What is it?
The pathological reactions of the denture bearing palatal mucosa appear under several titles and terms such as denture-induced stomatitis, denture sore mouth, denture stomatitis, inflammatory papillary hyperplasia and chronic atrophic candidosis. The term denture stomatitis will be used with the prefix Candida associated if the yeast candida is involved.
Three types of denture stomatitis can be distinguished.
Type I: A localizes simple inflammation or pinpoint heperemia.
Type II: An erythematous or generalized simple type seen as more diffuse erytheme involving a part or the entire denture-covered area.
Type III: A granular type (inflammotry papillary hyperplasia) commonly involving the central part of hard palate and the alveolar ridges. Type III often is seen in association with type I or type II.
Strains of genus Candida, in particular Candida Albicans , may cause denture stomatitis. Still this condition is not a specific disease entity because other causal factors exist such as bacterial infection, mechanical irritation, or allergy. Type I most often is trauma induced, whereas type II and III most often are caused by the prescence of microbial plaque accumulation (bacteria or yeast) on the fitting denture surface and the underlying mucosa. The often relative association of Candida associated denture stomatitis with angular chelitis or glossitis indicated a spread of infection from the denture covered mucosa to the angles of the mouth or the tongue, respectively.
The diagnosis of Candida associated denture stomatitis is confiemed by the finding of mycelia or pseudohyphae in a direct smear or the isolation of candida species in high numbers from the lesions(>/=50 colonies). Usually, yeast are recovered in higher numbers from the fitting surface of the dentures then from corresponding areas of the palatal mucosa. This indicates that Candida residing on the fitting surface of the denture is the primary source of infection.
Factors Predisposing To Candida Associated Denture Stomatitis:
Ø Old age
Ø Diabetes Millitus
Ø Nutritional deficiencies(iron, folate, or vit B12)
Ø Malignancies(acute leukemia, agranulocytosis)
Ø Immune defects
Ø Corticosteriods, Immunosuppressive drugs.
Ø Dentures(changes in environmental conditions, trauma, usage, denture cleanliness).
Ø Xerostomia(sjogren syndrome, irradiation, drug therapy).
Ø High carbohydrate diet.
Ø Broad spectrum antibiotics.
Ø Smoking tobacco.
ETIOLOGY AND PREDISPOSING FACTORS:
The direct predisposing factor for Candida associated denture stomatitis is the presence of the denture in the oral cavity(box 1). Thus the infection prevail in patients who are wearing their dentures both day and night; the infection will disappear if the dentures are not worn. It is likely that bacteria, which constitute the major part of the micro-organism of the denture plaque, are also involved in the infection. In addition, trauma could stimulate the turnover of the palatal epithelial cells, thereby reducing the degree of keratinization and the barrier function of the epithelium; thus the penetration of fungal and bacterial antigens can take place more easily.
The colonization of the fitting denture surface by Candida species depends on several factors, including adherence of yeast cells, interaction with oral commensal bacteria , redox potential of the site and surface properties of the acrylic resin. The pathogenicity of the plaque can be enhanced by the factors stimulating yeast propagation, such as poor oral hygiene, high carbohydrate intake, reduced salivary flow and continuous denture wearing. The more important factors that can modulate host-parasite relationship and increase the susceptibility to Candida associated denture stomatitis may be aging, malnutrition, immunosuppression, radiation therapy, diabetes mellitus and possibly treatment with antibacterial antibiotics.
Evidence supports that unclean dentures and poor hygiene care are major predisposing factors because healing of the lesions is often seen after meticulous oral and denture hygiene is instituted. However, the tissue surfaces of dentures usually shows micropits and microporosities that harbor microorganisms that are difficult to remove mechanically or by chemical cleansing. According to several in vitro studies, the microbial contamination of denture acrylic resins occurs very quickly, and yeast seems to adhere well to denture base materials.
Angular chelitis is often correlated to the presence of Candida associated stomatitis, and it is thought that the infection may start beneath the maxillary denture and from that area spread to the angels of the mouth. It seems, however, that this infection results from local and systemic predisposing conditions such as over closure of the jaws, nutritional deficiencies, or iron deficiency anemia. Frequently, a secondary infection caused by staphalococcus aureus could be present. It must be recognized that visible infection by Candida species can be an early indicator of immune dysfunction and the discovery of such should prompt a review of the patient’s clinical background.
Although denture stomatitis and angular chelitis usually do not reflect a serious predisposing disease or abnormality , with denture wearind as the direct cause of the lesions, it should be realized that severe infections by Candida species may occur in the immunocompromised host .