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Influence Of Removable Partial Dentures On Plaque Accumulation

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Journal of Prosthodontic Research 54 (2010) 29–35

www.elsevier.com/locate/jpor

Original article
Influence of removable partial dentures on the formation of dental plaque
on abutment teeth
Yoshiaki Shimura DDS*, Juro Wadachi DDS, PhD, Teruyasu Nakamura DDS, PhD,
Hiroshi Mizutani DDS, PhD, Yoshimasa Igarashi DDS, PhD
Removable Partial Denture Prosthodontics, Department of Masticatory Function Rehabilitation, Division of Oral Health Sciences,
Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
Received 5 February 2009; received in revised form 14 August 2009; accepted 30 August 2009
Available online 8 October 2009

Abstract
Purpose: This study aimed to clarify the relation between the shape of the retainers and the plaque formation on abutment teeth to improve the
denture design.
Methods: This study observed the buccal surface for the clasps and distoproximal surface for a guide plate of the mandibular first premolar which
was the abutment tooth with a direct retainer of a distal extension RPD. The buccal surface was observed in 10 subjects and the distoproximal
surface in 14 subjects. The latter cohort was divided into two groups (the group with an open type guide plane and a close type guide plane). All
subjects provided their informed consent. The state of plaque accumulation was inspected by standardized photography and bacterial quantification
and compared among the cast circumferential (CC), Ibar, wire circumferential (WC) and control (no clasps) in individuals regarding the buccal
surface and between the groups with the open type and close type guide plane of the distoproximal surface.
Results: No significant differences were observed among the CC, Ibar, WC and control (P > 0.05) regarding the buccal surface, while in regard to
the distoproximal surface, the group with the open type guide plane had significantly more plaque than the group with the close type guide plane
(P < 0.05).
Conclusion: The plaque formation on the buccal surface is not dependent on the types of clasps. It is effective to prepare a guide plane as close to
the gingival margin as possible to reduce the plaque accumulation on the distoproximal surface.
# 2009 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved.

Keywords: Removable partial denture; Abutment teeth; Plaque; Standardized photography; Bacterial quantification

1. Introduction tongue, which results in the accumulation of the dental plaque

The shape and function of the mouth following a disruption
caused by the loss of teeth are frequently restored by wearing
removable partial dentures, but this may also contribute to
various problems. RPDs have the physical, chemical and
biological adverse aspects which can cause caries of abutment
teeth, tooth mobility, inflammation of mucosa and residual
ridge resorption [1–19]. The biological adverse aspects are
thought to be serious [6–19]. Wearing a removable partial
denture complicates the oral environment and restricts the flow
of food and the self-cleaning action of the buccal mucosa and
* Corresponding author at: Department of Removable Partial Denture
Prosthodontics, Graduate School, Tokyo Medical and Dental University, 1-5-
45 Yushima, Bunkyo-ku, Tokyo 113-8549, Japan. Tel.: +81 3 5803 5517;
fax: +81 3 5803 5517.
E-mail address: yosi.rpro@tmd.ac.jp (Y. Shimura).
on the prosthesis and surrounding tissue. Therefore the control
of dental plaque is important to obtain good denture prognosis
and performance for a long period.
The adverse effect of the dental plaque is serious for
abutment teeth which are important for RPDs. Abutment teeth
have more plaque morbidity than any other teeth and cause
serious periodontal inflammation. This is due to plaque
accumulation caused by the prevention of self-cleaning action
by the clasps which are essential as the retentive elements of the
RPD. However, there have so far been few reports on the
relationship between the shape of the retainers and plaque
formation on abutment teeth [9,13] and the actual condition in
the patient’s mouth has not been clarified.
Therefore, this study was conducted in order to clarify the
region, area and quantity of plaque accumulated on abutment
teeth with different types of clasps and guide plates and provide
information for improving the denture design.

