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Efficacy of denture cleansers on

Candida spp. biofilm formed on polyamide


and polymethyl methacrylate resins
Frederico Silva de Freitas Fernandes, DDS,a Tatiana Pereira-
Cenci, DDS, MSc, PhD,b Wander Jose da Silva, DDS, MSc,
PhD,c Antonio Pedro Ricomini Filho, DDS, MSc,d Fabiana
Gouveia Straioto, DDS, MSc,e and Altair Antoninha Del Bel
Cury, DDS, MSc, PhDf
Piracicaba Dental School, State University of Campinas,
Piracicaba, São Paulo, Brazil; Federal University of Pelotas,
Pelotas, Rio Grande do Sul, Brazil

Statement of problem. Although new materials have emerged as options to fabricate removable dental prostheses,
the development of Candida biofilms on these materials and the effectiveness of methods to control these pathogenic
biofilms are poorly understood.

Purpose. The purpose of this study was to evaluate the efficacy of denture cleansers on Candida single- and dual-species
biofilms formed on polyamide resin.

Material and methods. Polymethyl methacrylate (PMMA) resin (Acron MC) and polyamide resin (Flexite M.P.) speci-
mens (n=116) were prepared, and their surface roughness was standardized (0.34 ±0.02 μm). Surface free energy
(SFE) was measured for some specimens (n=20 per resin), while the remainder were randomly divided by lottery into
24 groups (n=8) for biofilm assay. C. albicans and/or C. glabrata biofilm was formed for 72 hours, and then specimens
were treated with an enzymatic cleanser solution (Polident 3 Minutes), a cleanser solution (Corega Tabs), or 0.5% so-
dium hypochlorite (NaOCl) solution. Water served as the negative control. Remaining adherent microorganisms were
removed from the treated specimens by ultrasonic waves, and colony-forming units (CFU) of each microorganism
were calculated. SFE data were analyzed by 1-way ANOVA, and Candida species data were analyzed by 3-way ANOVA
followed by the Tukey-Kramer test (P=.05).

Results. All tested biofilms displayed significantly higher growth on polyamide resin (P<.001), which presented the
lowest SFE. Denture cleansers significantly decreased Candida levels; however, the 0.5% NaOCl solution was the only
effective cleanser. C. glabrata revealed significantly higher CFU counts under all experimental conditions (P<.001).

Conclusions. The highest Candida spp. biofilm growth was shown to occur on polyamide resin when compared with
PMMA. Denture cleansers were able to remove Candida spp. biofilm formed on both denture base resins. (J Prosthet
Dent 2010;105: 51-58)

Support for this research was provided by the Maranhão Research Foundation (FAPEMA-BM00042/08) and The National Council
for Scientific and Technological Development (CNPq).

a
Graduate student, Department of Prosthodontics and Periodontology, Piracicaba Dental School, State University of Campinas.
b
Associate Professor, Department of Restorative Dentistry, Federal University of Pelotas.
c
Research Fellow, Department of Prosthodontics and Periodontology, Piracicaba Dental School, State University of Campinas.
d
Graduate student, Department of Prosthodontics and Periodontology, Piracicaba Dental School, State University of Campinas.
e
Graduate student, Department of Prosthodontics and Periodontology, Piracicaba Dental School, State University of Campinas.
f
Professor, Department of Prosthodontics and Periodontology, Piracicaba Dental School, State University of Campinas.
Fernandes et al
52 Volume 105 Issue 1

Clinical Implications
Based on the results of this study, denture cleansers are able to
remove Candida spp. biofilm formed on the surface of polyamide and
PMMA denture base resins, and may be a useful hygiene method to
prevent denture stomatitis.

