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Contents lists available at ScienceDirect

Journal of Prosthodontic Research

journal homepage: www.elsevier.com/locate/jpor

Original article

Effectiveness of a combination denture-cleaning method versus a

mechanical method: comparison of denture cleanliness, patient
satisfaction, and oral health-related quality of life
Yuya Baba, Yusuke Sato* , Gaku Owada, Shunsuke Minakuchi
Gerodontology and Oral Rehabilitation, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan

A R T I C L E I N F O A B S T R A C T

Article history: Purpose: Effective denture plaque control is necessary in elderly individuals to prevent oral and systemic
Received 20 June 2017 diseases. However, comparative studies of denture cleaning methods are limited, especially those
Received in revised form 5 January 2018 investigating patient satisfaction. The present study aimed to evaluate effectiveness of a mechanical
Accepted 6 January 2018
denture cleaning method versus a combination of mechanical and chemical methods in terms of denture
Available online xxx
cleanliness, patient satisfaction, and oral health-related quality of life (OHRQoL).
Methods: Thirty edentulous participants were allocated to one of two groups: mechanical or combination
Keywords:
method. The mechanical method group was instructed to brush dentures after each meal for 2 min using
Dentures
Cleaning
tap water and a denture brush, and to soak them in saline solution while sleeping. The combination
Patient satisfaction method group was instructed to brush dentures the same way, but to soak them in denture cleansers
OHRQoL while sleeping. Both groups cleaned their dentures according to the respective method for 3 weeks.
ATP bioluminescence Denture cleanliness, patient satisfaction, and OHRQoL were examined.
Results: There were significant differences in adenosine triphosphate bioluminescence (p = 0.00003),
staining (p = 0.003), and Candida albicans (C. albicans) abundance in upper complete dentures (p = 0.002)
between methods. There were no significant differences in oral mucosa C. albicans abundance,
participant satisfaction, ease of cleaning, comfort, esthetics, or Oral Health Impact Profile for edentulous
patients (Japanese version) scores between methods.
Conclusions: A combination of mechanical and chemical denture cleaning methods was more effective at
cleaning dentures than the mechanical method alone. Even if denture cleaning improves denture
hygiene, it may not increase patient satisfaction or OHRQoL.
© 2018 Japan Prosthodontic Society. Published by Elsevier Ltd. All rights reserved.

1. Introduction There are three methods of denture cleaning: mechanical,

Recently, it has been suggested that oral microorganisms are
associated with systemic disease and that dentures represent a
reservoir for these microorganisms [1–4]. Denture plaque is
associated not only with oral disease, such as denture stomatitis,
periodontitis, and caries, but also systemic disease, including
aspiration pneumonia, gastrointestinal infection, and pleural
infection. Therefore, effective denture plaque control is necessary
to prevent these diseases, especially in an aging society [1–4].
* Corresponding author at: Gerodontology, Graduate School of Medical and
Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima Bunkyo-ku,
Tokyo 113-8510, Japan.
E-mail address: y.sato.gerd@tmd.ac.jp (Y. Sato).
chemical, and thermal. The mechanical method uses brushes and
ultrasonic devices, the chemical method involves soaking the
denture in cleansers, and the thermal method involves the use of
microwave ovens [1,3,4]. A systematic review by de Souza et al. [3]
reported that denture cleansers and brushing are more effective
than placebo at reducing plaque coverage and microbial counts of
anaerobes and aerobes on the complete denture base. However,
these findings are not generalizable due to the wide range of
different interventions and outcome variables.
An in vitro study by Paranhos et al. [5] demonstrated that a
combination of mechanical and chemical methods was more
effective at reducing microbial biofilms on acrylic resin specimens
than the chemical method alone. An in vivo study by Dills et al. [6]
showed that mechanical and chemical methods were more
effective than no treatment for reducing plaque microorganisms,