1883-1958/$ – see front matter # 2009 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved.
doi:10.1016/j.jpor.2009.08.003
30 Y. Shimura et al. / Journal of Prosthodontic Research 54 (2010) 29–35

Fig. 1. The framework of the experimental denture was made from a cobalt–chromium alloy. Every clasp was interchangeable.

Fig. 2. The open and close type guide planes. Group A consisted of those with an open type guide plane with a height of less than one-thirds of the crown length.
Group B consisted of those with a close type guide plane with a height more than two-thirds of the crown length.

2. Materials and methods
2.1. Subjects
The buccal and distoproximal surfaces of abutment teeth of
RPD wearers were observed. The buccal surfaces were observed
in 10 subjects (1 male, 9 females, mean age 72.9  7.0 years) and
the distoproximal surfaces in 14 subjects (2 males, 12 females
mean age 67.4  10.6 years) with mandibular distal extension
loss of teeth from second premolar to second molar. Nine of the
subjects participated in the observation of both the buccal and
distoproximal surface.
The subjects were recruited from the patients at Tokyo
Medical and Dental University and none had clinical
abnormalities. Applicants with severe periodontal disease and
history of periodontal treatment were excluded. Each subject
received a written and oral description of the study, and
informed consent was obtained prior to enrollment into the
study. All study related procedures and tests were approved by
the Ethical Committee at Tokyo Medical and Dental University
(No. 284).
2.2. Preparations and time schedule
The buccal surface for the clasps and distoproximal surface
for guide plate of mandibular first premolar which acts as the
abutment tooth for the direct retainer of a distal extension RPD
were observed in this study. Prior to measurements, the
experimental denture was fabricated so that every clasp was
interchangeable (Fig. 1). All impressions for the experimental
dentures were made with individual trays and silicon rubber
impression material (Exahiflex regular, GC Co., Tokyo,
Japan). The denture framework was made from a cobalt–
chromium alloy.
The mesial rest and mesio-distal guide plate were placed
on the tooth and the buccal surface was observed with three
sorts of clasps, cast circumferential (CC), Ibar and wire
circumferential (WC) and control without any clasps and the
 Y. Shimura et al. / Journal of Prosthodontic Research 54 (2010) 29–35 31

Fig. 3. The jig used for the preparation of the guide plane. The view from the occulusal plane (a) and from the plane perpendicular to Pound’s line (b).

distoproximal surface for a guide plate with the placement of

WC (Fig. 1). Regarding the guide plate, the subjects were
divided into two groups, Group A consisted of those with an
open type guide plane with a height is less than one-thirds of
the crown length and Group B consisted of those with a close
type guide plane with a height more than two-thirds of the
crown length (Fig. 2). The guide plane was prepared, using
the jig which was fabricated with a model, to determine the
direction and height (Fig. 3). The surface was polished by the
same way with silicon points (Silicon points M2 and M3,
SHOFU Inc., Kyoto Japan) to give a high polished surface
[20–22].
When the denture was set and the adjustments were
Fig. 4. The device for standardized photography. The photographs of the buccal
completed, the observation was initiated at intervals of 2 weeks
surface were taken at a distance of 40 mm perpendicular to Pound’s line.
in consideration of the plaque growth [13,23,24] after scaling
and polishing of the abutment teeth. The same denture was used
throughout the observation and only the clasps were changed at of the shape of teeth. Thereafter, the number of the pixels
clinic. No interventions, such as the instructions for tooth of the tooth and that of the red area were counted. The
cleaning, were performed during the study. percentage was calculated by dividing the pixels of the red
area by the pixels of the tooth. This process was repeated
2.3. Standardized photography and bacterial with three different pictures and the average pixels were
quantification calculated.

