kesehatan gigi

336
B.S.C. Mattos et al.
ISSn 0103-6440
Braz Dent J (2009) 20(4): 336-340
Candida albicans in Patients with Oronasal
Communication and Obturator Prostheses
INTRODUCTION
 Candida albicans is the most common fungus
found in the oral cavity. It may be present as part of
the normal microbial flora and, as such, is not an overt
pathogen (1).
However, oral candidal infection frequently occurs
when
host
defenses
are
lowered
by
local
factors

(prosthesis

irritation, xerostomia), medications (antibiotics,
immunosuppressant
drugs),
treatment
regimens

(chemotherapy,
radiation
therapy)
and
systemic
disorders
(physical
debilitation,
malnutrition,
and
endocrine

and
immune
disturbances)
(2,3).
Fungal
infection
have

increased
in
prevalence,
especially
in
denture-wearers

and
aged
people,
and
may
lead
to
invasive
infections

Braz Dent J 20(4) 2009
2
1
Beatriz Silva Câmara MattoS
andréa alves de SouSa
Marina Helena C. G. de MaGalHãeS
Marcia andré
reinaldo BrIto e dIaS
1
1
1
1
Department of Maxillofacial Surgery, Traumatology and Prosthodontics,
Dental School, University of São Paulo, São Paulo, SP, Brazil
2
Department of Oral Pathology, Dental School, University of São Paulo, São Paulo, SP, Brazil
Patients using obturator prostheses often present denture-induced stomatitis. In order to detect the presence of oral Candida albicans in
patients with oronasal communications and to evaluate the effectiveness of a topical antifungal treatment, cytological smears obtained
from the buccal and palatal mucosa of 10 adult patients, and from the nasal acrylic surface of their obturator prostheses were examined.
a
therapeutic
protocol
comprising
the
use
of
oral
nystatin
(Mycostatin
) and prosthesis disinfection with sodium hypochlorite
was prescribed for all patients. Seven patients were positive for C. albicans in the mucosa, with 1 negative result for the prosthetic
surface in this group of patients. Post-treatment evaluation revealed the absence of C. albicans on prosthesis surface and on the oral
mucosa of all patients. the severity of the candidal infection was significantly higher in the palatal mucosa than in the buccal mucosa,
but similar in the palatal mucosa and prosthesis surface, indicating that the mucosa underlying the prosthesis is more susceptible to
infection. the therapeutic protocol was effective in all cases, which emphasizes the need for denture disinfection in order to avoid
reinfection of the mucosa.
Key Words: Candida albicans, oronasal communication, obturator prostheses, candidiasis.
®
that havea high mortality rate (4).
 Several studies have mentioned the increased
occurrence of candidal infection and colonization in
patient
s wearing partial or total removable dentures (5,6)
and have discussed the involvement of C. albicans in
the establishment and persistence of denture-related stomatitis,
a
local
recurring
disease
that
affects
the
mucosa

underneath
the fitting surface of the prosthesis (7).
 Some aspects should be considered when analyzing
the
use
of
complete
or
partial
removable
dentures,

as
a
predisposing
factor
to
denture-induced
stomatitis

secondary
to
C.
albicans
overgrowth.
the
presence
of

an
overlying,
synthetic
material
alters
the
local
environment
by
decreasing
saliva
flow
and
lowering
pH
values,

creating
conditions
that
seem
to
facilitate
the
adherence

Correspondence: Profa. dra. Beatriz Silva Câmara Mattos, departamento de Cirurgia, Prótese e traumatologia Maxilo-Faciais, Faculdade de odontologia,
universidade
de
São
Paulo,
av.
Professor
lineu
Prestes,
2227,
05508-000
São
Paulo,
Brasil.
tel:
+55-11-3091-7879.
Fax:
+55-11–5181-2229.

