Download Denture Stomatitis - Tiffany Montes, RDH

Denture Stomatitis 1
Running Head: Denture Stomatitis
Denture Stomatitis
Tiffany Montes
Carrington College California, Dental Hygiene Program
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Introduction
Periodontitis is a serious condition that affects many people all around the world. Bad
bacteria like Porphyromonas gingivalis can infect the oral cavity, and if left untreated can cause
infection, inflammation, and bone loss. When periodontitis occurs it can spread from the gingiva
to the ligaments and bone that support the teeth, this is the primary cause of tooth loss in adults
(Rosenberg, 2010). Patients that are fully or partially edentulous have the option of wearing
dentures, but dentures are not an easy fix for patients that do not practice good home care or
maintain regular office visits. Dentures can cause oral mucosal lesions such as denture
stomatitis.
Candida albicans is a type of fungus or yeast that causes denture stomatitis. Denture
stomatitis is a candidacies that occurs only beneath a denture, in people who are fully or partially
edentulous and wear dentures. Candida albicans is often asymptomatic and can go unnoticed
until clinically observed. Although most patients are unaware of any problems, some may feel a
burning sensation, slight discomfort or a bad taste in their mouth (Yuntzu-Yen Chen, 2007).
There are many contributing factors to denture stomatitis. Local factors include the
wearing of dentures continuously, smoking, poor oral hygiene, poor denture cleanliness, ill
fitting dentures (too loose or too tight), decreased salivary flow, and the age of the dentures
(Yuntzu-Yen Chen, 2007).
The patient in this case study, William, presented with a full upper denture. Upon
removal of the denture for cleaning, atypical tissue was noted on the hard palate as well as the
edentulous alveolar ridge; this was diagnosed as denture stomatitis. The patient’s medical
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history showed multiple contributing factors for denture stomatitis. The patient is a smoker, has
a history of drug abuse, takes medication that can cause xerostomia, and stated that he does not
remove his dentures to sleep. The patient also stated that he does not clean his dentures
regularly. These are all contributing factors to denture stomatitis.
Research
Denture stomatitis has many contributing factors, but one of the main causes is failure to
keep the oral cavity and dentures clean. Although the prevalence of denture stomatitis can vary,
research shows that it can affect as many as two-thirds of the elderly denture wearers (KulakOzkan, 2002).
Candidiasis in the oral cavity is the fungus that is responsible for causing denture
stomatitis. There are eight different kinds of Candida fungi. They are: Candida albicans,
Candida glabrara, Candida tropicalis, Candida guillermondi, Candida cruser, Candida
parapsilosis, Candida stelatoidea and Candida kefyr. All of these can cause denture stomatitis,
but the one most commonly found in the oral cavity is Candida albicans which lives on the skin
and mucous membranes of the mouth (Hadžić, 2008).
Denture stomatitis has a higher prevalence in people who wear a maxillary denture as
opposed to a mandibular denture which has the lowest prevalence for denture stomatitis.
Research shows the greater the area covered by a denture the greater the risk for developing
denture stomatitis. Since the maxillary dentures must cover the entire hard palate this creates a
good host environment for the Candida to grow and thrive. Other contributing factors are heavy
smoking and vitamin A deficiency. It has been reported that low levels of vitamin A may
possibly alter the keratinization process which can influence the immune response and allow
denture stomatitis to thrive (Shulman, 2005).
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There are different divisions of denture stomatitis according to Newton’s classification. It
can be divided into three different groups: Type 1 denture stomatitis type one involves localized
inflammation; Type 2 denture stomatitis involves diffuse erythema (redness) without
hyperplasia; Type 3 denture stomatitis involves papillary hyperplasia (Hadžić, 2008). According
to Newton’s classification scale William falls into a type 3 denture stomatitis patient.
Denture stomatitis is not a permanent condition. It can be treated. Treatment of the oral
mucosa can be done by using an antifungal agent in the mouth and regular brushing of the palate.
To remove the fungus from dentures patients can soak them in a solution containing benzoic
acid. This can fully eradicate the Candida from the denture surface. Chlorhexidine can also be
used as a rinse intraorally as well as soaking the dentures in the solution, however staining and
discoloration is likely to occur so this should be discussed with the patient (Yuntzu-Yen Chen,
2007).
An alternative treatment for dentures causing denture stomatitis is microwaving them at
650 watts for 6 minutes three times a day. Research shows that at the end of 15 days of
microwave treatment that the dentures were 100% free of Candida (Neppelenbroek, 2008).
Studies show that there are many ways to prevent or cure denture stomatitis, however
they all seem to be somewhat time consuming and must be done daily or several times a day, and
could have unpleasant side effects like staining. This may be why there are so many denture
wearers with Candida infections. It would take meticulous home care to prevent denture
stomatitis and many do not have the dexterity or desire to take care of their oral health.
