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Journal of Prosthodontic Research 54 (2010) 2935 www.elsevier.com/locate/jpor

Original article

Inuence of removable partial dentures on the formation of dental plaque on abutment teeth
Yoshiaki Shimura DDS*, Juro Wadachi DDS, PhD, Teruyasu Nakamura DDS, PhD, Hiroshi Mizutani DDS, PhD, Yoshimasa Igarashi DDS, PhD
Removable Partial Denture Prosthodontics, Department of Masticatory Function Rehabilitation, Division of Oral Health Sciences, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan Received 5 February 2009; received in revised form 14 August 2009; accepted 30 August 2009 Available online 8 October 2009

Abstract Purpose: This study aimed to clarify the relation between the shape of the retainers and the plaque formation on abutment teeth to improve the denture design. Methods: This study observed the buccal surface for the clasps and distoproximal surface for a guide plate of the mandibular rst premolar which was the abutment tooth with a direct retainer of a distal extension RPD. The buccal surface was observed in 10 subjects and the distoproximal surface in 14 subjects. The latter cohort was divided into two groups (the group with an open type guide plane and a close type guide plane). All subjects provided their informed consent. The state of plaque accumulation was inspected by standardized photography and bacterial quantication and compared among the cast circumferential (CC), Ibar, wire circumferential (WC) and control (no clasps) in individuals regarding the buccal surface and between the groups with the open type and close type guide plane of the distoproximal surface. Results: No signicant differences were observed among the CC, Ibar, WC and control (P > 0.05) regarding the buccal surface, while in regard to the distoproximal surface, the group with the open type guide plane had signicantly more plaque than the group with the close type guide plane (P < 0.05). Conclusion: The plaque formation on the buccal surface is not dependent on the types of clasps. It is effective to prepare a guide plane as close to the gingival margin as possible to reduce the plaque accumulation on the distoproximal surface. # 2009 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved.
Keywords: Removable partial denture; Abutment teeth; Plaque; Standardized photography; Bacterial quantication

1. Introduction The shape and function of the mouth following a disruption caused by the loss of teeth are frequently restored by wearing removable partial dentures, but this may also contribute to various problems. RPDs have the physical, chemical and biological adverse aspects which can cause caries of abutment teeth, tooth mobility, inammation of mucosa and residual ridge resorption [119]. The biological adverse aspects are thought to be serious [619]. Wearing a removable partial denture complicates the oral environment and restricts the ow of food and the self-cleaning action of the buccal mucosa and

* Corresponding author at: Department of Removable Partial Denture Prosthodontics, Graduate School, Tokyo Medical and Dental University, 1-545 Yushima, Bunkyo-ku, Tokyo 113-8549, Japan. Tel.: +81 3 5803 5517; fax: +81 3 5803 5517. E-mail address: yosi.rpro@tmd.ac.jp (Y. Shimura).

tongue, which results in the accumulation of the dental plaque on the prosthesis and surrounding tissue. Therefore the control of dental plaque is important to obtain good denture prognosis and performance for a long period. The adverse effect of the dental plaque is serious for abutment teeth which are important for RPDs. Abutment teeth have more plaque morbidity than any other teeth and cause serious periodontal inammation. This is due to plaque accumulation caused by the prevention of self-cleaning action by the clasps which are essential as the retentive elements of the RPD. However, there have so far been few reports on the relationship between the shape of the retainers and plaque formation on abutment teeth [9,13] and the actual condition in the patients mouth has not been claried. Therefore, this study was conducted in order to clarify the region, area and quantity of plaque accumulated on abutment teeth with different types of clasps and guide plates and provide information for improving the denture design.

1883-1958/$ see front matter # 2009 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved. doi:10.1016/j.jpor.2009.08.003

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Fig. 1. The framework of the experimental denture was made from a cobaltchromium alloy. Every clasp was interchangeable.

Fig. 2. The open and close type guide planes. Group A consisted of those with an open type guide plane with a height of less than one-thirds of the crown length. Group B consisted of those with a close type guide plane with a height more than two-thirds of the crown length.

