Professional attitudes toward denture adhesives: A Delphi Technique

survey of academic prosthodontists

Ann Slaughter, DDS,a Ralph V. Katz, DMD, PhD,b and Joseph E. Grasso, DDS, MSc
University of Connecticut Health Center, Farmington, Conn.
Statement of problem. The use of denture adhesives and their role in prosthodontics has been an
intriguing and conflicted topic, both in clinical practice and dental education.
Purpose. This study generated discussion, and if possible, obtained a consensus on a series of issues related
to denture adhesives among a group of leading academic prosthodontists.
Material and methods. The Delphi Technique survey method was used. It consists of a series of survey
questionnaire rounds to a panel of experts to either develop a consensus (>70% agreement) or to clarify the
reasons for multiple schools of thought on a topic. A 24-item Delphi questionnaire was sent to an expert
panel that consisted of a 33% regionally stratified random sample of program directors of undergraduate
complete denture courses in US dental schools. The 5 major topic areas on denture adhesives addressed by
the questionnaire items were (1) general perceptions, (2) specific clinical uses/misuses, (3) patient educa-
tion, (4) inclusion in dental curriculums, and (5) overall opinions of utility.
Results. Of the 18 randomly selected panelists, 94% (n = 17) agreed to participate, with either 16 or 17
fully participating in each of the 3 survey rounds. The panel achieved consensus and clearly concluded that
denture adhesives: (1) are a useful adjunct in denture prosthesis services, having specific roles in both the
fabrication and postinsertion phases; (2) had the potential for misuse, both by dentists and by patients; and
(3) should be an integral part of patient education for all denture patients and of the undergraduate dental
curriculum. However, the panel was unable to achieve consensus on whether denture adhesives should be
used at the postinsertion phase for immediate denture patients and whether, on the whole, they were a ben-
eficial adjunct in denture patient management (59% agreed they were). The panelists also clearly expressed
their concerns that neither dentists nor patients should use denture adhesives as a substitute for either good
clinical practices or proper denture maintenance routines.
Conclusions. This panel of leading academic prosthodontists concluded that denture adhesives are a use-
ful adjunct in denture prosthesis services, with specific roles in both fabrication and postinsertion phases.
They also indicated that only through education, for dentists and patients, would the dual goals of maximiz-
ing the beneficial aspects of denture adhesive use while minimizing the misuse of denture adhesives be
achieved. (J Prosthet Dent 1999;82:80-9.)

CLINICAL IMPLICATIONS
The panelists in this survey concluded that denture adhesives are a useful adjunct in
denture prosthesis services, with specific roles in both the fabrication and postinsertion
phases. The panelists also pointed out the potential for misuses of denture adhesives, by
both dentists and patients. They also indicated that the way to maximize the beneficial
aspects of denture adhesive use, while maximizing the misuse of denture adhesives was
by education, namely, in both undergraduate didactic curriculum and in the dental
clinics through a routine and rigorous education program for all denture patients.

T he use of denture adhesives and their role in

prosthodontics is an intriguing topic because it has
received so little attention in the formal training of den-
tists, despite their widespread use among denture wear-
aNIDR/NIH NRSA Fellow, Department of Epidemiology, University
of Michigan; former Geriatric Dental Fellow, Travelers Center on
Aging, University of Connecticut Health Center.
bProfessor, Department of Behavioral Sciences and Community
Health, School of Dental Medicine, University of Connecticut
Health Center.
cProfessor, Department of Prosthodontics, School of Dental Medi-
cine, University of Connecticut Health Center.
ers. The topic of denture adhesives produces conflict-
ing viewpoints among dental professionals, which can
be described as (1) the traditional historical position
and (2) the advocate position.
The traditional historical position regards denture
adhesives as nothing more than a poor substitute for
proper fit and adjustment, and the use of denture adhe-
sives is equated with poor clinical skills and a lack of
prosthetic expertise.1,2 It was reported that the prevail-
ing opinions in educational institutions supports the
traditional historical position on denture adhesive use.1
Moreover, there is no statement in the current curricu-

80 THE JOURNAL OF PROSTHETIC DENTISTRY VOLUME 82 NUMBER 1

SLAUGHTER, KATZ, AND GRASSO
lum guidelines for dental schools mandating that the
use of denture adhesives should be included in prostho-
dontics requirements.3
In contrast, dentists who support the advocate
position suggest that denture adhesives can facilitate
clinical procedures, patient acceptance, and patient sat-
isfaction. They suggest denture adhesives can be used
to stabilize trial bases for accurate jaw relations and
improve the accuracy of the trial denture try-in stage of
denture fabrication.4 In addition, they suggest that
denture adhesives allay patients’ fears with respect to
the fit of the final processed denture, namely, feeling
more confident and secure are major underlying rea-
sons for denture adhesive use.2,4 Furthermore, advo-
cates feel that there are many beneficial uses for denture
adhesives that include increased stability and reten-
tion,5-8 reduction in denture mediolateral movement
and dislodgment, and greater levels of incisal bite force
during function.6,8-10
Despite the lack of attention to denture adhesives in
the dental curriculum historically, and the conflicting
viewpoints held within the dental profession, these facts
have not impeded millions of denture wearers from
buying and using the product. Annual US sales figures
for 1996-97 reveal that 55 million units of denture
adhesives (powders, pastes, and creams) were sold for
over $200 million dollars.11
Although the Delphi Technique has been widely
used for surveying experts to obtain a consensus on a
given topic of interest in the broad field of health
research,12-20 the use of the Delphi Technique within
dentistry has been limited. Only 6 studies in the dental
literature were identified with use of the Delphi survey
method and they covered such topics as the accessibili-
ty and availability of dental services for handicapped
adults; the development of an operational definition of
oral neglect for institutionalized elderly; a clinical per-
formance scale to evaluate implant systems retaining
mandibular overdentures; developing quality assess-
ment standards for diagnostic radiology; improved
dental care for the mentally ill elderly; and, predictions
of dentistry in the future.21-26 There is a recent study
of patient responses regarding the effectiveness of den-
ture adhesives27; however, a thorough review of the
dental literature revealed no published reports or sur-
veys regarding clinicians or educators opinions’ on the
role of denture adhesives in prosthodontics or their
appropriate use.
