Candida-associated denture stomatitis. Aetiology and management: a review. Part 2. Oral diseases caused by Candida species

Evaluating the antifungal effectiveness, leaching characteristics, flexural strength, and impact strength of polymethyl methacrylate added with small-scale silver nanoparticles - An in vitro study

AIM

(1) To assess the release of stable silver nanoparticles (AgNPs) of small scale dimension added to heat polymerized polymethyl methacrylate (PMMA) in 6 months. (2) Assessing the influence of incorporating minimal concentrations of stable AgNPs with nanoscale dimensions into heat polymerized PMMA over a 6 month period on its antifungal efficacy (AF), flexural strength (FS), and impact strength (IS).

SETTINGS AND DESIGN

Incorporating nanoparticles with a very small scale may have minimal impact on mechanical properties due to their diminutive size. However, the influence of these small scaled nanoparticles on antimicrobial efficacy and potential escalation in toxicity to host cells through leaching remains unexplored. AgNPs were prepared using an Ultrasonic Probe sonicator and the addition of ammonia to obtain stabilized AgNPs (< 0.01 nm) of small scale dimension. The characterization of these AgNPs involved ultraviolet visible spectroscopy, X ray diffraction, Zetasizer, and transmission electron microscopy with energy dispersive spectroscopy (TEM).

MATERIALS AND METHODS

The prepared AgNPs were then added in various percentages by weight (0%-0.5%) to fabricate 252 modified PMMA samples of sizes 10 mm × 3 mm (AF, n = 108), 65 mm × 10 mm × 3 mm (FS, n = 72), and 65 mm × 10 mm × 2.5 mm (IS, n = 72) as per ADA specification no. 12. These samples underwent testing for leaching out of AgNPs and efficacy against Candida albicans for 6 months. The effect on FS and IS was evaluated using the three point bending test and Charpy's Impact Tester, respectively.

STATISTICAL ANALYSIS USED

Intergroup comparison of CFU between various concentrations of AgNP was done using the Kruskal-Wallis ANOVA test succeeded by Mann-Whitney test for pair wise comparisons. Difference in CFU of various concentrations over 6 months was seen using one way ANOVA test. Intergroup comparison of FS and IS was performed using a one way ANOVA test, followed by a post hoc Tukey's test for pair wise comparisons.

RESULTS

Repeated tests showed no leaching out of AgNPs from the denture base resin into the storage medium. All concentrations of AgNPs incorporated in resin showed inhibition of Candida growth. Intergroup comparison of FS and IS revealed highly statistically significant differences (F = 15.076, P < 0.01 and F = 28.266, P < 0.01) between the groups showing a reduction in strength.

CONCLUSION

The AgNPs of small scale dimension incorporated into the denture base resin imparted a strong antifungal effectiveness against C. albicans, which did not decline during the study period and did not cause any release of nanoparticles. 0.5% showed the best antifungal efficacy. This may prove to be a viable and highly effective treatment for the prevention of Candida associated denture stomatitis. However, the inclusion of these particles resulted in a decrease in both FS and IS, and this reduction was directly proportional to the percentage of added AgNPs, with 0.5% demonstrating the least IS and FS.

Microbial Analysis of Obturators During Maxillofacial Prosthodontic Treatment Over an 8-Year Period

The aim of the study was to investigate the microbial colonization (by Candida species, anaerobic and facultative anaerobic bacteria) of maxillary obturators used for the restoration of maxillary defects, including during radiotherapy.

Retrospective cohort study.

Fifteen patients requiring a maxillary obturator prosthesis had swabs of their obturators and adjacent tissues taken at different stages of their treatment over a period of 8 years.

Identification of microbial species from the swabs was carried out using randomly amplified polymorphic DNA polymerase chain reaction (RAPD PCR) analysis, checkerboard DNA-DNA hybridization, CHROMagar Candida chromogenic agar, and DNA sequencing.

Candida species were detected in all patients and all patients developed mucositis and candidiasis during radiotherapy which was associated with an increase in colonization of surfaces with Candida spp., particularly C albicans. Microbial colonization increased during radiotherapy and as an obturator aged, and decreased following a reline, delivery of a new prosthesis, or antifungal treatment during radiotherapy.

Microbial colonization of maxillary obturators was related to the stage of treatment, age of the obturator material, radiotherapy and antifungal medications, and antifungal treatment may be recommended if C albicans colonization of palatal tissues is greater than 105 colony-forming units per cm2 following the first week of radiotherapy.

Efficacy of antimicrobial photodynamic therapy in disinfection of Candida biofilms on acrylic dentures: A systematic review

BACKGROUND

The aim of this systematic review was to critically analyze and summarize the currently available scientific evidence concerning antifungal efficacy of aPDT against Candida on acrylic surface.

METHODS

The focused question was: '"Is aPDT effective in minimizing the counts of Candida on acrylic dentures". A literature search was conducted interpedently on the following electronic research databases: PubMED/MEDLINE, Cochrane, Google Scholar and Embase. The MeSH terms used were: ((antimicrobial photodynamic therapy) OR (light) OR (laser) OR (photodynamic)) AND ((Candida) OR (denture stomatitis)) AND ((denture) OR (acrylic) OR (polymethylmethacrylate) OR (dental prosthesis)). Data was extracted from the studies and quality assessment was carried out using a modified version of the CONSORT checklist.

RESULTS

Eighteen in-vitro anti-microbial studies and 5 clinical studies were included. Twenty-two studies suggested that aPDT was effective in reducing the Candida count on acrylic dentures and one study did not have a significant effect. 19 out of 23 studies were graded as having 'medium' quality and 4 studies were graded as 'high'. Several photosensitizers, including methylene blue, porphyrin derivatives, toluidine blue-O and others were used. LED was the most popular light source used for photo-activation of the photosensitizers.

CONCLUSION

Within the limitations of this review, aPDT is effective in reducing Candida growth on acrylic dentures and may prove to be clinical effective in preventing or treating denture stomatitis. However, more long-term clinical research is required before its clinical efficacy can be determined.

