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 Côte-Sainte-Catherine Montreal, Quebec, H3T 1E2 Phone: (514) 340-7911 Fax: (514) 340-7514 Email: mgornits@den.jgh.mcgill.ca

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or Efferdent appeared to have a similar reduction in the level of plaque. stain and plaque accumulation was assessed.13) and Polident (P= 0.12) in comparison to the control group. all differing substantially from the control group. using the general linear model (SAS).01) were significantly greater than the control group. the efficacy in the reduction of food. Dentures that received Denture Brite. was related to the variance between study periods (F= 0. The significant difference in the rank of fungi count noted (P= 0. whereas dentures that received Efferdent had significant Streptococci mutans reduction (P= 0.02). Keywords: fungus. hospitalized geriatric population. dementia and poor dexterity.Abstract Elderly patients in long-term care hospitals cannot adequately brush their dentures due to disease. 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. For the statistical analysis.10) (Table 1).005).008). Considering all study periods. no significant difference in fungi or Streptococci mutans reduction was observed between all cleansers. Streptococci mutans. The use of denture cleansers significantly reduced the number of microorganisms. The rank of the differences of the fungi before and after the use of Denture Brite (P=0.01) and the variance between subjects (P= 0. but not with Efferdent (P=0. Microbiological samples were taken before and after each treatment by a microbiologist blinded to the assigned treatment. stain. the rank scores of the differences between the pretreatment and post-treatment scores of each treatment regimen were compared. and food. Additionally.04) and Polident (P=0. denture cleansure. 2 . Polident. No significant differences in Streptococci mutans reduction was observed between Denture Brite (P= 0. This may allow for the multiplication of bacteria and fungus.

1.4 Studies have revealed that poor dental hygiene and candida albicans infections are very common among elderly denture wearers. tartar.5 As well. The importance of clean dentures in these patients is not to be underestimated.3.12 Brushing alone has been indicated to be insufficient for denture plaque control. and stain cause irritation and subsequent tissue response. and pneumonia in patients with chronic obstructive pulmonary disease.8 however it was recently noted that periodontal disease did not significantly increase the risk of coronary artery disease. nurses in institutions are overburdened making it difficult for them to care for their patient’s dentures.7.2. or denture and palate. Patients. bacterial plaque and dental calculus are often found on denture surfaces. nursing staff. 3 These microorganisms may also serve as a reservoir for disseminated infections with gastrointestinal and pleuropulmonary involvement. 1. Food under dentures between denture and gingiva.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. 13 Information provided by the American Dental Hygienist Association on the care and cleaning of dentures recognized the value of commercially prepared denture powder. authorities.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.10 Fungal or bacterial infections may cause subacute bacterial endocarditis in patients with artificial heart valves. and patient’s relatives showed a lack of understanding of the oral hygiene needs of geriatric patients especially for the denture wearers. allow for the multiplication of bacteria and fungus which cause denture stomatitis 1 and multiple papillomatosis of the palate.11 It was revealed that denture cleaning and plaque elimination is a neglected function in most old age homes.3. however. 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. 3 . Regardless of their cleaning efforts. soft debris.9 Candida pneumonia has been reported in a non-immunosuppressed host. Dentures containing debris. paste or tablets.

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

Denture Brite TM TM was used initially overnight. During the study. Patients. Randomization and Blinding Subjects were distributed at random into four groups including the three denture cleansers and water (control group). patients were assigned to three denture cleansers or water (control group). These cleansers were used for all study periods (three weeks). before each cleanser day (day 1st . the primary outcome was the reduction of oral fungus and Streptococci mutans obtained after the use of the treatment protocol. Data Collection Laboratory assessment of the number of bacteria and fungi One week prior to initiation of treatment. 29th) and after the use of the cleanser for seven days (day 5 . Streptococci mutans and fungal cultures were taken on the first day of each week of testing. 15th.Treatment Protocol In this study. for 5 minutes to standardize the number of bacteria and fungus on the dentures. Additionally. tartar and plaque on the dentures after treatment. The soaking time for Polident Overnight TM and Efferdent New Concentrated Blue Tablet was overnight. all dentures were cleaned in an ultrasonic bath. two dental hygienists were responsible for the treatment protocol. These established periods were based on the manufacturer’s instructions. the microbiologist responsible for the cultures. following this for 20 minutes each day. 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). The secondary outcome was the decrease in the score of food accumulation. stain. and the dentists involved in the evaluation of the dentures were blinded to the assigned treatment group. and water was used only in the first period (first week). Study Outcome In the intention to treat analysis.