The purpose of this study was to generate discussion
and communication among a group of leading
prosthodontic educators on their viewpoints regarding
denture adhesives. Specifically, this was an effort to
provide a clarification on the wide array of issues on
denture adhesives. Such information could serve both
the dental profession and dental patients by presenting
both the range and distribution of professional opin-
JULY 1999
THE JOURNAL OF PROSTHETIC DENTISTRY
ions and beliefs of leading clinical educators on the
topic of denture adhesives. This study also presented a
forum for both those holding the traditional historical
and the advocate viewpoints to clarify their points of
agreement and disagreement on specific issues related
to the clinical use of, and educational practices related
to, denture adhesives. Ultimately, this survey could
provide more knowledge for clinicians and for dental
educators to counsel both patients and dental students
on the proper use and misuse of denture adhesives
given the reality of product use that reflects the per-
ceived need by the public for this product.
MATERIAL AND METHODS
This survey method was based on the Delphi Tech-
nique (Rand Corporation, 1950), a social science
method of research that aims to structure group opin-
ion and discussion from a panel of experts in the field
of interest through serial rounds of questionnaires. It
permits an interchange of information and opinion
without having to assemble the experts at 1 location for
a round table discussion and avoids the dominance of
any person’s opinion in the “discussion,” as all shared
responses are anonymous to the other panelists. The
goal of the Delphi Technique is either to develop a
group consensus for each question or to clarify the rea-
sons for multiple schools of thought on those questions
that fail to achieve a consensus among panelists.
The logistics of the Delphi Technique are as follows.
On round 1, panelists select their answers to the ques-
tions presented. All round 1 questions that achieved a
group consensus are considered complete and are not
presented for discussion in round 2. In round 2, all
questions that do not achieve a group consensus in
round 1 are repeated in round 2 to those individual
panelists whose responses were outside the majority
opinion, namely, those holding a minority opinion for
that given question. These panelists are requested to
state their decision to either join the majority opinion
or to maintain their minority position. Should the pan-
elist choose to remain in the minority position, they
must briefly state the reasons justifying their decision.
On round 3, questions that did not achieve consensus
after round 2 are presented to those individual panelists
of the majority opinion for that given question to
develop counter-arguments to the reasons given by
those defending minority opinions in round 2. If nec-
essary, a fourth round can continue the process to seek
a consensus with panelists who still remain in the
minority position responding to the counter-arguments
in round 3.
To conduct this Delphi study on denture adhesives,
a 43-item self-administered questionnaire was devel-
oped that emphasized the following topics regarding
denture adhesives: (1) general perceptions; (2) specific
uses and misuses; (3) role in denture service, including
81
THE JOURNAL OF PROSTHETIC DENTISTRY
patient education on denture adhesives; (4) inclusion
of denture adhesives in undergraduate dental curricu-
lums; and (5) an overall opinion of the clinical uses of
denture adhesives. A 4-point scale of measurement
(strongly agree, agree, disagree, or strongly disagree)
defined answer responses to questionnaire items. Addi-
tional space was included on the questionnaire under
each topic for respondents to write in comments. The
questionnaire was pretested by a group of academic
prosthodontists who are practicing clinicians and by an
oral epidemiologist. The study protocol was reviewed
by the Institutional Review Board at the University of
Connecticut Health Center and obtained expedited
review approval.
This Delphi study on denture adhesives was designed
to have 3 rounds of questionnaires. After completion of
round 3, any responses that had not achieved consensus
were classified as nonconsensus items. The round 1 sur-
vey packet was mailed to panelists and included a cover
letter, a demographic questionnaire to provide data on
the panelists regarding academic training, job descrip-
tion and academic teaching activities, round 1 ques-
tionnaire with instructions for completion, and a self-
addressed return envelope. Panelists were instructed to
return the demographic and round 1 questionnaires in
the self-addressed return envelope within 1 week (a spe-
cific date was stated in the cover letter). Panelists were
telephoned on the day the questionnaire was to be
delivered to confirm they had received the question-
naire. Nonrespondents at the return due date were
telephoned as a reminder to return the questionnaire
within 2 days or be excluded in the data analyses for that
round. Data were entered and verified using the SPSS
data entry and statistical program (SPSS Inc., Chicago,
Ill.). Descriptive statistics were generated for each des-
ignated Delphi question to determine whether a con-
sensus had been achieved on each question.