Host's Immunity and Candida Species Associated with Denture Stomatitis: A Narrative Review

Denture-related Candida stomatitis, which has been described clinically in the literature, is either localized or generalized inflammation of the oral mucosa in connection with a removable prosthesis. During this inflammatory process, the mycobacterial biofilm and the host’s immune response play an essential role. Among microorganisms of this mixed biofilm, the Candida species proliferates easily and changes from a commensal to an opportunistic pathogen. In this situation, the relationship between the Candida spp. and the host is influenced by the presence of the denture and conditioned both by the immune response and the oral microbiota. Specifically, this fungus is able to hijack the innate immune system of its host to cause infection. Additionally, older edentulous wearers of dentures may experience an imbalanced and decreased oral microbiome diversity. Under these conditions, the immune deficiency of these aging patients often promotes the spread of commensals and pathogens. The present narrative review aimed to analyze the innate and adaptive immune responses of patients with denture stomatitis and more particularly the involvement of Candida albicans sp. associated with this pathology.

The denture microbiome in health and disease: an exploration of a unique community

The United Nations suggests the global population of denture wearers (an artificial device that acts as a replacement for teeth) is likely to rise significantly by the year 2050. Dentures become colonized by microbial biofilms, the composition of which is influenced by complex factors such as patient’s age and health, and the nature of the denture material. Since colonization (and subsequent biofilm formation) by some micro‐organisms can significantly impact the health of the denture wearer, the study of denture microbiology has long been of interest to researchers. The specific local and systemic health risks of denture plaque are different from those of dental plaque, particularly with respect to the presence of the opportunist pathogen Candida albicans and various other nonoral opportunists. Here, we reflect on advancements in our understanding of the relationship between micro‐organisms, dentures, and the host, and highlight how our growing knowledge of the microbiome, biofilms, and novel antimicrobial technologies may better inform diagnosis, treatment, and prevention of denture‐associated infections, thereby enhancing the quality and longevity of denture wearers.

Geraniol and thymoquinone inhibit Candida spp. biofilm formation on acrylic denture resin without affecting surface roughness or color

PURPOSE

This study was designed to investigate the in vitro effects of geraniol (GE) and thymoquinone (TQ) on Candida biofilms on denture acrylic and any accompanying changes in acrylic surface roughness or color.

METHODS

The susceptibility of Candida species to GE and TQ was determined using the broth microdilution method and time-kill assay. A minimum biofilm eradication concentration (MBEC) assay was performed using 7-day Candida biofilms grown on denture acrylic.

RESULTS

The minimum inhibitory concentration (MIC) of GE and TQ for Candida spp. was 256 and 32 µg/mL, respectively. The Candida strain complete kill rates for GE and TQ at 5-fold MIC were determined after 1 h of incubation. At 5-fold MIC, GE and TQ inhibited the preformed biofilm activity (MBEC80) of all Candida strains on denture acrylic by more than 80% after treatment for 3 h. At sub-MIC levels, GE and TQ prevented the development of C. albicans and C. tropicalis hyphae. SEM images demonstrated that GE and TQ damaged the fungal cell membrane and induced cell lysis. On the other hand, GE and TQ at 10-fold MIC did not alter the surface roughness or color of the denture acrylic.

CONCLUSION

GE and TQ are interesting natural substances that could be developed as promising disinfectants for removable dentures.

Antimicrobial efficacy and biocompatibility of extracts from Cryptocarya species

This study evaluated the efficacy of Cryptocarya spp extracts on biofilm of Candida albicans and its biocompatibility. Mature biofilm of C. albicans was formed on denture base acrylic resin samples and the fungicidal effect of the extracts was evaluated by Alamar Blue® assay, counting colony-forming units (CFU/mL) and confocal laser scanning microscopy (CLSM). Cytotoxicity of extracts from Cryptocarya species was evaluated by AlamarBlue® assay, using normal oral keratinocytes (NOK) cells. In additional, Analysis of plant extracts by ultra-high-performance liquid chromatography-diode array detector-tandem mass spectrometry (UPLC-DAD-MS) was performed. The results showed significant reduction in the cellular metabolism and in the number of CFU/mL of C. albicans (p<0.05). The concentration of 0.045 g/mL completely inhibited the number of CFU/mL. Regarding cytotoxicity, all extracts decreased cell viability compared to the control group. CLSM analysis showed predominance of live cells, but with a great difference between the groups. Antimicrobial activity of extracts from Cryptocarya on C. albicans biofilm was confirmed. However, all extracts showed toxicity on NOK cells.

Development of a United Kingdom-centric cost-effectiveness model for denture cleaning strategies

STATEMENT OF PROBLEM

Denture stomatitis is a prevalent condition in denture wearers. Economic evaluations of health care can help stakeholders, including patients, make better decisions about treatments for a given condition. Economic models to assess the costs and benefits of different options for managing denture stomatitis are lacking.

PURPOSE

The purpose of this study was to explore the feasibility of developing a cost-effectiveness model to assess denture cleaning strategies aimed at preventing denture stomatitis from a denture-wearer perspective in the United Kingdom.

MATERIAL AND METHODS

A model was developed to identify and estimate the costs and effects associated with 3 denture cleaning strategies. These were low care (LC)-cleaning by brushing and soaking overnight in water; medium care (MC)-brushing with toothpaste and soaking overnight in water; and optimum care (OC)-brushing and soaking overnight in water and antimicrobial denture cleanser. Costs, outcome measures (denture stomatitis-free days), and probabilities (incidence of stomatitis, unscheduled dentist visits, prescription charges, self-medication) associated with each strategy were defined. A sensitivity analysis was used to identify key drivers and test the robustness of the model.

RESULTS

The model showed that the total costs for 2015 ranged from £1.07 (LC) to £18.42 (OC). Costs associated with LC were derived from unscheduled dentist visits and use of medication and/or prescription charges. Incremental costs per denture stomatitis-free day were £0.64 (MC) and £1.81 (OC) compared with LC. A sensitivity analysis showed that varying either or both key parameters (baseline incidence of denture stomatitis and relative effectiveness of MC and OC strategies) had a substantial effect. Incremental cost-effectiveness ratios ranged from £4.11 to £7.39 (worst-case scenario) and from £0.21 to £0.61 (best-case scenario).

CONCLUSIONS

A model was developed to assess the relative cost-effectiveness of different denture cleaning strategies to help improve denture hygiene. An important finding of the study was the lack of evidence on the relative effectiveness of different cleaning strategies, meaning that several assumptions had to be incorporated into the model. The model output would therefore likely be considerably improved and more robust if these evidence gaps were filled.