https://doi.org/10.1016/j.jpor.2018.01.005
1883-1958/ © 2018 Japan Prosthodontic Society. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Y. Baba, et al., Effectiveness of a combination denture-cleaning method versus a mechanical method:
comparison of denture cleanliness, patient satisfaction, and oral health-related quality of life, J Prosthodont Res (2018), https://doi.org/10.1016/
j.jpor.2018.01.005
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2 Y. Baba et al. / journal of prosthodontic research xxx (2018) xxx–xxx
and a combination of mechanical and chemical methods was more
effective than mechanical and chemical methods alone. It appears
that mechanical or chemical methods alone may be insufficient for
adequate denture cleaning, but a combination of the two is more
effective [1–10].
There is limited information available regarding the evaluation
of mechanical and chemical methods, and comparisons between
the two, due to lack of standardized methods for examining the
efficacy of denture cleaning methods [1,3,4]. Moreover, little is
known about the effect of different methods on patient satisfaction
and preferences, costs, adverse effects, and mucosa under the
denture base [3,4]. Although dentists tend to objectively evaluate
denture cleanliness, elderly patients often show little interest in
the matter.
Recently, the adenosine triphosphate (ATP) bioluminescence
method has increased in popularity for evaluating environmental
cleanliness [11]. ATP is a basic source of energy for all living
organisms. The ATP bioluminescence method measures the
amount of ATP as an indication of contaminant level. It is used
not only to evaluate public hygiene and cleanliness in hospitals, but
also to assess oral hygiene, caries risk, and root canal bacteria
[11–16]. Therefore, the ATP bioluminescence method can be
applied in various situations as a simple and rapid inspection
method; however, little is known about the appropriateness of this
method for evaluating denture cleanliness.
In the present study, we initially evaluated the reliability and
validity of ATP bioluminescence as an inspection method for
denture cleanliness. We then evaluated the effectiveness of the
mechanical denture cleaning method versus a combination of
mechanical and chemical methods in terms of denture cleanliness,
patient satisfaction, and oral health-related quality of life
(OHRQoL). To the best of our knowledge, no previous study has
investigated the effects of different denture cleaning methods on
patient satisfaction [3]. The null hypothesis of this study was that
there are no differences in denture cleanliness, patient satisfaction,
and OHRQoL between the mechanical method, and a combination
of mechanical and chemical methods.
2. Materials and methods
2.1. Pilot study
The reliability and validity of ATP bioluminescence as an
inspection method of denture cleanliness was evaluated. To
evaluate reliability, the upper complete dentures of five patients
were assessed three times using the ATP bioluminescence method,
and the interclass correlation coefficient was calculated. To
evaluate validity, the upper complete denture of 12 patients was
assessed using the ATP bioluminescence method, stained photo-
graph method, and a simple quantification of C. albicans at initial
patient hospital visit and after denture cleaning by dentists. The
Spearman's rank-correlation coefficient between the ATP biolumi-
nescence method and stained photograph method, and between
the ATP bioluminescence method and simple quantification of C.
albicans, was calculated.
The score of the correlation coefficients was judged in
accordance with the guideline. This guideline expressed 0.0–
0.20 as slight, 0.21–0.40 as fair, 0.41–0.60 as moderate, 0.61–0.80 as
substantial, and 0.81–1.00 as almost perfect [17].
The intraclass correlation coefficient of the ATP biolumines-
cence method was 0.93, which indicates high reliability. The
Spearman's rank-correlation coefficients between the ATP biolu-
minescence method and stained photograph method, and between
the ATP bioluminescence method and simple quantification of C.
albicans, were 0.63 (p = 0.001) and 0.52 (p = 0.001), respectively;
this indicates acceptable validity.
Please cite this article in press as: Y. Baba, et al., Effectiveness of a combination denture-cleaning method versus a mechanical method:
comparison of denture cleanliness, patient satisfaction, and oral health-related quality of life, J Prosthodont Res (2018), https://doi.org/10.1016/
j.jpor.2018.01.005
2.2. Participants
A total of 33 edentulous individuals were assessed for eligibility
in this study. The participants comprised patients who visited the
Tokyo Medical and Dental University Hospital Faculty of Dentistry
(Tokyo, Japan) for new fabrication, adjustment, or recall of
complete dentures during 2016. All participants provided written
informed consent and received an explanation of the study.
Exclusion criteria included the following: serious systemic illness;
difficulty with responding to the questionnaire; use of metallic
