40 Denture-related stomatitis
■ Smoking occasionally predisposes.
Key Points
■ Denture-related stomatitis is a symptomless red lesion under
a dental appliance, most typically a maxillary denture
■ Candida and bacterial species are commonly causal
■ Candida proliferates in the dental plaque, dental appliance
surface and on the mucosa
■ Candidiosis may also cause soreness at the commissures
(angular cheilitis)
■ Treatment includes correcting the local ecological factors,
and improving appliance hygiene, together with antifungal
medication
INTRODUCTION
Denture-related stomatitis (denture sore mouth; chronic atro-
phic candidosis) consists of mild inflammation and erythema
of the mucosa beneath a dental appliance, usually a complete
upper denture.
INCIDENCE
Common; in some studies of institutionalized older denture-
wearing patients, figures as high as 70% have been found, but
it is overall considerably less common in other people, par-
ticularly in normal healthy subjects.
AGE
This is a disease mainly of the middle-aged or older.
GENDER
It is slightly more prevalent in women than men.
GEOGRAPHIC
This is seen worldwide.
PREDISPOSING FACTORS
Dental appliance wearing (mainly maxillary dentures),
■ denture stomatitis, since most patients with denture-related
especially when worn throughout the night, or with a dry
mouth, is the major predisposing factor.
264
■ Diabetes or a high carbohydrate diet occasionally predispose.
■ Hyposalivation is a occasionally an underlying factor.
■ Haematinic deficiencies are a rare underlying factor.
■
HIV is a rare underlying factor.
■ Factors that are usually not significant include:
■ allergy to the dental material (if it were, denture-related
stomatitis would affect mucosae other than just that
beneath the appliance)
■ trauma; the condition is more common beneath maxillary
dentures than mandibular dentures, yet trauma is more
common under the latter
■ pharmacological agents.
AETIOLOGY AND PATHOGENESIS
Dentures and other appliances can produce a number of eco-
logical changes, including accumulation of microbial plaque
(bacteria and/or yeasts) on and in the fitting surface of the
denture and the underlying mucosa. Histological examination
of the soft tissue beneath dentures has shown proliferative or
degenerative responses with reduced keratinization and thin-
ner epithelium.
Fungi, such as Candida, are isolated in up to 90% of per-
sons with denture-related stomatitis, and when Candida
species are involved in denture-related stomatitis, the more
common terms ‘Candida-associated denture stomatitis’,
‘denture-induced candidosis’ or ‘chronic atrophic candi-
dosis’ are used. The most frequently isolated organism is
Candida albicans. In some persons, the cause appears to be
related to a non-specific plaque, which undergoes sequen-
tial development, and is finally colonized by Candida organ-
isms. Although there is no increased aspartyl proteinase
production from the Candida involved, the decreased sali-
vary flow and a low pH under the denture probably result in
a high Candida enzymatic activity, which can cause mucosal
inflammation.
Candida, however, are not the only microorganisms
associated with denture-related stomatitis; occasionally
bacterial infection is responsible, or mechanical irritation
has a role.
It not yet clear why only some denture-wearers develop
stomatitis appear otherwise healthy and they have no serious
cell-mediated immune defects, but they may sometimes be
 DENTURE-RELATED STOMATITIS 40
deficient in migration-inhibition factor (MIF) and may have
overactive suppressor T cells or other T lymphocyte or phago- CLASSIFICATION
cyte defects.
Denture-related stomatitis has been classified into three
clinical types (Newton types), increasing in severity
(Table 40.1).
CLINICAL FEATURES
The characteristic presenting features of denture-related DIAGNOSIS
stomatitis are:
This is a clinical diagnosis.
■ An absence of symptoms. The former term ‘denture sore
A full blood picture, haematinic assays and smears for
mouth’ was a misnomer.
fungal hyphae and culture may be warranted (Table 40.2).
■ Chronic erythema and oedema of the mucosa that contacts
If there is angular stomatitis, or other oral or systemic
the fitting surface of the denture, usually a complete upper
lesions, or a suspicion of an immunocompromising con-
denture (the denture-bearing area); the mucosa below lower
dition, then diabetes and HIV in particular should be
dentures is rarely involved (Figs 40.1 and 40.2).
excluded.
■ Uncommon complications, which include:
■ angular stomatitis, and rarely

■ papillary hyperplasia in the vault of the palate (idiopathic

papillary epithelial hyperplasia (IPEH), which usually
needs to be surgically removed before the appliance is
replaced or relined).
TREATMENT (see also Chs 4 and 5)
Patient information is probably the most important aspect in
management.
Any underlying systemic disease should be treated where
possible. Smoking cessation is important.
The denture or other appliance fitting surface and plaque
is infested, usually with Candida albicans. Scrupulous appli-
ance hygiene is mandatory, with daily thorough brushing.

Table 40.1 Newton classification of denture-related

stomatitis

Type Definition Comment

1 Localized simple inflammation Early lesion usually

or a pinpoint hyperaemia

2 Erythematous or generalized Common type

simple type presenting as
more diffuse erythema involving
Fig. 40.1 Denture-related stomatitis a part of, or the entire, denture-
covered mucosa

3 Granular type (inflammatory Uncommon

papillary hyperplasia)
commonly involving the central
part of the hard palate and the
alveolar ridge

Table 40.2 Aids that might be helpful in diagnosis/

prognosis/management in some patients suspected of
having denture-related stomatitis*

In most cases In rare cases

Full blood picture ESR

Serum ferritin, vitamin B12 and HIV test
corrected whole blood folate levels
Blood glucose
Culture and sensitivity
Fig. 40.2 Denture-related stomatitis (denture in situ; same
patient as in Fig. 40.1) *See text for details and glossary for abbreviations.