Efficacy of curcumin in the treatment of denture stomatitis: A randomized double-blind study

Background

The prevalence of denture stomatitis has been shown to vary from 15% to 65% in complete denture wearers. In recent years, a number of studies across the globe have investigated the various biological effects of curcumin, curcumin, a polyphenolic compound derived from dietary spice turmeric, possesses diverse pharmacologic effects including anti-inflammatory, antioxidant, antiproliferative and antiangiogenic activities. The aim of this study was to evaluate the efficacy of curcumin local application with common antifungal agent clotrimazole for the treatment of denture stomatitis.

Materials and Methods

A randomised double-blind clinical trial with approval of institutional ethical committee consisting fifty participants divided into two groups (17 men-33 women) with the clinical signs and symptoms of oral candidiasis. The diagnosis was supported by microbiological cultures. Group A patients were prescribed the clotrimazole and Group B patients were prescribed the curcumin ointment which was dispensed in similar amber coloured bottles. Data were analyzed using Chi-squared tests, Wilcoxon's signed rank sum test and Mann-Whitney test.

Results

The mean candidal colony counts before treatment in Groups A and Group B were 63.960 and 37.080, respectively. The mean candida colony counts after treatment in both the groups were 14.080 and 3.720, respectively. There was a statistically significant difference between the two groups when mean candida colony counts were calculated before and after treatment. However, intergroup comparison between the two groups considering the mycological eradication showed that there was no statistically significant difference with P = 0.404.

Conclusion

Topical application of curcumin as a natural ingredient could be an effective agent for the treatment of denture stomatitis as an alternative to regular clotrimazole therapy.

Novel antimicrobial denture adhesive containing S-PRG filler

The antimicrobial effects of denture adhesives containing novel surface pre-reacted glass-ionomer (S-PRG) fillers were assessed. We prepared denture adhesives containing S-PRG (particle sizes: 1 and 3 µm; quantities: 5, 7.5, and 10 wt%). We evaluated acid buffering capacity, ion release, and antimicrobial effects of denture adhesives with and without S-PRG. Significantly higher pH changes were observed in 1 µm S-PRG adhesives than in 3 µm S-PRG adhesives. Adhesives containing 7.5 and 10 wt% S-PRG exhibited significantly higher ion release than adhesives with 5 wt% S-PRG. The 1µm-10wt% S-PRG denture adhesive exhibited significantly lower colony-forming units on the denture adhesive contact surface than in the control group; additionally, it exhibited excellent acid buffering capacity, ion release properties, and antimicrobial effect against C. albicans, C. glabrata, S. mutans, and A. naeslundii. Longer contact periods resulted in significantly lower adhesion of Candida albicans to the denture base resin treated with denture adhesive.

Association between Vitamin D and Candida-Associated Denture Stomatitis

Candida-associated denture stomatitis (CADS) is a fungal infection affecting 60–65% of denture wearers. Its etiology is complex and multifactorial and often associated with host immunodeficiency. Evidence exists that vitamin D has potential immunomodulatory and anti-inflammatory effects. The aim of this case–control study was to assess the association between vitamin D levels and CADS. The study included 32 complete denture wearers with CADS and 32 sex- and age-matched complete denture wearers without CADS. The patients were clinically examined, and the severity of denture stomatitis was assessed according to Newton’s classification scale. The serum vitamin D level was determined via the use of an electrochemiluminescence assay. The vitamin D level in the CADS group and control group was 54.68 ± 17.07 and 56.82 ± 17.75 nmol/L, respectively. There was no significant difference between the groups (p = 0.622). Univariate logistic regression analysis showed that the presence of CADS was not associated with hypovitaminosis D (odds ratio (OR) = 1.44; 95% confidence interval (CI) = 0.37–5.54). It can be concluded that vitamin D is not associated with CADS and does not play a significant role in host susceptibility to CADS. This finding suggests that vitamin D screening is not indicated routinely in patients with Candida-associated denture stomatitis.

Evaluation of various denture cleansers on color stability and surface topography of polyetherketoneketone, polyamide, and polymethylmethacrylate

The aim of this study was to evaluate the effect of sodium perborate effervescent tablets and citric acid solution on the color stability and surface topography of a new generation of high-performance polymer polyetherketoneketone (PEKK), thermoinjection-molded polyamide, and polymethylmethacrylate (PMMA). Fifty disc-shaped specimens were fabricated (10 mm × 2 mm) from PEKK (P group), polyamide (D group), and PMMA (M group). These groups were divided into five subgroups (n = 10) according to the storage media. The test groups were immersed in the following solutions: distilled water (Control), Corega, Protefix, Perlodent, and Curaprox. The color stability values (ΔE) were measured using a spectrophotometer before and after immersion in distilled water and four different denture cleansers for 8 hr/day for 140 days. Topography alterations after treatments were assessed with scanning electron microscopy (SEM). Data were analyzed by one-way analysis of variance (ANOVA) followed by Tukey's Honest Significant Difference test. The p < .05 was considered significant. All denture cleansers increased the ΔE values relative to the baseline values in the M, D, and P groups (p < .05). The Perlodent denture cleanser demonstrated the highest ΔE value in all groups, which was unacceptable. Curaprox denture cleanser showed the lowest ΔE value in the M and D groups (p < .05). Curaprox in all groups showed a ∆E value less than 3.7. For patients who have PEKK- and polyamide-based prosthesis, the use of citric acid-based cleansers may be more recommended than sodium perborate-containing cleansers because of its clinically acceptable color changes on polymers in terms of color stability.

Effect of Antibacterial Silver-Releasing Filler on the Physicochemical Properties of Poly(Methyl Methacrylate) Denture Base Material

Colonization of polymeric dental prosthetic materials by yeast-like fungi and the association of these microorganisms with complications occurring during prosthetic treatment are important clinical problems. In previously presented research, submicron inorganic particles of silver sodium hydrogen zirconium phosphate (S-P) were introduced into poly(methyl methacrylate) (PMMA) denture base material which allowed for obtaining the antimicrobial effect during a 90 day experiment. The aim of the present study was to investigate the flexural strength, impact strength, hardness, wear resistance, sorption, and solubility during three months of storage in distilled water. With increasing S-P concentration after 2 days of conditioning in distilled water, reduced values of flexural strength (107-72 MPa), impact strength (18.4-5.5 MPa) as well as enhanced solubility (0.95-1.49 µg/mm3) were registered, but they were at acceptable levels, and the sorption was stable. Favorable changes included increased hardness (198-238 MPa), flexural modulus (2.9-3.3 GPa), and decreased volume loss during wear test (2.9-0.2 mm3). The percentage changes of the analyzed properties during the 90 days of storage in distilled water were similar for all materials.