Oral candidosis is a common op- ers are used.20 Although soaking den- to evaluate the efficacy of denture
portunistic infection in denture wear- tures in disinfectant solutions21-23 or cleansers on Candida single- and dual-
ers,1 with the Candida species being denture cleansers24-27 has been shown species biofilms formed on denture
the primary etiological agent.2,3 Den- to be an effective method to control resins. The null hypotheses were that:
ture surfaces usually act as a reservoir Candida albicans colonization, there (1) the substratum type would not in-
for yeasts, and the disease is aggravat- is a lack of evidence about the com- terfere with biofilm formation, (2) the
ed by poorly fitting dentures and in- parative effectiveness of those cleans- type of biofilm would not interfere
adequate oral and denture hygiene.4 ing agents on other Candida biofilms, with denture cleanser efficacy, and (3)
Although Candida albicans is consid- such as C. glabrata28 and mixed C. al- there would be no difference among
ered the predominant isolate in this bicans and C. glabrata biofilms, which the chemical cleansers in decreasing
infection,5,6 a shift towards non-albi- have an important role in the patho- Candida levels.
cans species, such as Candida glabrata, genesis of denture stomatitis.
has been observed.7,8 Furthermore, over the last few MATERIAL AND METHODS
C. glabrata, an emerging fungal years, new materials such as poly-
pathogen, exhibits superior adhesion amide thermoplastic resin have been Experimental design
to acrylic resin surfaces when com- developed for use in the fabrication
pared with Candida albicans,9-12 and is of removable prostheses. Polyamide This in vitro study had a random-
responsible for 15% of mucosal and thermoplastic resin is more flexible ized and blinded design (in regard to
systemic candidosis.13 C. glabrata is than the more widely used acrylic CFU counts), with substratum type
associated with severe inflammation resins, providing patients with com- (microwave-polymerized polymethyl
in denture wearers,14 particularly in fortable long-term use. Therefore, it methacrylate resin and polyamide
combination with C. albicans, sug- is often recommended for geriatric thermoplastic resin), biofilm type
gesting a synergistic relationship be- and disabled denture wearers.29 Con- (single-species biofilms: C. albicans
tween these 2 species.8,12 Considering sidering the poor denture hygiene of and C. glabrata, and dual-species bio-
the pathogenicity and the high preva- these patients as a result of their lim- films: C. albicans plus C. glabrata), and
lence of mixed C. albicans and C. glabrata ited motor capacity, it is important treatment with chemical cleansers
biofilms in patients with denture stoma- to assess the effectiveness of denture (enzymatic cleanser solution, cleans-
titis,5,14 it is crucial to assess the effec- cleansers on Candida biofilms formed er solution, or 0.5% sodium hypo-
tiveness of methods that can remove on polyamide resins. Moreover, few chlorite, NaOCl) as factors. Contact
both C. albicans and C. glabrata from studies have examined the develop- angle, surface free energy, and colo-
colonized dentures and oral mucosa. ment of Candida biofilms and how ny-forming unit (CFU) counts of C.
Apparently, mechanical denture surface properties such as surface albicans and C. glabrata were the vari-
cleansing is an effective measure for free energy (SFE) are related to fungal ables. Surface roughness was stan-
routine biofilm control15; however, colonization. SFE is considered an im- dardized for both resins studied.
some denture wearers may have dif- portant property, as it may alter the Specimens were fabricated accord-
ficulty in keeping their dentures clean, denture pellicle composition and ini- ing to the manufacturer’s instructions,
especially geriatric patients and those tial adherence of microorganisms to and the number of specimens in each
with limited motor capacity.16,17 For denture surfaces.30-33 test group was determined by prelimi-
these patients, a combination of Since Candida species biofilms, nary tests, which demonstrated that
mechanical and chemical cleansing denture base materials, and oral hy- the sample size yielded an adequate
with immersion in denture cleansers giene all have an important role in the power (80%) for detecting statisti-
is mandatory for reducing microbial onset and severity of denture stoma- cally significant differences (n=116).
biofilm accumulation on removable titis, the purpose of this study was After surface roughness standardiza-
prostheses.18,19 Nevertheless, clini- to compare C. albicans and C. glabrata tion, the surface free energy in a por-
cians should be aware of the potential single- and dual-species biofilm de- tion of the specimens was measured