The survey packets for rounds 2 and 3 were mailed
to panelists 2 weeks after the receipt of the previous
round’s questionnaires. Both rounds 2 and 3 survey
packets included a cover letter, an individualized ques-
tionnaire to panelists, and a self-addressed return enve-
lope. Panelists were given 1 week to return the ques-
tionnaires from rounds 2 and 3. The same mailing,
confirmation and follow-up procedures were followed
as in round 1. The round 2 questionnaire, individual-
ized for each panelist, addressed those questions for
which their individual responses on round 1 had been
included among the minority opinions. The round 3
questionnaire addressed those questions that did not
achieve a consensus response among panelists on round
2. For remaining nonconsensus questions on round 3,
round 2 comments from those panelists holding the
minority opinions were sent to those panelists who held
the majority opinion on round 1 for that specific ques-
tion, and those persons were asked to either convert to
82
SLAUGHTER, KATZ, AND GRASSO
the minority opinion or to provide brief justifications
for maintaining their majority opinion.
The panel of 18 experts identified for this Delphi
survey on denture adhesives was composed of a 33%
stratified random sample of program directors of the
undergraduate complete dentures curriculum of the 53
US dental schools. Dental schools were stratified into
regions: South (n = 16), Northeast (n = 14), Midwest
(n = 15), and West (n = 8). Within each region, dental
schools were numbered and a table of random numbers
was used to select the target number of 18 dental
schools for inclusion in this study, which was propor-
tional to the overall regional distribution of US dental
schools. A reserve list of 3 eligible schools within each
region was also randomly selected in case the selected
target school was unable to participate. Selected target
schools were telephoned to obtain the specific name of
the program director of undergraduate complete den-
tures curriculum. The identified program directors
were recruited into the study through telephone con-
tact by the investigators.
Before the round 1 questionnaire was mailed, the
following decisions were made regarding data analyses.
(1) Of the 43 total number of items on the round 1
questionnaire, 24 specific questions were designated as
Delphi questions for analyses. (2) Operational defini-
tions of opinion category were (a) consensus opinion
required a 70% agreement or better of the sample, (b)
majority opinion meant 51% to 69% agreement of the
sample, (c) minority opinion meant less than 50% of
the sample. (3) Primary analysis would collapse the 4-
point spectrum of responses (strongly agree, agree, dis-
agree, and strongly disagree) into 2 broad categories
(agree and disagree) to calculate consensus opinions for
any given question in each round. (4) The full 4-point
spectrum of responses would be used only in secondary
analysis discussions to discern the intensity of the pan-
elists’ opinions.
Two alterations in the study design were made with-
in the Northeast region. One selected target school was
replaced by the first eligible school on the reserve list
for that region as a result of repeatedly not being able
to contact the target school’s complete dentures pro-
gram director. Secondly, 1 selected target school was
replaced by the second eligible school on the reserve
list for that region to eliminate having 2 schools from
the same city. One original panelist in round 1 returned
the questionnaire unanswered and requested to be
eliminated from this study resulting in the final sample
being 17 participating schools. Investigators made the
decision not to choose an alternate school to replace
this panelist, given that the study had already been ini-
tiated. Thus, of the 18 chosen and contacted program
directors, 94% (n = 17) participated in the survey.
The original round 1 questionnaire consisted of 24
separate Delphi Technique questions organized in the
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Table I. The 17 directors* of undergraduate complete Table II. Topic I: Perceptions of denture adhesives, question 1
denture courses in US dental schools who comprised the
Delphi Technique panelists in this survey of academic Question 1: Denture adhesives have the potential (either positive
or negative) to influence the following:
prosthodontists
a) Enhancing the fit of the prosthesis (ie, the retention and
Participating dental schools Program directors/panelists stability)
SA = 5%, A = 71%, D = 12%, SD = 12%
Southern Region
The panel achieved a consensus with 76% agreeing on round 1.
Howard University Dr Lynette Stuart
b) Avoiding good clinical practice
Medical College of Virginia Dr Donald Crabtree
SA = 24%, A = 59%, D = 12%, SD = 5%
University of Florida Dr Venita Sposetti
The panel achieved a consensus with 83% agreeing on round 1.
Louisiana State University Dr John Shannon
c) Providing a psychological comfort to the denture patient
University of Maryland Dr Stuart Prymas
SA = 29%, A = 71%, D = 0%, SD = 0%
Northeast Region
The panel achieved a consensus with 100% agreeing on round 1.
Tufts University Dr Nancy Arbree
d) Masking underlying denture problems
University of Pennsylvania Dr Gerald Weintraub
SA = 76%, A = 24%, D = 0%, SD = 0%
Temple University Dr George Monasky
The panel achieved a consensus with 100% agreeing on round 1.
University of Connecticut Dr Jacquelyn Duncan
e) Contributing to patients not seeing a dentist for recall and/or
University of Dentistry of New Jersey Dr Ronald Haeberle
to avoid fees (ie, spending money) associated with denture
Midwest Region
care, adjustment, or replacement
University of Illinois at Chicago Dr Stephen Campbell
SA = 76%, A = 24%, D = 0%, SD = 0%
Indiana University Dr Steven Haug
The panel achieved a consensus with 100% agreeing on round 1.