2. Materials and methods 2.1. Subjects

the Ethical Committee at Tokyo Medical and Dental University (No. 284). 2.2. Preparations and time schedule

The buccal and distoproximal surfaces of abutment teeth of RPD wearers were observed. The buccal surfaces were observed in 10 subjects (1 male, 9 females, mean age 72.9 7.0 years) and the distoproximal surfaces in 14 subjects (2 males, 12 females mean age 67.4 10.6 years) with mandibular distal extension loss of teeth from second premolar to second molar. Nine of the subjects participated in the observation of both the buccal and distoproximal surface. The subjects were recruited from the patients at Tokyo Medical and Dental University and none had clinical abnormalities. Applicants with severe periodontal disease and history of periodontal treatment were excluded. Each subject received a written and oral description of the study, and informed consent was obtained prior to enrollment into the study. All study related procedures and tests were approved by

The buccal surface for the clasps and distoproximal surface for guide plate of mandibular rst premolar which acts as the abutment tooth for the direct retainer of a distal extension RPD were observed in this study. Prior to measurements, the experimental denture was fabricated so that every clasp was interchangeable (Fig. 1). All impressions for the experimental dentures were made with individual trays and silicon rubber impression material (Exahiex regular, GC Co., Tokyo, Japan). The denture framework was made from a cobalt chromium alloy. The mesial rest and mesio-distal guide plate were placed on the tooth and the buccal surface was observed with three sorts of clasps, cast circumferential (CC), Ibar and wire circumferential (WC) and control without any clasps and the

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Fig. 3. The jig used for the preparation of the guide plane. The view from the occulusal plane (a) and from the plane perpendicular to Pounds line (b).

distoproximal surface for a guide plate with the placement of WC (Fig. 1). Regarding the guide plate, the subjects were divided into two groups, Group A consisted of those with an open type guide plane with a height is less than one-thirds of the crown length and Group B consisted of those with a close type guide plane with a height more than two-thirds of the crown length (Fig. 2). The guide plane was prepared, using the jig which was fabricated with a model, to determine the direction and height (Fig. 3). The surface was polished by the same way with silicon points (Silicon points M2 and M3, SHOFU Inc., Kyoto Japan) to give a high polished surface [2022]. When the denture was set and the adjustments were completed, the observation was initiated at intervals of 2 weeks in consideration of the plaque growth [13,23,24] after scaling and polishing of the abutment teeth. The same denture was used throughout the observation and only the clasps were changed at clinic. No interventions, such as the instructions for tooth cleaning, were performed during the study. 2.3. Standardized photography and bacterial quantication Standardized photography and bacterial quantication were performed in this study. Standardized photographs of the buccal surface were taken at a distance of 40 mm perpendicular to Pounds line (Fig. 4) [25], and of the distoproximal surface at a distance of 50 mm parallel to Pounds line with a metal mirror (YDM Co., Tokyo, Japan; Fig. 5). At the clinic, the plaque was dyed by Red-Cote (Butler Co., Chicago, Illinois, USA) and some photographs were taken using a Thanko USB microscope (Thanko Co., Tokyo, Japan) with 352 288 pixels. Then the plaque was wiped with a cotton bud to obtain specimens to quantify the bacteria. 2.4. Handling method 2.4.1. Photographic processing The photographs were analyzed using the photographic software (Photoshop 7.0, Adobe systems Inc., Tokyo, Japan). The outline of the tooth was extracted from the photographs. The buccal surface was dened as the whole part of a tooth and the distal surface as the gonial to gonial in consideration

Fig. 4. The device for standardized photography. The photographs of the buccal surface were taken at a distance of 40 mm perpendicular to Pounds line.

of the shape of teeth. Thereafter, the number of the pixels of the tooth and that of the red area were counted. The percentage was calculated by dividing the pixels of the red area by the pixels of the tooth. This process was repeated with three different pictures and the average pixels were calculated. 2.4.2. Bacterial quantication The specimens were diluted 10 and 100 to minimize the effect of red cote since red cote could reduce the number of bacteria detected. After applying an extraction and luminous reagent, the bacteria was quantied using ATPtester (AF-70, DKK-TOA Co., Tokyo, Japan), a multiplied by the dilution factor to determine the original number and the average was calculated. The number of bacteria was divided by the pixels of the tooth and the number of bacteria per pixel was calculated. 2.5. Analysis 2.5.1. Buccal surface The data from the control, CC, Ibar and WC were compared in individual subjects. The statistical analysis was performed using SPSS version 11.5J (SPSS Japan Inc., Tokyo, Japan). The data from both the standardized photography and bacterial quantication were analyzed by one-way repeated measures ANOVA and the probability level was set at P < 0.05.

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Fig. 5. The device for standardized photography and the camera with a metal mirror attached to it. The photographs of the distoproximal surface were taken at a distance of 50 mm parallel to Pounds line.

Fig. 6. Examples of the photographs of the buccal surface.