Salivary Biomarkers in Denture Stomatitis: A Systematic Review

OBJECTIVE

Denture stomatitis (DS) is an oral biofilm-associated inflammation of the denture-bearing mucosa. The objective of this review was to identify and evaluate the quality of evidence on the association between the levels of salivary biomarkers and DS among adults with and without palatal DS.

MATERIALS AND METHODS

Following the PRISMA guidelines, Medline, PubMed, EMBASE, and the Cochrane Central Register for Controlled Trials were searched for eligible studies from the beginning of the archives until December 2018. Experimental and observational studies with adult participants were included that had a control group or subgroup analysis and provided data on salivary biomarkers and DS. Articles in languages other than English or French were excluded. The level of evidence and grades of recommendation were established with the 2011 scale of the Oxford Centre for Evidence-Based Medicine. Additionally, the assessment of methodological quality was conducted with the STROBE statement (Strengthening the Reporting of Observational Studies in Epidemiology) and graded according to the Olmos scale.

RESULTS

From 1,008 citations, 9 studies were included in the systematic review (8 observational, 1 clinical trial). Seven studies suggested a statistically significant difference in the levels of salivary cytokines (IL-6, CCL3, TGF-β, CXCL8, GM-CSF, and TNF-α) between participants with DS and controls (P < 0.05). In contrast, 2 studies concluded that the difference in the levels of several salivary cytokines (IL2, IL12, IFN-g, IL-4, IL-8, IL-10, IL-17, TNF-α, and ICAM-1) between the groups was not statistically significant. The level of evidence for the majority of studies was 3, while the grade of recommendation for all the studies was B, interpreted as "favorable." In terms of methodological quality, most studies met 50% to 80% of STROBE criteria and were graded B.

CONCLUSION

Palatal inflammation in DS is significantly associated with the levels of salivary cytokines.

KNOWLEDGE TRANSFER STATEMENT

The results of this study identified altered levels of specific salivary biomarkers associated with denture stomatitis, which may aid in the early diagnosis and treatment of this disease.

Effect of Mongolian Herbal Tea on Growth of Candida albicans

Candida albicans, one of the main pathogens in the oral cavity, is involved in the development of oral candidiasis. Various components of tea, and especially polyphenols, are believed to be effective against the growth of yeast or bacteria. The purpose of this study was to investigate the effect of polyphenols in Mongolian herbal tea on growth of C. albicans. Tea extract was prepared from Mongolian herbal tea and diluted with distilled water (DW) at concentrations of 10, 20, 30, 40, or 50%. Distilled water was used as the control. Acidification of the medium was determined by measuring its pH; the presence of polyphenols by the Folin-Ciocalteau colorimetric method; and growth of C. albicans by absorbance at a wavelength of 630 nm at 0-, 6-, 12-, and 24-hr intervals. The pH of the medium was 5.2 to 5.27 in all experimental groups compared with 7.1 in the control group. Polyphenols were present in all experimental groups, and at significantly higher levels than in the control group. Growth of C. albicans showed a significant and time-dependent increase in the control and all experimental groups. Growth of C. albicans in all the experimental groups was higher than that in the control group. These results suggest that Mongolian herbal tea promotes the growth of C. albicans, despite the presence of polyphenols.

Kinetics of antifungal activity of home-generated ozonated water on Candida albicans

Background and Purpose:

Candida-associated denture stomatitis is one of the most common forms of oral candidiasis among denture wearers. Regarding this, the aim of the present study was to evaluate the antifungal effects of home-generated ozonated water on the adhesion of the C. albicans attached to the surface of the denture base acrylic resins.

Materials and Methods:

For the purpose of the study, different concentrations of C. albicans were added to the tubes containing acrylic resin blocks, and then incubated for 2 h at 35°C. The samples were assigned into three groups, each of which contained 42 samples, including normal saline (NS) solution as the negative control, nystatin (N) solution as the positive control, and ozonated water as the test group. The samples were washed and placed in an ultrasonic bath. Subsequently, the saline solution was cultured on Sabouraud dextrose agar. The concentrations of Candida were evaluated during the contact times.

Results:

The test group (i.e., ozonated water) with 114 colony-forming units (CFU) showed a significant reduction of Candida colonies, compared to the NS group with 2,172 CFU. The 120- and 1-minute incubation with ozonated water showed the highest and lowest effects on the viability of Candida adhered to the acrylic resin, respectively.

Conclusion:

Based on the findings, home-generated ozonated water can be applied to remove the Candida attached to the surface of the denture plates.

Cytokine gene polymorphism in denture stomatitis patients: A clinical study

OBJECTIVE

This clinical study investigated the association between cytokine gene polymorphism and Candida growth in denture stomatitis (DS) patients.

SUBJECTS AND METHODS

Saliva and blood samples of 160 complete denture wearers (80 healthy controls and 80 with DS) were collected for mycological and gene polymorphism testing, respectively. Salivary Candida growth and TNF-α, TGF-β, IL-6, and IL-10 genotypes were investigated. Data were analyzed using Student's t test, Mann-Whitney U test, chi-square analysis, and continuity (yates) correction tests (p < .05).

RESULTS

Candida albicans colony counts in saliva were significantly higher in the DS group and in the TNF-α GG genotype (p < .05). TGF-β TC GG and TGF-β CC GG haplotypes were significantly higher in DS and control groups, respectively (p < .05). C. albicans colony counts were significantly higher in control group in the TGF-β TC GG haplotype (p < .05). Candida glabrata colony counts were significantly higher in the DS group than the control group in IL-6 GG genotype (p < .05). The difference between DS types in IL-6 genotypes was significant with lower expression level in DS type 3 than DS type 1 and also type 2 (p ≤ .01).

