Oral Health Foundation (UK) Guidelines for Denture Care & Denture Adhesive Use

Compiled by Prof. Dr. Fazal Ghani, Head of Department of Prosthodontics & Dean Postgraduate Dental Sciences, Peshawar Dental College, Peshawar

It is expected that some two billion people will be aged 60 or older by the year 2050, a figure more than double the today’s figure. The older a person is, the more likely he/she is to have lost all, or nearly all, his / her natural teeth, meaning increased demand for removable complete or partial dentures. The World Health Organization’s Global Health Survey, carried out between 2002 and 2004 showed the condition of edentulism as a highly prevalent condition worldwide. For people aged 65 and over, there was an overall average prevalence of 32.9% and in individual countries this ranged from as low as 7% in Egypt up to 72% in Iceland. There was a large variation between countries that had similar income levels. This suggests that average income per head may not be the main cause of the rate of edentulism in a given country. Other factors such as oral hygiene practices, nutritional habits, and socioeconomic inequalities have been suggested as being stronger driving factors. Edentulism remains a highly prevalent condition worldwide. It seems to be a more common problem in low- to middle-income countries, where the prevalence of caries and periodontal problems increases due to recent changes in dietary and lifestyle habits. The following factors were associated with edentulism in older age groups:

1. Socio-demographic factors (for example, lower education)
2. Lifestyle habits (for example, smoking)
3. Health conditions (for example, arthritis, asthma and diabetes)

Despite the condition of edentulism and denture use by many, a comprehensive review of scientific and evidence-based research has found contradictory guidance and a lack of consistency in the recommendations for cleaning and maintaining removable dentures. Most surveys show that the majority of the denture-wearing population are failing to keep their dentures clean. A Turkish study from 2001 revealed data on denture cleanliness and denture cleaning habits (method used and how often). The study used 70 full-denture wearers attending the Department of Prosthetic Dentistry at Marmara University (Istanbul). In this limited study, 46.6% of patients were scored with poor cleanliness of their dentures while only 15.7% scored ‘excellent’. From the total group:

1. 25.7% said they cleaned their dentures less than once a day
2. 45.7% said they cleaned their dentures more than once a day
3. 11.5% said that they neither soaked nor brushed their dentures
4. 17.1% soaked their dentures in water only
5. only 8.6% claimed to do both brushing and soaking

Keeping this in mind, the Oral Health Foundation (UK) through its Global Task Force for Care of Full Dentures have developed global guidelines on optimal denture care, so that correct advice can be given to patients.

Denture Care Guidelines:

The panel explored a number of issues, including; the challenges denture-wearers face, problems with current guidance and the evidence which is available. Here are some of the conclusions:

1. A lack of denture cleanliness can lead to poorer oral health, as well as general health problems.
2. The general cleaning habits of denture-wearers remains poor.
3. People with dentures are using a variety of ways to clean their dentures. This ranges from soap and water to toothpastes, bleaches and commercial products.
4. Recommendations to both dental professionals and denture wearers vary between countries and within a country, and usually rely on personal experience.
5. Also, opinion leaders provide contradictory guidance for cleaning and maintaining dentures.

Funding for the development of these guidelines was provided by GlaxoSmithKline Consumer Healthcare to the Oral Health Foundation (UK). No editorial control, apart from ensuring compliance with legal and regulatory considerations / requirements, has been exercised by GlaxoSmithKline Consumer Healthcare. The guidelines are supported by best evidence and based on consensus from key international experts. Four key steps to optimal denture care are summarized below:

1. Daily cleaning of the dentures using mechanical action – brushing with a toothbrush or denture brush and an effective, non-abrasive denture cleanser (no dentifrice).
2. Daily soaking in a denture-cleansing solution – this seems to deliver extra chemical breakdown of the remaining plaque and some level of disinfection of the denture. Denture-cleansing solutions should only be used outside the mouth, and denture wearers should strictly follow the manufacturers’ guidelines.
3. Denture wearers should not keep their dentures in the mouth overnight, unless there are specific reasons for keeping them in. This guideline is even more important for people at a higher risk of developing stomatitis and for frail or institutionalized older people. Soaking in a denture cleanser solution after mechanical cleaning seems to be beneficial for preventing denture stomatitis and the potential risk of pneumonia events in these groups of people.
4. All patients who wear removable dentures should be enrolled into a regular recall and maintenance program with their dental professional.