for color change when denture cleans- velopment on polyamide resin, and (n=20 per resin), while the remaining
The Journal of Prosthetic Dentistry Fernandes et al
January 2011 53
specimens were randomly divided by ings were made for each specimen, Biofilm assays
lottery into 24 groups (n=8) for bio- and a mean value was calculated.36
film assay. Single- and dual-species For both resins, Ra was standardized Biofilm assays were performed
biofilms were formed for 72 hours, at 0.34 ±0.02 μm. with single-species biofilms of C. al-
and specimens were then assigned After surface roughness measure- bicans or C. glabrata, and dual-species
to 1 of the 4 treatments with denture ments were completed, the specimens biofilms of C. albicans plus C. glabrata.
cleansers. Remaining adherent mi- were ultrasonically cleansed (Thorn- Discs of the 2 materials were placed
croorganisms were removed from the ton T 740; Thornton-Inpec Eletrônica vertically in 24-well (each well was 15
treated specimens by sonication, and Ltda, Vinhedo, Brazil) in sterilized, mm in diameter) polystyrene cell cul-
CFU counts of each microorganism distilled water for 20 minutes prior ture plates (Cellstar 24 Well Cell Cul-
were calculated. to measuring the surface free energy ture Plates; Greiner Bio-One GmbH,
(SFE) or biofilm formation, to remove Frickenhausen, Germany). Subsequent-
Specimen preparation any contaminants and artifacts from ly, 2 ml of each cell suspension (106
the surfaces.9 All procedures were CFUs C. albicans and/or C. glabrata in
All materials were prepared ac- performed by a single operator. YNB) was added to each well.
cording to the manufacturers’ in- Biofilms were formed on saliva-
structions at room temperature (25 Contact angle and surface free energy coated PMMA and polyamide resin
±1°C and 50 ±5% relative humidity), measurements discs. The disc surface area was 219.8
under aseptic conditions. Initially, cy- mm2. The discs were prepared by in-
lindrical wax pattern discs (10 mm Three liquids were chosen for con- cubation with clarified human whole
in diameter and 2 mm thick) were tact angle measurement: distilled water, saliva for 30 minutes at 37°C. Human
prepared using an aluminum matrix. formamide, and 1-bromonaphthalene. whole saliva was collected during mas-
Discs were invested in plastic or injec- Contact angle (degrees) was measured ticatory stimulation with flexible film
tion flasks for microwave-polymerized by dispensing a droplet (10 μl) of each (Parafilm M; American Can Co, Neen-
polymethyl methacrylate (PMMA) liquid on the specimen surface. The ah, Wis) in an ice-chilled polypropyl-
(Acron MC; GC America, Alsip, Ill) images of the droplets were captured ene tube and clarified by centrifuga-
or polyamide thermoplastic resin immediately and contact angles were tion at 10,000 g for 10 minutes at
(Flexite M.P.; Rapid Injection Systems measured (AutoCAD Release 14; Au- 4oC. The volunteer provided written
Corp, Mineola, NY), respectively, and todesk, Inc, San Rafael, Calif ) from the informed consent, and the study was
the wax was softened and eliminated left boundaries of the magnified picture previously approved by the Research
with boiling water. The PMMA resin to the point of air-water-specimen inter- and Ethics Committee of Piracicaba
was then packed and the plastic flasks section. Each specimen was measured 3 Dental School, State University of
were placed in a microwave oven for times for each liquid at 25 ±1.0°C, and Campinas. For every experiment, the
polymerization, while the injection a mean was determined. The surface saliva sample was collected at the
flasks were sprued, closed, and in- free energy (mN·m-1) was calculated us- same time of day and the volume was
jected with the polyamide resin. Once ing the cosine of the contact angle val- limited to 50 ml per collection peri-
processed, all flasks were allowed to ues obtained previously.37 od, so as to account for the circadian
bench cool for 2 hours. Afterwards, rhythm in saliva composition.38 The
the specimens were removed and im- Inoculum and growth conditions supernatant was removed and imme-
mersed in distilled water at 37°C for diately used.
12 hours for residual monomer re- A loopful of stock yeast cultures of All biofilm assays were performed
lease.34,35 Specimens were ground us- C. albicans (ATCC 90028) and C. gla- in duplicate in at least 4 independent
ing progressively smoother aluminum brata (ATCC 2001) were reactivated experiments on different days. The
oxide papers (320-, 400-, and 600- from their original cultures at -70°C organisms were grown at 37°C at 75
grit) in a horizontal polisher (model and incubated for 24 hours at 37°C. rpm in an orbital shaker (Kline agita-
