An investigation into the effect of denture adhesives in limiting food impaction ABSTRACT Aim of the study: To compare the

weight of retrieved food accumulated under the dentures base with and without adhesive treatment. Materials and Method: Each subject was given 32 g of non-salted dry roasted peanuts to chew and swallow. After finishing all the peanuts, the subject was asked to brush their denture using toothbrush and toothpaste without removing the denture from the mouth and rinsed their mouth vigorously with water. The weight of the retrieved peanuts accumulated under the denture base collected, dried, and weighted. All procedures were repeated with denture adhesive. Results: On average, the mean weight of peanuts particles recovered beneath upper dentures without application of denture adhesive was 51.21 mg which is higher than the mean weight of upper denture with adhesive treatment (35.36 mg). The similar pattern was detected for the lower dentures but at higher mean weight. Conclusion: Application of denture adhesive significantly reduced the amount of retrieved peanut particles collected under the denture base compared to no-adhesive treatment (p< 0.005). Keywords: Food occlusion, denture adhesive, satisfaction, quality of life.

This research has been presented at the 66TH MDA AGM/ FDI International Scientific Conference & Trade Exhibition (2nd place winner for poster presentation)

INTRODUCTION Denture adhesive is used to refer to a commercially available, non toxic, soluble material (powder, cream, liquid) that is applied to the fitting surface of the denture in order to enhance denture retention, stability and performance.1 It is also defined as thin wafers of water soluble material that are adherent to both basal tissue and denture base, and which lack the ability to flow and therefore do not have capacity to direct uneven and point pressure against bearing tissue. 1,2 Denture adhesives increase denture retention and thereby improve chewing ability, reduce denture wobble, improve comfort and confidence, and reduce amount of food particles collecting under the dentures. Moreover, adhesives undoubtedly provide an increased sense of security and satisfaction. Patients claimed that the main reasons for trying denture adhesive are to improve fit, chewing ability, and also to improve confidence in wearing dentures. 3 Fenlon et al in 2004 reported an improvement in chewing efficiency during adjustment to new dentures progresses further in patients who employ a denture adhesive product. 4 Chewing rate has been reported to increase immediately after application, at 2-hours and 4-hours after denture adhesive was applied. Resume to more natural chewing at a faster rate indirectly limiting discomfort during mastication, pain and food restriction. 5 Earlier studies have shown that well-fitting and ill-fitting dentures are subject to movement even without the use of denture adhesive; and that a denture adhesive significantly reduces movement in even well fitting maxillary and mandibular dentures.6,7 Chew et al in 1984 also documented that denture adhesive exerted their greatest effect with ill-fitting dentures.8 This is supported by study of Grasso et al which suggested that improved retention of well fitting denture helps to achieve improved functions.9

Patients response to the use of these materials is not universally positive. Some patients object to the grainy or gritty texture of powder, or to the taste or sensation of semi dissolved adhesive material that escapes from the posterior and other peripheries (often due to use of excessive quantity or use in an inadequate prosthesis). Denture adhesives are designed with sticky materials to provide retention. Denture adhesives should also be designed for easy removal from dentures. But, most of the subjects found the denture adhesives not easy to remove from the inner surfaces of the dentures. The residual adhesive left on the bearing tissue was claimed to give discomfort to them. Adhesives can be very tenacious, and if they are not completely removed from the denture and the mouth, they can harbor organisms harmful to the patients oral health. 10 The number one complaint of denture patients is that food gets trapped under their dentures, which can cause serious irritation namely oral infections, bad odor and unpleasant taste and sensation.11 Until recent year, there is still lacking of investigations looking into this serious matter. However, the use of a denture adhesive is not a treatment modality. Its recommendation as an adjunct to denture treatment. 12 The present clinical study evaluates whether the adhesives has an ability to increase denture adhesion to the mucosa covering the edentulous alveolar ridged and directly preventing food from entering the space between denture bases and tissue bearing area.

