine clinical examination. Finally, all inflammatory processes should be completely resolved before fabricating a new prosthesis for a patient.

References

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From Decisions in Dentistry. January/February 2024; 10(1):24-27