A CLINICAL AND MICROBIOLOGICAL EVALUATION OF DENTURE CLEANSERS FOR GERIATRIC PATIENTS IN LONG TERM CARE INSTITUTIONS

M. Gornitsky B.Sc., D.D.S., F.R.C.D. (C ) 1,2 I. Paradis D.H. 1, G. Landaverde D.H. 1, A.M. Malo D.H.1, Ana M. Velly., D.D.S , Ph.D. 1, 2 Sir Mortimer B. Davis Jewish General Hospital, Dental Department 1, McGill University, Faculty of Dentistry 2, Montreal, Quebec, Canada

Correspondence should be addressed to: Dr. Mervyn Gornitsky Sir Mortimer B. Davis Jewish General Hospital, Dental Department, Room A024 3755, chemin de la Cte-Sainte-Catherine Montreal, Quebec, H3T 1E2 Phone: (514) 340-7911 Fax: (514) 340-7514 Email: mgornits@den.jgh.mcgill.ca

Abstract Elderly patients in long-term care hospitals cannot adequately brush their dentures due to disease, dementia and poor dexterity. This may allow for the multiplication of bacteria and fungus, which could serve as a reservoir for disseminating infections. This study was undertaken to assess the efficacy between three denture cleansers to reduce microorganisms (fungi and Streptococci mutans) on dentures among a hospitalized geriatric population. Microbiological samples were taken before and after each treatment by a microbiologist blinded to the assigned treatment. For the statistical analysis, the rank scores of the differences between the pretreatment and post-treatment scores of each treatment regimen were compared, using the general linear model (SAS). Additionally, the efficacy in the reduction of food, stain and plaque accumulation was assessed. The rank of the differences of the fungi before and after the use of Denture Brite (P=0.04) and Polident (P=0.01) were significantly greater than the control group, but not with Efferdent (P=0.10) (Table 1). No significant differences in Streptococci mutans reduction was observed between Denture Brite (P= 0.13) and Polident (P= 0.12) in comparison to the control group, whereas dentures that received Efferdent had significant Streptococci mutans reduction (P= 0.02). Considering all study periods, no significant difference in fungi or Streptococci mutans reduction was observed between all cleansers. Dentures that received Denture Brite, Polident, or Efferdent appeared to have a similar reduction in the level of plaque, stain, and food, all differing substantially from the control group. The significant difference in the rank of fungi count noted (P= 0.005), was related to the variance between study periods (F= 0.01) and the variance between subjects (P= 0.008). The use of denture cleansers significantly reduced the number of microorganisms. Keywords: fungus, Streptococci mutans, denture cleansure, hospitalized geriatric population.

A CLINICAL AND MICROBIOLOGICAL EVALUATION OF DENTURE CLEANSERS FOR GERIATRIC PATIENTS IN LONG TERM CARE INSTITUTIONS Introduction It is common knowledge that edentulous patients in long term care hospitals cannot adequately brush or maintain their dentures due to disease and poor dexterity. 1,2,3,4 Studies have revealed that poor dental hygiene and candida albicans infections are very common among elderly denture wearers.3,5 As well, nurses in institutions are overburdened making it difficult for them to care for their patients dentures. Regardless of their cleaning efforts, however, soft debris, bacterial plaque and dental calculus are often found on denture surfaces.1,6 Many rely on the ability of denture cleansers to reduce or eliminate food particles and stain by placing their dentures in a container with cleanser according to directions. The importance of clean dentures in these patients is not to be underestimated. Dentures containing debris, tartar, and stain cause irritation and subsequent tissue response. Food under dentures between denture and gingiva, or denture and palate, allow for the multiplication of bacteria and fungus which cause denture stomatitis
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and multiple papillomatosis of the palate. 3 These microorganisms may also serve as a reservoir for disseminated infections with gastrointestinal and pleuropulmonary involvement,7,8 however it was recently noted that periodontal disease did not significantly increase the risk of coronary artery disease.9 Candida pneumonia has been reported in a non-immunosuppressed host.10 Fungal or bacterial infections may cause subacute bacterial endocarditis in patients with artificial heart valves, and pneumonia in patients with chronic obstructive pulmonary disease.11 It was revealed that denture cleaning and plaque elimination is a neglected function in most old age homes. Patients, authorities, nursing staff, and patients relatives showed a lack of understanding of the oral hygiene needs of geriatric patients especially for the denture wearers. It is thus extremely important that chemical denture cleansers be used as an adjunct in those cases where patients are unable to properly maintain their oral hygiene and dentures.12 Brushing alone has been indicated to be insufficient for denture plaque control. 13 Information provided by the American Dental Hygienist Association on the care and cleaning of dentures recognized the value of commercially prepared denture powder, paste or tablets.