Case Selection
Medical, Dental and Dental Hygiene History
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On all of William’s appointments his vitals were within normal limits. The only
exception was during the second visit his blood pressure was 144/78 which is stage one
hypertensive. It seemed to be quite a bit higher than his last few appointments; the blood
pressure was taken again 30 minutes later and had settled to 128/72, which was much closer to
William’s previous blood pressure readings. Both William’s pulse and respiration were within
normal limits at each visit.
The patient, William disclosed that he was a previous cigarette smoker and had smoked
approximately fifteen cigarettes a day for many years. At Williams first recare appointment he
stated that he was no longer smoking cigarettes with tobacco, but instead a mixture of the herbs,
Mullen, Mugwart, Catnip, White sage, Yerba Santa, and Damiana. When asked William also
disclosed that he does not remove his denture while smoking, and rarely removes it at all, even
while sleeping.
The patient has a very detailed medical history. The medical history form shows a
history of drug addiction/use. Patient stated he used Cocaine for many years but quit in 1985.
The patient also has a past of recreational drug use; William has used drugs such as Marijuana
until April 2009 and Methamphetamine until 1985.
The patient also has medical problems. William suffers from Arthritis, Ulcers, High
blood pressure, cold sores and occasional psychiatric disorders. William has also had
Gonorrhea in the late 1960’s, and was exposed to hepatitis A,B and C, but was vaccinated for
hepatitis A and B and shows negative on lab tests for the virus’. The patient was hospitalized in
1992 due to a torn meniscus, 1995 due to a broken neck, and in 1996 due to a hernia. William
was classified as an ASA II due to his smoking habit as well as his high blood pressure. There
were no contraindications for treatment.
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William is on Omeprazole for his ulcers. This medication can cause xerostomia and
esophageal candidacies, both of which can contribute to denture stomatitis. He is also on
Simvastatin to maintain his cholesterol, Lisinopril for his high blood pressure,
Hydrochlorothiazide for hypertension, and multivitamins. These other medications did not
contribute to William’s denture stomatitis.
William recently started trying to schedule regular dental hygiene visits. He stated that it
had been three months since his last cleaning, but he had not been to the Carrington College
California Dental hygiene clinic since March of 2010, approximately one year prior to the most
recent treatment. Prior to the March 2010 appointment William had a scaling and root planning
done at Carrington Dental hygiene clinic in January 2010.
Extra-Oral, Intra-Oral Exam, Gingival Description
William appeared happy during his appointments. He was very light hearted and told a
lot of jokes. During the extra oral exam it was noted that William had bilateral 5x5mm scars on
his forehead above each eyebrow. Upon further questioning it was discovered that the patient
had worn a halo head piece after he broke his neck in 1995. The intra oral exam showed a
slightly fissured and coated tongue, absent tonsils, and prominent salivary glands on the palate.
The most significant finding was a 12x6mm area on the hard palate that appeared red and raised.
There were also some areas along the patients’ edentulous alveolar ridge of the maxilla that
appeared red and irritated. The instructor as well as the Dr. on duty examined the patient and
came to the conclusion that the abnormal region on the palate and alveolar ridge was Denture
stomatitis. An intra oral picture was taken to capture the exact appearance of the denture
stomatitis on Williams palate and to add to the patients records.
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Williams gingiva showed signs of mild chronic periodontitis. His gingiva was
generalized pale pink. His papilla was generalized blunted and the margins were generalized
rolled, slightly stippled and slightly spongy.
CAMBRA
During the CAMBRA evaluation it was determined that William was a high risk for
caries. He admitted to eating sugary snacks more than three times a day between meals, he has a
removable denture, exposed roots, uses recreational drugs, and doesn’t have fluoridated water.
He is also on Omeprazole for his ulcers and this medication can cause xerostomia which can
cause caries. William’s pH levels were 6.2 resting and 6.4 active, alone this isn’t acidic enough
to cause caries in the enamel, but it is borderline for causing caries on exposed root surfaces.
The patient was given recommendations to rinse with a fluoride mouthwash daily to help prevent
caries.
Radiographs, Dental Charting and Occlusion
Seven periapical radiograph films were taken on William. He did not need a full mouth
set because his maxillary arch is fully edentulous. It was a struggle to take radiographs on him
due to his edentulous upper arch, but after placing his partial in it was much easier. Radiographs
showed generalized horizontal bone loss throughout the mouth.
Dental charting showed a fully edentulous upper arch. The patient wore a partial denture
for the maxillary arch, however it was ill fitting due to his dog chewing on it and chipping a few
areas. William also had fillings on all of his remaining posterior teeth. Attrition was also
present along the mandibular arch from teeth number 20-29.
No occlusion was charted due to the patients’ full upper denture.
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Periodontal Charting and Debris Description
During periodontal probing the patient presented with generalized 5 to 7mm pockets.