CONCLUSION

The significant differences in some genotypes of the TNF-α, TGF-β, and IL-6 in DS patients are promising in understanding the host defense in DS.

Properties of an acrylic resin after immersion in antiseptic soaps: Low-cost, easy-access procedure for the prevention of denture stomatitis

Denture stomatitis triggered by Candida species requires better preventive measures. This study evaluated the physical and biological properties of a denture base acrylic resin after immersion in antiseptic soaps. Acrylic resin specimens were prepared and stored in distinct solutions for 0, 7, 14, 21, and 28 days. The solutions were as follows: DW: distilled water at 37°C (control group); DS: cycles of daily immersion in Dettol soap for 8 hours at room temperature, followed by immersion in distilled water for 16 hours at 37°C; PS: cycles of daily immersion in Protex soap, as described for the previous group; LS: cycles of daily immersion in Lifebuoy soap, as described for the DS group. The parameters evaluated at each time point were the following: biofilm formation capacity by Candida albicans and reduction of preformed fungal biofilms, cytotoxicity, surface roughness, hardness, and color change. For the fungal adhesion phase, the type of soap had a statistically significant effect (p = 0.0292), but after 24 hours, no differences were found between solutions or between storage times. Regarding the efficacy of biofilm reduction, there was a significant difference when the groups were compared to each other (p = 0.014). Dettol and Lifebuoy eliminated the preformed biofilm on the specimens. Moreover, all the soaps were classified as non-cytotoxic (on HaCaT cell line) because there was no difference in cell viability between the different groups, except after 21 days, when a decrease in cell viability occurred, regardless of the type of soap. Regarding the roughness, there was no statistically significant difference (p > 0.05) between the groups. Lifebuoy decreased resin hardness regardless of storage time (p = 0.003). After 21 and 28 days of storage, there was an increase in hardness value, regardless of the type of soap. The specimens’ color, according to the National Bureau of Standards values, ranged from 0.27 to 0.58 (i.e., imperceptible or mild color changes). In general, the disinfectant soaps were not able to prevent biofilm formation, but all the soaps were effective in reducing the preformed biofilm. In addition, all soaps were non-cytotoxic and did not change surface roughness, hardness (except Lifebuoy), and color (except Lifebuoy). Therefore, immersion in two antiseptic soaps (Protex and Dettol) may be a cheap and easy procedure for preventing denture stomatitis.

Use of Haploid Model of Candida albicans to Uncover Mechanism of Action of a Novel Antifungal Agent

Antifungal agents for the treatment of Candida albicans infections are limited. We recently discovered a novel antifungal small molecule, SM21, with promising in vivo activity. Herein, we employed the newly developed C. albicans haploid toolbox to uncover the mechanism of action of SM21. Comprehensive RNA-Seq analyses of the haploid susceptible GZY803 strain revealed significant gene expression changes related to mitochondria when exposed to SM21. Mitochondrial structure visualization and measurement of ATP generation, reactive oxygen species (ROS) levels, and the antioxidant potential of SM21-treated and untreated GZY803, mitochondrial structure defective haploid mutant (dnm1Δ), and wild-type diploid SC5314 strains confirmed defects in mitochondria. Exploiting the advantage of C. albicans haploids as a single ploidy model, we further exposed GZY803 to repetitive treatments of SM21 in order to generate resistant mutants. Three colonies designated S3, S5 and S6, which displayed resistance to SM21, were isolated. All resistant strains exhibited enhanced transcriptomic responses for peptide and protein metabolism and secreted aspartate proteases (SAPs) activity under SM21 treatment compared to the parent strain GZY803. Consistently, supplementing the resistant strains, GZY803, and SC5314 with peptone, a form of digested peptides, decreased susceptibility to SM21. The present study demonstrates the usefulness of haploid C. albicans model in antifungal drug discovery. The findings will be invaluable to develop SM21 as a novel antifungal agent, which will benefit millions of patients suffering from Candida infections.

Photodynamic inactivation of Candida ssp. on denture stomatitis. A clinical trial involving palatal mucosa and prosthesis disinfection

Denture stomatitis (DS) is the most common oral fungal infection in denture wearers. Photodynamic inactivation (PDI) has been showing to be an effective technique in vivo against fungi, including fungal infections in the oral cavity. The disinfection of both oral mucosa and denture may represent a real advantage in terms of fungus control. This clinical study was designed to explore methylene blue (MB)-mediated PDI on oral mucosa and prosthesis of patients with DS. Subjects with DS were divided into two groups. One group received treatment based on the use of oral miconazole gel 2% (MIC). The other group received treatment by PDI using MB at 450 μg/mL and a diode laser (λ = 660 nm) with 100 mW and fluence of 28 J/cm². Clinical outcome was evaluated regarding the degree of oral mucosa erythema and microbiological reduction of Candida spp. located in both palatal mucosa and prosthesis. Our results showed that PDI was significantly more effective than MIC in ameliorating inflammation after 15 days. Following 30 days, no statistically significant differences were observed between groups. Regarding the fungal burden, although the MIC group has presented more pronounced inactivation than PDI for both mucosa and prosthesis, no statistically significant differences were detected between them. This clinical study suggests that PDI can reduce fungal load and decrease the inflammation degree in patients with Candida-associated denture stomatitis.

Salivary polypeptide/hyaluronic acid multilayer coatings act as "fungal repellents" and prevent biofilm formation on biomaterials

Candida-associated denture stomatitis (CADS) is a common, recurring clinical complication in denture wearers that can lead to serious oral and systemic health problems. Current management strategies are not satisfactory due to their short-acting and ineffective therapeutic effects. Here, we describe a new fungal biofilm controlling strategy using the polyelectrolyte layer-by-layer (LBL) self-assembly technology on denture materials. Conventional poly(methyl methacrylate) (PMMA) denture material discs were functionalized with negatively charged poly(methacrylic acid) (PMAA) via plasma-initiated surface grafting, followed by repetitive alternating coating with the salivary antimicrobial polypeptide histatin 5 (H-5; cationic polymer) and hyaluronic acid (HA; anionic polymer). On the other hand, the H-5/HA LBL coatings (i.e., the outermost layer was H-5) inhibited fungal attachment/adhesion, significantly reduced fungal biofilm formation, and showed synergistic effects with the antifungal drug miconazole. LBL surface hydrophilicity was not the key mechanism in controlling Candida biofilm formation. The current approach demonstrates the utility of a new design principle for fabricating anticandidal denture materials, as well as potentially other related medical devices, for controlling fungal biofilm formation and combating insidious infections.

