Journal of Oral Rehabilitation 2004 31; 453–459
Efficacy of sodium hypochlorite and coconut soap used as
disinfecting agents in the reduction of denture stomatitis,
Streptococcus mutans and Candida albicans
W . B A R N A B É * , †, T . D E M E N D O N Ç A N E T O * , F . C . P I M E N T A ‡, L . F . P E G O R A R O * &
J . M . S C O L A R O * *Department of Prosthodontics, Bauru School of Dentistry, University of São Paulo, São Paulo, †Department of
Prosthodontics, Federal University of Goiás, and ‡Department of Microbiology, Immunology and Pathology, Federal University of Goiás, Brazil
SUMMARY This study evaluated the reduction of
denture stomatitis and the antimicrobial activity of
0Æ05% sodium hypochlorite opposed to Candida
albicans and Streptococcus mutans (SGM) when associ-
ated with brushing complete dentures with coconut
soap. The mucosal characteristics were evaluated
according to Newton’s classification at baseline, after
cleansing the dentures with coconut soap for 15 days
in group 1 (nine patients). In the other group
(19 patients) the analysis were made before and after
cleansing the dentures with coconut soap and with
disinfection in a soak solution of 0Æ05% sodium
hypochlorite for 10 min during 15 days. Microbiolo-
gical tests were used to isolate C. albicans and SGM.
Mann–Whitney and Wilcoxon tests were used to
Introduction
Oral candidose, in the form of denture stomatitis attacks
65% of complete denture users (1, 2). Its aetiology is
multifactorial, with Candida albicans being the primary
aetiological agent (3–5), which may be associated with
the presence of bacterial plaque, trauma, the continu-
ous use of the prostheses, allergic reaction to the
denture base material and the cleansing products,
lack of hygiene, inadequate diet, use of antibiotics,
birth control pills and predisposing systemic conditions
(1, 3–7).
Although some authors point out that C. albicans has
a main role in the development of denture stomatitis
(2, 4, 5, 8), others (9, 10) consider the amount of
micro-organisms such as Streptococcus, Staphylococcus,
ª 2004 Blackwell Publishing Ltd
compare the mucosal characteristics and Fisher test
and McNemar test to compare C. albicans and SGM
levels. Statistical analysis at the 95% confidence
level (P < 0Æ05) showed that: (i) the association of
coconut soap and 0Æ05% sodium hypochlorite signi-
ficantly reduced clinical signs of denture stomatitis,
(ii) C. albicans did not reduce in counts, (iii) SGM were
reduced but not significantly and (iv) the association
of coconut soap and 0Æ5% sodium hypochlorite was
effective in controlling denture biofilm.
KEYWORDS: complete dentures, disinfection agents,
denture cleanses, Candida albicans, denture stomati-
tis, Streptococcus mutans
Accepted for publication 3 July 2003
Neisseria Lactobacillus, Bacteroides and Actinomices a more
important aetiological factor than the normal level
of C. albicans. Nyquist (11) considered trauma as a
dominant aetiological factor in the prevalence of den-
ture stomatitis (1) and Cawson (12) did not find evi-
dence that the disease was caused by trauma or
hypersensitivity to the denture base material. However,
Budtz-jorgensen et al. (4) concluded that the main
aetiological factor for denture stomatitis was trauma
associated with infection caused by Candida sp. (1, 4).
In the oral cavity, the initial stage of denture
stomatitis takes place with the adhesion of Candida to
the epithelial cells of the mucosa (2, 12), followed by
growth and tissue invasion. However, the mechanism
involved in the production of virulence factors in
Candida sp. is complex and can vary according to the
453
454 W . B A R N A B É et al.
location, the stage of invasion and the nature of the
host response (7, 13). The adhesion of Candida to the
mucosa surface may also be dictated by non-specific
forces, such as van der Waals forces, the London forces
and hydrophobic interactions (6, 13) as well as specific
factors such as the presence of monoprotean cell
surfaces (6, 14, 15) and the formation of hyphae (6).
Another known adhesion mechanism is the con-
gregation of yeasts with oral bacteria, mainly SGM (6)
that are responsible for creating an acid environment,
ideal for the growth of other micro-organisms. This
mechanism was demonstrated in experimental studies
that revealed (16) the ability of Candida sp. to adhere