base dentures; constant use of denture stabilizers; and use of
dental tissue conditioner with dentures.
The sample size was based on information from a previous
report. The primary outcome was measured according to the
stained photograph method. This study reported that the mean
and SD of the mechanical method are 39.53 and 22.56, respectively,
and the mean and SD of the combination method are 18.40 and
16.11, respectively [10]. We calculated the sample size with a power
of 80 % at a 5 % level of significance (two-tailed test), assuming a 20
% dropout rate. The total sample size for the two groups was
calculated to be 30 participants.
2.3. Study design
This study was a controlled, before-and-after trial involving two
parallel groups. Thirty participants were randomly allocated to one
of two groups (n = 15 each): mechanical method or combination
method. Baseline data of the participants were examined and
dentists were assigned to clean each denture by brushing for 1 min
using a denture brush (Erac Gishi brush, Lion, Tokyo, Japan) and
denture cleansers (Polident Fresh Cleanse, GlaxoSmithKline,
Tokyo, Japan), followed by cleaning the dentures using ultrasonic
vibration (SPEED SONIC 1510, Mortia, Tokyo, Japan) in a specific
ultrasonic vibration denture cleanser (Denture Cleaner, GC, Tokyo,
Japan), and then brushing them again in the same manner.
The specific method of denture cleaning was then explained to
each group of study participants. Participants in the mechanical
method group were instructed to brush their dentures after each
meal for 2 min using tap water and a denture brush, and soak the
dentures in saline solution (isotonic sodium chloride solution,
Chemix Inc., Yokohama, Japan) while they slept. Individuals in the
combination method group were instructed to brush the dentures
the same way, but to soak them in denture cleansers (Polident1,
GlaxoSmithKline) while they slept. Both groups were required to
clean the dentures accordingly for 3 weeks. The study protocol was
approved by the Tokyo Medical and Dental University (Ethics
Committee of the Faculty of Dentistry, Tokyo Medical and Dental
University, No. 1276).
2.4. Outcomes
For the objective evaluation of denture cleanliness, the ATP
bioluminescence method, stained photograph method, and simple
quantification of C. albicans in the upper complete denture and oral
mucosa were performed. General participant satisfaction, ease of
cleaning, comfort, and esthetics were measured using a 100 mm
visual analog scale (VAS). OHRQoL was measured using the
Japanese version of the Oral Health Impact Profile for edentulous
patients (OHIP-EDENT-J). These parameters were examined
immediately before the intervention and three weeks after the
intervention.
2.4.1. ATP bioluminescence method
The ATP bioluminescence method is based on a chemical
reaction catalyzed by luciferase. The amount of light generated by
this reaction, which is proportional to the amount of ATP present, is
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expressed as relative light units (RLU) [11–16]. The upper complete
denture was first rinsed under running water for 10 s. The specific
pen (LuciPac Pen, Kikkomanbiochemifa, Tokyo, Japan) was then
moistened, and the internal surfaces of the upper complete
denture were swabbed using the pen for 30 s. Finally, the pen was
set in an ATP bioluminescence meter (Lumitester PD-30, Kikko-
manbiochemifa) for 10 s, after which the RLU value was calculated.
2.4.2. Stained photograph method
The internal surface denture plaque was initially stained in
upper complete dentures using a plaque staining solution
(Prospec, GC). The surfaces were then photographed using a
digital camera (D70, Nikon, Tokyo, Japan) with standard film-
object distance and exposure time. The camera was fixed on a
stand (CSC-10, LPL, Tokyo, Japan) and camera platform (PHD-51,
Velbon, Tokyo, Japan). Photographs were imported to a computer.
Total surface area and stained area were measured using image-
processing software (ImageJ). The percentage of stained area was
calculated using the total surface area of the internal denture base
[10,18].
2.4.3. Simple quantification of C. albicans
The upper complete denture and oral mucosa were examined
for C. albicans using a specific swab (Stomastat, Dentsplay, Tokyo,
Japan) [19–21]. Following attachment, the swab was soaked in
culture solution and placed in an incubator at 37  C for 24 h after
20 s of swabbing. C. albicans was quantified according to three
stages; < 100 colony-forming units (CFU)/mL ( stage); approxi-
mately 7000 CFU/mL (stage); and > 70,000 CFU/mL (+stage).
Each stage was assigned a score as follows: stage = 1; stage = 2;
and +stage = 3.
2.4.4. Participant satisfaction and OHRQoL
General participant satisfaction, ease of cleaning, comfort, and
esthetics were evaluated using the 100 mm VAS for subjective
satisfaction [22,23]. OHRQoL was evaluated using the OHIP-
EDENT-J. The OHIP-EDENT-J is scored between 0 and 76, and the
higher the score, the lower the OHRQoL [24].
2.5. Randomization process
Block randomization was conducted for participant grouping.