MATERIALS AND METHODS The study was carried out in 32 patients aged 18 years and above with removable complete dentures dependently selected based on their denture quality using Modified Kapur Index Scale (MKIS) (Table 1). All complete dentures must be worn for at least 3 months and not exceeded 3 years in function, well made and fitting with MKIS 10. The patients were must not being a denture adhesive user. Patient with known allergy to peanut, uncontrolled medical complications or any history of substance used were excluded from the study. Written informed consents were obtained from the selected patients. Soft tissue examination was performed to assess the denture bearing tissue: the shape of alveolar ridge, tissue resiliency and location of border tissue attachment based on Denture Bearing Tissues Score (DBTS) (Table 2). Table 1. Classification of maxillary and mandibular complete denture based of MKIS Table 2: Denture Bearing Tissues Score (DBTS) for ridge shape, tissue resiliency and location of border tissue attachment, for maxillary and mandibular arches Table 3. Classification of denture bearing tissue score (DBTS) 32 gram non-salted dry roasted peanuts (Cap Tangan, Ngan Yin, Perak, Malaysia) were weighed using an electronic weighing device (METTLER TOLEDO M Sdn Bhd, Selangor, Malaysia) and later packed into plastic bag (6 X 9 cm). The bags containing the peanuts were then labelled. Patient was given a packed of 32 gram dry roasted peanuts (Cap Tangan, Ngan Yin, Perak, Malaysia) each to chew and swallow for a duration of 15 minutes. Once completed, the patient was asked to brush their denture using toothbrush and toothpaste with the denture in situ and rinse vigorously with water. Any remnants of peanut particles that did not retained under the dentures base should be fully removed.

Upper denture was removed from patients mouth. Any residual peanut particles were removed from the subjects palate or denture bearing area using a piece of gauze. The gauze and denture was later placed into a 500 ml beaker (Kimax KG-33 Glass, Vineland, NJ, USA) coded with the subject reference number and capital U for upper denture. The procedures were

repeated for the lower denture, as well as for the lower denture bearing area. The upper and lower denture of each subject placed in the coded beakers (U & L) with the gauze (upper and lower separately). 100 ml of 60 C hot water was added to the beakers and later were sonicated in Bransonic Ultrasonic Cleaner (SweepZone, Kearny, NJ, USA) for 30 minutes to loosen any adhering peanut particles. Figure 1: Retrieved peanuts particles under (a) the upper denture base and (b) the lower denture base. The mixture of water, saliva and peanut particles in beaker U and beaker L was heated into boiling with frequent stirring. The mixture in each beaker was strained through a standard testing sieve (Sartorius Stedim Biotech, Germany). The remaining residual on the sieve was rinsed repeatedly with hot water to remove any saliva and air dried. The dried peanut particles were later transferred into 50-ml beakers coded with subjects reference number, before having them sonicated for 15 minutes. The peanut particles were strained again through a standard testing sieve. The peanut particles were air dried on the petri dish coded (subject reference number, U/L and date) for 1 hour. Final drying was completed in an oven (Memmert GmbH Limited) at 105 F for 5 hours. The dish was then cooled to room temperature and later weighed, to determine the weight of the particles collected from each denture (weight of the retrieved

peanuts). All procedures were repeated with application of denture adhesive (Polident; GlaxoSmithKline, Ireland). The weight of the particles collected from each denture (weight of the retrieved peanuts) was recorded and analyzed using Statistical Package for the Social Sciences (SPSS version 12.0).

RESULTS The frequency of distribution of patients gender and age is displayed in Figure 1. Figure 2: Number of subjects according to the age and gender Twenty nine (90.6%) set of complete dentures scored MKIS10 qualified with score between 10 and 14 (59.4%), followed by score more than 14 (31.3%) as illustrated in Figure 2. The overall patients for this study were 29 (90.6%). Figure 3: The classification of complete dentures according to Modified Kapur Index Scale (MKIS) While, 15 patients (51.7%) scored between 14 and 17 for DBTS, 8 patients scored less than 14 followed by 9 patients scored above 17 as demonstrated in Figure 3. Figure 4: The classification of patients denture bearing tissue according to Denture Bearing Tissues Score (DBTS) Relative to the amount of peanut particles, most of the upper (44.83%) and lower dentures (34.48%) have accumulated the highest amount peanuts particles between 20-39 mg.

Weight higher than 100 mg was collected from lower dentures. Without application of denture adhesive, most of the lower dentures fall into group weight of 80-99 mg (34.48%), followed by group 40-59 mg (n=5) and more than 100mg weight (n=5). While, most of upper dentures fall into group 60-79 mg of weight (34.48%), followed by group of 20-39 mg (n=4) and 0-19 mg (n=3). There were higher number of lower dentures (n=5) accounted for weight more than 100 mg. Figure 5: Weight in milligram (mg) of retrieved peanut particles accumulated under dentures with adhesive (N=29) Figure 6: Weight in mg of retrieved peanut particles accumulated under dentures without adhesive (N=29) In comparison with its counterpart, the mean weight of peanuts particles recovered beneath upper dentures without application of denture adhesive was 51.21 mg. However, the mean weight of upper denture with adhesive treatment was much less (35.36 mg). The similar pattern was detected for the lower dentures but at higher mean weight as shown in Table 8. Table 5: The mean weight in milligram (mg) of retrieved peanut particles