The Interface between Fungal Biofilms and Innate Immunity

Fungal biofilms are communities of adherent cells surrounded by an extracellular matrix. These biofilms are commonly found during infection caused by a variety of fungal pathogens. Clinically, biofilm infections can be extremely difficult to eradicate due to their resistance to antifungals and host defenses. Biofilm formation can protect fungal pathogens from many aspects of the innate immune system, including killing by neutrophils and monocytes. Altered immune recognition during this phase of growth is also evident by changes in the cytokine profiles of monocytes and macrophages exposed to biofilm. In this manuscript, we review the host response to fungal biofilms, focusing on how these structures are recognized by the innate immune system. Biofilms formed by Candida, Aspergillus, and Cryptococcus have received the most attention and are highlighted. We describe common themes involved in the resilience of fungal biofilms to host immunity and give examples of biofilm defenses that are pathogen-specific.

Isolation and Identification of Nonoral Pathogenic Bacteria in the Oral Cavity of Patients with Removable Dentures

Aims and Objectives:

Dentures in the oral cavity may act as a reservoir of microorganisms, which may be related to systemic infections. The aim of this study was to investigate the nonoral pathogenic bacteria in the oral cavity of patients with removable dentures in Shiraz, Southern Iran.

Materials and Methods:

The bacterial flora of saliva samples from 50 men and 50 women with removable dentures and 100 age- and sex-matched controls with normal dentate were compared using culture, Gram staining, and API20E Kit methods. All data were analyzed using SPSS software.

Results:

Except for Enterobacter cloacae isolate (P = 0.03), there was no significant difference between both groups for the presence of Escherichia coli, Klebsiella pneumoniae, nonfermenting Gram-negative bacilli, Raoultella ornithinolytica, Raoultella planticola, Kluyvera spp., and Enterobacter aerogenes. No significant correlation was noticed between age and presence of bacteria in the oral cavity. The Gram-negative rod bacteria were more in males, but the difference was not significant. When a total of Gram-negative rods were considered, there was a significant difference between case and control groups (P = 0.004).

Conclusions:

Based on our findings that nonoral pathogenic bacteria are detected from the saliva of the denture wearers, general and oral health measures in patients with removable dentures should be adopted to decrease the risk of cross infection.

Nicotine Upregulates Coaggregation of Candida albicans and Streptococcus mutans

PURPOSE

Denture stomatitis is a condition of painless inflammation of denture-bearing mucosa. Reports indicate that nicotine, the major psychoactive ingredient in tobacco, increases growth of Streptococcus mutans and Candida albicans in denture biofilm. The purpose of this study was to determine the in vitro effects of nicotine on coaggregation of C. albicans with S. mutans.

MATERIAL AND METHODS

C. albicans strain ATCC 10231, S. mutans strain UA159 (ATTC 700610), and nicotine dilutions (ranging from 0 to 32 mg/ml) were used for this study. Both microorganisms were grown for 24 hours in dilutions of nicotine (0 to 32 mg/ml) made in tryptic soy broth (TSB) or TSB supplemented with 1% sucrose (TSBS; S. mutans) or yeast peptone dextrose broth (YPD; C. albicans). Suspensions of the nicotine-treated cells were prepared, mixed together and incubated for up to 24 hours to determine if there was an increase in coaggregation of nicotine-treated cells compared to the no nicotine control cells. Qualitative analysis of coaggregation was performed using a visual aggregation assay and light microscopic observation. A spectrophotometric assay was used to provide a quantitative analysis of the coaggregation.

RESULTS

The visual aggregation assay indicated a significant increase in coaggregation between C. albicans and S. mutans with increasing incubation time (0 to 24 hours) and nicotine concentrations (0 to 4 mg/ml). Microbial growth in nicotine at 4 mg/ml demonstrated a significant increase in coaggregation after 24 hours of incubation. The numbers of coaggregated S. mutans/C. albicans cells exhibited a significant increase with incubation time and nicotine concentrations when the samples were examined microscopically. More coaggregation of S. mutans and C. albicans was observed with incubation time and increased nicotine compared to the 0 mg/ml nicotine group. There was a noticeable increase of coaggregation when cells were grown in TSBS compared to TSB. Absorbance of nicotine-treated cells (0.25 to 4 mg/ml) exhibited a decrease in values compared to 0 mg/ml at 0 hours of incubation, confirming increased coaggregation.

CONCLUSION

These results demonstrated the effect of nicotine in increasing the coaggregation of S. mutans with C. albicans. Coaggregation increased with incubation time and nicotine concentration. Coaggregation was increased with S. mutans grown in TSBS compared to TSB, suggesting that growth in sucrose media leads to an increase in receptors responsible for coaggregation.

Prevalence of Chronic Erythematous Candidiasis in Lebanese Denture Wearers: a Clinico-microbiological Study

Objective:

Chronic erythematous candidiasis also known as denture-related stomatitis refers to inflammatory changes of the denture-bearing mucosa. The aim of this study was to evaluate the prevalence of chronic erythematous candidiasis in a Lebanese population using clinical and microbiological examinations.

Materials and Methods:

Ninety-eight patients wearing full acrylic maxillary denture (50 women and 48 men) were included in this study. A clinical oral assessment and a microbiological exam using swab samples collected from the palate of these patients were performed and the data obtained were analyzed statistically.

Results:

Sixty-nine point thirty-eight per cent (69.38%) of the patients examined, (68 out of 98; 25 men and 43 women), presented chronic erythematous candidiasis. The statistical analysis showed that patient’s gender was a significant predictor of the disease while no statistically significant relationship with the patient’s age was found.

Conclusion:

Within the limits of this study, the prevalence of chronic erythematous candidiasis is estimated to be high in Lebanon. Women were more affected than men.

Promise of Combining Antifungal Agents in Denture Adhesives to Fight Candida Species Infections

PURPOSE

Several complications may arise in patients wearing complete prosthetic appliances, including denture-associated infections and mucosal stomatitis due to Candida species. This study evaluated the activity of anti-Candida agents in denture adhesive and the cytotoxicities of these preparations for primary human gingival epithelial (GE) keratinocytes.