The randomization scheme was generated using an online protocol
(www.randomization.com) [25]. Participants were randomized
into 3 blocks.
2.6. Statistical analysis
Data regarding the ATP bioluminescence method, stained
photograph method, simple quantification of C. albicans, each
category of the 100 mm VAS, and the OHIP-EDENT-J OHRQoL, were
found to be non-normally distributed. The Mann–Whitney U test
was used to compare results from the ATP bioluminescence
method, stained photograph method, simple quantification of C.
albicans, each category of the 100 mm VAS, and OHIP-EDENT-J
OHRQoL between the two groups, at baseline and after interven-
tion. Statistical analyses were performed using statistical analysis
software (SPSS version 22, IBM, Armonk, NY, USA). The significance
level was set at 0.05.
3. Results
3.1. Participants
A flow diagram for the study is presented in Fig. 1. A total of 33
edentulous individuals were assessed for eligibility in this study.
Please cite this article in press as: Y. Baba, et al., Effectiveness of a combination denture-cleaning method versus a mechanical method:
comparison of denture cleanliness, patient satisfaction, and oral health-related quality of life, J Prosthodont Res (2018), https://doi.org/10.1016/
j.jpor.2018.01.005
3
One individual declined to participate. One participant in each
group was lost to follow-up. Therefore, a total of 30 participants (19
men, 11 women; mean [ standard deviation] age, 79.4  6.9 years;
range, 64–92 years) were analyzed in this study.
3.2. Baseline characteristics
The baseline characteristics of the participants are summarized
in Table 1 and Table 2. There were no significant differences in any
characteristic between the groups.
3.3. Between-group comparison after intervention
Between-group comparisons are summarized in Table 3. No
significant differences were found for C. albicans abundance in the
oral mucosa, general participant satisfaction, ease of cleaning,
comfort and esthetics, or OHIP-EDENT-J.
4. Discussion
This study evaluated the effectiveness of a mechanical denture
cleaning method versus a combination of mechanical and chemical
methods on denture cleanliness, patient satisfaction, and OHRQoL.
Current understanding of the effects of different denture cleaning
methods on patient satisfaction and OHRQoL is limited [3,4].
Patients themselves necessarily perform denture cleaning. To
maintain adequate denture cleaning habits, however, the cleaning
method should improve not only objective denture cleanliness, but
also patient satisfaction and OHRQoL, which in turn would
enhance the motivation to clean dentures properly and thoroughly.
To the best of our knowledge, this was the first study to assess the
effect of denture cleaning on patient satisfaction and OHRQoL.
Although there are numerous denture cleanliness inspection
methods, no previous study appears to have evaluated the ATP
bioluminescence method [1,3,4]. An in vivo study by Chan et al. [7]
attempted to homogenize denture condition before interventions
by refraining from denture cleaning for 48 h. The in vivo study by
Cruz et al. [10] homogenized denture condition before interven-
tions by brushing with a denture brush and liquid soap. There is a
large variability in denture contamination due to differences in
baseline usage conditions. Therefore, we should attempt to
homogenize denture contamination before intervention to in-
crease the accuracy of comparisons. Previous studies have used
two methods of homogenizing denture contamination: denture
contamination and denture cleaning. We selected the latter
method for the present study due to the measurement limitations
of the ATP bioluminescence method. If the levels of contaminants
on the denture are excessive, the RLU often exceeds the
measurement limitation, resulting in an inaccurate measurement
value, making changes between before and after intervention
undetectable. Therefore, we believe that the denture cleaning
method leads to the most accurate intervention comparisons.
The ATP bioluminescence method is a simple and rapid
inspection method, mainly used to evaluate public hygiene and
cleanliness in hospitals. However, little is known about its
suitability for evaluating denture cleanliness [11–16]. Therefore,
we evaluated the reliability and validity of the ATP biolumines-
cence method as an inspection method of denture cleanliness in a
pilot study. The results showed that the reliability and validity of
the ATP bioluminescence method are high, indicating that it is a
useful inspection method for denture cleanliness. Alternative
methods require specific equipment and are more time consum-
ing. The stained photograph method requires a camera, stand,
computer, and image processing time. The simple quantification of
C. albicans requires an incubator and 24 h of culture. In contrast, the
ATP bioluminescence method is easy and only takes approximately
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Fig. 1. Flow diagram of progress through the phases of a parallel randomized trial of two groups.