University of Iowa Dr James Clancy
University of Louisville Dr Jack Morris
University of Detroit Mercy Dr Rick Jude
West Region
University of Southern California Dr Richard Phillips comment sections.) For each question, panelists had
University of the Pacific Dr Eugene La Barre the opportunity to make comments, and a summary of
*One of the original 18 enrolled directors chose not to participate in the sur- these comments is also provided for each question.
vey after receiving the round 1 questionnaire. In response to the 5 subquestions that addressed the
potential that denture adhesives have to influence
aspects of denture treatments, panelists reached a con-
questionnaire as 9 stem questions with 4 of the ques- sensus on all 5 aspects in round 1 (Table II). Panelists
tions having from 3 to 6 subquestions. In addition, the concurred that denture adhesives have the potential to
round 1 questionnaire consisted of 8 demographic data enhance the fit of the prosthesis (76%) and to provide
items on the respondents and an 11 additional ques- psychologic comfort to the patient (100%). They also
tions that were intended as 1-time survey questions, concurred that denture adhesives have the negative
namely, not a part of the Delphi process. This study potential to permit avoidance of good clinical practice
reports on the findings from the 24 Delphi questions (83%), to mask underlying denture problems (100%),
and the 8 demographic data questions. and to contribute to patients not seeing a dentist for
recall visits (100%).
RESULTS
In their additional comments related to these 5 sub-
Table I represents a listing of the participating pan- questions, panelists noted that patients’ expectations
elists for this study. As a group, this expert panel of play a big part in their satisfaction with their dentures
prosthodontic specialists consisted of full-time academ- and some patients expect too much from a complete
ic faculty who, on the average, had been in the field of denture prosthesis. Although panelists indicated adhe-
prosthodontics 19 years with 88% having certificates in sives can provide a feeling of well-being for denture
prosthodontics, 71% having a master’s degree, and 85% patients, they pointed out that adhesives may prevent a
of the panel currently practicing dentistry either intra- patient from returning to the dentist for recall appoint-
murally or extramurally. ments, leaving the patient unaware that the denture no
Panelists were instructed to circle 1 choice of either longer fits properly. With respect to clinical practice,
strongly agree (SA), agree (A), disagree (D), or strong- some experts’ opinions were that the dentist may pay
ly disagree (SD) in response to each question. Tables II less attention to fabrication steps (proper border exten-
through VII present the questions in their final format sion, posterior palatal seal placement, and jaw relation
accompanied by the distribution of panelists’ respons- records) when a “crutch” is available and the emphasis
es. (Most questions retained their original wording should be on “proper” clinical evaluation and technique.
throughout the Delphi rounds, whereas 2 questions Although the panel was in 100% agreement that denture
evolved into their final wording over the sequential adhesives provide a sense of comfort to the denture
rounds through suggestions from respondents in the patient, several panelists noted that a contributing factor

JULY 1999 83
THE JOURNAL OF PROSTHETIC DENTISTRY
Table III. Topic I: Perceptions of denture adhesives, ques-
tion 2
Question 2: In your clinical opinion, denture adhesives can con-
tribute to the development of the following conditions:
a) Oral cancer
SA = 0%, A = 18%, D = 59%, SD = 23%
The panel achieved a consensus with 82% disagreeing on round 1.
b) Denture stomatitis
SA = 18%, A = 65%, D = 12%, SD = 5%
The panel achieved a consensus with 83% agreeing on round 1.
c) Leukoplakia
SA = 5%, A = 24%, D = 59%, SD = 12%
The panel achieved a consensus with 71% disagreeing on round 1.
d) Candidiasis
SA = 12%, A = 71%, D = 12%, SD = 5%
The panel achieved a consensus with 83% agreeing on round 1.
e) An imbalance in the oral flora due to microbial contamination
SA = 12%, A = 63%, D = 19%, SD = 6%
The panel achieved a consensus with 75% agreeing on round 1.
f) Resorption of the alveolar bone as a result of tissue irritation
SA = 29%, A = 47%, D = 24%, SD = 0%
The panel achieved a consensus with 76% agreeing on round 1.
to this psychologic security need was the denture manu-
facturers who, through their advertisements, portray
exaggerated attributes (biting into an apple with the
appropriate sound effects) of the product. Further, the
panel, having concurred that the use of denture adhe-
sives could prevent a patient from recognizing that the
denture was not fitting properly, expressed a concern
that this could lead to a “false” sense of security for the
patient using the denture adhesive.
Table III shows that panelists reached a consensus
on round 1 regarding the 5 questions on the etiologic
relationship between the use of denture adhesives and
6 oral diseases or conditions. Panelists concurred that
denture adhesives contribute to the development of
denture stomatitis (83%), candidiasis (83%), imbalance
of oral flora as a result of microbial contamination
(75%), and resorption of alveolar bone (76%), but not
to the development of oral cancer (82%) or leukoplakia
(71%). In their additional comments, some panelists
expressed concerns that denture adhesives would con-
tribute to alveolar bone resorption by causing an
uneven seating of denture bases on the residual ridge,
thereby leading to occlusal problems and interferences,
which in turn would lead to further movement of the
dentures and, ultimately, to ridge resorption.
On the 5 subquestions on the specific clinical use
and misuse of denture adhesives, panelists achieved
consensus for 4 of the 5 questions (Table IV). In round
1, panelists concurred that denture adhesives were use-
ful to stabilize trial bases during the early stages of den-
ture fabrication (88%) and to allay the patient’s fears at
the trial arrangement of denture teeth (76%), but were
84
SLAUGHTER, KATZ, AND GRASSO
Table IV. Topic II: Specific clinical use and misuse of den-
ture adhesives
Question 3: Denture adhesives can be useful for the following
clinical situations:
a) To stabilize trial bases in the early stages of denture fabrication
(ie, while recording centric and vertical relation)
SA = 41%, A = 47%, D = 12%, SD = 0%
The panel achieved a consensus with 88% agreeing on round 1.