Standardized photography and bacterial quantification were 2.4.2. Bacterial quantification

performed in this study. Standardized photographs of the buccal
surface were taken at a distance of 40 mm perpendicular to
Pound’s line (Fig. 4) [25], and of the distoproximal surface at a
distance of 50 mm parallel to Pound’s line with a metal mirror
(YDM Co., Tokyo, Japan; Fig. 5).
At the clinic, the plaque was dyed by Red-Cote (Butler Co.,
Chicago, Illinois, USA) and some photographs were taken
using a Thanko USB microscope (Thanko Co., Tokyo, Japan)
with 352  288 pixels. Then the plaque was wiped with a
cotton bud to obtain specimens to quantify the bacteria.
2.4. Handling method
2.4.1. Photographic processing
The photographs were analyzed using the photographic
software (Photoshop 7.0, Adobe systems Inc., Tokyo, Japan).
The outline of the tooth was extracted from the photographs.
The buccal surface was defined as the whole part of a tooth
and the distal surface as the gonial to gonial in consideration
The specimens were diluted 10 and 100 to minimize
the effect of red cote since red cote could reduce the number
of bacteria detected. After applying an extraction and
luminous reagent, the bacteria was quantified using ATPtester
(AF-70, DKK-TOA Co., Tokyo, Japan), a multiplied by the
dilution factor to determine the original number and the
average was calculated. The number of bacteria was divided
by the pixels of the tooth and the number of bacteria per pixel
was calculated.
2.5. Analysis
2.5.1. Buccal surface
The data from the control, CC, Ibar and WC were compared
in individual subjects. The statistical analysis was performed
using SPSS version 11.5J (SPSS Japan Inc., Tokyo, Japan). The
data from both the standardized photography and bacterial
quantification were analyzed by one-way repeated measures
ANOVA and the probability level was set at P < 0.05.
32 Y. Shimura et al. / Journal of Prosthodontic Research 54 (2010) 29–35

Fig. 5. The device for standardized photography and the camera with a metal mirror attached to it. The photographs of the distoproximal surface were taken at a
distance of 50 mm parallel to Pound’s line.

Fig. 6. Examples of the photographs of the buccal surface.

 Y. Shimura et al. / Journal of Prosthodontic Research 54 (2010) 29–35 33

2.5.2. Distoproximal surface

The data from Group A were compared to that from Group
B. The statistical analysis was performed using SPSS version
11.5J (SPSS Japan Inc., Tokyo, Japan). The data from the
standardized photography were analyzed by Welch’s t-test and
the data from the bacterial quantification were analyzed by
Mann–Whitney’s U-test and the probability of both level was
set at P < 0.05.

3. Results

3.1. Buccal surfaces Fig. 7. The percentage of plaque on the buccal surface. No significant
difference was seen among the type of clasps (one-way repeated measures
ANOVA).
The 10 abutment teeth observed to evaluate the buccal
surface included 3 natural and 7 crowned teeth (2 were metal
crowns and 5 were porcelain fused metal crowns). Examples of
the photographs of the buccal surface in this study are shown in
Fig. 6. Fig. 7 shows the percentage of plaque on the dental
surface with the control, CC, Ibar and WC and all of them are
less than 10%. Figs. 6 and 7 demonstrate the presence of little
plaque on the buccal surface and no significant difference was
observed among the types of clasps (P = 0.650). The number of
bacteria per pixel is shown in Fig. 8. There were no particular Fig. 8. The number of bacteria per pixel on the buccal surface. No significant
tendencies among the data from the control, CC, Ibar and WC, difference was seen among the type of clasps (one-way repeated measures
ANOVA).
and no significant differences between them (P = 0.290).

