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The role of
antifungal
drugs in the
management of
denture-associated
stomatitis

2012
THE INTERNATIONAL ARABIC JOURNAL
OF ANTIMICROBIAL AGENTS

Vol. 2 No. 1:1

doi: 10.3823/705

Najla S.Dar-Odeh1, Mohammad Al-Beyari2,

Osama A. Abu-Hammad1
1 Professor, Faculty of dentistry,
University of Jordan, Amman,
Jordan.

2Assistant Professor, Faculty

of Dentistry, Um Al Qura
University, Mecca, Saudi
Arabia.

Correspondence:
Najla S.Dar-Odeh
najla_dar_odeh@yahoo.com

Abstract
Background: Denture-associated stomatitis is a chronic infection of the oral cavity that may be associated with a number of bacterial and candidal organisms as
well as some predisposing factors. Its management may prove to be difficult if the
treatment plan was not comprehensive in addressing all the factors involved in its
etiology. The aim of this review is to underline the effectiveness of antifungal drugs
in the management of denture-associated stomatitis according to our personal
experience and the recently published literature.

Methods: Articles were obtained from pubmed as well as by a hand search.

Denture stomatitis and antifungal were used as keywords. Only articles written
in English and which were published starting from the year 1990 were included.

Conclusions: Antifungal drugs certainly have a place in the management of

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denture-associated stomatitis. However, their use should be called upon after the
control of factors known to cause this infection. Denture and oral hygiene, and
management of adverse medical conditions should be the primary goal of treatment. This should go hand in hand with the application of topical antifungal agents
particularly those in the cream or gel form for better patients compliance.

Key words: Denture-associated stomatitis, antifungal drugs.

Introduction
Denture-associated stomatitis (DAS) (Candida-associated
denture stomatitis, chronic atrophic candidiasis, denture-sore
mouth) is a chronic infection of the oral mucosa caused solely
by Candida species or in association with bacteria (1). The role
of Candida, and specifically C. albicans, in development of
denture stomatitis is associated with pathogenic overgrowth
of Candida on denture surfaces and the oral mucosa, and is
widely accepted as a leading etiological factor.
It affects 24-60% of denture wearers (2), and it is usually
found on the palatal mucosa beneath the fitting surface of
the upper denture. Dental prostheses may produce a local

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environment of lowered pH and anaerobic conditions by decreasing the flow of oxygen and saliva to the underlying tissue;
these conditions favor fungal overgrowth (3-5). Furthermore,
biofilms in denture plaque represent a protective reservoir for
oral microbes (6). It has also been demonstrated that Candida
organisms have an affinity for the tissue side of the denture
and although Candida infection is the primary aetiology of
most of these lesions, other factors such as poor denture
hygiene and associated bacterial flora, continuous denture
wearing, ill-fitting and traumatic dentures, carbohydrate-rich
diet and rarely, allergy to denture material are contributory
co-factors (7). It was noticed that the prevalence is associated
with the amount of tissue covered by dentures (2). It was
also found that wearing denture at night and smoking were
associated with the most extensive inflammation (8).

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There is chronic erythema and edema of the mucosa in contact with the fitting surface of the denture which is usually
the maxillary denture. However, mucosa under mandibular
dentures is hardly ever involved being protected by salivary
flow (1). Clinically, there are three subtypes of DAS; type I is
a localized simple inflammation or pinpoint hyperemia, type
II is an erythematous or generalized simple type presenting
as more diffuse erythema involving a part of or the entire
denture-covered mucosa, and type III is a granular or papillary type commonly involving the central part of the hard
palate and alveolar ridge (Inflammatory Papillary hyperplasia).
All three types can be found simultaneously and in varying
combinations. (2) Although the lesion is not painful, it might
cause some unfavorable complications. The affected mucosa
is atrophic providing less support for the dentures. Some patients complain of burning sensation or tingling sensation beneath the denture. Patients may also complain of associated
angular cheilitis (1). Early reports pointed to the carcinogenic
potential of candidal infections (9). In some patients with
HIV infection, oral candidiasis may also lead to secondary
complications such as esophageal candidiasis.(1)
Management of DAS depends upon a compehensive treatment plan. Elimination of predisposing factors is considered
the first and most crucial step. The use of topical and systemic
antifungal drugs is also considered an important measure.
The goals of treatment are to identify and eliminate possible contributing factors, prevent systemic dissemination and
eliminate any associated discomfort (10).
The aim of this paper is to discuss the management of DAS
with special emphasis on antifungal drugs, a rapidly developing field for the treatment of this infection as well as other
types of oral candidiasis.