more easily to polystyrene in the presence of Streptococ-
cus. This may correlate with adhesion to acrylic resin,
where, in the hyphae stage, the proteins that are
produced help to break the integrity of the mucosa (6,
17, 18). This explains the close relationship between
colonization of the denture bases by C. albicans and
denture stomatitis (18) (Fig. 3) revealing the need to
clean the denture in order to remove micro-organisms
(7).
The non-utilization of denture cleansers is considered
to be another aetiological factor for denture stomatitis
as it is frequently neglected by patients and the dentists
(4, 8, 19). Apparently, the mechanical cleaning of the
dentures is an effective mean to keep the mucosa
healthy, however patients usually present difficulty in
keeping them clean as it is necessary to use chemical
cleansing agents to reduce the number of active micro-
organisms (20). Furthermore, studies (21, 22) have
concluded that denture stomatitis is associated with the
growth of Candida on denture biofilm, and not on the
mucosa of the palate, suggesting that treatment would
be better directed towards the denture, and not towards
the mucosa (1).
Tarbet (23) confirmed that when a rigorous cleaning
regime was instituted, the lesions improved, or disap-
peared (1), emphasizing the importance of instituting a
homecare cleaning programme capable of removing
plaque that forms on the surface of the denture,
specially the plaque which is in contact with the soft
tissues, in regular intervals.
Webb et al.(2) and Kulak et al. (6) show that denture
biofilm control that uses only brushing is not as
effective as chemical cleansing, in reducing prostheses
plaque, and also in preventing denture stomatitis
associated with Candida.
ª 2004 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 31; 453–459
Although there is a great variety of methods and
cleansing agents for dentures, many studies (4, 9, 19,
20) have shown that fewer than 60% of prostheses
wearers use chemical cleansing products and that
60–90% use mechanical cleansing in association with
some product, such as tooth paste, soap or water (24).
Among those who use chemical products there is a
preference for homemade products – this being easy to
handle, cheap – and effective methods that completely
satisfy the users’ needs (25).
Of the available disinfectants, sodium hypochlorite is
one of the earliest and most widely used disinfectant
(24, 26). It can be a bactericide and fungicide, because it
acts directly on the organic matrix of the plaque,
resulting in the dissolution of the polymer’s structure,
probably because of oxidation of the protean compo-
nent or significantly reducing the adhesion of most
Candida sp. to the oral epithelial cells (7). These
characteristics allow the hypochlorite to reduce Candida
sp. adhesive ability, but it does not work as an anti-
invasive barrier, as it is not able to prevent the
production of proteinases by the Candida sp. (5, 7).
These findings show that sodium hypochlorite acts as
an anti-fungi agent if used as a solution to submerge
dentures in cases of denture stomatitis, even in short-
term immersions (5, 24).
The immersion of dentures, contaminated with
micro-organisms, in 0Æ525% sodium hypochlorite, for
1 and 3 min showed evidence of viable bacteria,
whereas a 5-min immersion was sufficient to disinfect
the dentures (26). The time and the pH of the solutions
used in this work were based on Schwartz’s study (27)
who observed that solutions with a pH between 7 and
11 for 10 min reduced the majority of viable micro-
organisms, and can be used as a quick, safe and
clinically effective disinfection method (26).
Coconut soap (coconut oil, sodium hydroxide,
sodium chloride, water, coadjutant, antioxidant and
glycerin) is a natural, biodegradable and antibacterial
soap largely used for cleaning and hand washing (28).
Although diverse types of cleansing agents have been
used in the microbiological control of dentures, there is
little data available concerning the effectiveness of
these homemade agents in the reduction of denture
stomatitis. Therefore, the objective of the study was to
evaluate the efficacy of sodium hypochlorite and
coconut soap used as disinfecting agents in the reduc-
tion of denture stomatitis, SGM and C. albicans.
 EFFICACY OF DISINFECTING AGENTS IN THE REDUCTION OF DENTURE STOMATITIS 455