APL-4; Arotec, São Paulo, Brazil) to Cells were harvested, suspended in tor NT 151; Nova Técnica, São Paulo,
standardize surface roughness. Yeast Nitrogen Base (YNB) broth Brazil) for 72 hours to allow biofilm
Subsequently, surface roughness (Becton Dickinson, Franklin Lakes, formation.
(Ra) of the specimens was measured NJ) supplemented with 100-mM glu-
using a profilometer (Surfcorder cose, and standardized to 1 to 5 x 106 Treatment protocols
SE1700; Kosaka Laboratory Ltd, To- cells·mL-1, ascertained spectrophoto-
kyo, Japan) with a resolution of 0.01 metrically (Spectronic 20; Bausch & After the biofilm development
mm, calibrated at a specimen length Lomb, Rochester, NY) at an absor- phase (72 hours), specimens were
of 0.8 mm, 2.4-mm percussion of bance of 0.38 at 520 nm.34 randomly divided by lottery into 4
measure, and 0.5 mm/s. Three read- groups of separate treatments: dis-
Fernandes et al
54 Volume 105 Issue 1
tilled water (DDW), negative control; Louis, Mo), at pH 7.4 for 2 seconds. by 1-way ANOVA, considering polyam-
enzymatic cleanser solution (PD) ide and PMMA resin groups. Factors
(Polident 3 Minute; GlaxoSmithKline, Biofilm analysis interfering in the response variable “vi-
Philadelphia, Pa); cleanser solution able cells of Candida species” (material,
(CT) (Corega Tabs; Block Drug Co, After treatment, discs were placed type of biofilm, and treatment) were
Jersey City, NJ), or 0.5% sodium hy- into a polypropylene tube containing analyzed by 3-way ANOVA. Post hoc
pochlorite solution (HC) (Proderma 3 ml of sterilized PBS. Adherent mi- comparisons were performed using the
Pharmacy, Piracicaba, Brazil), which croorganisms were removed from the Tukey-Kramer test.
served as the positive control. Clean- specimens by sonication at 7 W for
ing tablets were placed into 8 ml 30 seconds.39 The sonicated solutions RESULTS
(40°C) of deionized distilled water.28 were serially diluted in PBS, and 20-
Exposure to the immersion efferves- μL specimens were plated in triplicate Mean surface free energy values
cent denture cleansers was controlled on agar (BBL CHROMagar Candida; (SD) of the PMMA and polyamide
to allow all surfaces of the specimen Becton Dickinson, Franklin Lakes, NJ) resins were 37.16 (1.06) and 36.35
to be in contact with the cleanser. and blood agar (Blood Agar Base; (1.36), respectively. One-way ANOVA
Denture cleanser solutions were pre- Becton Dickinson). The latter was revealed that PMMA exhibited sig-
pared according to the manufactur- used to verify possible contamination. nificantly higher SFE when compared
ers’ instructions. PD specimens were The plates were incubated at 37°C with polyamide resin (df=1; F=4.4,
treated for 3 minutes, CT specimens under aerobic conditions for 24-72 P=.04). Three-way ANOVA revealed
were treated for 5 minutes, and HC hours. CFU were counted using a ste- nonsignificant interactions between
specimens were treated for 10 min- reomicroscope (Coleman Equipamen- the material, type of biofilm, and
utes. The negative control group was tos para Laboratórios, Santo Andre, treatment (P>.05) (Table I). All test-
not subjected to any treatment, as Brazil), and the results were expressed ed biofilms (single and dual species)
it would be impossible to prepare a in colony-forming units per area. showed significantly higher growth
common placebo for the 2 denture The statistical analysis was per- on polyamide resin (P<.001) (Table
cleansers tested. In this group, speci- formed using statistical software II). Candida glabrata single-species bio-
mens remained in deionized distilled (SAS v. 9.0; SAS Institute, Inc, Cary, film revealed significantly higher CFU
water for 10 minutes as a reference NC) with a significance level fixed at counts in all treatments compared
for the longer time period used (HC 5%. The assumptions of equality of to Candida albicans single-species bio-
group). variances and normal distribution of film (P<.001) (Table II), under all
Before and after the treatment, errors were evaluated for each vari- experimental conditions; however,
each specimen was subsequently re- able, and, when violated, the data dual-species biofilms did not differ
moved and gently washed twice in a were transformed as suggested by significantly from both single-species
new well of a new polystyrene tissue the software.40 As mean values were biofilms, with respect to Candida
culture plate (TPP AG, Trasadingen, not normally distributed, the data of counts (Table II). Denture cleansers
Switzerland) containing 2 ml of ster- the viable cells of Candida species were significantly decreased Candida spe-
ilized phosphate-buffered saline so- transformed by exponentiation (y0.2). cies levels compared with the negative
lution (PBS; Sigma-Aldrich Corp, St. Surface free energy values were assessed control; however, the 0.5% NaOCl