Antifungal therapy of
denture-associated stomatitis
Antifungal agents are either polyenes (nystatin and amphotericin B) or azoles which are classified into: imidazoles(
clotrimazole, econazole, fenticonazole, isoconazole, ketoconazole, miconazole, sulconazole, tioconazole); and triazoles
(fluconazole, itraconazole) (1). Some of these drugs are used
topically, while others are used in a systemic form. Recent research has concentrated upon a number of antifungal drugs
for the treatment of DAS namely, fluconazole, itraconazole,
miconazole and nystatin.

Vol. 2 No. 1:1

doi: 10.3823/705

Topical Antifungals
Topical antifungal therapy for oral candidal infections is available in many forms like pastilles, troches, creams, ointments
and oral suspensions and remains the cornerstone of treatment in mild, localized cases of candidoses in healthy patients
(10).
It was shown that most Candida species are susceptible to
topical antifungal drugs like amphotericin B, (11, 12) nystatin
(13), Miconazole (14-17) and clotrimazole (1). Being recommended as the first choice of treatment, (1) Amphotericin B
is usually in the form of lozenges or oral suspension, while
nystatin can be in the form of cream, pastille and oral suspension. On the other hand, clotrimazole is usually presented
in a cream or solution form; the cream form also has an
antistaphylococcal activity (1). Miconazole can be used as a
lacquer (15, 18), gel (12, 17) or cream. The gel form of miconazole was shown to be more effective than the lacquer
form (17). Chlorhexidine in the form of mouth wash (0.2%)
and 2% suspension for overnight denture disinfection, can
also be used to supplement antifungal drugs (19).

Systemic antifungals
Systemic antifungal agents have been recommended for patients with poor compliance such as patients with special
needs. They are also recommended for immunocompromised
patients (20). Among systemic antifungal drugs, fluconazole
and itraconazole have been the most extensively studied and
proven as efficient antifungal drugs (21,22). Specifically, fluconazole is one of the most effective agents for the treatment of oropharyngeal candidiasis in HIV-infected patients
as well as prophylaxis for fungal infections in neutropenic
patients undergoing bone marrow transplantation (23,24).
It was shown to be effective, especially when administered
with an oral antiseptic such as chlorhexidine.(25) Compared
to miconazole, it was demonstrated that fluconazole is more
effective (16). It is the drug of choice in the management of
HIV-related oral candidiasis and it is superior to other topically administered or systemic antifungals due to its watersolubility, oral bioavailability and good safety profile (26).
Fluconazole is usually used in the form of 50 or 100 mg
capsules. However, it should be given with caution in certain
circumstances as it interacts with anticoagulants among other
drugs. It is also contraindicated in pregnancy and liver and
renal disease. Itraconazole also was shown to be effective
in the management of DAS, (22) and even more effective
than fluconazole (21). Martin-Mazuelos et al., (1997) showed

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that itraconazole was effective against 100% of fluconazoleresistant strains (27). Similar to fluconazole, it is usually used
in the form of 100 mg capsules.