e-mail:
bscmatto@usp.br
Candida albicans and obturator prosthesis
337
of this microorganism (7). tissue microtrauma, resulting
from denture misfit may be present, and traumatic injury
can reduce tissue resistance to infection and increase
epithelial permeability to soluble Candida antigens and
toxins (5,8). the acrylic surface allows microbial adhesion
and
facilitates
multilayered
candidal
colonization

and

biofilm formation of blastospores as well as the
hyphal phase (3). this situation may worsen in the case
of poor oral hygiene and defective denture cleansing.
the purposes of the present study were to investigate the
prevalence of C. albicans on the mucosa of 10 patients
with oronasal communication using obturator prostheses,
and to evaluate the effectiveness of a topical antifungal
regimen.
MATERIAL AND METHODS
 ten patients attending the Maxillofacial Prosthesis
outpatient
Service
of
the
dental
School,
university
of
São
Paulo,
Brazil,
for
prosthetic
rehabilitation

were
selected
for
the
study.
the
subjects
were
healthy

adult
volunteers
(9
females
and
1
male)
aged
18
years

or

older presenting cleft lip and palate with oronasal
communication due to the lack of reconstructive palatoplasty
or
sequelae.
all
patients
had
been
using
obturator

prosthesis

for at least 1 year, and were not receiving
systemic antibiotics or steroidal antiinflammatory drugs
at the time of the investigation.
 oral candidiasis is the most frequent clinical
infection of the oral cavity and oropharynx in irradiated
patients (9). radiation therapy administered to patients
Figure 1. nasal side of a palatopharyngeal obturator prosthesis.
with oral neoplasia may be part of a combined radiationsurgery
management,
and
maxillary
resection
may
lead

to
a
defect
that
can
be
rehabilitated
with
obturator
prosthesis.
In
the
present
study,
patients
subjected
to
radiation
therapy
were
excluded
from
the
study
to
observe

the

alterations caused by the presence of an oronasal
communication alone. the protocol did not include the
fabrication of new prostheses since prosthetic treatment
has no therapeutic effect on denture-induced stomatitis
caused by candidal infection (10).

two samples were collected from each patient for
cytological analysis. the first oral sample was taken by
gently scraping the mucosa at the edge of the oronasal
communication with a wooden spatula; the second oral
sample was taken from the buccal mucosa. addition-
ally, a third sample was obtained from the acrylic nasal
surface of the obturator prosthesis (Fig. 1). the samples
were smeared onto glass slides, labeled with the patient’s
identification number and oral location, and stained
using the Periodic acid-Schiff (PaS) Method to reveal
the fungal organisms. Patients who were positive for
C. albicans at any given oral site, or on the prosthesis
itself, received treatment, regardless of clinical signs or
symptoms of oral candidiasis.
a combined treatment involving brushing the
prosthesis with a denture paste, and chemical soaking.
during treatment, patients were instructed to brush their
prostheses with a denture cleaning paste followed by soaking
in
a
sodium
hypochlorite
solution
overnight,
which

has
been
shown
to
provide
the
best
result
in
removing

residual
food,
bacteria
and
yeasts
(11),
and
then
rinsing

carefully
in tepid water before use the next morning.
Commercially available denture cleansers are
divided into several types, depending on their chemical
constituents (12). alkaline sodium hypochlorite was
the substance of choice in the present study due to its
low cost and efficacy as an antimicrobial agent. the
solution used in this study has no corrosive effect on
metallic frameworks (13). the oral mucosa was treated
with Mycostatin
, a mouthwash of topical nystatin and
water (4:1), 4 times a day. after 10 days of treatment,
the patients were re-evaluated for oral infection and
prosthetic colonization by C. albicans.
®
the cytological analyses regarding contamination
level were scored 0 (negative), 1 (low), 2 (moderate)
and 3 (high). data were analyzed statistically by Fisher’s
exact test. a significance level of 5% was set for all
analysis (α=0.05).

