Denture plaque: Quiet destroyer
Willard J Tarbet, D.D.S., Ph.D.*
Vick Oral Sciences Research Center, Shelton, Conn.
S ince the 1960s the work of L6e and others’-5
established a relationship between dental plaque accu-
mulation on natural teeth and gingival tissue disease
levels. These early studies, which confirmed the patho-
genicity of plaque, showed the need to control plaque
accumulations to promote gingival tissue health and
preserve the supporting structures of the teeth. Profes-
sional involvement in proper home care oral hygiene
programs has made the public more aware of the
necessity of daily removal of plaque.
The relationship between oral tissue disease and the
presence on the denture surface of a developing or
mature plaque mass has not been widely recognized by
the dental profession nor well publicized to individuals
who wear dentures. This is unfortunate, all the more
since the probable effects of denture cleanliness on oral
health have been explored for more than 30 years.
As early as 1952 Fisher’ proposed that poor denture
hygiene might dispose to denture stomatitis. However,
in 1953 Nyquist7 found no such relationship. Love et
al.* in 1967 and McKendrick’ in 1968 reported rela-
tionships between lack of denture cleanliness and
denture stomatitis. In 1970 Budtz- Jorgensen and Ber-
tramI also showed a relationship between unclean
dentures and denture stomatitis. Most recently Abel-
son” pointed out in 1981 that of the most commonly
cited triad associated with soft tissue changes in den-
ture wearers (ill fit, trauma, and unclean dentures), the
plaque that forms on the tissue-fitted surfaces probably
is of the greatest clinical significance.
However, none of these workers has provided quan-
titative objective evidence of the relationship between
denture plaque levels and the health of the oral
tissues.
In the first phase of this study we report a quantita-
Presented at the American Prosthodontic Society meeting, Chicago,
Ill.
tl)eceased. Formerly Director of Dental Sciences and Oral
I-lyqkne.
(1022-3913 0?2,‘120647 + 06$00.60/O d) 1982 The C. V. Mosby Co.
tive approach to assessing the relationship among
denture plaque levels, Candida species counts, and
mucosal irritation levels. In the second phase we
demonstrate mucosal health improvements and a corre-
sponding reduction in denture plaque levels brought
about by a rigorous denture hygiene program.
MATERIAL AND METHODS
Phase I: Quantitative assessments
Phase I lasted 63 days. Each of the 60 subjects (16
men, 44 women) wore at least a complete upper
denture. The mean age of the study population was 61
years; the mean edentulous period was 14.4 years; and
the mean study denture age was 9 years. All subjects
were instructed to follow their normal regimen of
denture and oral hygiene during this.part of the study.
The primary denture cleansing method was tablet/
soaking in 39 subjects. Paste/brush was used by 21.
Plaque scoring
The fitted surface of each maxillary denture was
divided into four sections approximately equal in area
by mentally drawing a line anteroposteriorly at the
midline and another line perpendicular to the midline
at about the premolar region. Plaque was disclosed
with FD&C red No. 3, and each of these quadrants
was scored on day Nos. 0,21, and 63 as: 0 = no plaque;
1 = light plaque (25% or less of the quadrant covered);
2 = moderate plaque (26% to 50% of the quadrant
covered); 3 = heavy plaque (51% to 75% of the quad-
rant covered); and 4 = very heavy plaque (76% to
100% of the quadrant covered). A total denture plaque
score was obtained by summing the quadrant scores.
(Maximum score = 16.)
Mucosal irritation
Mucosal irritation of the hard palate, the alveolar
ridge, and the vestibular tissues was clinically assessed
as: 1 = mild; 2 = moderate; and 3 = severe. These
denture-bearing areas were assessed six times during
phase I on day Nos. 0, 7, 14, 21, 42, and 63.
THE JOURNAL OF PROSTHETIC DENTrSTRY 647
 TARBET

Table I. Phase I: plaque scores Table III. Distribution of erythema scores

for vestibular tissues
No. of
Day No. Subjects Mean SD Day No.