Table I. Three-way ANOVA comparison of material, type of biofilm, and treatments on cell counts
Sum of Mean
Source of Variation df Squares Square F P

Material 1 92305 92305 19.57 <.001

Type of biofilm 2 79203 39602 8.40 <.001

Treatment 3 1980587 660196 140 <.001

Material x type of biofilm 2 5584 2792 0.59 .554

Material x treatment 3 36647 12216 2.59 .055

Type of biofilm x treatment 6 57566 9594 2.03 .064

Material x type of biofilm x treatment 6 8468 1411 0.30 .937

The Journal of Prosthetic Dentistry Fernandes et al


January 2011 55

Table II. C. albicans and C. glabrata viable cells (CFU/mm2) after treatment (Mean ±SD)
Material

Type of Biofilm Treatment PMMA Polyamide

C. albicans 1075 ±712 Aa 1826 ±1596 Ba


C. glabrata H2O * 1209 ±767 Ab 2235 ±1528 Bb
C. albicans + C. glabrata 1189 ±1047 Aa,b 1596 ±213 Ba,b

C. albicans 401 ±274 Aa 489 ±280 Ba


C. glabrata Polident § 600 ±519 Ab 1698 ±1352 Bb
C. albicans + C. glabrata 412 ±243 Aa,b 850 ±491 Ba,b

C. albicans 244 ±284 Aa 535 ±307 Ba


C. glabrata Corega Tabs § 542 ±508 Ab 1725 ±1135 Bb
C. albicans + C. glabrata 562 ±358 Aa,b 837 ±487 Ba,b

C. albicans 0 ±0 Aa 0 ±0 Aa
C. glabrata 0.5% NaOCl # 0 ±0 Aa 0 ±0 Aa
C. albicans + C. glabrata 0 ±0 Aa 0 ±0 Aa

Different uppercase letters represent statistically significant differences between materials.


Different lowercase letters represent differences among types of Candida biofilm within materials.
Different symbols represent statistical differences among treatments (Tukey-Kramer test; P<.05).

Table III. Reduction in percentage of C. albicans and C. glabrata treatment compared to negative control.
Material

Type of Biofilm Treatment PMMA Polyamide

C. albicans – –
C. glabrata H2O * – –
C. albicans + C. glabrata – –

C. albicans 57.8 ±36.2 Ab 64.8 ±19.1 Ab


C. glabrata Polident § 62.9 ±31.7 Ab,c 41.3 ±23.3 Ab,c
C. albicans + C. glabrata 58.1 ±22.8 Ac 43.5 ±32.4 Ac

C. albicans 76.1 ±27.4 Ab 72.2 ±19.4 Ab


C. glabrata Corega Tabs § 51.6 ±28.7 Ab,c 49.6 ±10.0 Ab,c
C. albicans + C. glabrata 53.7 ±20.4 Ac 37.5 ±17.2 Ac

C. albicans 100% Aa 100% Aa


C. glabrata 0.5% NaOCl # 100% Aa 100% Aa
C. albicans + C. glabrata 100% Aa 100% Aa

Different uppercase letters represent statistically significant differences between materials.