b) To allay the patient’s fears at the trial arrangement of teeth on
denture bases visit
SA = 23%, A = 53%, D = 24%, SD = 0%
The panel achieved a consensus with 76% agreeing on round l.
c) To augment retention, comfort, and function during the interim
period after insertion of immediate dentures
SA = 12%, A = 38%, D = 50%, SD = 0%
The panel did not achieve a consensus on round 3 with 50%
agreeing and 50% disagreeing.
d) To overcome patients’ anxiety for a short period (2-3 wk) after
insertion of new complete dentures (ie, not immediate dentures)
SA = 6%, A = 18%, D = 41%, SD = 35%
The panel achieved a consensus with 76% disagreeing on
round 1.
e) To provide additional retention and stability for patients who
have inadequate oral anatomy
SA = 12%, A = 88%, D = 0%, SD = 0%
The panel achieved a consensus with 100% agreeing on
round 3.
not useful to overcome patients anxiety during the
postinsertion period for traditional complete denture
(76%). On round 3, panelists reached a consensus that
denture adhesives were also useful to provide addition-
al retention and stability for patients who have inade-
quate oral anatomy (100%).
The remaining question of these 5 (question 3c)
failed to achieve a consensus among the panelists.
Those panelists who maintained the position of “agree-
ing” commented that adhesives can be used remotely
from the surgical areas for 3 to 4 weeks after extractions
during the time of the remodeling phase of bone, when
rapid changes in ridge structure may reduce the reten-
tion of the denture and, thus, allow the remodeling
phase to occur before an acrylic resin reline procedure
is performed. Also, if a soft liner material is used, adhe-
sive can be used during periods of “progressive loosen-
ing” that occur between soft liner appointments. For
those panelists who maintained the opinion of “dis-
agreeing,” they commented that a soft liner (not a den-
ture adhesive) was the material of choice after insertion
of immediate dentures, even if the denture would
require frequent changes of that soft liner until a hard
reline was indicated. In addition, they expressed con-
cern that the use of an adhesive with the soft liner
would be difficult to clean and would slow the healing
process as a result of contamination of the sockets
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SLAUGHTER, KATZ, AND GRASSO
Table V. Topic III: Patient education
Question 4: Patient education on the use (appropriate and/or
inappropriate) of denture adhesives is an important part of den-
ture service for patients with ill-fitting dentures
SA = 47%, A = 35%, D = 6%, SD = 12%
The panel achieved a consensus with 82% agreeing on round 1.
Question 5: Patient education on the use (appropriate and/or
inappropriate) of denture adhesives is an important part of den-
ture service for patients with well-fitting dentures
SA = 23%, A = 53%, D = 12%, SD = 12%
The panel achieved a consensus with 76% agreeing on round 1.
because of the potential unhygienic nature of adhesives.
Regarding question 3e, the panel was in total agree-
ment; however, the point was emphasized by several
panelists that adhesives provide minimal stability.
Consensus was achieved on round 1 for the 2 sub-
questions on patient education (Table V). Panelists
concurred that patient education on the use of denture
adhesives is an important part of denture service for
patients with either ill-fitting dentures (82%) or well-
fitting dentures (76%). Taken as a whole, the panel sug-
gested, in additional comments, that the following
range of instructions be provided to denture patients
regarding denture adhesives: use sparingly; clean out
old before applying new; clean tissues well to remove
adhesive; do not use adhesives to stabilize a poorly fit-
ting denture; do not use pads; use of adhesive may
cause future problems; discontinue use if any reaction
occurs; and, most importantly, see the dentist for recall
visits for evaluation of denture fit. A few panelists com-
mented that the instructions to denture patients should
be to not use adhesives under any circumstances.
Table VI shows the results of the questions on the
inclusion of denture adhesives in the undergraduate den-
tal curriculums. Given that all but 1 panelist (94%)
agreed that new competency-based criteria should
require undergraduate students to be competent in the
management of simple, straight-forward, routine denture
patients, 81% of panelists concurred that 1 component of
being judged competent in these types of denture cases
should be the ability to appropriately use and inform
their denture patients on both the use and misuse of den-
ture adhesives. An even higher percentage of the panelists
(94%) thought that regardless of whether denture adhe-
sives are directly included in the AADS undergraduate
guidelines, the topic should be an integral component in
the undergraduate dental curriculum.
In their additional comments on these questions, the
panel commented that the use of adhesives is a realistic
component of after-delivery care and even “routine
patients” may not adapt to well-made dentures. The
dentist should be the source of correct information for
patients, and patient education on the pros and cons of
JULY 1999
THE JOURNAL OF PROSTHETIC DENTISTRY
Table VI. Topic IV: Inclusion of denture adhesives in under-
graduate dental curriculum
Question 6: The AADS guidelines for undergraduate dental cur-
riculum will likely be using competency-based criteria, in your
opinion:
a) Should these competency-based criteria require undergraduate
students to be competent in the management of simple,
straight-forward, routine denture patients?
YES = 94%, NO = 6%
The panel achieved a consensus with 94% agreeing on round 2.
b) Should one of the components of being “judged competent” in
the management of simple, straight-forward, routine denture
patients be the student’s ability to appropriately use and inform
their denture patients regarding denture adhesives use and
abuse?
YES = 81%, NO = 19%
The panel achieved a consensus with 81% agreeing on round 2.
c) Regardless of whether denture adhesives are directly included
in the AADS undergraduate guidelines, the topic of denture
adhesives should be addressed and taught in the undergraduate
dental curriculum
SA = 24%, A = 71%, D = 5%, SD = 0%
The panel achieved a consensus with 95% agreeing on round 2.