Table 1 was no significant difference in C. albicans in the oral mucosa

Comparison of participant baseline data between denture cleaning groups.
Mechanical group Combination group
Mean SD Mean
Age (years) 77.5 7.92 81.2
Gender (men:women) 10:5 9:6
a
Student's t test.
b
Fisher exact test.
1 min, with relatively few pieces of equipment. Moreover, it
requires only one hospital visit; therefore, it can reduce time and
costs compared with other methods. Furthermore, the ATP
bioluminescence meter and pen are small and easy to carry.
Therefore, this method can be used to evaluate denture hygiene not
only in a large hospital or research laboratory, but also in clinics,
care facilities, and at home. It is expected that the ATP
bioluminescence method will become useful for the evaluation
of denture cleanliness and for instructing patients on denture
cleaning. For these reasons, we believe that the ATP biolumines-
cence method is feasible and can be standardized.
There were no significant differences in participant baseline
characteristics due to block randomization. The results of this
study showed that, based on ATP bioluminescence, staining, and C.
albicans abundance in the upper complete dentures, the combina-
tion method was significantly more effective at denture cleaning
than the mechanical method alone. These findings are in
agreement with previous studies [1–5,7–10]. However, there
between the methods. This indicates that the combination method
p-value can effectively remove more C. albicans from dentures, but not
SD
from the oral mucosa.
In the present study, the effects of different denture cleaning
4.79 0.15a
0.728b
methods on patient satisfaction and OHRQoL did not become
evident. There were also no significant differences in general
participant satisfaction, ease of cleaning, comfort, esthetics, and
OHRQoL between methods. A previous study reported that OHIP-
EDENT-J score decreased by 10 compared with before and after
fabrication of upper and lower complete dentures [24]. There are
no previous studies investigating OHIP-EDENT-J of denture
cleaning method. Therefore, we used this score as an alternative
for clinically significant changes in OHIP-EDENT-J. In this study,
OHIP-EDENT-J score of the mechanical method decreased by 1 and
OHIP-EDENT-J score of the combination method decreased by 5
compared with before and after intervention. Therefore, this would
suggest there were no clinically significant changes from the
intervention. However, even if denture cleaning improves denture
hygiene, it does not necessarily increase participant satisfaction or
OHRQoL. This may have been because some of the participants
were elderly individuals, who may have devoted little attention to
denture cleanliness. Alternatively, it may be due to differences in
denture cleanliness standards between the dentists and partic-
ipants [26]. Nevertheless, there could have been a significant
amount of contaminants on the dentures, regardless of whether
the patients reported general satisfaction or high OHRQoL scores;
therefore, we may not simply accept patient impressions about

Please cite this article in press as: Y. Baba, et al., Effectiveness of a combination denture-cleaning method versus a mechanical method:
comparison of denture cleanliness, patient satisfaction, and oral health-related quality of life, J Prosthodont Res (2018), https://doi.org/10.1016/
j.jpor.2018.01.005
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Y. Baba et al. / journal of prosthodontic research xxx (2018) xxx–xxx 5

Table 2
Comparison of participant measurement score between denture cleaning groups.

Mechanical group Combination group p-value

Median The first quartile The third quartile Median The first quartile The third quartile
ATP bioluminescence method (RLU) 21,116 10,497 542,074 28,411 11,043 114,882 1
Stained photograph method (%) 3.15 1.36 5.93 3.2 0.389 8.14 0.494
Simple quantification of Candida on denture 1 1 2 1 1 1.5 0.471
Simple quantification of Candida on mucosa 2 1 3 2 2 3 0.239
General satisfaction 75 49 87 75 66.5 90 0.901
Ease of cleaning 81 77.5 86.5 82 80 90.5 0.319
Comfort 76 62 85.5 81 63.5 92 0.619
Esthetics 85 79.5 90 82 71.5 92.5 0.647
OHIP-EDENT-J 28 21 37 34 30 40.5 0.101

ATP, adenosine triphosphate; OHIP-EDENT-J, Japanese version of the Oral Health Impact Profile for edentulous patients; RLU, relative light unit.
Mann–Whitney U test.