0 60 5.52 3.95 Score 0 7 14 21 42 63

21 58 5.83 4.5
63 57 5.58 4.24 Missing 0 5 3 2 3 3
0 43, 37 38 31 38 35
1 13 14 11 20 12 20
1.5 3 4 7 4 6 0
Table II. Distribution of erythema scores 2 1 0 1 3 1 2
Mean 0.32 0.36 0.41 0.55 0.4 0.42
for hard palate area
p value - .61 .54 .04 .58 .19
Day No.
*No. of subjects.
Score 0 7 14 21 42 63

Missing 0 5 3 2 3 3 lected. Their mean age was 60.3 years, and the mean
0 30’ 25 21 15 14 12
31 32
edentulousperiod was 14.7 years. Other demographic
1 19 20 24 27
1.5 4 9 11 12 7 10 data did not vgry significantly from the phase I group
2 7 1 1 3 5 3 except the re@ortedprimary method of cleaning den-
2.5 0 0 0 1 0 0 tures. In phase II subjectstablet/soaking and paste/
Mean 0.65 0.65 0.75 0.92 0.9 0.93 brushing were equally reported asthe primary method;
p value - .66 .03 ,001 .OOl ,001
in phaseI thesefigures were 65%and 35%,respectively.
*No. of subjects. Plaque scores and irritation scores were again
recordedon a new day No. 0 (0’) and day No. 33 using
the samescalesaspreviously described.However, after
Cfzndidu species counts the day No. 0’ evaluations each subject was given a
Candida species were determined as described by denture brush and a tube of Complete (Richardson-
Renner et al.” A triangular area of the hard palate was Vicks Inc., Wilton, Conn.), a low abrasion paste for
defined by inscribing a line from the incisive papilla denture cleansing.They were instructed to brush their
posteriorly along the medial aspect of the alveolar ridge dentures twice daily for 2 minutes and to pay particu-
to a point opposite the parotid duct opening, across the lar attention to the tissue-fitted surface.
hard palate to the opposite parotid duct opening, and
anteriorly along the medial aspect of the other alveolar RESULTS: PHASE I
ridge back to the incisive papilla. This area, including Plaque
all rugal folds, was vigorously swabbed for 30 seconds The meanplaque scoreson the three evaluation days
with a sterile cotton-tipped applicator. The applicator are shown in Table I. A breakout of the group
was rotated to optimize collection of the sample. according to plaque score showedthat three of the 60
Immediately after sampling, the applicator was had 0 plaque scores.Four of the 60 had a scoreof 1,
dropped into a sterile tube containing 5 ml of potato that is, a scoreof 1 in only one quadrant; and sevenof
dextrose broth (Difco Laboratories, Detroit, Mich.). At the 60 had a score of 2. Thus, about three fourths
the laboratory the samples were thoroughly mixed in a (76.7%) of the subjectshad up to 50% of the fitted
vortex mixer for 60 seconds, dilutions up to 10’ made, surface of the denture covered with plaque. This
and 0.1 ml aliquots of each dilution plated in triplicate distribution was approximated at all examinations.
on potato dextrose agar (Difco). They were counted
after 7 days of aerobic room temperature incubation. Tissue health
The area of the swabbed surface was calculated as A normal healthy tissuecondition for all parts of the
outlined by Renner et a1.,12and the data were analyzed mouth was found in only 20 subjects,or 33.3% of the
as counts/mm2. population at the baselineevaluation. Over the course
of the study, the number of subjectsconsideredto have
Phase II: Effects of denture hygiene completely normal tissuesdeclined steadily until the
From among the 60 subjects in phase I, 12 (two men, day No. 63 examination, when only seven of 56
10 women) who consistently showedpatterns of irrita- (12.5%) were judged to be free from signs of tissue
tion of the maxillary denture-bearing area were se- irritation.

648 DECEMBER 1982 VOLUME 48 NUMBER 6

DENTURE PLAQUE

Table IV. Distribution of erythema scores

for alveolar ridge
Day No.

Score 0 7 14 21 42 63

Missing 0 5 3 2 3 3
0 46” 45 45 49 47 41
1 10 8 9 8 5 15
1.5 1 0 3 1 4 0
2 3 2 0 0 1 1
Mean 0.29 0.22 0.24 0.16 0.23 0.3
p value - .I4 .64 .09 .43 .83

*No. of subjects

Table V. Correlation analysis between study

parameters
Fig. 1. Incidence of Candida speciesisolation
Plaque Yeast Erythema

Plaque
I 1 0.22 0.41 Table VI. Phase II: plaque scores
p value .O .26 ,002
Yeast No. of
r 1 0.61 Day No. subjects Mean SD
p value .O < .OOl
0' 12 7.8 4.3
Erythema
33 11 3.6 1.6
r 1 p value = .OW
p value .O