Different lowercase letters represent differences among types of Candida biofilm within materials.
Different symbols represent statistical differences among treatments (Tukey-Kramer test; P<.05).

Fernandes et al
56 Volume 105 Issue 1
solution was the only effective agent, capable of reducing adhesion and in- of 0.5% sodium hypochlorite has been
as no viable cells were observed af- hibiting the growth of Candida.32 In the shown with regard to the initial adher-
ter treatments. There was no signifi- present study, the immersion in dis- ence of C. albicans21 and C. glabrata,28
cant difference between the denture tilled water for 12 hours for residual even though the previously mentioned
cleanser solutions in decreasing Can- monomer release may not have been reports did not assess the effect of this
dida species levels (Table II). Denture sufficient to completely eliminate disinfection solution on a mature and
cleansers resulted in a greater reduc- residual monomer from the PMMA mixed Candida species biofilm, as was
tion of C. albicans than C. glabrata in specimens.35 This may explain why all done in the present study.
the dual-species biofilm (Table III), tested biofilms demonstrated signifi- It has been proposed that the abil-
since, after the treatments, a signifi- cantly lower growth on PMMA resin ity of Candida species to form biofilm
cantly (P=.004) higher number of vi- when compared with the polyamide on the surfaces of denture materials
able cells of C. glabrata was observed resin. Moreover, it has been shown is important regarding the virulence
when compared to C. albicans. that saliva immersion produces differ- of Candida.8 The present study dem-
ences in the SFE of denture resins31; onstrated significantly higher Candida
DISCUSSION therefore, further studies evaluating glabrata colonization on the resin sur-
the SFE of saliva-coated specimens faces studied, when compared with C.
The data did not support rejec- are necessary to increase understand- albicans. These results are in agreement
tion of the null hypothesis that the ing of the role of this substance in with previous findings,9-12 although
type of biofilm would not interfere controlling Candida colonization and these studies did not assess the effect
with the efficacy of denture cleans- its effect on surface properties. of denture cleansers. The different col-
ers; however, the null hypotheses that Although many studies have eval- onization results may be explained by
the substratum type would not inter- uated the effect of denture cleansers the complexity and phenotypic hetero-
fere with biofilm formation and that and disinfectant solutions on initial geneity of the Candida species popula-
there would be no difference among Candida adherence to denture base tion. This heterogeneity is displayed by
the chemical cleansers in decreas- materials,26-28 little attention has been a variable surface hydrophobicity, the
ing Candida levels were rejected. This paid to the effect of these denture- absence or presence of secreted extra-
study has shown that the new denture cleansing agents on Candida-associat- cellular proteinases, hyphae formation
material studied is easily colonized by ed mature biofilm,19 the cells of which and/or thigmotropism, which all have
Candida species, suggesting that poly- are known to be more resistant to an- a direct influence on Candida adher-
amide resins, like polymethyl meth- timicrobial compounds and chemical ence to plastic surfaces.8,9
acrylate resin surfaces, may present cleansing.24 That is why the present Recent studies have found that C.
a convenient substratum for micro- study used 72-hour biofilms to gain glabrata is frequently coisolated with
bial colonization. Candida growth on an understanding of dual-species C. albicans from severe inflammation
the polyamide resin was even higher biofilms formed on the different sur- in denture wearers.5,14 It is intriguing
than that observed on the PMMA faces and their relationship with den- to speculate that a synergistic rela-
material. Although a linear relation- ture cleansing. The results show that tionship may be involved in the en-
ship between SFE and Candida adher- the denture cleanser solutions, with hanced pathogenic potential of this
ence has been demonstrated,30 in the or without enzymes, were effective combination.12 The present study
present study, this surface property in controlling Candida spp. biofilms, was the first to evaluate the effect of
seemed to have no direct influence and especially in reducing C. albicans chemical cleansers on this pathogenic
on Candida biofilm development, as levels; however, they were not able mixed C. albicans and C. glabrata bio-
the polyamide resin demonstrated to completely eliminate Candida cells film. It was observed that the denture
the highest Candida colonization and from the dental materials, as did the cleansers tested were more effective
the lowest SFE values in comparison sodium hypochlorite solution. in diminishing C. albicans than C. gla-
with the PMMA resin. These results Previous studies have shown that brata in the mixed Candida biofilm.
corroborate those of recent studies soaking dentures in 5.25% sodium These new results are important, as
that found no correlation between hypochlorite solution is an effective the daily use of cleanser solutions
SFE values and Candida colonization, method for killing adherent Candida regularly used in clinical practice may
suggesting that other factors may be albicans.22,23 However, in high concen- promote a population shift towards
involved in initial Candida adherence trations, this disinfection solution non-albicans species, such as C. gla-
and biofilm formation on denture may damage denture materials.18 In brata, which is increasingly implicated
materials.11,32,33 Previous studies have the present study, hypochlorite solu- in human infection and associated
suggested that the residual monomer tion in a lower percentage was able to with systemic infections having a high
found in the PMMA resin produces completely eliminate the Candida cells mortality rate.8
differences in the resin surface charge from the specimens. The effectiveness The results of the present study
The Journal of Prosthetic Dentistry Fernandes et al
January 2011 57
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Copyright © 2010 by the Editorial Council for