in saline solution through 10)4. Aliquots of 0Æ1 mL of

Materials and methods
each decimal dilution were seeded in SB20 agar (casitone
A total of 60 patients wearing conventional maxillary 15 g, yeast extract 5 g, L-cystein 0Æ20 g, sodium sulphite
dentures were included in this study (mean age of 0Æ1 g, sodium acetate 20 g, sucrose 200 g, agar 15 g,
60 years) and divided in two groups: group 1 consisting water 1000 mL and sucrose-bacitracin 20%) and incu-
30 patients in treatment at a dental school were bated as for the yeasts. The SB20 agar is a culture
instructed to brush their dentures with coconut soap medium for growth of oral bacteria and contains
followed by immersion in a solution of filtered water bacitracin, which prevents the growth of yeasts. After
(200 mL) and distilled water (10 mL) (placebo solu- the incubation period, the colonies with typical mor-
tion), for 10 min. Group 2 consisting 30 patients living phological characteristics of SGM were counted on a
in home for old people received instructions to brush stereomicroscope. The yeast colonies were submitted to
their dentures with coconut soap, followed by immer- identification by micro-cultivation in lamina, germ tube
sion in a solution of filtered water (200 mL) and 1% production and carbohydrate assimilation (Fig. 5).
sodium hypochlorite (10 mL), resulting in a 0Æ05% The comparison of mucosal characteristics before and
solution with pH 8Æ5 in-use dilution, for 10 min. This after detreatment was determined by Mann–Whitney
solution is an alkaline hypochlorite which eliminates and Wilcoxon tests. Fisher and McNemar tests were
denture plaque effectively even after short-term expo- used to compare SGM and C. albicans levels before and
sure because of the presence of undissociated hypoch- after the treatment. The statistical analysis was con-
lorous acid (HOCl), where the concentration depends ducted at the 95% level of confidence (P < 0Æ05).
on pH, and which oxidases sulphydryl (-SH) of amino
acids and proteins to the disulphide form (S-S) (29).
Results
Before and 15 days after starting treatment, the den-
ture biofilm was collected in Petry’s plaque rubbing all Analysis of the data showed that from the 28 patients
denture surfaces using a sterilized toothbrush with 10 mL included in this study 19 patients (67Æ85%) presented
of saline solution, for 1 min, resulting in a solution that
was transferred with pipette to a sterilized test tube, Table 1. Analysis of the patient’s mucosa before and after
(Fig. 5) and the clinical analysis in both groups was treatment
conducted to classify the quality of the mucosa and to
verify the cleanliness of the dentures, before and 15 days Before After
Wilcoxon
after starting treatment. The quality of the mucosa was Groups 0† 1† 2† 3† 0† 1† 2† 3† test (P)
classified according to Newton (30): 0, the lesions were
1 2 4 3 0 8 0 1 0 0Æ028 *
absent; 1, (initial stage): presence of inflammation; 2, the
2 7 9 2 1 17 2 0 0 0Æ005 *
inflammation was simple and diffuse, with the presence Mann–Whitney 0Æ327 ns 0Æ891 ns
of oedema on the mucosa confined under the surface of test (P)
the dentures, without pain and 3, the inflammation was
ns, not significant.
granular and hyperplasic characterized by nodular †
Newton’s classification.
lesions associated with painful atrophic areas. *P < 0Æ05.
The patients were instructed to clear the dentures
once a day and all clinical examination and data
Table 2. Absence and presence of Candida albicans in patients
collections were performed by one examiner and 28
before and after treatment
patients (nine of group 1 and 19 of group 2) returned
for second follow-up. Before After
In order to isolate the yeasts, the suspension was McNemar
seeded with a platinum handle on a Sabouraud agar Groups Absence Presence Absence Presence test (P)

tube and incubated in candle jar at 37 C, for 72 h (17) 1 4 5 5 4 1Æ000 ns

for the colony-foming units (cfu) count (2). For the 2 4 15 7 12 0Æ450 ns
SGM count, 0Æ5 mL of the suspension were transferred Fisher test 0Æ371 ns 0Æ432 ns
(P)
to test tubes containing 4Æ5 mL of saline solution (0Æ85%
NaCl), homogenized and submitted to 10-fold dilutions ns, not significant; P < 0Æ05.

ª 2004 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 31; 453–459

456 W . B A R N A B É et al.

Table 3. Counting of Streptococcus mutans in patients before and

after treatment

Before After

Groups High Low High Low McNemar (P)

1 6 3 5 4 1Æ000 ns
2 10 9 5 14 0Æ131 ns
Fisher test (P) 0Æ687 ns 0Æ210 ns

ns, not significant; P < 0Æ005; P < 0Æ05.

Fig. 2. Denture stomatitis lesions reduced after treatment.

