Oropharyngeal candidosis in the older patient.

Colonization of the oral and pharyngeal regions by Candida spp., particularly C. albicans, is extremely common in humans, particularly in early and late life. A variety of local and systemic conditions predispose the transformation of the benign colonization to a pathological state, which may have severe local or serious systemic consequences. The finding of oropharyngeal candidosis in an older patient, therefore, merits investigation of the likely host factors responsible for the organism adopting its pathogenic behavior. This paper provides non-dental clinicians managing older patients a review of the clinical characteristics, risk factors, diagnosis, and management of oropharyngeal candidosis in older adults.

A survey of temporomandibular disorder conducted by the Greater New York Academy of Prosthodontics.

The results of a temporomandibular joint survey sent to 167 members of the Greater New York Academy of Prosthodontics indicated a great variation in the diagnosis and treatment of patients with temporomandibular joint dysfunction. Although most indicated that their background in temporomandibular joint disorders was from clinical experience and/or textbooks and the dental literature, only 59% treated patients for these disorders. The most common diagnostic procedures were occlusal evaluation; joint evaluation for tenderness, crepitus, and click; evaluation of range of motion of the mandible; and a muscular evaluation. Only 35% used a formal temporomandibular joint dysfunction questionnaire. The percentage of complete denture patients with these symptoms was 5% or less. Thirty-three percent of clinicians sometimes treated asymptomatic patients who were without pain but had a click. Two thirds of the respondents believed that surgery was sometimes indicated for disk degeneration and displacement. More recent graduates are more likely to treat patients who have temporomandibular joint dysfunction than are older more experienced practitioners.

Immunological status of patients with denture stomatitis and yeast infection after treatment of maxillofacial tumors.

Therapeutic modalities employed in the treatment of maxillofacial malignancy, tumor resection, radiation and chemotherapy, can result in local and systemic changes in healthy oral tissues many years after anticancer therapy has been stopped. The immunologic status of a select group of nine individuals who underwent surgery of the maxillofacial region and after head and neck irradiation, with severe and persistent denture stomatitis was studied. A significant impairment of granulocyte and lymphocyte functions and increased concentrations of serum IgG, as compared to healthy controls, were found in the patients of the study group. It is concluded, that this group of patients show immunological abnormalities many years post therapy, which must be recognized by the clinician in order to effect a cure.

Assessment of antimicrobial treatment of denture stomatitis using an in vivo replica model system: therapeutic efficacy of an oral rinse.

Five denture stomatitis patients demonstrating Candida albicans on both maxillary dentures and palates volunteered to test the effects of Peridex oral rinse in treating their oral disease. They used Peridex rinse both as a mouthrinse and as a denture soak for a period of 24 days. Agar replicas of the tissue-fitting surfaces of the maxillary dentures revealed elimination of C. albicans. Significant decreases in palatal inflammation were also noted, although some inflammation was still evident. Several weeks after the termination of Peridex oral rinses, inflammation increased as concentrations of C. albicans on the denture surface returned to pretreatment levels. A marked similarity in the site-specific localization of this yeast species on the denture was noted before and after Peridex rinse treatment.

In vivo antifungal efficacy of salivary histidine-rich polypeptides: preliminary findings in a denture stomatitis model system.

Six denture stomatitis patients, all found to have Candida albicans on their maxillary denture and palatal tissue surfaces, volunteered in this preliminary study to test the in vivo efficacy of human salivary antifungal histidine-rich polypeptides (HRPs) in treating their oral disease. The patients were equally divided among the Newton types classification and, as expected, the severity of the inflammation was greatest in the Newton type III patients and least in the Newton type I patients. Patients received sterile solutions of either HRP-3 or HRP-4, which they used both as a mouthrinse and as a denture soak for a period of 1 week. Agar replicas of the tissue-fitting surface of the maxillary dentures revealed HRP reduction and/or elimination of C. albicans from the denture; in one Newton type II individual, this finding directly correlated with a site-specific reduction in palatal inflammation. In the Newton type II and type III individuals alike, there was a significant generalized decrease in inflammation suggesting the therapeutic efficacy of the HRPs. Killing of this yeast species by the HRPs, as determined by scanning electron microscopy (SEM), was probably responsible for the observed clinical benefits noted in this investigation. In the SEM, HRP-treated blastospores appeared severely deflated, as if they had been emptied of significant quantities of intracellular material.

Sensitivity of the replica method in the detection of candidal infection among denture wearers with clinically healthy oral mucosa.

To ascertain the role of Candida in denture stomatitis, the practitioner must conduct a mycologic examination of the acrylic resin denture surface, because it acts as a reservoir for continuous reinfection of the palate. Twenty-two patients were examined to compare the sensitivity of the standard technique of swabbing the denture to that of a newly developed cast agar replica technique for detecting Candida albicans. The dentures were swabbed and cast replicas of the tissue-fitting surface of the dentures were made of both study populations. The majority of cultures obtained by swabbing failed to detect the presence of Candida albicans, while all cast agar replicas grew Candida albicans. The replica method for the detection of Candida albicans in edentulous patients seemed to be a more sensitive method than currently available mycologic methods.

The overdenture concept.

The biomechanical rationale for the treatment of patients with overdentures, and their advantages and disadvantages are presented. The indications and contraindications for the treatment of partially edentulous patients with removable partial overdentures are discussed. The patient's and dentist's responsibilities for the success of therapy are enumerated.

Periodontal considerations of the removable partial overdenture.