Braz Dent J 20(4) 2009
338
B.S.C. Mattos et al.
RESULTS
the distribution of scores for C. albicans infection
on the oral mucosa and obturator prosthesis surface is
shown in table 1. the palatal region around the oronasal
communication gave 7 positive results, 3 being rated low,
2 moderate and 2 high. all infected patients exhibited
palatal contamination, but only 1 patient had C. albicans
on the buccal mucosa. this patient was also positive
for C. albicans on the palatal mucosa and prosthesis,
presenting heavy contamination in all analyzed regions.
the acrylic surface was colonized, with hyphae present
in 6 prostheses (Fig. 2), 1 case rated as moderate and
5 cases rated as high. all patients with C. albicans detected
on
their
prostheses,
presented
similar
or
heavier

contamination on the palatal mucosa. the nasal acrylic
surface seemed to facilitate C. albicans colonization,
permitting the development of large hyphal structures.
Seventy percent of the patients were positive for
C. albicans on the oral mucosa and 60% of the patients
were using contaminated obturator prostheses. all
positive patients receiving the combined treatment were
negative (score 0) for C. albicans on the oral mucosa
and on the prosthesis when re-evaluated.
 the Fisher’s test showed that infection of the
palatal mucosa was significantly higher compared to
table 1. Score distribution for Candida albicans infection on the
oral mucosa and obturator prosthesis surface.
Patient oral mucosa
obturator
Braz Dent J 20(4) 2009
prosthesis
Buccal Palatal
1 0 1 3
2 0 2 3
3 0 3 3
4 0 1 2
5 0 2 3
6 0 1 0
7 3 3 3
8 0 0 0
9 0 0 0
10 0 0 0
Scores for candidal infection: 0 = negative; 1= low; 2 = moderate;
infection of the buccal mucosa (p=0.019). However there
was no statistically significant difference (p>0.05) between
the
palatal
mucosa
and
the
prosthetic
surface.
the

palatal
mucosa
infection
was
also
significantly
higher

when
compared
to
that
of
the
buccal
mucosa
(p=0.027).

there
was
no
significant
difference
(p>0.05)
between

the
palatal
mucosa
and
the
prosthetic
surface.
Prosthesis

infection

was significantly higher when compared to
that of the buccal mucosa (p=0.043).
DISCUSSION
C. albicans is a typical oral commensal present
in 30 to 70% of apparently healthy persons. dentureinduced
stomatitis
affects
approximately
65%
of
patients

who wear prosthetic devices, mostly in the maxillary
arch (2,5). the multifactorial etiology of this condition
has long been suggested, including local and systemic
factors such as trauma from ill-fitting dentures, microbial
infection,
poor
denture
hygiene,
continuous
denture

wear,
diet
and
antibiotic
drug
use
(8).
the
presence
of

large
oronasal
communications
alters
the
normal
oral

environment
and
different
results
are
expected
in
this

situation.

However, 70% of patients evaluated in the
present study were positive for C. albicans, which is
a value similar to those reported in the literature for
normal populations.
additionally, none of the patients evaluated mentioned
the
most
common
symptom
of
oral
candidiasis,

a
sore
mouth.
two
patients
displayed
small,
grapelike,

3= high.
Figure 2. Cytological smear from palatal mucosa demonstrating
branching hyphae stained with PaS.
Candida albicans and obturator prosthesis
339
bright red areas on the palatal mucosa, but none on
the buccal mucosa. the isolation of C. albicans from
the palatal mucosa and the presence of hyphae on the
nasal acrylic surface confirm that denture use increases
candidal colonization and predisposes the user to oral
candidiasis. the findings of the present study showed
that the oral mucosa underlying the prosthesis is more
susceptible to colonization by C. albicans, and that the
presence of an oronasal communication in this region
had no direct effect on candidal infection. Furthermore,
alterations to the overall oral environment seem not to
affect oral mucosa colonization, since the results of the
present study confirm those reported in the literature for
normal, edentulous populations.
Studies regarding the colonization of the nasal
floor by aerobic (14) and anaerobic (15) oral flora in
patients with cleft palate and oronasal fistulae indicated
poor transmission of bacteria through the fistula, competition
with
commensal
nasal
flora,
or
an
inability
of
oral

bacteria
to
survive
in
a
saliva-depleted
area.
nevertheless,
the
high
colonization
of
the
nasal
acrylic
surface

by
C.
albicans
should
be
matter
of
concern
since
it
is
in

direct
relation
to
the
nasal
floor
and
adds
contamination

to
the nasal cavity.