Table VII. Topic V: Overall opinion of denture adhesives
Question 7: Overall, denture adhesives can be a beneficial adjunct
to the dentist when fabricating dentures
SA = 5%, A = 71%, D = 12%, SD = 12%
The panel achieved a consensus with 76% agreeing on round 1.
Question 8: Overall, denture adhesives can be a beneficial adjunct
to the dentist related to patient management (eg, patient accep-
tance of the denture)
SA = 0%, A = 59%, D = 17%, SD = 24%
The panel did not achieve a consensus on round 3 with 59%
agreeing and 41% disagreeing.
Question 9: Recognizing that some patients may independently
choose to use a denture adhesive, dentists should routinely inform
patients of the proper use and misuse of denture adhesives
(regardless of whether the dentist deems a denture adhesive nec-
essary for that patient)
SA = 41%, A = 47%, D = 12%, SD = 0%
The panel achieved a consensus with 88% agreeing on round 1.
denture adhesives is the responsibility of those who
provide professional service. Moreover, dental educa-
tion has an obligation to maintain current information
about proprietary products, even those that are avail-
able to the public without sanction by professional
organizations. Of the small minority opinion group, a
few panelists commented that students should only
advise “nonuse” and get patients to respect the need
for properly fitted and constructed dentures and that
addressing denture adhesives in the AADS guidelines
85
THE JOURNAL OF PROSTHETIC DENTISTRY SLAUGHTER, KATZ, AND GRASSO

Table VIII. Summary of final outcome on the 24 Delphi questions as regards achievement of consensus opinions by the panelists
Consensus Nonconsensus
Topic Question opinion achieved* majority opinion†

I. Perceptions of denture adhesives

Enhance fit 1a Agree —
Avoid good clinical practice 1b Agree —
Provide psychological comfort 1c Agree —
Mask underlying denture problems 1d Agree —
Contribute to avoiding dental visits 1e Agree —
Cause oral cancer 2a Disagree —
Cause denture stomatitis 2b Agree —
Cause leukoplakia 2c Disagree —
Cause candidiasis 2d Agree —
Cause imbalance in oral flora 2e Agree —
Cause alveolar bone resorption 2f Agree —
II. Specific clinical use/misuse of denture adhesives
Stabilize trial bases 3a Agree —
Useful at trial arrangement of teeth visit 3b Agree —
Useful after insertion of immediate dentures 3c — 50-50 split
Useful after insertion of conventional dentures 3d Disagree —
Useful for patients with inadequate anatomy 3e Agree —
III. Patient education
Important for patients with ill-fitting dentures 4 Agree —
Important for patients with well-fitting dentures 5 Agree —
IV. Inclusion of denture adhesives in curriculum
Students should be competent in management of routine denture patient 6a Agree —
Judgement of competency should include appropriate use of denture adhesives 6b Agree —
as well as patient education
Topic of denture adhesives should be taught in undergraduate curriculum 6c Agree —
V. Overall opinion of denture adhesives
Beneficial adjunct in fabricating dentures 7 Agree —
Beneficial adjunct in patient management 8 — 59% agree
Patient education on denture adhesives should be routine for all denture patients 9 Agree —
*Consensus opinion achieved = 70% or greater agreement among panelists.
†Nonconsensus majority opinion = 51% to 69% agreement among panelists.

would imply support of their use. These few panelists
stressed that adhesive use should not be a routine
option for patients and to subordinate the factors of
retention (physical, mechanical, biologic) to adhesives
is irresponsible on the part of the dentist. These few
panelists cautioned that students should not be taught
to rely on denture adhesives as a solution for poor work
and depend on the product as a “crutch.”
The final 3 questions asked the panelists about their
overall opinion of denture adhesives (Table VII). On
round 1, the panelists concurred, overall, that denture
adhesives can be a beneficial adjunct in the fabrication
of dentures (76%) and that dentists should routinely
inform all denture patients of the proper use and mis-
use of denture adhesives (88%). With only 59% agree-
ing on question 8, panelists were unable to reach a
consensus as to whether denture adhesives can be a
beneficial adjunct to the dentist related to patient man-
agement issues.
Regarding question 8 (which failed to achieve a con-
sensus), panelists who maintained a minority position of
“disagreeing” justified their position by commenting that
denture patients may have unrealistic expectations and
they have to learn how to use a denture. This minority
opinion group expressed concern that reliance on a den-
ture adhesive by a dentist would result in poor design of
the prosthesis and poor patient education; further, they
were concerned that the dentist would abandon pursuit
of making a proper denture and would use the denture
adhesive as a crutch. Several of the majority opinion pan-
elists (those who “agreed”) commented that, although it
is not suggested that all denture patients should be
advised to use adhesives, denture adhesives can be bene-
ficial to patient management in certain situations and
during treatment. They further stated that the dentist can
usually identify those patients who may require the use of
adhesives to function comfortably, namely, those patients
who have poor ridge resorption, decreased salivary flow,
poor neuromuscular coordination, a low level of adapt-
ability, and a decreased learning capability. Finally, sever-
al panelists commented that a technically excellent den-
ture made by excellent clinicians may still fail to meet the

86 VOLUME 82 NUMBER 1
SLAUGHTER, KATZ, AND GRASSO
expectations of patients and that does not reflect nega-
tively on the ability of the dentist.
