Denture Stomatitis - Classification, Etiology, Risks, and Management

Introduction

Dentures are often advised to rehabilitate oral functions in patients with missing teeth. These dentures are fabricated using certain chemical compounds. Dentures are often provided to patients with a set of instructions to follow. As these dentures are designed to sit in close contact with the underlying mucosal tissue, they can evoke an inflammatory response in the mucosa covering the oral cavity, typically the area that comes in contact with the denture surface. It also enhances the growth of certain fungal species underneath the denture-bearing area. These forms of mucosal inflammation triggered by the long-term wearing of dentures are categorized as denture stomatitis.

What Causes Inflammation in Oral Mucosa?

Denture stomatitis is a common oral condition in long-term or all-time denture wearers. This is a mucosal inflammation condition characterized by local inflammation and redness or erythema of oral mucosal areas that are in localized contact with the surface of the denture. Despite the increased frequency of this condition occurring in regular denture wearers, the etiology of denture stomatitis remains elusive. Several predisposing risk factors may be responsible for the underlying inflammation.

Etiology and Pathogenesis of Denture Stomatitis:

The prevalence of denture stomatitis ranges approximately between 20 to 70 % amongst most denture wearers. It is most commonly observed either on the palatal mucosa (the maxillary denture stomatitis being most common) or in areas in direct contact with the denture surface. Hence, it is not uncommon for the dentist to note oral mucosal inflammation in relation to removable dentures. Denture stomatitis is more common in females and is mainly considered a benign (noncancerous) lesion without any scope for aggressive transformation to primary oral lesions. Research also indicates the main reason why the mandibular or lower oral mucosa tends to be more protected is because of increased salivary flow in this region. Saliva possesses antimicrobial properties and essential immunoglobulins. In addition, it prevents the inflammatory response to lower dentures. Hence the incidence of mandibular denture stomatitis is comparatively low.

What Are the Risk Factors of Denture Stomatitis?

The denture stomatitis risk factors are divided into two types, local and systemic. The pathogenesis of denture stomatitis is attributed to the localized trauma or inflammation that may be due to decreased flow of oxygen or lessened saliva in the maxillary dentures to the underlying tissue. This can facilitate a local environment that promotes colonization by yeast, Candida albicans, or bacterial ingress solely upon the ill-fitting surface of the denture prosthesis. Dental research indicates the precise interaction between the number of predisposing local or systemic risk factors in relation to denture stomatitis.

Local risk factors include:

• Xerostomia or dry mouth.

• Localized trauma occurs most often due to denture defects or an ill-fitting surface of the denture.

• Poor plaque control and inadequate denture hygiene.

• Continuous wearing of dentures even through the night.

• Diet rich in carbohydrates.

• Acidic salivary pH as a result of systemic conditions.

• Smoking.

• Chronic alcoholism.

Systemic risk factors include:

• Immunosuppressive patients.

• Patients suffering from nutritional and dietary deficiencies in hematological disorders.

• Patients on systemic drug therapies that can cause drug-induced gingival enlargement (DIGO).

• Immunocompromised conditions.

What Is the Classification of Denture Stomatitis?

Clinically on observation, the buccal and labial mucosa that tend to be in direct contact with the maxillary denture base is most often prone to exhibiting this condition. The traditional classification followed for categorizing the types of denture stomatitis is according to Newton's classification proposed in 1962 and is as follows:

• Type I Denture Stomatitis: In this type, the inflammation of oral mucosal membranes is very localized and occurs only as an effect or impact of trauma.

• Type II Denture Stomatitis: The denture‐bearing or contacting oral mucosa is of diffuse involvement.

• Type III Denture Stomatitis: This is also called granular denture stomatitis or commonly known as Inflammatory papillary hyperplasia. As the name suggests, this advanced stage of inflammation is accompanied by chronic low to moderate pain, oral discomfiture, and certain unfavorable clinical symptoms like a burning sensation under the denture. In addition, in granular inflammatory hyperplasia, it is not uncommon for the patient to report other low-grade or chronic oral cavity infections, like fungal infections and tingling sensations underneath the denture surface. Hence investigation should also be prompted by the maxillofacial surgeon or the dentist for detecting associated conditions in relation to denture stomatitis like angular cheilitis, atrophic glossitis, and acute, chronic, or pseudomembranous forms of candidiasis.

How Is Denture Stomatitis Managed?

In most cases, the dentist's management of this condition involves comprehensive treatment strategy planning and, firstly, elimination of all predisposing local and systemic risk factors.

• The prosthodontist or the general dentist should always examine and focus on the preliminary examination of denture surfaces and any faults that might be a source of local irritation to the oral mucosal membranes. If such defects are observed, repair of the denture and tissue conditioning by using soft tissue liners or tissue conditioners can be used to prevent further trauma to the region of inflammation.

• Patient awareness should be a mandatory effort to combat denture stomatitis, and the dentist should advise instructions to control denture plaque. Also, as some people tend to wear removable dentures overnight continuously, it should be strictly prohibited.

• Underlying inflammatory conditions associated with denture stomatitis, like the acute, chronic, or hyperplastic forms of candidiasis, should be treated by antifungal therapeutic agents. This is because, in recent decades, the increased association with Candida albicans colonization and research upon its group to nearly affect 60 to 100 % of denture wearers is why dentists need to investigate fungal infections of the oral cavity like candidiasis as well in relation to denture stomatitis.

• The dental or maxillofacial surgeon can also recommend antimicrobial gel, mouthwash accompanied by microwave disinfection of the denture, or accessory photodynamic therapy to treat denture stomatitis.

Conclusion:

To conclude, denture stomatitis is an inflammatory condition most commonly induced by denture trauma or defects, long-term wear, and irregular plaque control. Hence appropriate measures and timely dental management will ensure that other inflammatory oral conditions do not accompany the preexisting denture stomatitis.