these results reinforce the need for patient education
regarding
personal
hygiene
habits
and
prosthetic

care.
Previous
evaluation
of
methods
for
cleaning
denture

on
biofilms
formed
in

vitro on acrylic resins demonstrated
that
mechanical
and
combination
methods
were

similar

and more effective than chemical method for
C. albicans (16). the combination treatment proposed
here was based on methods and substances proven to
be effective. alkaline hypochlorite was the substance of
choice here, owing to its low cost and efficacy as denture
disinfecting solution. all the prostheses examined in this
study were made of heat-polymerized acrylic resin and no
alteration was observed in this material after treatment.
the solution used in this study had no corrosive effect on
the metallic partial-denture frameworks (13). the effect
of alkaline hypochlorite on the physical properties of
the resilient resins employed as denture-lining material
should be evaluated since soft liners are known to be
susceptible to deterioration by denture cleansers (17).
the elimination of C. albicans from human tissue
has been performed effectively with topical nystatin for
nearly 30 years (1,2) and the patients have responded
positively to topical treatment with this antifungal agent.
aiming to prevent C. albicans biofilm formation on
denture material, in vitro studies have reported positive
results when using thin-film polymer PMMa associated
with antifungal medications for coating denture material
(18) or pre-coating with antifungal agents (19), suggesting
that
these
methods
should
be
evaluated
as
a
potential

preventive
therapy for denture-induced stomatitis.
C. albicans infection in patients with oronasal
communication and obturator prostheses is similar to
that presented by patients using conventional prosthesis.
the greater infection of the palatal mucosa and nasal
acrylic surface of the prosthesis, indicates that the
mucosa underlying the prosthesis is more susceptible
to infection, and should be considered the best site for
diagnosis. the treatment proposed in the present study
was effective in eliminating C. albicans from the oral
mucosa and disinfecting the prostheses. Patients wear-
ing prosthetic obturators should be evaluated regularly,
and microbiological control should be performed periodically
to
detect
and
prevent
the
development
of
oral

candidiasis.
RESUMO
os pacientes portadores de prótese obturadora freqüentemente
apresentam estomatite protética. Com o objetivo de detectar a
presença de Candida albicans oral em pacientes com comunicação

oronasal e avaliar a eficácia de um tratamento tópico
antifúngico foi realizada citologia esfoliativa da mucosa palatina
e jugal e da superfície acrílica nasal da prótese obturadora. o
protocolo terapêutico consistiu de nistatina (Mycostatin®) para
tratamento da mucosa oral e uma solução de hipoclorito de sódio
para desinfecção da prótese. Sete pacientes (70%) apresentaram
resultado positivo para C. albicans na mucosa, com um resultado
negativo para a superfície protética neste grupo. a avaliação
após o tratamento revelou ausência de C. albicans na mucosa
oral de todos os pacientes, bem como na superfície protética. a
infecção por C. albicans das mucosas jugal e palatina diferiram
significantemente, enquanto que a mucosa palatina e a superfície
protética apresentaram valores semelhantes. o grau de infecção da
mucosa palatina foi significantemente maior quando comparado
àquele da mucosa jugal e semelhante ao apresentado pela prótese,
sugerindo que a mucosa subjacente à prótese é mais susceptível à
infecção. o protocolo terapêutico foi efetivo em todos os casos, o
que enfatiza a necessidade da desinfecção protética para se evitar
a reinfecção da mucosa oral.
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Accepted October 16, 2009