The immersion type chemical solutions for cleansing dentures may be divided into two major groups: denture cleansers and disinfectants. Commercial denture cleansers may be classified into the following groups based on their mode of action, or main component: alkaline hypochlorites, alkaline peroxides, neutral peroxides with enzymes, enzymes, acids, crude drugs and mouth rinses or oral rinses for dentures. 14 At present, a review of the literature reveals a plethora of laboratory but few clinical studies especially those targeting the hospitalized geriatric population. The efficacy of some cleansers have been tested in the laboratory. However, results of laboratory studies do not necessarily agree with the experience in vivo.15 It is the purpose of this study to determine the effectiveness of the cleansers Denture BriteTM, Polident OvernightTM ,and Efferdent New Concentrated Blue TabletTM , in reducing bacteria and fungus from the denture surfaces as well as dislodging food and reducing stain, tartar and plaque in the long term institutionalized geriatric population. Material and Methods Study Population This is a randomized cross-over study, approved by the Research-Ethics Committees of the Sir Mortimer B Davis Jewish General Hospital (SMBD JGH) and the Jewish Nursing Home, (JNH) Montreal, Quebec, Canada. Subjects were selected by one dental hygienist between January and May 2000, among the long term care facilities of the SMBD JGH and JNH . Eligible subjects should have an upper complete acrylic denture. Subjects with partial or lower dentures only, or with a history of denture cleanser use within the last two weeks were not eligible for this study. Clinical Examination After the consent form was signed, subjects had a complete oral examination performed by the same dentist (L.De K.).

Treatment Protocol In this study, patients were assigned to three denture cleansers or water (control group). Denture Brite
TM TM

was used initially overnight, following this for 20 minutes each day. The

soaking time for Polident Overnight TM and Efferdent New Concentrated Blue Tablet was overnight. These established periods were based on the manufacturers instructions. These cleansers were used for all study periods (three weeks), and water was used only in the first period (first week). Additionally, there was a washout period of one week between the use of each treatment to allow bacteria and fungus to repopulate the dentures and to eliminate the effects of the previous cleanser16 (Figure 1). Randomization and Blinding Subjects were distributed at random into four groups including the three denture cleansers and water (control group). During the study, two dental hygienists were responsible for the treatment protocol. Patients, the microbiologist responsible for the cultures, and the dentists involved in the evaluation of the dentures were blinded to the assigned treatment group. Study Outcome In the intention to treat analysis, the primary outcome was the reduction of oral fungus and Streptococci mutans obtained after the use of the treatment protocol. The secondary outcome was the decrease in the score of food accumulation, stain, tartar and plaque on the dentures after treatment. Data Collection Laboratory assessment of the number of bacteria and fungi One week prior to initiation of treatment, all dentures were cleaned in an ultrasonic bath, for 5 minutes to standardize the number of bacteria and fungus on the dentures. Streptococci mutans and fungal cultures were taken on the first day of each week of testing, before each cleanser day (day 1st , 15th, 29th) and after the use of the cleanser for seven days (day