Discussion
The field of antifungal therapy is rapidly developing, especially that there is a better understanding of the pathogenesis of disease and the worldwide problem of antimicrobial
resistance. The multifaceted nature of DAS etiology involves
numerous predisposing factors operating locally and systemically. Consequently, treatment plan should address all possible etiological factors before the decision on the antifungal
drug is made. Denture and oral hygiene were found to be
of primary importance in healing of lesions and preventing
its recurrence (28).
This is to improve prognosis and to prevent the recurrence
of infection (29,30). Denture cleaning plays an important role
in eliminating the conditions that favor candidal growth. This
can be achieved by mechanical means, such as ultrasonic
cleaners, or chemical cleansers which are particularly of benefit for institutionalized elders or patients who are unable
to maintain a proper level of oral hygiene due to mental or
physical disability.
Antifungal drugs should be used alongside denture care.
However, and despite the availability of a number of antifungal drugs, therapeutic failure is not uncommon. This is in part
due to the diluent effect of saliva and cleansing action of the
oral musculature which often tend to reduce the availability
of the antifungal drug below the effective therapeutic concentration. Another cause of failure is the presence of Candida biofilms on mucosal and inert surfaces like prostheses
and implants. In response to attachment to a surface, fungal
cells produce biofilms, three-dimensional structures made up
of cells surrounded by exo-polymeric, mostly polysaccharide
matrices that contribute to the infectious process and antibiotic resistance (31). Biofilms are difficult to eliminate and
are a source of many refractory infections (28). It was shown
that development of antifungal resistance was associated
with increased pathogenicity in systemic infection as well as
increased propensity for biofilm formation (32). Furthermore,
the use of topical antifungals may be associated with lower
patient compliance because it is required from the patient to
use multiple daily doses for a relatively long period of time
that may extend to three or four weeks (33). Poor patient
compliance coupled with possible underlying immunodeficiency and emergence of drug resistance are all additional

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Vol. 2 No. 1:1

doi: 10.3823/705

factors against complete recovery, leading to chronic recurrences of the disease (1). Another factor that would affect
prognosis of this infection is its severity. Mild and moderate
types are usually more responsive to antimicrobial therapy
than the severe type which usually requires systemic antifungals and may need additional surgical treatment to achieve
a better prognosis (18).
Other factors that may complicate treatment is the systemic
condition of the patient that plays an important role in modifying the immune response to different sorts of infections.
Medical problems can complicate local infections particulary
in immunocompromised patients (28), Diabetes (34), and HIV
infection (35), for instance, present a problem when treating
oral Candidal infections.
Smoking is considered an important factor in modulating
the response of oral mucosa to the different factors (36),
however, this relationship was not confirmed in the case of
DAS (37).
Pharmacologic treatment should be tailored to the individual
patient, based on his/her health status and the clinical presentation and severity of infection. Leaving dentures out at
night and improvement of denture hygiene should be the
primary therapeutic approach, prior to instituting antifungal
therapy.
Antifungal drugs certainly have a place in treating DAS. In
healthy patients, the antifungal drugs of choice would be
a topical polyene drug. However, if the patient is immunocompromised, the need to a systemic antifungal drug like
fluconazole may arise. It was shown that fluconazole inhibits
biofilm formation by both fluconazole-susceptible and fluconazole-resistant Candida albicans strains (38). Patient education regarding denture hygiene, the number of daily doses
and duration of therapy is important. Another important
aspect is the follow-up of patients condition to determine
the response to treatment. Failure of treatment may necessitate culture and susceptibility testing together with further
investigating the patients medical condition. Some studies
have shown that some C. glabrata strains are developing resistance to fluconzole and were detected in association with
denture-related stomatitis and among patients treated in intensive care units (12, 39). Previous fluconazole use has also
been identified as a significant risk factor for development of
fluconazole-resistant among non-albicans Candida species,
especially Candida glabrata and Candida krusei ( 39 ). Therefore, there is a need to identify patients at risk of developing
candidasis caused by species resistant to fluconazole in order
to initiate adequate empirical antifungal therapy.

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