MATERIALS AND METHODS

The anti-Candida activities of antimicrobial peptides, antimicrobial lipids, and antifungal agents against C. albicans ATCC 64124 or HMV4C were assessed in microdilution assays containing water or 1% denture adhesive. The minimal inhibitory concentrations (MIC) and the minimal bactericidal concentrations (MBC) were determined. The cytotoxicities of denture adhesive compounded with these agents were assessed in 1.0 × 10⁵ primary GE keratinocytes in LGM-3 media with resazurin.

RESULTS

Lactoferricin B, SMAP28, sphingosine, dihydrosphingosine, and phytosphingosine in 1% denture adhesive lost antimicrobial activity for C. albicans (p < 0.05). Amphotericin B, chlorhexidine dihydrochloride, chlorhexidine gluconate, fluconazole, and nystatin in 1% denture adhesive or compounded directly into denture adhesive and then diluted to 1% adhesive, did not lose antimicrobial activity. Compounded formulations were not cytotoxic (LD₅₀ > 100.0 μg/ml) against primary human GE keratinocytes.

CONCLUSIONS

Antimicrobial peptides and antimicrobial lipids had diminished activities in 1% adhesive, suggesting that components in adhesives may inactivate local innate immune factors in the oral cavity, possibly predisposing denture wearers to Candida species infections. More importantly, antifungal agents retained their anti-C. albicans activities in denture adhesive, strongly suggesting that antifungal agents could be candidates for inclusion in adhesive formulations and used as prescribed topical treatments for individuals with denture stomatitis.

EVALUATION OF DENTURE-RELATED FACTORS PREDISPOSING TO DENTURE STOMATITIS IN A LEBANESE POPULATION

BACKGROUND

Denture stomatitis is a common fungal oral infection of multifactorial etiology. Denture-related factors such as denture's age, hygiene, night wearing and colonization by Candida albicans are known to predispose to denture stomatitis. The aim of this study was to evaluate these factors and their relationship with the occurrence of denture stomatitis in a Lebanese population.

MATERIAL AND METHODS

Sixty patients (40 women, 20 men; age range 40-80 years) showing clinical evidence of denture-related stomatitis were selected for this study. Swab samples from the palate and the palatal surfaces of the upper dentures of these patients were collected and examined mycologically. Denture's age, hygiene, night wearing and colonization by Candida albicans were evaluated and analyzed statistically.

RESULTS

The statistical analysis showed a significant role for denture's hygiene, night wearing, and colonization by Candida albicans in the installation of the denture stomatitis. Patient's gender and age, as well as the denture's age, were not significant predictors of the disease.

CONCLUSION

In a sample of Lebanese population, poor denture hygiene, continuous denture use, and Candida denture colonization are important etiological factors that contribute to denture stomatitis.

Effect of Storage in Distilled Water for Three Months on the Antimicrobial Properties of Poly(methyl methacrylate) Denture Base Material Doped with Inorganic Filler

The colonization of poly(methyl methacrylate) (PMMA) denture base materials by pathogenic microorganisms is a major problem associated with the use of prostheses, and the incorporation of antimicrobial fillers is a method of improving the antimicrobial properties of these materials. Numerous studies have demonstrated the initial in vitro antimicrobial effectiveness of this type of material; however, reports demonstrating the stability of these fillers over longer periods are not available. In this study, silver sodium hydrogen zirconium phosphate was introduced into the powder component of a PMMA denture base material at concentrations of 0.25%, 0.5%, 1%, 2%, 4%, and 8% (w/w). The survival rates of the gram-positive bacterium Staphylococcus aureus, gram-negative bacterium Escherichia coli and yeast-type fungus Candida albicans were established after fungal or bacterial suspensions were incubated with samples that had been previously stored in distilled water. Storage over a three-month period led to the progressive reduction of the initial antimicrobial properties. The results of this study suggest that additional microbiological tests should be conducted for materials that are treated with antimicrobial fillers and intended for long-term use. Future long-term studies of the migration of silver ions from the polymer matrix and the influence of different media on this ion emission are required.

Fungal Biofilms: In Vivo Models for Discovery of Anti-Biofilm Drugs

During infection, fungi frequently transition to a biofilm lifestyle, proliferating as communities of surface-adherent aggregates of cells. Phenotypically, cells in a biofilm are distinct from free-floating cells. Their high tolerance of antifungals and ability to withstand host defenses are two characteristics that foster resilience. Biofilm infections are particularly difficult to eradicate, and most available antifungals have minimal activity. Therefore, the discovery of novel compounds and innovative strategies to treat fungal biofilms is of great interest. Although many fungi have been observed to form biofilms, the most well-studied is Candida albicans. Animal models have been developed to simulate common Candida device-associated infections, including those involving vascular catheters, dentures, urinary catheters, and subcutaneous implants. Models have also reproduced the most common mucosal biofilm infections: oropharyngeal and vaginal candidiasis. These models incorporate the anatomical site, immune components, and fluid dynamics of clinical niches and have been instrumental in the study of drug resistance and investigation of novel therapies. This chapter describes the significance of fungal biofilm infections, the animal models developed for biofilm study, and how these models have contributed to the development of new strategies for the eradication of fungal biofilm infections.

Controlling fungal biofilms with functional drug delivery denture biomaterials

Candida-associated denture stomatitis (CADS), caused by colonization and biofilm-formation of Candida species on denture surfaces, is a significant clinical concern. We show here that modification of conventional denture materials with functional groups can significantly increase drug binding capacity and control drug release rate of the resulting denture materials for potentially managing CADS. In our approach, poly(methyl methacrylate) (PMMA)-based denture resins were surface grafted with three kinds of polymers, poly(1-vinyl-2-pyrrolidinone) (PNVP), poly(methacrylic acid) (PMAA), and poly(2-hydroxyethyl methacrylate) (PHEMA), through plasma-initiated grafting polymerization. With a grafting yield as low as 2 wt%, the three classes of new functionalized denture materials showed significantly higher drug binding capacities toward miconazole, a widely used antifungal drug, than the original PMMA denture resin control, leading to sustained drug release and potent biofilm-controlling effects against Candida. Among the three classes of functionalized denture materials, PNVP-grafted resin provided the highest miconazole binding capability and the most powerful antifungal and biofilm-controlling activities. Drug binding mechanisms were studied. These results demonstrated the importance of specific interactions between drug molecules and functional groups on biomaterials, shedding lights on future design of CADS-managing denture materials and other related devices for controlled drug delivery.