8th, 22nd, and 36th). The total study period was 35 days: 21 days of cleanser use, and 14 days of wash-out with water (Figure 1). Cultures were taken from the palatal surface of the upper denture using a 2cm x 2 cm template with culture swabs (Culturette, Becton Dickinson, Sparks, Maryland) by one investigator. The cultures were placed in a culture tube, placed in a refrigerator and sent to the Universit de Montral bacteriology department within 6 hours. The microbiologist was blinded to the type of cleansing solution used. Food accumulation, stain, tartar and plaque To determine the efficacy of the cleansers in comparison to water (control group) in the reduction of food accumulation, stain, and plaque, two photographs of the dentures were evaluated by three dentists. These photographs were taken prior to (first day) and after the treatment protocol (day 8 final period of this analysis), by a member of the audiovisual department of SMBD JGH. The score of food accumulation, stain, and plaque was assessed on visual analogue scale (VAS 0-10 cm). Three VAS were set up with; 1 no food, 2 no stain, 3 no plaque on the left anchor (0); and 1 heavy accumulation of food, 2 heavy accumulation of stain, 3 heavy accumulation of plaque on the right anchor (10). The dentists marked their responses with a line on the scale in relation to the above, comparing all these aspects of the dentures before and after the treatment protocol. Therefore the greater the score the lower the efficacy of the specific treatment. The dentists were unaware of the type of solution in which the dentures had been placed. A very good agreement between dentists was noted in the level of plaque (ICC=79%), stain (ICC=79%), and food (ICC=81%). Statistical Analysis The difference of the mean in the number of fungi and Streptococci mutans as noted at the first baseline period (day 1), and after seven days of treatment (day 8) was used to assess their

efficacy. Additionally, during all periods, these differences before (day 1, 15, 29) and after the treatment protocol regimen (day 8, 22, and 36) were used to compare the efficacy between all cleansers. As these differences were not normally distributed, a rank of these differences was used in the analyses. General linear model was used to assess these outcomes. Data analysis was accomplished with SAS software. The differences of the mean score in food accumulation, stain, and plaque between the four treatments were used additionally to assess the efficacy of the cleansers. Results Thirty-seven patients were invited to participate in this study. From these, two were not eligible to participate due to their emotional state, three refused and five that accepted were discharged after randomisation, but before the data was collected. The remaining 27 patients, with a mean age of 84 (SD. 8.8 years ), consisted of 14 males and 13 females. The results of the intra-oral examination of the 27 patients, included in this study , revealed that 14 (52%) of the subjects presented with denture stomatitis. According to the Newton classification, 40% patients were classified in Grade 1, 13% grade 2a, 20% grade 2b, 13% grade 3a and finally 13% grade 3b. No difference was noted between groups related to the presence of stomatitis ( gender (
2 2 2

= 1.94; 3 df; P = 0.59), age (

= 1.10; 4 df; P = 0.37) and

= 3.09; 3 df; P = 0.38).

Efficacy of cleansers The rank of the differences of the fungi before and after the use of Denture Brite (P=0.04) and Polident (P=0.01) were significantly greater than the control group, but not with Efferdent (P=0.10) (Table 1). No significant differences in Streptococci mutans reduction were observed between Denture Brite (P=0.13) and Polident (P=0.12) in comparison to the control group, whereas dentures that received Efferdent had significant Streptococci mutans reduction (P=0.02) (Table 1). A great variance in the count of the fungi and Streptococci mutans between cleansers was noted during the different study periods. In a multivariate analysis, including all study periods, a

significant difference in the rank of fungi count was noted (F=2.53; P=0.005). Dentures that received Denture Brite appeared to have significantly greater reduction in the number of fungi (P=0.06) than those with Efferdent. However, this difference was not related to the treatment (F=1.95; P=0.16). No difference was observed between Denture Brite and Polident (P=0.25) or between Polident and Efferdent (P=0.43). In addition, this difference was not related to the treatment sequence (F=1.34; P=0.27). Nevertheless the difference was associated to the variance between study periods (F=4.76; P=0.01) and to the variance between subjects (F=2.25; P=0.008) (Table 2). The rank difference related to Streptococci mutans revealed no significance between individuals (F= 1.34; P=0.22), treatment group (F= 0.38; P= 0.69), period (F= 0.31; P= 0.74), or sequence (F= 0.37; P= 0.69) (Table 2). Efficacy in dislodging food and reducing stain, tartar and plaque Dentures that received Denture Brite, Polident, or Efferdent appeared to have a similar reduction in the level of plaque, stain, and food. These differences were significantly different than the control group (Table 3). Discussion The results of this study revealed different levels of effectiveness between cleansers depending on the type of micro-organism. Denture Brite and Polident, are effective against fungi in comparison to water. In contrast, Efferdent had a significant reduction in the number of Streptococci mutans when compared with water. However, we noted a considerable reduction in the number of micro-organisms before and after the use of cleanser (Table 1), when compared with water. The use of denture cleansers appears to be clinically useful in the reduction of micro-organisms. We also noted that the use of cleanser significantly reduced the amount of food, stain and plaque on the dentures (Table 3).