The Journal of Prosthetic Dentistry.

Noteworthy Abstracts of the Current Literature


The immediately loaded single implant–retained mandibular overdenture: A 36-month
prospective study

Liddelow G, Henry P.
Int J Prosthodont 2010;23:13-21.

Purpose. The aim of this study was to ascertain whether simplifying mandibular overdenture treatment by using
single-stage surgery and immediate prosthetic loading of a single implant will achieve acceptable implant success
rates, functional improvement, and increased patient satisfaction. As part of this study, the Mk III Brånemark implant
with an oxidized surface was compared to the classic machined Mk III Brånemark implant.

Materials and Methods. Thirty-five patients (mean age: 68 years) with problematic mandibular dentures were
treated. The primary complaints among the patients referred to the clinic for treatment were poor retention of the
mandibular denture, instability, denture sores, and phonetic problems. Initially, patients were placed randomly into
the “machined surface” or “oxidized surface” groups. A single implant was placed in the mandibular midline with high
initial stability. A ball attachment was placed and the retentive cap incorporated into the existing denture. Reviews
took place at 3, 12, and 36 months posttreatment. Clinical assessments, radiographs made with custom film holders,
and stability measurements by both manual and resonance frequency analysis methods were recorded. All complica-
tions, failures, maintenance, and reasons for dropout were noted. Visual analog scale questionnaires were used to
record patient satisfaction (analysis of variance: P < .05).

Results. Three of eight machined-surface implants failed, representing an unacceptably high failure rate (37.5%). The
machined surface was therefore discontinued for this study. One machined and two oxidized-surface implants did not
achieve sufficient primary stability to be immediately loaded, so they were treated with a two-stage delayed loading
protocol. The 25 immediately loaded oxidized-surface implants were all classified as surviving at the 36-month recall.
Patient satisfaction was very high with a significant increase in all comfort and functional parameters.

Conclusions. Within the limitations of this study and research design, it appears that over a 3-year observation
period, the immediately loaded single implant–retained mandibular overdenture, using an oxidized-surface implant
and the existing prosthesis in a small group of prosthetically maladaptive patients, can provide a beneficial treatment
outcome with a minimal financial outlay.

Reprinted with permission of Quintessence Publishing.

The Journal of Prosthetic Dentistry Fernandes et al

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