1. An overdenture, whether complete or partial, is an excellent mode of treatment in the mutilated dentition for the preservation of the residual ridge. 2. Selection of patients for an overdenture should be based on past history of dental neglect, the status of the teeth and their periodontium, including present oral hygiene status, and patient motivation. The patients with a history of dental neglect, poor oral hygiene, and lack of motivation in having the teeth and the periodontium restored to health as well as strict compliance to a home-care regimen and recall schedule are not good candidates for treatment with an overdenture. 3. The choice of teeth or roots to serve as overdenture abutments must include their periodontal evaluation, which should consist of a detailed periodontal examination, diagnosis, prognosis, and treatment when this is indicated, including chemical protection (fluoride gel) and an oral hygiene regimen tailored to individual needs. 4. The knowledge and expertise in the selection and implementation of appropriate periodontal treatment modalities is of paramount importance in restoring optimum periodontal health to the overdenture abutments before overdenture fabrication. 5. The maintenance phase of the overdenture abutments as well as of the existing natural teeth is of critical importance in the preservation of health of these abutments and teeth. This maintenance phase should consist of periodic recalls based on individual needs; a detailed periodontal evaluation, including patient's motivation and status of oral hygiene and denture hygiene; and detection of caries. If necessary, appropriate periodontal and/or restorative therapy should be performed, and oral hygiene measures reinforced. This will ensure longevity of both abutment teeth or roots and of the existing natural teeth resulting in a long-term success of an overdenture. 6. Because there is evidence of high incidence of periodontal disease and dental caries in overdenture wearers, and because this evidence is attributed mainly to lack of motivation and compliance of adequate oral hygiene as well as to frequency of recall visits, patients should be made aware of the importance of their role in the maintenance phase of treatment and in the factors that lead to ultimate success of overdenture therapy. 7. With (a) proper selection of the patient and the abutment teeth, (b) adequate periodontal and restorative health and treatment to ensure optimum health prior to RPOD construction, (c) a well-designed home-care regimen and frequency of recalls, and (d) proper execution of maintenance care, changes for long-term success of overdenture therapy will be much improved.

An in vivo replica method for the site-specific detection of Candida albicans on the denture surface in denture stomatitis patients: correlation with clinical disease.

A site-specific agar replica technique for detecting Candida albicans on the acrylic resin denture surface of denture stomatitis patients has been developed. The method is selective for C. albicans during a finite incubation period with a specific synthetic growth medium. C. albicans colonies can be geographically observed on the replica and their presence can be correlated with inflammatory lesions visible on the mucosa of the maxillary and mandibular residual ridges. In 12 denture stomatitis patients studied, a close clinical correlation of Newton type III patients was noted but this clinical correlation could not be observed in Newton type I and II patients. In general, the number of C. albicans colonies increased with the severity of the inflammation. The findings are discussed in light of lack of knowledge of the etiology of the stomatitis. The importance of the replica method is also discussed.

In vitro study on the inhibiting effect of different agents on the growth of Candida albicans on acrylic resin surfaces.

This study evaluated at the in vitro level the antifungal effectiveness of nystatin, chlorhexidine, and a homologous histidine polypeptide on the surface of acrylic resin disks. The agents were used in a way that simulated storage of a denture by a denture wearer. Results indicated that pretreatment with poly-L-histidine was not protective against C albicans adherence and growth regardless of whether disks were stored in water or in the open air for the 8-hour period following yeast contamination. Chlorhexidine was totally effective in preventing C albicans attachment to, and growth on, the acrylic resin, even after a period of 8 days of turbidimetric monitoring. Pretreatment with Nystatin, followed by drying, was protective, yielding results similar to those obtained with chlorhexidine.

Mechanical evaluation of splint therapy in treatment of the edentulous patient.

Many edentulous patients have temporomandibular joint (TMJ) dysfunction that affects the use of their complete dentures. During the diagnostic and treatment-planning phase an ordered series of procedures must be performed. An arbitrary axis mounting, needlepoint and pantographic tracings on stabilized record bases will aid the dentist in determining the functional state of the TMJ and associated muscles. If no pathosis is found, a conventional denture technique can be used. If TMJ dysfunction is noted on the basis of an analysis of the tracings, an interim mandibular denture can be modified to correct the TMJ and musculature before new complete dentures are made. The occlusal scheme chosen for each patient can be based on a careful analysis of the tracings over a period of months.

Model system for the in vitro testing of a synthetic histidine peptide against Candida species grown directly on the denture surface of patients with denture stomatitis.

The denture surface provides a nidus for the growth of microbial species that act to initiate, aggravate, and maintain clinical disease. The present investigation describes the development of a model system for the testing of the effectiveness of agents against these microbial species inhabiting the denture surface. It was observed through in vitro growth patterns that the model permitted the testing of representative samples of the microbial flora. Poly-L-histidine was observed to inhibit both Candida albicans and C. glabrata from growing from the denture surface into nutrient broth. Scanning electron microscopy of control and treated denture disks revealed that poly-L-histidine had either eliminated most microbial flora from the denture surface or had effected a noticeable distortion of those Candida blastospores still present on the surface. From microbiologic studies, it appeared that poly-L-histidine had inflicted direct but not lethal damage to the still-attached distorted blastospores because the latter were still able to promote growth in agent-free broth. The antifungal effects of poly-L-histidine were observed to be dependent on the concentration of the polypeptide. The data obtained were consistent for all of the patients regardless of their denture stomatitis classification.