Table 3
Comparison of participant measurement score after intervention between denture cleaning groups.

Mechanical group Combination group p-value

Median The first quartile The third quartile Median The first quartile The third quartile
ATP bioluminescence method (RLU) 124,211 47,464 426,487.5 14,375 3879.5 25,286 0.00003*
Stained photograph method (%) 1.83 0.842 3.72 0.472 0.15 1.4 0.03*
Simple quantification of Candida on denture 1 1 2.5 1 1 1 0.02*
Simple quantification of Candida on mucosa 2 1.5 2 2 1 2 0.75
General satisfaction 78 51 92.5 78 74 83.5 0.618
Ease of cleaning 88 62 92.5 90 83 93.5 0.506
Comfort 82 61 93 81 76 93 0.787
Esthetics 84 79 90 80 75 90 0.709
OHIP-EDENT-J 24 21 36 30 26 35 0.183

ATP, adenosine triphosphate; OHIP-EDENT-J, Japanese version of the Oral Health Impact Profile for edentulous patients; RLU, relative light unit.
Mann–Whitney U test.
*
p < 0.05.

cleanliness. We may choose to make patients aware of how much
contaminant is present on their dentures by showing them stained
dentures and ATP bioluminescence scores, and explaining how
harmful denture contaminants can be, causing not only oral
disease(s), such as denture stomatitis, periodontitis, and caries, but
also systemic diseases, including aspiration pneumonia, gastroin-
testinal infection, and pleural infection. We must educate patients
about denture care, and patients should be encouraged to be more
concerned with denture cleanliness and maintenance.
This study had several limitations. The intervention period was
3 weeks, which may have been too short to observe changes in C.
albicans that had already colonized the oral mucosa, patient
satisfaction, and OHRQoL based on daily habits. Therefore, further
studies with longer-term intervention are required. In this study,
the primary outcome was measured using the stained photograph
method, and the sample size was calculated. Our sample size,
however, may have been too small to detect significant differences
in general participant satisfaction, ease of cleaning, comfort,
esthetics, and OHRQoL. The participants included only patients
who visited the hospital; therefore, they may tend to report high
general satisfaction, ease of cleaning, comfort, esthetics, and
OHRQoL. More participants from a wider sphere (e.g., care facilities
and homes) are needed in future studies. Especially with regard to
general participant satisfaction, ease of cleaning, comfort, and
esthetics, the average baseline scores (70.5, 82.9, 72.7, and 79.5)
were all high; therefore, a ceiling effect may have been present,
which would have made the emergence of significant differences
difficult to detect.
In addition, we did not analyze the effect of denture character-
istics, such as duration of use and repair marks, on the
effectiveness of the denture cleaning methods because the number
of participants was relatively small. Considering that denture
characteristics can vary widely, future studies should enroll a
larger number of participants. This study allocated participants to
one of only two cleaning groups; however, there are several other
denture cleaning methods, including the chemical method alone
and an ultrasonic device method. A greater variety of methods
should, therefore, be evaluated and compared in future studies.
5. Conclusion
A combination of mechanical and chemical denture cleaning
methods is more effective at improving objective denture
cleanliness than the mechanical method alone. Although a
combination of mechanical and chemical methods reduces the
abundance of C. albicans on dentures to a greater extent than the
mechanical method alone, it does not achieve the same effect in
the oral mucosa. Furthermore, even if denture cleaning improves
denture hygiene, it may not increase patient satisfaction and
OHRQoL.
Conflicts of interest
There are no conflicts of interest to declare.
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Please cite this article in press as: Y. Baba, et al., Effectiveness of a combination denture-cleaning method versus a mechanical method:
comparison of denture cleanliness, patient satisfaction, and oral health-related quality of life, J Prosthodont Res (2018), https://doi.org/10.1016/
j.jpor.2018.01.005
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