July 3, 2018
by Lorin Berland, DDS
Oral appliance homecare has a major impact on continuing compliance, treatment success, and the patient’s overall experience with the process. Individuals utilizing dentures, sleep devices, retainers, aligners and mouth guards are at a significantly greater risk of developing oral infections. Clinical research consistently demonstrates that, in a majority of patients, these appliances become infected over time. The most common pathogens – Candida Albicans, Streptococcus, Staphylococcus and Actinomyces – are the leading causes of Oral Thrush, Denture Stomatitis and Pneumonia.
The absence of proper appliance hygiene protocols has made the problem so prevalent in North America that tens of millions of people are infected, often without any awareness of the problem. Many of these sufferers have been affected by chronic low-grade infections for so long that they do not even realize that there is a problem, and that they are sick. Over time, the visible and recognizable symptoms – redness, discomfort, white tongue and loss of taste – become the “new” normal. 1
As people continue to use their oral appliances well beyond their recommended replacement times, effective oral care routines are essential for maintaining both the health of the mouth and the functionality of the appliances (Fig. 1). The likelihood of developing oral infections increases considerably with factors such as advancing age, deleterious habits and both short and long-term illness. In addition, certain medications can exacerbate these problems by disrupting saliva formation, the normal oral flora and/or causing dry mouth. Dental professionals must be on the lookout for these signs; they are then in a position to develop curative and preventive recommendations and protocols which are shared with their patients. 2
This conversation must be initiated at the very beginning of appliance utilization; when patients have problems with their dentures or mouthguards at some later point, they tend to seek solutions at a pharmacy or a supermarket, not a dentist. Unfortunately, these patients typically cannot identify the problem, much less the solution. They are at a complete loss in identifying a specific over-the-counter product that will alleviate their situation. Ultimately, the underlying cause(s) of their infections are left untreated. Even if, by chance, the patient happens to stumble on the proper treatment for oral thrush (for example), but continues to use the Candida-infected appliance, there is a re-infection of the oral tissues, and the patient continues to suffer from the same infections (Fig. 2).
Commonly used oral appliances.
Communicating with the patient.
Although the number of people with oral appliances keeps growing rapidly, there is relatively little scientifically-based, accessible information about proper denture, appliance, and gingival hygiene, both within the profession, and for the public at large. If patients are not educated about recognizing and preventing oral thrush, stomatitis and pneumonia from their dental care providers, they will then most likely search for this information online.
If one googles “how to clean dentures”, one is inundated with a plethora of imaginative and unscientific do it yourself methods that are widely circulated on the internet. Most of these techniques are useless, and some are downright harmful. It is thus the responsibility of dental professionals to ensure that their patients do not do anything to damage themselves or their appliances through the cleansing process.
Most patients are not aware that regular toothpaste is too abrasive for removable oral appliances. Dentures, partial dentures, overdentures, mouth guards, sleep devices, retainers and aligners are actually much softer than teeth; regular toothpaste and the old-fashioned denture-brush can damage these appliances, roughen their surfaces, and actually make them less clean. As the microscopic scratches gradually abrade the surface of the appliance, there is a visible loss in shine, color, and finish. The surface-marred appliance becomes a biological sponge, an ideal environment for pathogens to thrive 3 (Fig. 3).
While much of the focus of denture cleaning involves a passive daily soaking of the appliance, cleaning the ridges and gingiva underneath the appliance, particularly hard-to-reach “hidden” areas around implant-bridges, can provide a meaningful improvement in oral health and hygiene. Simply teaching denture-wearers how to properly clean their supportive soft tissues and prostheses can dramatically improve the way the appliance feels in their mouth. In support of this concept, the American Dental Association recently dedicated a special section of its newsletter to recommend that “the mouth cavity, tongue and the jaws should be well cleaned to remove all plaques, before putting on the clean denture” in an article titled “Vital Information about Types of Dentures and Their Care”. 4
Regular toothpastes and brushes can be very abrasive; dental professionals should always take care to recommend that an extra soft toothbrush be used with a low-abrasive denture paste. Similarly, very gentle brushes and pastes must be used to remove any remaining adhesive from the denture and the potentially sensitive areas of the oral cavity.
Cleanadent Paste (Dr. B Dental Solutions, Dallas, TX) was initially developed to provide a low-abrasive, gentler alternative substance for patients to brush their tissues lightly prior to impressions. It effectively removes both remaining adhesive and biofilm, greatly facilitating the impression process.
Furthermore, the cleanser is specifically formulated to be gentle enough to safely clean the denture.
Cleanadent Paste contains (among other ingredients): aloe vera, coconut oil, tea tree oil, and vitamins A, D, and E to reduce dry mouth and oral irritation. This is important because saliva regulates the normal levels of the oral flora and dry mouth is an almost universal complaint of denturewearers, particularly those that utilize adhesive. Chronic dry mouth can lead to chronic infection and soreness.
While the prevalence of oral infections in patients wearing appliances and oral prosthetics has been widely known and documented within the dental profession, there has been little that could be recommended as a routine preventive home care measure. Most existing denture care products are soak cleansers that only claim to kill “odor-causing bacteria”, while doing little or nothing to prevent diseases recurring from infected dentures and other oral appliances.
Cleanadent Crystals are dissolved in water to make a soak cleanser that instantly kills Candida Albicans, Streptococcus, and Actinomyces without harmful chemicals such as bleach or chlorine. The activated soak also removes tough stains and eliminates odor from prostheses and appliances (Fig. 4).
The availability of these effective products begins the discussions on denture hygiene that has been missing in the dentist-patient relationship. When patients are given products with realistically easy regimens and the comprehensive Cleanadent instructions, they tend to take a more positive charge of their home care, and to accomplish the task more effectively. The protocol is offered to all patients with new, or existing, dentures and oral appliances; not surprisingly, this is a significant segment of every practice (Fig. 5).
Oral appliance before and after 10 minute Cleanadent Crystals soak.
Cleanadent Crystals and Paste.
Typically, the dental team will begin seeing fewer infections, less discomfort, and far less gingival irritation in patients with appliances. There are fewer reports of oral thrush, stomatitis, and pneumonia, and patients report feeling better generally and having better outcomes with their now cleaner appliances.
With oral appliances of any type, the right habits can make a big difference. Whether patients are being fitted for a first appliance, or seeking help with their existing appliances, they look to their dental professionals for solid recommendations on how to make the right decisions in their oral care. As the prevalence of oral appliance treatments continually increases, and publicly available information (both correct and incorrect) is ever more accessible, the dental team must ensure that their patients are suitably educated in the maintenance of their appliances, in understanding the risks facing their oral health, and in making the right product and protocol decisions in the development of their home oral hygiene routine. OH
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About the Author
Lorin Berland, DDS, is one of the most published authors on clinical dentistry and dental education with over 100 articles, best-selling books and instructional videos including the Lorin Library Smile Style Guide. Dr. Berland was recognized by the AACD for “Outstanding Contributions to the Arts & Science of Cosmetic Dentistry”, and has been featured in major national print and TV publications for his work. Dr. B began his career as a denture technician, and after more than 35 years of listening to patients and running a multi-specialty practice, he has started Dr. B Dental Solutions with a line of products specially designed to treat the real issues affecting people with oral appliances, like Oral Infections and Dry Mouth, which can be found at www.DrBDentalSolutions.com. For more information, contact Dr. Berland at email@example.com or 1-844-372-3368 (DRB-DENT).