When the erythema scores were analyzed by ana-
tomic area, the distribution shown in Tables II, III,
and IV was obtained.
The shift in the number of subjects in the 0 score
category of the hard palate area is noteworthy. It
accounts for the steady decline in the number of
subjects considered to have normal tissues.
Because the irritation score is derived from clinical
judgment, the hard palate data might suggest a change
in investigator scoring criteria over the course of the
study. However, there were no similar trends in the
other two areas scored, and this in my opinion supports
the reality of these changes.
Candida species isolation
The percents of subjects who were Candida positive
at the 0,21, and 63 day sampling were 67%, 54%, and
64%, respectively. This yields an overall study average
of 62% (Fig. 1).
Factor correlations
There was a significant (p = .002) correlation
between plaque levels and erythema scores, but not
between plaque levels and Can&u counts (Table V).
There was also a significant (p < .OOl) correlation
between Cundidu counts and erythema scores.I inter-
pret thesedata as indicating that plaque and Candida
are operating as two independent factors in influencing
tissue erythema scores.
RESULTS: PHASE II
Plaque levels
Plaque scoreson day No. 0’ and day No. 33 are
shown in Table VI. The mean plaque scoreat initia-
tion of phaseII was considerablyhigher than the mean
for the larger group, which is to be expected if the
relationship betweenplaque scoreand erythema estab-
lished in phaseI holdstrue. At day No. 33, however, a
significant ($ = .005) reduction in plaque levels was
found.
Irritation scores
When analyzed according to anatomic area as
before, the scores for the alveolar ridge and the
vestibular areas were significantly (p = .03) reduced.
The hard palate scoresshowed no significant change.
These data are displayed in Table VII. A representa-
tive clinical picture and corresponding denture plaque

THE JOURNAL OF PROSTHETIC DENTISTRY 649

 Figs. 2 and 3. For legend, see opposite page.

650 DECEMBER 1982 VOLUME 48 NUMBER 6

DENTURE PLAQUE

Table VII. Subject distribution by anatomic site

Vestibular area Alveolar ridge Hard palate
Day Day Day Day Day Day
Score No. 0’ No. 33 No. 0’ No. 33 No. 0’ No. 33

Missing 0 1 0 1 0 I
0 3” 8 3 9 1 1
1 5 3 8 2 5 I
1.5 2 0 1 0 4 3
2 2 0 0 0 2 0
Mean 1 0.27t 0.79 0.18t 1.2 I$

*No. of subjects.
$Significantly lower than day No. 0’, p = .03.
*Not significantly different from day No. 0’, p = .35.

level at day No. 0’ and day No. 33 are shown in Figs. 2
and 3.
DISCUSSION AND CONCLUSIONS
Although there are many references about the
importance of denture cleanlinessin maintaining oral
health, little experimental data in denture wearers
could be found.
I believed that a sound experimental basis linking
denture plaque with oral pathology was neededto help
clearly delineate the factors that might be contributing
to mucosaldiseaseand to provide a meansfor evaluat-
ing effects of treatment. Hopefully, resultsof this study
will lay the foundation for such a data base.
In this study the overall percent of subjects with
somelevel of pathology on entering the study (66.7%)
was considerably higher than the 43.3% reported by
Love et al.* I believe that this might be due to
consistently poor oral hygiene habits in our older study
group.
Several factors have been proposedin dental litera-
ture as being involved in the etiology of denture
stomatitis, also called denture sore mouth. The three
mostoften cited are trauma from poor-fitting dentures,
Cundidu infection, and lack of denture cleanliness.Of
these, only Candida has been well studied.
As to the role in mucosal irritation of trauma from
poor-fitting dentures, Sheppard et a1.,13contrary to
expectations, showed that subjectswith maximal den-
ture retention had more papillomatous lesionsthan did
those with less retention. In addition, mandibular
dentures are notoriously ill fitting; yet the incidenceof
inflammatory mandibular lesionsis very low. Mucosal
irritation has also been associatedwith continuous
wearing of dentures, and the incidenceof inflammatory
lesionsis reducedin thosewho removetheir denture for
6 to 8 hours each day.
Each of these observations can be adequately
explained if the denture is consideredto be a “plaque
applicator,” as suggestedby Penhall.14 By holding
plaque massesin contact with the oral mucosa for
extended periodsof time, the toxic effects, asevidenced
by mucosalabnormalities, are aspredictable in denture
wearers as they are in the periodontal patient. When
this intimate relationship is interrupted, tissue health
improves. The most important aspectof control of this
interface is good denture hygiene.
Currently, patient attitudes do not reflect adequate
educational emphasisregarding home care procedures
for denture wearers. Thus, from surveys as recent as
1977 and 1978, Bauman” has reported that 65% and
40.8% of patients, respectively, had received no
instructions for home care of their dentures. Clearly,
greater efforts, oral and/or written, must be made by
dentists to educate denture patients in proper denture
hygiene practices. Such renewed efforts would make
more of these patients aware of the consequencesof
neglecting regular hygiene.
In establishing good cleansing programs with den-
ture patients, dentists must also recognize two distinct
levels of patient interest. First, and at present of
paramount concern to the patient, is the social or

Fig. 2. Subject No. 1. A, Denture plaque at day No. 0’. B, Tissuecondition at day No. 0’.
C, Denture plaque at day No. 33. D, Tissuecondition at day No. 33.
Fig. 3. Subject No. 2. A, Denture plaque at day No. 0’. B, Tissuecondition at day No. 0’.
C, Denture plaque at day No. 33. D, Tissuecondition at day No. 33.