Table VIII presents the summary of the final out-
come on the 24 Delphi questions regarding whether a
given question achieved a consensus opinion among
the panelists and whether that consensus opinion was
to agree or disagree with the statement as posed in the
questionnaire. If no consensus opinion was achieved in
the survey, Table VIII presents the nonconsensus
majority opinion that was expressed by the panelists,
and shows that consensus was achieved on 91.6%
(n = 22) of the 24 separate questions/subquestions.
Consensus occurred rapidly on virtually all questions
with 18 of the questions achieving consensus on round
1. The 3 questions that achieved consensus in round 2
all dealt with the topic of the inclusion of denture adhe-
sives in the undergraduate dental curriculum and the
panel arrived at a quick consensus once the wording of
the questions reflected the new ADA self-study termi-
nology of “competency-based” criteria. The remaining
question achieved consensus on round 3 and again
reflected more the need to correct the wording of the
question than a fundamental difference of opinion
among the panelists, the final consensus on this ques-
tion was 100% “agreeing” with the statement.
DISCUSSION
The panel showed a high level of interest and coop-
eration, as reflected in the mean response rate of 96%
for the 3 rounds of questionnaires and by their compli-
ance with the request for rapid return of the question-
naire rounds. The opinions of the panel resulted in cer-
tain questions being reworded for a clearer interpreta-
tion. Specifically, on round 1 the original question
regarding the AADS guidelines asked if the topic of
denture adhesives should be included in the under-
graduate prosthetic curriculum or should the topic of
denture adhesives continue to be excluded from the
AADS guidelines. The panel raised the issue that the
future AADS guidelines would be toward competency-
based criteria, so this question was revised to address
the revised guidelines. In round 2, original question 3e
was phrased: “Denture adhesives can be useful for the
following clinical situation: to provide additional sup-
port for patients who have inadequate oral anatomy.”
The panel raised the issue that denture adhesives do not
provide “support.” On the basis of these comments,
the word support was replaced with the words “reten-
tion and stability.”
Data in Table VIII provide evidence that not only
did the panel achieve consensus on all but 2 of the 24
questions/subquestions (91.6%), but that they did so
in a rapid manner. If one eliminates the rounds it took
to get the question worded properly in a couple of
instances, consensus was achieved on the first round
after wording was acceptable to the entire panel for all
JULY 1999
THE JOURNAL OF PROSTHETIC DENTISTRY
but 1 of the 22 questions that achieved consensus. This
would appear to indicate that current academic
prosthodontists, as a group, do hold consensus opin-
ions on nearly all the wide-ranging issues addressed in
this questionnaire. Although there were a few panelists
who were consistently negative regarding any use of
denture adhesives, the vast majority supported
thoughtful, selective, and monitored use of denture
adhesives. This survey asked questions under the fol-
lowing 5 topics regarding denture adhesives.
Topic I: General perceptions of denture
adhesives—questions 1 and 2
Panelists achieved a rapid consensus on round 1 on
all 5 subquestions of question 1. They perceived that
denture adhesive use had the potential for both positive
and negative clinical outcomes. On the positive side,
the panel achieved a consensus that denture adhesive
would enhance the fit of the prosthesis and would pro-
vide psychologic comfort to the patient. On the nega-
tive side, the panel achieved consensus in expressing
concerns about denture adhesives contributing to den-
tists avoiding good clinical practice, about the masking
of underlying denture problems and in contributing to
patients not seeing a dentist for recall and/or to avoid
fees. Similarly, panelists achieved an equally rapid con-
sensus on round 1 for all 6 subquestions of question 2.
Although the panelists agreed that denture adhesives
could contribute to the development of 4 diseases/
conditions (denture stomatitis, candidiasis, an imbal-
ance of oral flora, and the resorption of alveolar bone),
panelists were also in consensus that neither oral cancer
nor leukoplakia would result from the use of denture
adhesives.
Topic II: Use and misuse of denture
adhesives—question 3
Panelists achieved a rapid consensus on round 1 for 3
of the 5 subquestions in question 3. For 2 of these 3
subquestions, the panelists agreed that denture adhe-
sives would be clinically useful for 2 steps in denture fab-
rication, namely, to stabilize trial bases at early stages of
fabrication and to allay patient fears at trial arrangement
of teeth on the denture bases. The remaining 3 sub-
questions addressed postdenture fabrication situations
and the panel produced mixed results across these situa-
tions. When asked about the postdenture insertion peri-
od, panelists achieved rapid consensus on round 1 that
denture adhesives were not appropriate for use with con-
ventional dentures, but they never achieved any consen-
sus regarding denture adhesive use with immediate den-
tures (they were evenly split on this latter topic). On the
final subquestion in question 3, panelists eventually
achieved agreement on round 3 that denture adhesives
would provide additional retention and stability for
patients who have inadequate oral anatomy. The delay in
87
THE JOURNAL OF PROSTHETIC DENTISTRY
achieving consensus agreement was largely due to word-
ing issues with the question as originally stated and once
the wording was altered through panel discussion, con-
sensus was then quickly achieved.
Topic III: Patient education on denture
adhesives—questions 4 and 5
For both of the questions on this topic, the panelists
achieved a rapid consensus on round 1 indicating that
patient education on denture adhesives was appropriate
for all denture patients, both those with well-fitting
dentures and those with ill-fitting dentures. Although
panelists achieved a consensus in indicating that patient
education was appropriate for all denture patients
(those with well-fitting dentures and for those with ill-
fitting dentures), the panel indicated a somewhat
stronger opinion about patient education on denture
adhesives for those patients with ill-fitting dentures,
namely, twice as many panelists “strongly agreed” with
patient education on denture adhesives for patients
with ill-fitting dentures (47% vs 23%).
