Journal of Oral Rehabilitation 2002 29; 300304

Oral hygiene habits, denture cleanliness, presence of yeasts and stomatitis in elderly people
Y. KULAK-OZKAN, E. KAZAZOGLU & A. ARIKAN
Marmara, Istanbul, Turkey Department of Prosthetic Dentistry, University of

SUMMARY

The purpose of this study was to determine oral hygiene habits, denture cleanliness, presence of yeasts and denture stomatitis in elderly people. Seventy complete denture wearers were investigated clinically and mycologically. Subjects were evaluated according to, presence of denture stomatitis, presence of yeasts, denture cleanliness, frequency of denture brushing and denture cleaning methods. Swabs were taken from the palate inves-

tigated mycologically in order to identify the yeast colonies. No statistical relationship was found between denture stomatitis and frequency of denture brushing and denture cleaning methods. However, there was a statistically signicant relationship between denture stomatitis, yeasts' presence and denture cleanliness. KEYWORDS : denture stomatitis, oral hygiene, elderly people

Introduction
Previous studies have shown a generally poor oral health among elderly people (Heloe, 1973; Ritchie et al., 1979; Schou et al., 1987). Most surveys indicate that the majority of the denture wearing population are failing to keep dentures clean (Budtz-Jorgensen et al., 1975; Hoad-Reddick et al., 1990; Collis & Stafford, 1994). Beyond aesthetic concerns the maintaining of good denture hygiene plays an essential role in the prevention of denture stomatitis (Collis & Stafford, 1994). The prevalence of denture stomatitis varies, the condition may effect as many as two-thirds of an elderly population of denture wearers. Despite our understanding of these aspects, however, there is no clear picture of its aetiology. The factors most strongly implicated in initiating the condition are trauma or infection related to the wearing of dentures (BudtzJorgensen & Bertram, 1970a; Budtz-Jorgensen & Loe, 1972; Budtz-Jorgensen, 1976; Kulak et al., 1997; Fenlon et al., 1998). In wearers of complete dentures, yeast proliferation in the space between the maxillary denture and the palatal mucosa may give rise to denture stomatitis (Budtz-Jorgensen et al., 1975; Arendorf & Walker, 1979).
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The aetiology of denture stomatitis in relation to trauma and infection has been studied by BudtzJorgensen and Bertram (1970a). They found a pronounced statistically signicant correlation between poor denture cleanliness and heavy inammation. In a review of materials and methods for cleaning dentures, it was concluded that bacterial and yeast plaque on dentures may cause infection and therefore it was recommended that denture wearers should be instructed and motivated to brush their dentures (Neill, 1968; Hoad-Reddick et al., 1990; Collis & Stafford, 1994; Keng & Lim, 1996). The purpose of the present study was to further examine the relationship between oral hygiene habits, denture cleanliness, and the presence of yeasts and denture stomatitis in elderly patients.

Materials and methods

A survey was made of 70 full denture wearers attending the Department of Prosthetic Dentistry. To standardize the effect of diurnal variations, meals and tooth brushing, the investigation was carried out at midmorning at least 2 h after drinking, eating or any oral hygiene procedure.

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Methods of examination The age, sex, frequency of denture brushing, denture cleaning methods and dental history were recorded. Clinical investigation The degree of palatal erythema was scored by using the following clinical index. 0: No inammation 1: Slight inammation (Localized slight hyperaemia) 2: Moderate inammation (Diffuse hyperaemia) 3: Severe inammation (Diffuse and papillary hyperplasia). Mycological examination For all subjects the palatal mucosa was swabbed with plain cotton wool. Swabs were cultured in Saubauroud's medium at 37 C for 48 h, and the count of colony-forming units was recorded. Germ tube formation and its ability to grow on cornmeal agar identied Candida albicans. Examination of denture cleanliness An examination of denture cleanliness was made using a plaque detector (proavine-monosulphate in 03% aqueous solution) to disclose the plaque on the tting surface of the maxillary denture. According to the quantity of plaque on the denture base, patients could be divided into three groups by using BudtzJorgensen's Index (Budtz-Jorgensen & Bertram, 1970b) of denture cleanliness. Excellent: None or only few spots of plaque Fair: More extended plaque, less than half of the denture base covered by plaque Poor: More than half of denture base covered by plaque A chi-squared test was used to analyse the results and values of P < 005 and P < 001 were considered as statistically signicant.
Excellent Fair Poor Total Table 1. Prevalence of denture stomatitis in subjects n (%) Healthy Local Diffuse Granular Total 39 (557) 16 (229) 12 (171) 3 (43) 70 (100)

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Table 2. Growth of different yeast types cultured from the palate of subjects n (%) No growth Candida albicans C. tropicalis C. krusei C. quilliermondii C. parapsilosis Total 43 (614) 15 (214) 6 (85) 2 (29) 2 (29) 2 (29) 70 (100)

Table 3. Denture cleanliness of the subjects n (%) 11 (157) 25 (357) 34 (486) 70 (100)

Results
A total of 39 (557%) subjects did not have any symptoms of denture stomatitis whereas 31 (44%) had either local (229%), diffuse (171%) or granular (43%) stomatitis (Table 1).
2002 Blackwell Science Ltd, Journal of Oral Rehabilitation 29; 300304

The cultured swabs from the palate showed no growth of yeast in 43 (614%) subjects and growth of different Candida types in 37 (386%) of the subjects (Table 2). Candida albicans was the most frequent type of yeast grown and C. krusei, C. quilliermondii and C. parapsilosis the least frequent. The denture cleanliness is shown in Table 3. A total of 34 (486%) subjects' dentures were found poor, 25 (357%) dentures found fair and 11 (157%) dentures found excellent. In general denture hygiene was extremely poor in most of the subjects. Frequency of denture cleaning is shown in Table 4. A total of 18 (257%) people reported they occasionally cleaned their dentures. Twenty (286%) subjects reported they cleaned their dentures once a day, and 32 (457%) reported they cleaned their dentures more than once.

