Denture Stomatitis

Denture stomatitis is chronic inflammation of the mucosa under a removable denture, nearly always the maxillary denture bearing area. It is the commonest oral mucosal condition in denture wearers, found in roughly 15 to 70% depending on the population studied.

Three clinical grades are used. Grade 1 is localised pinpoint hyperaemia. Grade 2 is diffuse erythema covering the whole denture bearing area. Grade 3 is granular or papillary hyperplasia of the central palate.

Pathophysiology. A multifactorial condition in which a Candida rich biofilm on the acrylic fitting surface, most often Candida albicans, sits against mucosa irritated by trauma, poor fit or continuous wear.

Contributing factors are wearing dentures overnight, poor denture hygiene, hyposalivation, diabetes, inhaled or systemic corticosteroids, smoking, immunosuppression, iron, folate or vitamin B12 deficiency, and rarely contact allergy to acrylic monomer.

Most patients have no symptoms. Some report soreness, burning, a bad taste, halitosis or bleeding. Angular cheilitis and a coated or atrophic tongue often coexist.

The mucosa under the denture is red, sharply limited to the denture outline, sometimes with a fine papillary surface. Check denture fit, occlusion, age of the denture, whether it is worn at night and how it is cleaned.

• Clinical diagnosis, with grading of the lesion.
• Swab of the palate and denture fitting surface for Candida culture, or a denture imprint culture, when treatment fails or immunosuppression is present.
• Blood glucose or HbA1c, full blood count, ferritin, vitamin B12 and folate when recurrent or severe.
• Check salivary flow when the mouth is dry.
• Patch testing for acrylic monomer when erythema persists with a clean, well fitting denture.
• Biopsy of papillary hyperplasia that is firm, ulcerated or persistent after treatment.

Differential diagnosis.

• Pseudomembranous or erythematous candidiasis unrelated to the denture
• Contact allergy to denture materials or adhesive
• Traumatic ulceration or inflammatory papillary hyperplasia from poor fit
• Lichen planus or lichenoid reaction
• Nutritional deficiency glossitis
• Oral squamous cell carcinoma (for a persistent erosion)

• Denture care is the main treatment: remove the denture at night, brush it with a soft brush and soap or non-abrasive cleanser twice daily, and store it dry or in an antiseptic solution.
• Soak acrylic dentures for 15 minutes daily in chlorhexidine 0.2% solution, or in sodium hypochlorite diluted to about 0.1% for 10 to 15 minutes. Do not soak metal containing dentures in hypochlorite, because it corrodes the metal. Rinse well before wearing.
• Refer back to the dentist for refit, reline with a tissue conditioner or soft liner, or replacement of an ill fitting or old denture.
• Antifungal for symptomatic or persistent disease, together with denture disinfection, otherwise relapse is the norm:
  • Miconazole oral gel 20 mg/g, 2.5 mL four times daily, applied to the fitting surface of the denture and the palate for at least 7 days and continued for 7 days after healing. It raises the INR with warfarin and interacts with simvastatin and sulphonylureas, so avoid it with warfarin or check the INR within 3 to 5 days.
  • Nystatin oral suspension 100 000 units/mL, 1 mL four times daily after food for 7 days, continued for 48 hours after healing, applied to the denture surface. It is not absorbed and has no major interactions.
  • Fluconazole 50 mg orally once daily for 7 to 14 days for widespread disease, immunosuppression or failed topical therapy. Reduce to half the dose when eGFR is under 50. Avoid with QT-prolonging drugs, and warfarin and statins need dose adjustment and monitoring.
• Treat diabetes, correct deficiencies, stop inhaled steroid misuse without spacer and rinse after use, and treat dry mouth.
• Grade 3 papillary hyperplasia that does not resolve may need surgical removal or laser, after antifungal and denture refit.

Special groups. Immunosuppressed or HIV-positive patients and those on high dose steroids need earlier systemic treatment and review for oesophageal candidiasis if dysphagia occurs.

Monitoring. Review at 2 to 4 weeks, again at 3 months and at least annually while wearing dentures. Recurrence is common when hygiene lapses.

Referral and escalation. Refer to the dentist for denture repair or replacement. Refer to oral medicine for treatment failure after 2 courses, suspected allergy, or a non-healing erosion or red patch with induration.