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

02) (Table 1). P = 0. revealed that 14 (52%) of the subjects presented with denture stomatitis.10) (Table 1). 3 df.8 years ). three refused and five that accepted were discharged after randomisation. 15. included in this study .38). consisted of 14 males and 13 females. but not with Efferdent (P=0. According to the Newton classification.09.efficacy. and plaque between the four treatments were used additionally to assess the efficacy of the cleansers. Efficacy of cleansers The rank of the differences of the fungi before and after the use of Denture Brite (P=0. Additionally. The differences of the mean score in food accumulation.59). 20% grade 2b. a 7 . 22. In a multivariate analysis. 13% grade 3a and finally 13% grade 3b. 4 df.04) and Polident (P=0. 13% grade 2a. whereas dentures that received Efferdent had significant Streptococci mutans reduction (P=0.94.37) and = 3. General linear model was used to assess these outcomes. 29) and after the treatment protocol regimen (day 8. during all periods. A great variance in the count of the fungi and Streptococci mutans between cleansers was noted during the different study periods.13) and Polident (P=0. age ( = 1. and 36) were used to compare the efficacy between all cleansers. The remaining 27 patients. 3 df. but before the data was collected. The results of the intra-oral examination of the 27 patients. P = 0. From these. two were not eligible to participate due to their emotional state. P = 0.10. No difference was noted between groups related to the presence of stomatitis ( gender ( 2 2 2 = 1. Results Thirty-seven patients were invited to participate in this study. As these differences were not normally distributed. with a mean age of 84 (SD. 40% patients were classified in Grade 1. a rank of these differences was used in the analyses.12) in comparison to the control group. No significant differences in Streptococci mutans reduction were observed between Denture Brite (P=0. including all study periods. Data analysis was accomplished with SAS software.01) were significantly greater than the control group. 8. stain. these differences before (day 1.

No difference was observed between Denture Brite and Polident (P=0. P=0.69) (Table 2). and food. are effective against fungi in comparison to water.53.25) or between Polident and Efferdent (P=0. stain. We also noted that the use of cleanser significantly reduced the amount of food. stain and plaque on the dentures (Table 3).31. P= 0. Nevertheless the difference was associated to the variance between study periods (F=4. P=0. period (F= 0. In addition. Polident.01) and to the variance between subjects (F=2.34. or Efferdent appeared to have a similar reduction in the level of plaque.06) than those with Efferdent.37. In contrast. Efferdent had a significant reduction in the number of Streptococci mutans when compared with water.43).22).16). Discussion The results of this study revealed different levels of effectiveness between cleansers depending on the type of micro-organism. 8 . we noted a considerable reduction in the number of micro-organisms before and after the use of cleanser (Table 1). this difference was not related to the treatment sequence (F=1.significant difference in the rank of fungi count was noted (F=2. Denture Brite and Polident. However.76. or sequence (F= 0. However. P=0. P=0. P= 0. Efficacy in dislodging food and reducing stain.005). this difference was not related to the treatment (F=1. The use of denture cleansers appears to be “clinically” useful in the reduction of micro-organisms.25.34. Dentures that received Denture Brite appeared to have significantly greater reduction in the number of fungi (P=0. P=0.69). These differences were significantly different than the control group (Table 3). tartar and plaque Dentures that received Denture Brite. when compared with water.38.008) (Table 2). The rank difference related to Streptococci mutans revealed no significance between individuals (F= 1. P=0. treatment group (F= 0.27).74).95. P= 0.