The panel commented that, because patients will use
denture adhesives whether advised to or not, the den-
tist should be prepared to educate the patient on cor-
rect usage. Of the panelists who were not in the con-
sensus group of “agreeing,” a few expressed the opin-
ion that denture adhesives should not be considered a
routine solution to denture problems and patients
should be counseled only on the misuse of denture
adhesives and on the importance of recall appointments
with the dentist.
Topic IV: Inclusion of denture adhesives in
undergraduate dental curriculums—question 6
Once the question was reworded on round 2 to
describe the future AADS guidelines in terms of “com-
petency-based” criteria, the panel achieved rapid con-
sensus on all 3 subquestions in question 6. On the basis
of the panelists’ reply to all 3 subquestions, the panel
clearly indicated a strong opinion that for a student to
be judged “competent” in the management of denture
patients, the student would have to be capable of both
appropriately using denture adhesives and providing
patient education on denture adhesive use and misuse.
In addition, panelists were near unanimous that the
topic of denture adhesives should be taught in the
undergraduate dental curriculum.
Topic V: Overall opinion of denture
adhesives—questions 7, 8, and 9
This final section of the questionnaire sought the
“overall opinion” of the panelists on denture adhesives,
the proverbial “bottom line.” The panelists rapidly
achieved consensus on 2 of the 3 questions. Panelists
expressed a consensus opinion that overall denture
adhesives can be a beneficial adjunct to the dentist in
88
SLAUGHTER, KATZ, AND GRASSO
the fabrication of dentures and that dentists should
routinely inform all patients of both the use and misuse
of denture adhesives.
However, panelists were unable to achieve a con-
sensus on the question of whether denture adhesives
can be a beneficial adjunct to the dentist related to
patient management, namely, patient acceptance of
the denture. Although a majority (59%) agreed with
this statement, the remaining 41% of panelists dis-
agreed, and over half of those 41% who disagreed
indicated that they “strongly disagreed.” While this
appears to be in conflict with the panelists’ consensus
opinion in question 1c where they indicated agree-
ment that denture adhesives could provide psycholog-
ic comfort to the patient, it appears to be in keeping
with the panel’s consensus as expressed in questions
1b, d, and e where the panel expressed concerns about
the negative aspects of denture adhesive use. So,
although the panel was able to reach consensus on the
5 specific issues in topic I, when asked for a “bottom
line” (overall opinion in topic V on a related ques-
tion), they were unable to achieve a consensus
(although there was a clear majority in agreement at
59%). It is also reasonable to see their differing
answers regarding the appropriateness of the use of
denture adhesive in the postinsertion period for
immediate (where no consensus was achieved) vs con-
ventional dentures (consensus achieved on “dis-
agree”) as another conflicted factor when they
attempted to give their “bottom line,” their overall
opinion on patient management. Results of this survey
seem to support the statement that, although a strong
majority of these academic prosthodontists believed
that denture adhesives were, overall, a beneficial
adjunct in patient management, they, as a group, har-
bored enough concerns and cautions that they were
unable to achieve a clear consensus on this issue.
CONCLUSIONS
This panel of leading academic prosthodontists
achieved consensus agreement regarding denture adhe-
sives on most of the discussed issues/topics. Specifical-
ly, the panel agreed that, denture adhesives
1. can enhance the fit of a denture and provide psy-
chologic comfort to the patient;
2. can have negative influences on both the patient
and the dentist (by masking underlying denture prob-
lems, avoiding necessary dental visits and by offering an
alternative to good clinical practices);
3. can contribute to the development of certain oral
conditions (denture stomatitis, candidiasis, alveolar
bone resorption, and an imbalance in oral flora) but
not leukoplakia or oral cancer;
4. have specific uses during the fabrication of den-
tures, namely, to stabilize trial bases and be useful at the
trial arrangement of teeth;
VOLUME 82 NUMBER 1
SLAUGHTER, KATZ, AND GRASSO
5. are appropriate for use at the postinsertion phase
for conventional dentures, only in patients with inade-
quate oral anatomy;
6. should be an integral part of patient education for
all denture patients with inclusion of both appropriate
use and misuse; and
7. should be an integral component of the under-
graduate denture curriculum.
However, the panel was unable to achieve consensus
agreement on whether denture adhesives:
1. should be used at the postinsertion phase for
immediate denture patients (a 50-50 split on this
issue); and
2. are, on the whole, a beneficial adjunct in denture
patient management (59% agreed that they were).
Further, through written comments, the panelists
clearly expressed their concerns that neither dentists
nor patients should use denture adhesives as an alterna-
tive to either good clinical practices or proper denture
maintenance routines.
We express our appreciation to each of the panelists for their
enthusiastic cooperation and their willingness to share their exper-
tise both in answering the questionnaire rounds and in writing
detailed and clear comments that enriched the Delphi process in this
study.
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Reprints requests to:
DR JOSEPH E. GRASSO
DEPARTMENT OF PROSTHODONTICS, MC 1615
SCHOOL OF DENTAL MEDICINE
UNIVERSITY OF CONNECTICUT HEALTH CENTER
FARMINGTON, CT 06030
FAX: (860)679-1370
E-MAIL: GRASSO@NSO1.UCHC.EDU
Copyright © 1999 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/99/$8.00 + 0. 10/1/96643
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