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2.5.2. Distoproximal surface The data from Group A were compared to that from Group B. The statistical analysis was performed using SPSS version 11.5J (SPSS Japan Inc., Tokyo, Japan). The data from the standardized photography were analyzed by Welchs t-test and the data from the bacterial quantication were analyzed by MannWhitneys U-test and the probability of both level was set at P < 0.05. 3. Results 3.1. Buccal surfaces The 10 abutment teeth observed to evaluate the buccal surface included 3 natural and 7 crowned teeth (2 were metal crowns and 5 were porcelain fused metal crowns). Examples of the photographs of the buccal surface in this study are shown in Fig. 6. Fig. 7 shows the percentage of plaque on the dental surface with the control, CC, Ibar and WC and all of them are less than 10%. Figs. 6 and 7 demonstrate the presence of little plaque on the buccal surface and no signicant difference was observed among the types of clasps (P = 0.650). The number of bacteria per pixel is shown in Fig. 8. There were no particular tendencies among the data from the control, CC, Ibar and WC, and no signicant differences between them (P = 0.290). 3.2. Distoproximal surface Group A included four natural teeth and three crowned teeth of which the surfaces were metal and Group B included one natural tooth and six crowned teeth of which the surfaces were metal. Examples of the photographs of the distoproximal surfaces are shown in Fig. 9. Fig. 10 shows the percentage of plaque on the dental surface of Groups A and B. The plaque on the distoproximal surface accumulated in the dead space or void under the guide plane. There was signicantly more plaque in Group A than in Group B (P = 0.001). The number of bacteria per pixel is shown in Fig. 11. There was signicantly more plaque on Group A than on Group B (P = 0.038). 4. Discussion 4.1. The measurements Digital photography has recently been applied for use in dental studies [26,27], however, the reliability remains questionable. The reliability of standardized photography was assessed by comparing the pixels of the buccal surface of the tooth with control, CC, Ibar and WC. The data were analyzed by One-way repeated measures ANOVA using SPSS version 11.5J (SPSS Japan Inc., Tokyo, Japan) and there was no signicant difference (P = 0.34 > 0.05). This conrmed the reliability of the standardized photography. To count the number of bacteria in the plaque, adenosine triphosphate (ATP) was quantied using bioluminescence apparatus (AF-70, DKK-TOA Co., Tokyo, Japan). This apparatus used the rey luciferase system to determine the concentration of cellular ATP and is based upon the measurement of light emission produced during the oxidation of luciferin by molecular oxygen in the presence of ATP and magnesium ions. In this system the light intensity is directly proportional to the concentration of ATP. This bioluminescent ATP assay is known as a simple and convenient method for the accurate enumeration of viable cells [28], however, one cannot rule out the possibility that some of the plaque may be overlooked and thus not be sampled. 4.2. Buccal surface In this study, there was little plaque on buccal surface and no signicant difference, regardless of natural or crowned teeth [29,30], although Shimizu reported that plaque accumulated along clasps [13]. This is probably because while there were conditions of the prohibition on the brushing and removing dentures in their study, there was no condition in the current study. These results do not contradict the previous report [7]. The discrepancies in bacterial quantication may be because the number of the bacteria in the plaque ranged from 104 to 106 in this study and therefore a small error may thus be amplied by the dilution factor [31]. 4.3. Distoproximal surface The data from the distoproximal surface were collected with placement of WC. In addition, no reciprocal arm was observed on the lingual surface to unify the form. There was plaque accumulation in the dead space or void under the guide plane of
Fig. 7. The percentage of plaque on the buccal surface. No signicant difference was seen among the type of clasps (one-way repeated measures ANOVA).

Fig. 8. The number of bacteria per pixel on the buccal surface. No signicant difference was seen among the type of clasps (one-way repeated measures ANOVA).

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Fig. 9. Examples of the photographs of the distoproximal surface.

Fig. 10. The percentage of plaque on the distoproximal surface. Group A had signicantly more plaque than Group B (according to Welchs t-test).

the plaque accumulated in the void. A close type guide plane is thought to be effective to reduce the plaque accumulation, however it is difcult to prepare a guide plane to the gingival margin, especially with natural abutment teeth. Therefore, special tooth brushing [32,33] is essential for denture wearers to remove the plaque which is increased by wearing partial dentures [7]. The close type guide plane is considered to be ideal to purge plaque accumulation by reducing the void at the distoproximal area between the abutment and the associated denture saddle [34], however, this close type guide plane has also been reported to cause gingival inammation [35], and it is necessary to address both plaque accumulation and gingival inammation. 5. Conclusion Within the limitations of this study, the following conclusion can be drawn. The plaque formation on the buccal surface is not dependent on the type or placement of clasps. It is effective to prepare the guide plane as close to the gingival margin as possible to reduce the plaque accumulation on the distoproximal surface. References
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Fig. 11. The number of bacteria per pixel on the distoproximal surface. Group A had signicantly more plaque than Group B (according to MannWhitneys U-test).

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