Fig. 1. Denture stomatitis lesion.

clinical lesions characteristic of prosthetic stomatitis

prior to treatment (Table 1). The first microbiological
test of the denture biofilm showed a high rate of
Candida sp., isolated in 20 patients (71Æ42%) (Table 2) Fig. 3. Complete denture contaminated with Streptococcus mutans
associated with a high count of SGM, >106 cfu mL)1 in and Candida albicans.

16 patients (57Æ14%) (Table 3). In the second clinical

evaluation, only three patients (10Æ71%) showed clin-
ical lesions characteristic of denture stomatitis. In the
second microbiological evaluation, it was found a
reduction of C. albicans in 16 patients (57Æ14%) (Table
2) (Fig. 6), and in the count of SGM in 10 patients
(34Æ5%) (Table 3) (Fig. 7) without significant differ-
ences in the two groups (P < 0Æ05). The results show
that the homecare cleansing protocol led to a significant
reduction in lesions of denture stomatitis for both
groups without differences between treatments (Table
1) (P < 0Æ05).
Discussion
A clinical improvement was observed in the patients’
oral mucosa without significant reduction in Candida sp.
in both groups, probably because Candida sp. is part of
the autochthonous microbiota of the mouth. This fact
shows that the treatment was able to control the
candida pathogenicity, to inhibit its opportunistic
action, which is prejudicial to prosthesis users, partic-
ularly when associated with other predisposing factors
(2).

ª 2004 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 31; 453–459

 EFFICACY OF DISINFECTING AGENTS IN THE REDUCTION OF DENTURE STOMATITIS 457

Although statistically non-significant, 50% of the

Fig. 4. Complete denture after treatment with coconut soap and
0Æ05% sodium hypochlorite.
patients in group 2 had the SGM count reduced when
compared with group 1, suggesting the effectiveness of
sodium hypochlorite in controlling the pathogenicity of
SGM in the denture biofilm.
When associated with yeasts, SGM favour the
appearance of stomatitis lesions (17) and this explains
why the reduction in its pathogenicity promoted
inhibitory action of the yeasts leading to a significant
clinical reduction in the denture stomatitis lesions that
were visible in the initial stage (5, 7). (Figs 1 and 2).
The hypochlorite reduces the adhesive ability of Can-
dida by decreasing denture stomatitis and SGM.
This study confirmed the need to recommend chem-
ical cleansing agents to reduce the pathogenicity of the
micro-organisms present on the surface of complete
denture (Fig. 4), resulting in clinical improvement of
the denture stomatitis lesions and in controlling

10 mL of saline solution 10 10–1 10–2 10–3 10–4

0·5 mL 0·5 mL 0·5 mL 0·5 mL 0·5 mL

10 mL 10 mL 4·5 mL of saline 4·5 mL of saline 4·5 mL of saline 4·5 mL of saline

solution solution solution solution
0·5 mL 0·5 mL 0·5 mL 0·5 mL 0·5 mL

Sabouroud SB20 agar SB20 agar SB20 agar SB20 agar SB20 agar
agar
Brushing denture
for one minute

10–4

Counting of cfu Counting of SGM

Fig. 5. Diagram of cultures of Candida albicans and Streptococcus mutans.

ª 2004 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 31; 453–459

458 W . B A R N A B É et al.

Fig. 6. Yeast culture plaques before (left) and after (right) treatment.

Fig. 7. Streptococcus mutans culture plaques before (left) and after (right) treatment.

Candida sp. and Streptococcus of the denture plaque. This
is in agreement with many studies (1, 5, 20) reporting
that mechanical cleansing is not sufficient to remove
the micro-organisms that colonize resinous materials,
and that chemical agents may be an important alter-
native to mechanical cleansing, especially in the elderly
and/or handicapped patients (20).
According to the methodology and limitation of this
study, the following conclusions were drawn: the
association between coconut soap and 0Æ05% sodium
hypochlorite significantly reduced the clinical signs of
denture stomatitis; C. albicans did not reduce in counts
and SGM were reduced but not significantly; the
association between coconut soap and 0Æ5% sodium
hypochlorite was effective in controlling denture bio-
film.
Acknowledgments
This study was supported by CAPES.

ª 2004 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 31; 453–459

 EFFICACY OF DISINFECTING AGENTS IN THE REDUCTION OF DENTURE STOMATITIS
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Correspondence: W. Barnabé, Ruat-36 n. 3011, Apt 1001 St Bueno
Goiãnia, Goiás, Brazil CEP: 74223-050.
E-mail: wbarnabe@hotmail.com