It was interesting to note that the significant difference in fungus, between cleansers noted in the multivariate analysis, was not related to the type of cleanser but to the variability between study periods and subjects (Table 2). We do not have an explanation for this. However, the large difference in the number of microorganisms may explain the variability in our study and probably the controversy between studies. In another study, including 15 individuals wearing maxillary and mandibular complete dentures, Efferdent was a little more effective than Polident, in the reduction of plaque, but less effective than other cleansers (Mersene and Clorox-Calgon). 17 McCabe et al , did not find significant difference related to the reduction of calculus 16. It must be noted that the effects of the cleanser in vivo are constantly being challenged by the continued daily ingestion of food. The validity of the results of this study is related to its methodology. Treatment was applied by two trained hygienists, following the same protocol in order to decrease bias among groups. Individuals were not informed about the study hypotheses, and the microbiologist was blind to the assigned treatment. Another advantage was the long washout period to accumulate bacteria and fungi. Further, the microbiologic quantification, the most accurate method to examine the microbial plaque was applied in this study 15. Finally, the very good agreement between dentists in the scores related to food, stain and plaque, in spite of obvious inter-operator subjectivity, contribute to the validation of our results. However this study has some limitations. The individuals were selected in one location, which may limit the generalization of the results. Further, it was not possible to verify if individuals during the day cleaned their dentures. However, this may not have occurred due to the physical limitation of the patients. In addition, even if this occurred, it should not allow for differentiation between treatments. Another constraint of this study was the evaluation of microbes only in a specific position of the denture, and the unspecified type of fungus. It has recently been suggested that micro-organisms in denture plaque from the whole surface of the denture is preferable 15.

The significant reduction in the number of micro-organisms, food, stain and plaque noted in this study suggests that denture cleansers are indicated for cleaning dentures in the geriatric hospitalized population. This is also supported by the conclusions of Chan and collaborators 12 that brushing alone with a denture abrasive is not recommended for the maintenance of good denture hygiene, particularly for elderly individuals with a lack of manual dexterity. Of concern, is the increase in the number of micro-organisms when dentures were soaked in water. Further studies are needed to determine if daily use of a cleanser will reduce the high incidence (52%) of denture stomatitis in this cohort of patients. Acknowledgements We wish to thank Dr. Jean Barbeau, Microbiologist and Jacinthe Sguin, Research Assistant, and Dr. Louis De Koninck, Faculty of Dentistry, Universit de Montreal, as well as Thierry Ducruet and Lubo Alexandro of the Centre for Clinical Epidemiology and Community Studies at the Sir Mortimer B. Davis-Jewish General Hospital, Montreal, Quebec, Canada, for their assistance in the statistical analyses. This study received financial assistance from Advantage Products Ltd for Denture Brite, Pfizer Warner-Lambert Consumer Group for Efferdent and GlaxoSmithKline for Polident .

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Table 1: Characteristics and difference after treatment during first study period.

Characteristics

Treatment Groups

Age mean Females (%) Stomatitis (%) Mean Fungi before treatment (SD) Mean Fungi after treatment (SD) Mean Streptococci mutans before treatment (SD) Mean Streptococci mutans after treatment (SD) Fungi rank1 Streptococci mutans

Denture Brite 79.2 52.4 57.1 285095.5

Polident 83.6 52.4 57.1 560173.3

Efferdent 84 52.4 57.1 732950

Control (Water) 80 33.3 33.3 145558.3

(301523.1) 76.7

(624579.7) 133

(9895869.8) 495541.1

(181975.6) 181550

(187.8) 361250

(270.8) 21974.3

(960145.1) 373675

(124683.8) 108950

(584756.1) 117166.7

(37271.5) 445.7

(499248.3) 25130

(156900.4) 666332.5

(286998.6) 51.3* 41.7

(1179.3) 58.4* 42

(42545.4) 43.6 51.4*

(1272414.5) 22.5 19.6

rank 1 Significant difference noted between cleanser and control in first study period (P< 0.05)
1