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Table 4. Frequency of denture cleaning of subjects n (%) Less than 1 a day One a day More than 1 a day Total 18 (257) 20 (286) 32 (457) 70 (100)
35

Healthy subjects
30 25 20 15 10

Localized D.S Generalized D.S Papiller hyperplasia

Table 5. Denture soaking and brushing habits in subjects n (%) Brushing only Soaking in solution only Soaking in water only Brushing and soaking Nothing Total 40 (571) 4 (57) 12 (171) 6 (86) 8 (115) 70 (100)

5 0 Candida absent Candida present

Fig. 1. The relationship between prevalence of denture stomatitis and yeast.

25 20

Table 5 shows brushing and soaking habits together. Eight (115%) subjects neither soaked nor brushed, 12 (171%) soaked their dentures in water only whereas only 6 (86%) claimed to do both. The relationship between prevalence of denture stomatitis and yeast colonization Yeast was identied in 100% subjects who had generalized denture stomatitis, 375% of subjects had localized denture stomatitis, 153% of subjects had no obvious denture stomatitis. There was statistically signicant relationship between denture stomatitis and yeast colonization (P 00001) (Fig. 1). The relationship between prevalence of denture stomatitis and denture cleanliness The incidence of denture stomatitis was higher in cases of poor denture cleanliness (88%). A pronounced statistical signicance was found between poor denture cleanliness and denture stomatitis (P 00001) (Fig. 2). The relationship between prevalence of denture stomatitis and frequency of denture cleaning There was no statistically signicant correlation between denture stomatitis and frequency of denture cleaning (P 0984) (Fig. 3).

15 10 5 0 Good Fair Poor

Healthy subjects Localized D.S Generalized D.S Papillar hyparplasia

Fig. 2. The relationship between prevalence of denture stomatitis and denture cleanliness.

28 24 20 16 12 8 4 0
Less than one a day One a day More than one a day

Healthy subject s Localized D.S Generalized D.S Papiller Hyperplasia

Fig. 3. The relationship between prevalence of denture stomatitis and frequency of denture cleanliness.

Discussion
The study of oral hygiene in elderly denture wearers is becoming increasingly important because of the increasing numbers of elderly people in the world. Poor denture hygiene is frequently cited as a local aetiological
2002 Blackwell Science Ltd, Journal of Oral Rehabilitation 29; 300304

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factor in denture stomatitis (Budtz-Jorgensen & Bertram, 1970a; Arendorf & Walker, 1987; Radford & Radford, 1993). Previous studies of different populations have shown a variation in the prevalence of denture stomatitis from 11 to 67% (Budtz-Jorgensen & Loe, 1972; Arendorf & Walker, 1987; Bartholomew et al., 1987; Catalan et al., 1987). Different diagnostic criteria or differences in the groups could explain the variation. The present study showed a prevalence of 34% the same as Schou et al. (1987) whose report is the most comparable study with our study. Our results differ greatly from the 65% found by Budtz-Jorgensen et al. (1975). The differences may be explained by different diagnostic criteria or differences in the groups such as age, institutionalized versus. noninstitutionalized or even the inuences of other factors such as drugs or diseases. Symptom-free oral carriage of candidal organism, has been recognized for many years and the reported prevalence in clinically normal mouths of healthy adults range from 3 to 48%. In our study yeast was identied in 153% of subjects who had no obvious denture stomatitis. This disparity may reect differences in sampling technique, the sites sampled and the selection of subjects. In the present study we found that the yeast colonies in generalized denture stomatitis cases were more numerous than in both localized denture stomatitis cases and healthy denture wearers. This nding supports the ndings of, Davenport (1970), Budtz-Jorgensen (1974), Arendorf and Walker (1987) and Kulak et al. (1997). The correlation between poor denture cleanliness and denture stomatitis was statistically signicant. This nding supports those Budtz-Jorgensen and Bertram (1970a) and Schou et al. (1987). Because denture plaque is an important factor in stomatitis in patients who wear dentures, cleaning of dentures and the removal of plaque are obviously important steps in the maintenance of good oral health. The relationship between frequency of denture cleaning, denture stomatitis and yeast colonization showed that unexpectedly more stomatitis and yeast colonization was seen in patients who cleaned their dentures once a day. These results surprisingly did not support a relationship between frequency of denture cleaning, yeast colonization and denture stomatitis. Effective plaque removal requires a degree of manual dexterity that is often lacking, especially among elderly individuals. The nding of our survey is similar to
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those of earlier workers that many elderly people apparently do not know how to keep dentures clean (Budtz-Jorgensen & Bertram, 1970a; Schou et al., 1987). It is clearly an important duty of the dental profession, at a time when the number of elderly is rapidly rising, to ensure that the denture wearing public know how to clean their dentures properly.

References
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Correspondence: Dr Yasemin Kulak-Ozkan, Bagdat cad. Santral apt., Kat.2, D:6, 81090, Caddebostan, Kadikoy, Istanbul, Turkey. E-mail: drozkan@hotmail.com

2002 Blackwell Science Ltd, Journal of Oral Rehabilitation 29; 300304