THE JOURNAL OF PROSTHETIC DENTISTRY 651

 TARBET

cosmetic aspect of cleansing. This has been widely 2. L&z, H.: Experimental gingivitis in man. J Periodont Res
!2:282, 1967.
promoted by many manufacturers of commercial den-
3. Lee, H.: Human research model for the production and
ture cleansers. Second, and far lower in priority, is the
prevention of gingivitis. J Dent Res 50~256, 1971.
need to thoroughly remove denture plaque at regular 4. Liie, H., Theilade, E., Jensen, S. B., and Schioot, C.: Experi-
intervals, especially on the tissue-fitted surfaces. Many mental gingivitis in man. III. The influence of antibiotics on
patients believe that fulfilling the first need automati- gingival plaque development. J Periodont Res 2~282, 1967.
5. Theilade, E., Wright, W. H., Jensen, S. B., and L6e, H.:
cally takes care of the second.16
Experimental gingivitis in man. II. A longitudinal clinical and
Data from the present study show just how errone-
bacteriological investigation. J Periodont Res l:l, 1966.
ous this belief is. Fifty percent of the subjects entering 6. Fisher, A. A.: Allergic sensitization of the skin and oral mucosa
phase II of this study reported that they used a paste to acrylic resin denture materials. J PROSTHET DENT 6~593,
and brush to regularly clean their dentures. It is 1956.
7. Nyquist, G.: The influence of denture hygiene and the bacterial
obvious from the changes induced in both the plaque
flora on the condition of the oral mucosa in full denture
and tissue irritation scores when a rigorous cleansing wearers. Acta Odontol Stand 11:24, 1953.
regimen was instituted that the previous brushing 8. Love, W. D., Goska, F. A., and Mixson, R. J.: The etiology of
habits were totally inadequate. Once instructed in the mucosal inflammation associated with dentures. J PROSTHET
procedure to follow, compliance was quick and thor- DENT l&515, 1967.
9. McKendrick, A. S. W.: Denture stomatitis and angular chilitis
ough in most subjects. In addition, when the rigorous
in patients receiving long-term tetracycline therapy. Br Dent J
denture hygiene program in this study was followed,
124~412, 1968.
many of the subjects commented on how much cleaner 10. Budtz-Jorgensen, E., and Bertram, U.: Denture stomatitis, I.
their dentures appeared and felt in the mouth. Thus, it The etiology in relation to trauma and infection. Acta Odontol
appears that focusing on a procedure wherein the more Stand 28~71, 1970.
11. Abelson, D. C.: Denture plaque and denture cleansers. J
important health aspect of cleansing (plaque removal)
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is accomplished also allows accomplishment of the
12. Renner, R. P., Lee, M., Andors, L., and McNamara, T. J.:
other need (esthetics); the reverse does not appear to be The role of C. albicans in denture stomatitis. Oral Surg 47~323,
generally true. 1979.
Dentists should accept responsibility for providing 13. Sheppard, I. M., Schwartz, L. R., and Sheppard, S. M.: Survey
adequate instruction in denture home care as an of the oral status of complete denture patients. J PROSTHET
DENT 28~121, 1972.
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14. Penhall, B.: Preventive measures to control further bone loss
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program can be of benefit to both the patient and the 15. Bauman, R.: Survey of dentists’ attitudes regarding instructions
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tissues.
16. Tarbet, W. J: Unpublished data.
I thank Mr. B. C. Tillery, Manager of R&D Publications, for
editorial assistance, and Mr. Salvatore Colucci for the statistical Heprlnl reyues1s lo:
analyses. MR. B. C. TILLERY
VICK ORAL SCIENCES RESEARCH CENTER
REFERENCES
ONE FAR MILL CR~~SINC
1. L&Z, H., Theilade, E., and Jensen, S. B.: Experimental SHELTON, CT 06484
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652 DECEMBER 1982 VOLUME 48 NUMBER 6