3.2. Distoproximal surface

Group A included four natural teeth and three crowned teeth
of which the surfaces were metal and Group B included one
natural tooth and six crowned teeth of which the surfaces were
metal. Examples of the photographs of the distoproximal
surfaces are shown in Fig. 9. Fig. 10 shows the percentage of
plaque on the dental surface of Groups A and B. The plaque on
the distoproximal surface accumulated in the dead space or
void under the guide plane. There was significantly more plaque
in Group A than in Group B (P = 0.001). The number of
bacteria per pixel is shown in Fig. 11. There was significantly
more plaque on Group A than on Group B (P = 0.038).
4. Discussion
4.1. The measurements
Digital photography has recently been applied for use in
dental studies [26,27], however, the reliability remains
questionable. The reliability of standardized photography
was assessed by comparing the pixels of the buccal surface
of the tooth with control, CC, Ibar and WC. The data were
analyzed by One-way repeated measures ANOVA using SPSS
version 11.5J (SPSS Japan Inc., Tokyo, Japan) and there was no
significant difference (P = 0.34 > 0.05). This confirmed the
reliability of the standardized photography.
To count the number of bacteria in the plaque, adenosine
triphosphate (ATP) was quantified using bioluminescence
apparatus (AF-70, DKK-TOA Co., Tokyo, Japan). This
apparatus used the firefly luciferase system to determine the
concentration of cellular ATP and is based upon the
measurement of light emission produced during the oxidation
of luciferin by molecular oxygen in the presence of ATP and
magnesium ions. In this system the light intensity is directly
proportional to the concentration of ATP. This bioluminescent
ATP assay is known as a simple and convenient method for the
accurate enumeration of viable cells [28], however, one cannot
rule out the possibility that some of the plaque may be
overlooked and thus not be sampled.
4.2. Buccal surface
In this study, there was little plaque on buccal surface and no
significant difference, regardless of natural or crowned teeth
[29,30], although Shimizu reported that plaque accumulated
along clasps [13]. This is probably because while there were
conditions of the prohibition on the brushing and removing
dentures in their study, there was no condition in the current
study. These results do not contradict the previous report [7].
The discrepancies in bacterial quantification may be because
the number of the bacteria in the plaque ranged from 104 to 106
in this study and therefore a small error may thus be amplified
by the dilution factor [31].
4.3. Distoproximal surface
The data from the distoproximal surface were collected with
placement of WC. In addition, no reciprocal arm was observed
on the lingual surface to unify the form. There was plaque
accumulation in the dead space or void under the guide plane of
34 Y. Shimura et al. / Journal of Prosthodontic Research 54 (2010) 29–35
Fig. 9. Examples of the photographs of the distoproximal surface.
Fig. 10. The percentage of plaque on the distoproximal surface. Group A had
significantly more plaque than Group B (according to Welch’s t-test).
Fig. 11. The number of bacteria per pixel on the distoproximal surface. Group
A had significantly more plaque than Group B (according to Mann–Whitney’s
U-test).
both Group A and Group B, regardless of natural or crowned
teeth [29,30], in contrast to the buccal surface and Group A had
significantly more plaque than Group B. These results were
consistent with the prognostic assessment [5]. Furthermore, the
results of the bacterial quantification were consistent with those
of the photographs, although there was some variation. The
plaque accumulation on the distoproximal surface was due to
the difficulty in removing plaque with ordinary brushing
[32,33]. In addition, the guide plate did not contact and remove
the plaque accumulated in the void. A close type guide plane is
thought to be effective to reduce the plaque accumulation,
however it is difficult to prepare a guide plane to the gingival
margin, especially with natural abutment teeth. Therefore,
special tooth brushing [32,33] is essential for denture wearers to
remove the plaque which is increased by wearing partial
dentures [7]. The close type guide plane is considered to be
ideal to purge plaque accumulation by reducing the void at the
distoproximal area between the abutment and the associated
denture saddle [34], however, this close type guide plane has
also been reported to cause gingival inflammation [35], and it is
necessary to address both plaque accumulation and gingival
inflammation.
5. Conclusion
Within the limitations of this study, the following conclusion
can be drawn. The plaque formation on the buccal surface is not
dependent on the type or placement of clasps. It is effective to
prepare the guide plane as close to the gingival margin as
possible to reduce the plaque accumulation on the distoprox-
imal surface.
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