Generalized bleeding on probing was present throughout the entire mandibular arch. William
also had generalized 4-5mm areas of recession. The patient presented with only light plaque and
calculus. There were scattered spicules subgingivally on the mandibular arch and generalized
moderate roughness supragingivally. During the Oral hygiene index simplified only a partial
score was obtained due to the missing teeth in the upper arch. Teeth numbers 30L, 24F, and 19L
were examined. The patient had a fair plaque rating score of 1.66 on both visits. Gum go
betweens and an interdental aid were dispensed to the patient to help clean between the contacts
in the embrasures.
Treatment Recommended and Provided
After assessments were complete they were reviewed and William was classified as a
case 5 patient due to his severe bone loss and current periodontal status. His AAP classification
was a IIB which is generalized chronic periodontitis. The recommended treatment for this
patient was a complete scaling and root planning using both hand instruments and the ultrasonic
scaler on the entire mandibular arch as well as improved home care and regular three month
recare visits. The patient needed local anesthesia prior to scaling due to the depths of the pockets
and the exposed root surfaces.
William’s scaling and root planning appointments were broken up into two visits due to
the need for local anesthesia. The local anesthesia didn’t seem to last very long for William, but
overall he handled the procedure well. After the last quad was scaled the patients’ dentures were
cleaned and his mandibular arch was polished. 5% NaF fluoride varnish was applied to Williams
lower arch to help with caries prevention as well as root sensitivity. The patient was placed on a
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three month recare visit and improved home care was stressed. The patient was encouraged to
remove his dentures before bed and clean them regularly. He was also encouraged to quit
smoking, or in the very least remove his dentures while smoking.
Conclusion
William’s denture stomatitis had gone unnoticed for what seemed like a long period of
time. He was unaware of the problem and stated that he had no discomfort associated with it.
The only thing that seemed to bother William was the denture fitting loosely. The dentist on
staff recommended that he get a new denture, and if he could not afford that then he should
consider getting his dentures relined. The dentist said that the ill fitting denture was a
contributing factor for the denture stomatitis.
William returned to Carrington College California dental hygiene clinic in June 2011 for
a recare appointment. At this time his denture stomatitis seemed to have grown from the
previous 12x6mm to 20x10mm. Another clinical photo was taken and William was urged to see
a dentist to get treatment for the Candida infection.
Overall William did not have any improvement in his periodontitis on his three month
recare appointment. He was still a class 5 and AAP IIB. His oral hygiene had not improved
either. William also presented with sever xerostomia due to the Omeprazole medication he was
taking for his ulcers.
For William’s denture stomatitis it would have been nice to recommend some of the new
things discovered through the research. Chlorhexidine could have been recommended to help
kill some of the Candida; however William’s xerostomia prevents him from using this because it
could cause further drying of the oral cavity which could in turn make the denture stomatitis
worse. Microwaving the patient’s dentures was also something that could be advised, but if this
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was recommended to the patient and the dentures broke or melted Carrington College California
could be liable. Increased home care was recommended at William’s last visit. The importance
of cleaning the denture and removing it at night and to smoke was stressed at the last
appointment. Tobacco cessation was also performed, but the patient is not willing to quit at this
time.
The most important recommendations given to William was to seek attention from a
physician or dentist that could further diagnosis his condition and properly treat it. He was
referred to get a denture reline as well as to get the denture stomatitis looked at.
On William’s next visit he will be advised to brush his palate daily along with his teeth
and tongue. He will also be reminded of the importance of getting the denture stomatitis looked
at and treated. William will continue to be on a 3 month recare schedule to try to maintain the
remaining teeth in his mouth and to restore the health of his gingiva.
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References
Hadžić, S. D.-V. (2008, June 26). Influence of candida infection on denture stomatitis. Retrieved June 1,
2011, from Ebscohost: http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?vid
Kulak-Ozkan, E. (2002). Oral hygiene habits, denture cleanliness, presence of yeast and stomatitis in
elderly people. Journal of Oral Rehabilitation , 300-304.
Neppelenbroek, K. P. (2008). Effectiveness of microwave disinfection of complete dentures on the
treatment of Candida-related denture stomatitis. Journal of Oral Rehabilitation , 836-846.
Rosenberg, J. D. (2010, Feb 22). Periodontitis. Retrieved June 1, 2011, from PubMed:
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002054/
Shulman, J. R.-H. (2005). Risk factors associated with denture stomatitis in the United States. J Oral
Pathol Med , 340-346.
Yuntzu-Yen Chen, A. B., & Zirwas, M. J. (2007). Denture Stomatitis . SKINmed , 92-94.
Yuntzu-Yen Chen, A. (2007, March). Denture Stomatitis. Retrieved May 30, 2011, from Ebsco:
http://web.ebscohost.com/ehost/detail?sid