The Host's Reply to Candida Biofilm

Candida spp. are among the most common nosocomial fungal pathogens and are notorious for their propensity toward biofilm formation. When growing on a medical device or mucosal surface, these organisms reside as communities embedded in a protective matrix, resisting host defenses. The host responds to Candida biofilm by depositing a variety of proteins that become incorporated into the biofilm matrix. Compared to free-floating Candida, leukocytes are less effective against Candida within a biofilm. This review highlights recent advances describing the host's response to Candida biofilms using ex vivo and in vivo models of mucosal and device-associated biofilm infections.

Role of salivary and candidal proteins in denture stomatitis: an exploratory proteomic analysis

Denture stomatitis, inflammation and redness beneath a denture, affects nearly half of all denture wearers. Candidal organisms, the presence of a denture, saliva, and host immunity are the key etiological factors for the condition. The role of salivary proteins in denture stomatitis is not clear. In this study 30 edentulous subjects wearing a maxillary complete denture were recruited. Unstimulated whole saliva from each subject was collected and pooled into two groups (n = 15 each), healthy and stomatitis (Newton classification II and III). Label-free multidimensional liquid chromatography/tandem mass spectrometry (2D-LC-MS/MS) proteomics on two mass spectrometry platforms were used to determine peptide mass differences between control and stomatitis groups. Cluster analysis and principal component analysis were used to determine the differential expression among the groups. The two proteomic platforms identified 97 and 176 proteins (ANOVA; p < 0.01) differentially expressed among the healthy, type 2 and 3 stomatitis groups. Three proteins including carbonic anhydrase 6, cystatin C, and cystatin SN were found to be the same as previous study. Salivary proteomic profiles of patients with denture stomatitis were found to be uniquely different from controls. Analysis of protein components suggests that certain salivary proteins may predispose some patients to denture stomatitis while others are believed to be involved in the reaction to fungal infection. Analysis of candidal proteins suggests that multiple species of candidal organisms play a role in denture stomatitis.

Effectiveness of a Chlorhexidine Digluconate 0.12% and Cetylpyridinium Chloride 0.05% Solution in eliminating Candida albicans Colonizing Dentures: A Randomized Clinical in vivo Study

BACKGROUND

Effective denture hygiene is important for patients suffering from denture stomatitis (DS). This study aimed to evaluate the efficacy of a solution containing 0.12% chlorhexidine (CHX) digluconate and 0.05% cetylpyridinium chloride (CPC) in eliminating Candida albicans colonizing dentures.

MATERIALS AND METHODS

Forty denture wearers (11 men, 29 women; age range 40 to 80 years) with clinical evidence of DS were randomly divided into two groups, one test and one control. The dentures of the test group were treated by immersion in a solution of 0.12% CHX and 0.05% CPC while those of the control group were immersed in distilled water. Swabs were collected from the fitting surfaces of the upper dentures prior and post cleaner use and examined mycologically.

RESULTS

Reduction in the number of colony-forming units (CFU) of Candida albicans after immersion of the dentures in a solution of 0.12% CHX and 0.05% CPC was significantly greater than that of the control group.

CONCLUSION

A solution of 0.12% CHX and 0.05% CPC tested as a product of disinfection of the acrylic dentures showed significant results after immersion of 8 night hours for 4 days.

Influence of a new denture cleaning technique based on photolysis of H(2)O(2) the mechanical properties and color change of acrylic denture base resin

The purpose of this study was to evaluate the influence of a disinfection technique based on photolysis of H2O2 on the mechanical properties and color change of acrylic denture base resin. Resin specimens were immersed in 1 M H2O2 irradiated with light-emitting diode (LED) light at 400 nm for 1 week. The immersion duration of 1 week (168 h) corresponded to performing approximately 500 times of 20-min cleaning. Hydroxyl radicals are potent oxidants and they were generated via the photolysis of H2O2. Oxidative damage caused by these radicals included reduced flexural strength and altered color for the acrylic resin. Nonetheless, the degraded flexural strength and altered color of acrylic resin after 500 times of cleaning in the disinfection system would be within clinically acceptable levels.

Antifungal Effect of Zataria multiflora Essence on Experimentally Contaminated Acryl Resin Plates With Candida albicans

Background:

Adherence and colonization of Candida species particularly C. albicans on denture surfaces, forms a microbial biofilm, which may result denture stomatitis in complete denture users.

Objectives:

The purpose of the present study was to evaluate the antifungal effect Zataria multiflora essence in removing of Candida albicans biofilms on experimentally contaminated resin acryl plates.

Materials and Methods:

In the present experimental study, 160 resin acrylic plates (10 × 10 × 1 mm) were contaminated by immersion in 1 × 10³ C. albicans suspension for 24 hours to prepare experimental Candida biofilms. The total number of Candida cells, which adhered to 20 randomly selected acryl resin plates was determined as the Candia load before cleaning. The remaining 140 plates were divided to seven groups of 20 and immersed in five concentrations of Zataria multiflora essence from 50 to 3.125 mg/mL as test, 100000 IU nystatin as the positive and sterile physiologic serum as the negative control. The remaining Candida cells on each acryl plate were also enumerated and data were analyzed using the SPSS 16 software with Kruskal-Wallis and Wilcoxon tests.

Results:

Zataria essence at concentrations of 50 and 25 mg/mL removed 100% of attached Candida cells similar to nystatine (MFC), while weaker Zataria essence solutions cleaned 88%, 60.5% and 44.7% of attached Candida cells. Kruskal-wallis test showed a statistically significant difference between all test groups (P = 0.0001). In this study 12.5 mg/mL concentration of Zataria multiflora was considered as the minimum inhibitory concentration (MIC₉₀).

Conclusions:

Zataria essence, at concentrations of 50 and 25 mg/mL, effectively removed Candida cells that had adhered to the denture surface, similar to the level of removal observed for 100000 IU nystatin.