Several chemical formulations for denture cleansers are available on the market:

1. Alkali hypochlorite disrupts the bacterial cell membrane and dissolves mucins in the plaque. Sodium hypochlorite is not recommended for long-term soaking of acrylic dentures.  Soaking for more than 10 minutes may damage and lighten the colour of the acrylic denture material. It is not recommended for metal-based dentures.
2. Alkali peroxide disrupts the denture plaque through a process of effervescence.
3. Acid-based cleansers disrupt the bacterial cell membrane and dissolve calculus.
4. Enzyme-based cleansers use specific enzymes that degrade fats, glycoproteins and other structures that then help destroy microorganisms in the plaque.
5. Oral rinses include any dental mouthwash products available on the market, and these have a good range of antibacterial properties. They can be used to soak dentures in. However, those containing chlorhexidine can stain dentures.

The characteristics of an ideal denture cleanser include the following:

 A denture cleanser should:

1. Demonstrate an effect on biofilm mass
2. Deliver substantial stain removal
3. Be antibacterial and antifungal, to reduce the level of biofilm harmful pathogens below clinically relevant levels (level to be defined)

Denture Adhesives Guidelines

Research shows that around the world there are almost no guidelines on the proper use of denture adhesives by people who wear full dentures. This means denture wearers can be left without any guidance on how best to use denture adhesives. Also, the advice varies tremendously regarding;

1. The type of denture adhesive to use
2. How to apply it
3. How much to use
4. How often to use it
5. how to remove it

Misusing or overusing denture adhesive may have consequences – but making the best use of it can improve;

1. Quality of life
2. Quality of diet
3. Overall wellbeing for full-denture wearers.

In response, the Global Task Force for care of full dentures developed guidelines to guide dental health care professionals, caregivers and patients on the optimal use of denture adhesive creams. These are supported by best evidence and based on consensus from key international experts. The panel explored a number of issues about denture adhesives. Here are some of the conclusions:

1. Patient satisfaction has become a decisive factor for the overall success of prosthodontic treatment in patients wearing removable dentures.
2. Denture adhesives can enhance the retention of, and reduce food accumulation beneath, well-fitting removable dentures.
3. Denture adhesives can be beneficial to the patient. They may enhance comfort, provide psychological satisfaction, increase confidence and thus wellbeing, while increasing retention and stability, and improving function.
4. The effectiveness of denture adhesives cannot compensate for significant denture deficiencies.
5. Dental professionals should provide guidance and instructions to the patient on the correct application and use of the adhesive, and on removing it and cleaning the denture.
6. The optimum time to advise on the use of an adhesive varies between patients. For well-fitting dentures but with retention problems that might occur at a review appointment, or for patients finding problems with compliance at the time of fitting or soon after.
7. Four key steps to follow by denture wearers for optimal denture care and denture adhesive use are summarized below;

1. Make sure the denture is clean and dry. Put a small amount of denture adhesive cream onto its fitting surface (remembering that it is only needed once a day).
2. Putting the denture into mouth and firmly closing the mouth for a couple of seconds. If the adhesive cream overflows, it shows too much has been used. Any spare adhesive is to be removed and not to swallow it. Avoid eating or drinking anything for the next 5 minutes.
3. Before sleeping take the denture out. Clean the denture and the inside of the mouth thoroughly to remove any adhesive.
   1. Denture wearers are advised to ask their dentist for a regular appointment so they can check their mouth and dentures.

The American College of Prosthodontics published in 2011 their Evidence-based guidelines for the care and maintenance of complete dentures. Based on the ‘best available evidence’, they published the following guidelines for the effective cleaning of dentures:

1. Careful daily removal of the bacterial biofilm present in the oral cavity and on complete dentures is of paramount importance to minimize denture stomatitis and to help contribute to good oral and general health.
2. To reduce levels of biofilm and potentially harmful bacteria and fungi, patients who wear dentures should do the following:
   1. Dentures should be cleaned daily by soaking and brushing with an effective, nonabrasive denture cleanser.
   1. Denture cleansers should ONLY be used to clean dentures outside of the mouth.
   1.  Dentures should always be thoroughly rinsed after soaking and brushing with denture cleansing solutions prior to reinsertion into the oral cavity. Always follow the product usage instructions.
3. Although the evidence is weak, dentures should be cleaned annually by a dentist or dental professional using ultrasonic cleansers to minimize biofilm accumulation over time.
4. Dentures should never be placed in boiling water.
5. Dentures should not be soaked in sodium hypochlorite bleach, or in products containing sodium hypochlorite, for periods that exceed 10 minutes. Placement of dentures in sodium hypochlorite solutions for periods longer than 10 minutes may damage dentures.
6. Dentures should be stored immersed in water after cleaning, when not replaced in the oral cavity, to avoid warping.
7. Patients who wear dentures should be checked annually by the dentist, prosthodontist, or dental professional for maintenance of optimum denture fit and function, for evaluation for oral lesions and bone loss, and for assessment of oral health status.