the microbiologic quantification. the large difference in the number of microorganisms may explain the variability in our study and probably the controversy between studies. We do not have an explanation for this. In another study. The validity of the results of this study is related to its methodology. and the unspecified type of fungus. Further. The individuals were selected in one location. 9 . in spite of obvious inter-operator subjectivity. including 15 individuals wearing maxillary and mandibular complete dentures. Further. Finally. the most accurate method to examine the microbial plaque was applied in this study 15. stain and plaque. 17 McCabe et al . contribute to the validation of our results. It has recently been suggested that micro-organisms in denture plaque from the whole surface of the denture is preferable 15. between cleansers noted in the multivariate analysis. the very good agreement between dentists in the scores related to food. However. Efferdent was a little more effective than Polident. it was not possible to verify if individuals during the day cleaned their dentures. did not find significant difference related to the reduction of calculus 16. but less effective than other cleansers (Mersene and Clorox-Calgon). which may limit the generalization of the results. Another advantage was the long washout period to accumulate bacteria and fungi.It was interesting to note that the significant difference in fungus. In addition. However. and the microbiologist was blind to the assigned treatment. Treatment was applied by two trained hygienists. this may not have occurred due to the physical limitation of the patients. It must be noted that the effects of the cleanser in vivo are constantly being challenged by the continued daily ingestion of food. following the same protocol in order to decrease bias among groups. was not related to the type of cleanser but to the variability between study periods and subjects (Table 2). Another constraint of this study was the evaluation of microbes only in a specific position of the denture. even if this occurred. However this study has some limitations. it should not allow for differentiation between treatments. in the reduction of plaque. Individuals were not informed about the study hypotheses.

Research Assistant. Acknowledgements We wish to thank Dr. as well as Thierry Ducruet and Lubo Alexandro of the Centre for Clinical Epidemiology and Community Studies at the Sir Mortimer B. This study received financial assistance from Advantage Products Ltd for Denture Brite.The significant reduction in the number of micro-organisms. Quebec. 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. and Dr. Faculty of Dentistry. Canada. Montreal. stain and plaque noted in this study suggests that denture cleansers are indicated for cleaning dentures in the geriatric hospitalized population. Davis-Jewish General Hospital. Pfizer Warner-Lambert Consumer Group for Efferdent and GlaxoSmithKline for Polident . Jean Barbeau. particularly for elderly individuals with a lack of manual dexterity. Microbiologist and Jacinthe Séguin. 10 . Louis De Koninck. Of concern. for their assistance in the statistical analyses. Université de Montreal. food. 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.

3 Efferdent 84 52.4 57.1 285095.5 Polident 83.4) 666332.6) 51.1) 117166.8) 361250 (270.1) 373675 (124683.Table 1: Characteristics and difference after treatment during first study period.3) 25130 (156900.8) 21974.2 52.5) 22.5 (286998.3 33.5 19.3 (301523.4* 42 (42545.3 145558.3 (960145.4* (1272414.05) 1 Rank difference Standard Deviation (SD) 11 .7) 133 (9895869.4) 43.1 560173.3) 58.6 52.1) 76.7 (37271.7 (1179.8) 108950 (584756.7 (499248.4 57.1 732950 Control (Water) 80 33.4 57.5) 445. 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 79.6 51.6 rank 1 Significant difference noted between cleanser and control in first study period (P< 0.1 (181975.3* 41.6) 181550 (187.8) 495541.7 (624579.

86 62.14 18.94 14.07 13.22 25. stain and food after treatment first study period Treatment Groups Denture Brite Polident Efferdent Control Plaque 16.78 *Significant difference was noted between all cleansers against the control group (P> 0.95 65.83 Stain 16.0001).Table 2 Difference in level of plaque.06 18. but not between the cleansers 12 .62 61 Food 20.57 21.

4** P1 41.4 46.4 43.4 44.9** 42. No significant difference related to Streptococci mutans was noted (P> 0.1 52.6 P2 36.7 32.1 32.7 Fungi Streptococci mutans P3 29.7 42 51.2 47.8 43.3 58.6 44.Table 3 Rank of the difference after treatment during study Treatment Groups Denture Brite Polident Efferdent P1 51.05) 13 .3 42.8 46.06).7 38.2 P3 34.6 All 48.3 All 39.4 P2 42.9 **Tendency to a significant difference in the rank of fungi noted between cleanser Denture Brite and Efferdent including all study period (P= 0.

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