Rank difference

Standard Deviation (SD)

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Table 2

Difference in level of plaque, stain and food after treatment first study period Treatment Groups Denture Brite Polident Efferdent Control Plaque 16.94 14.07 13.86 62.83 Stain 16.22 25.57 21.62 61 Food 20.06 18.14 18.95 65.78

*Significant difference was noted between all cleansers against the control group (P> 0.0001), but not between the cleansers

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Table 3 Rank of the difference after treatment during study

Treatment Groups Denture Brite Polident Efferdent P1 51.3 58.4 43.6 P2 36.8 43.1 52.7

Fungi

Streptococci mutans

P3 29.3 42.7 32.6

All 48.9** 42.7 38.4**

P1 41.7 42 51.4

P2 42.2 47.1 32.2

P3 34.8 46.4 46.3

All 39.6 44.4 44.9

**Tendency to a significant difference in the rank of fungi noted between cleanser Denture Brite and Efferdent including all study period (P= 0.06). No significant difference related to Streptococci mutans was noted (P> 0.05)

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References 1. Manderson RD, Ettinger RL. Dental status of the institutionalized elderly population of Edinburgh. Community Dentistry & Oral Epidemiology 1975; 3:100-107. 2. Vigild M. Oral mucosal lesions among institutionalized elderly in Denmark. Community Dentistry & Oral Epidemiology 1987; 15:309-313. 3. Ekelund R. Oral mucosal disorders in institutionalied elderly people. Age & Ageing 1988; 17:193-198. 4. Jorge Junior J, de Almeida OP, Bozzo L, Scully C, Graner E. Oral mucosal health and disease in institutionalized elderly in Brazil. Community Dentistry & Oral Epidemiology 1991; 19: 173-175. 5. Budtz-Jorgensen E, Bertham U. Denture stomatitis. I. The etiology in relation to trauma and infection. Acta Odontologia, Scandinavica 1970; 28:71-92. 6. Pietrokovski J, Azuclos J, Tau S, Mostavoy R. Oral findings in elderly nursing home residence in selected countries: oral hygiene conditions and plague accumulation on denture surfaces. Journal of Prosthetic Dentistry 1995; 73: 136-141. 7. Green SL. Anaerobic pleuropulmonary infections. Post Grad Medicine 1979; 65:62-66. 8. Martin BJ, Corlew MM, Wood H, Olson D, Golopo LA, Wing OM, Kirmani N. The Association of Swallowing Disfunction and Aspiration Pneumonia, Dysphagia 1994;9:16. 9. Hujoel PP, Drangsholt M, Spiekerman C, DeRouen TA. Periodontal disease and coronary heart disease risk. Journal American Medical Association 2000; 284:1406-1410. 10. Worthington M. Fetal candida pneumonia in a non-immunosupressed host. Journal of infection 1983; 7:159-161.

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11. Smith JM, Sheiham A. How dental conditions handicap the elderly. Community Dentistry & Oral Epidemiology 1979; 7:305-310. 12. Chan EC, Iugovaz I, Siboo R, Bilyk M, Barolet R, Amsel R, Wooley C, Klitorinos A. Comparison of two popular methods for removal and killing of bacteria from dentures. Journal Canadian Dental Association 1991; 57:937-939. 13. Dills SS, Olshan AM, Goldner S, Brogdon C. Comparison of the antimicrobial capability of an abrasive paste and chemical soak denture cleansers. Journal of Prosthetic Dentistry 1988; 60: 467-470. 14. Budtz-Jorgensen E. Materials and methods for cleaning dentures. Journal of Prosthetic Dentistry 1979; 42: 619-623. 15. Nikawa H, Hamada T, HirofumiY, Kumagai H. A review of in vitro and in vivo methods to evaluate the efficacy of denture cleansers. International Journal of Prosthodontics 1999; 12:153-159. 16. McCabe JF, Murray ID, Kelly JP. The Efficacy of Denture Cleansers. European Journal of Prosthodontics & Restorative Dentistry 1995; 3:203-207. 17. Ghalichebaf M, Graser GN, Zander HA. The efficacy of denture-cleansing agents. Journal of Prosthetic Dentistry 1982; 48:515-20.

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