265
40 SECTION 4 COMMON AND IMPORTANT OROFACIAL CONDITIONS

mucoadhesive tablets, or fluconazole suspension, or topical

ketoconazole if available, which can be administered concur-
rently with an oral antiseptic with antifungal activity – such as
chlorhexidine. Lacquer or tissue conditioners containing anti-
fungals are also effective
Studies of sensitivity to antifungal agents have shown that
isolates from different strains are sensitive to nystatin, but less
sensitive to miconazole and fluconazole.

FOLLOW-UP OF PATIENTS
Long-term follow-up in primary care is usually appropriate.
Fig. 40.3 Denture plaque needs removing
PATIENT INFORMATION SHEET
Denture sore mouth
The appliance should be removed from the mouth over- ▼ Please read this information sheet. If you have any questions, particu-
night and as much as possible at other times (Fig. 40.3), larly about the treatment or potential side-effects, please ask your doctor.
while the denture is cleaned and disinfected. This can be ■ Denture sore mouth is common but not sore.
achieved by microwave irradiation for 3 min at 650 W with ■ It is caused by a fungus (Candida) that usually lives harmlessly in the
the appliance immersed in 200 mL of water. Disinfection mouth and elsewhere.
can also be achieved using an inexpensive option of 10% ■ It is caused mainly by wearing a dental appliance, which allows the
acetic acid (vinegar) or an antiseptic denture cleanser, and fungus to grow.
storing the appliance in it overnight. Suitable antiseptic solu- ■ It may be precipitated by prolonged appliance-wearing, especially at night.
tions include chlorhexidine or dilute sodium hypochlorite ■ It predisposes to sores at the corners of the mouth.
It has no serious long-term consequences.
(10 drops of household bleach in a 500 mL container filled ■

Blood tests, microbiological studies or biopsy may be required.

with tap water). Hypochlorite however, can turn chrome
■

■ It may be controlled by:

cobalt dentures black. Many other cleansers are available ■ leaving out the denture, to allow the mouth to heal
(alkaline peroxides, alkaline hypochlorites, acids, yeast ■ disinfecting the denture

lytic enzymes), proteolytic enzymes, tea tree oil (Melaleuca ■ using antifungal creams or gels (e.g. Daktarin) or tablets

alternifolia) and Punica granatum (dwarf pomegranate). (e.g. Nystan, Fungilin, Diflucan) regularly for up to 4 weeks
The mucosal infection is eradicated by brushing the pal- ■ the dentures may require adjustment.

ate and using antifungals for 4 weeks (Table 40.3), with the
denture removed from the mouth and being disinfected as
frequently as possible. Antifungal agents (e.g. miconazole PATIENT INFORMATION SHEET
gel) should also be applied to the tissue-contacting surface Denture care
of the appliance before every re-insertion. Effective topical ▼ Please read this information sheet. If you have any questions, particu-
antifungals include nystatin suspension, miconazole gel or larly about the treatment or potential side-effects, please ask your doctor.
■ If you still have some natural teeth, these will need regular attention,
because wearing a denture can encourage food accumulation.
■ Keep your dentures as clean as natural teeth. Clean both surfaces of
Table 40.3 Regimens that might be helpful in your dentures (inside and outside) after meals and at night. Use wash-
management of patient suspected of having ing-up liquid and a toothbrush and lukewarm water and hold it over a
denture-related stomatitis basin containing water, in case you drop the denture, which could cause
it to break. Never use hot water, as it may alter the denture colour. A
Use in primary or
Regimen secondary care disclosing agent, e.g. Rayner's Blue or red food colouring (available at
most supermarkets), can be applied with cotton buds, to help you see
Beneficial Nystatin whether you are cleaning the denture thoroughly enough. If stains or
Miconazole calculus deposits are difficult to remove, try an overnight immersion
Fluconazole (e.g. Dentural, Milton or Steradent) or an application of Denclen.
Itraconazole ■ Your dentures should be left out overnight, so that your mouth has a
rest. It is not natural for your palate to be covered all the time, and the
Unproven effectiveness Chlorhexidine chances of getting an infection are increased if the dentures are worn
Gentian violet
24 h a day. Ensure you leave the dentures out for at least some time and
Probiotics
Punica granatum keep them in water, Dentural or Steradent, or in a damp tissue, as they
Yoghurt may distort if allowed to dry out.
■ Special precautions for dentures with metal parts: Denclen, Dentural
Supportive Chlorhexidine and Milton may discolour metal, so use with care. Brush briefly to
Dental appliance hygiene remove stains and deposits, rinse well with lukewarm water and do not
Smoking cessation soak overnight in these solutions.
■ Before re-use, brush the dentures to remove loosened deposits.

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USEFUL WEBSITES
Medscape, Denture Stomatitis. http://emedicine.
medscape.com/article/1075994
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