DISCUSSION The key reasons for using denture adhesives are to improve fit, comfort, chewing ability, and patient confidence. The number one complaint of denture patients is that food gets trapped under their dentures, which can cause serious irritation namely oral infections, bad odor and unpleasant taste and sensation.11 which can cause serious irritation namely oral infections, bad odor and unpleasant taste and sensation. Until recent year, there is still lacking of investigations looking into this serious matter. This clinical protocol was designed to explore the certainty concerning the condition under the dentures after eating. Peanut particles underneath the denture base were reduced in weight while the retention and stability of the dentures improved as the denture adhesive created an additional seal or barrier by elimination of voids in between both surfaces. The differences in weight of peanuts particles in the presence of denture adhesive were statistically significance (p<0.05). The results confirmed the hypothesis; that denture adhesive has an ability to reduce amount of food impaction under the denture base. These findings were supported by other studies showing that denture adhesive was effective in improving maximum incisal force and retention of complete dentures.5, 13-15

Floystrand F et al indicated that chewing rate increased with increasing time of application of adhesive.6 However, the patients started chewing peanuts right after application of denture adhesive allowing only a few minutes for denture adhesive to flow under the denture base, which may contribute to the less effect of adhesive on upper dentures. Over the time, the denture adhesive should gain more adhesiveness improving the chewing process. In this study, at later period the chewing became more regular and effective. Food impaction was evidently less in those subjects whose denture bearing tissues (DBTS) were judged as satisfactory. On the other hand, the subjects whose tissues were predicted by clinical assessment as not providing a good denture bearing tissue had much higher in weight of trapped food particles. This is comparable with the findings obtained from the study by Tarbet, which indicated that the quality of the denture bearing tissues could have a significant influence on denture stability as reflected by reduced food impaction.
16

The findings thus

indicated that clinical assessment of the denture bearing tissue could reliably predict the natural stability and retention of a well-adapted denture, insofar as it was reflected by food impaction values. This finding did not represent the lower denture as MKIS revealed that stability or retention of several lower dentures were unsatisfactory. Although this study provides valuable information on the positive effects of denture adhesive in terms of reducing food impaction, a few important limitations must be considered. Some patients encountered difficulty and experienced tiredness over time to finish 64 gram of peanuts (two phases; adhesive and non-adhesive). These procedures were just too time consuming for the elderly patients. Peanuts might not be something they include in their daily diet. A number of studies have shown that wearing dentures contributes to avoidance of difficult to chew foods such as peanuts. Some fresh fruits and raw vegetables are difficult for denture-

wearers to eat, but these problems can be overcome with food preparation.

18

Bradbury in 2008

concluded that if the diet of denture-wearers is to be improved, psychosocial factors, as well as perceived chewing ability, must be addressed.
19

Difficulty in removing the retrieved peanuts

particles especially when denture adhesive came into contact delayed the whole procedures. Extra care was taken to minimize losing some of the particles from the gauze as well as the particles within denture adhesive. However, there might be some of the particles still remain entrapped together with the gauze and adhesive.

CONCLUSION Application of denture adhesive significantly reduced amount of retrieved peanut particles under the denture base compared to non-adhesive treatment (p< 0.005).

ACKNOWLEDGEMENT We would like to thank GlaxoSmithKline for supporting this research project with samples of denture adhesive. Thanks are also extended to all staff of the Faculty of Dentistry, Universiti Kebangsaan Malaysia, especially in the Prosthodontic Specialist Clinic and Department of Prosthodontics for all their time and support.

REFERRENCES
1. Shay K. Denture adhesives: Choosing the right powders and pastes. J Am Dent Assoc

1991; 122: 70-6. 2. Yadav A. Denture Adhesive: Their stand in prosthodontic. J Indian Prosthodont Soc 2005; 5: 62-4.
3. Oshlan AM, Ross NM. A modified Kapur scale for evaluating denture retention and

stability: methodology study. Am J Dent 1992; 5: 88-90. 4. Fenlon MR, Sheriff M. Investigation of new complete denture quality and patients satisfaction with and use of dentures after two years. J of Dent 2004; 32: 32733. 5. Ozcan M, Kulak W. The effect of a new denture adhesive on bite force until denture dislodgement J Prosthodont 2005; 5: 122-126. 6. Floystrand F, Koppang R, Williams VD, 0rstavik J. A method for testing denture adhesives. J Prosthet Dent 1991; 66:501-504.

7. Wallace DA. Acceptance of Corega denture adhesive powder is announced. J Am Dent Ass 1946; 33: 1593-1594. 8. McKevitt FH. Denture adhesive powders: J Calif Dent Assoc Nevada State Dent Soc 1957; 33: 469-472. 9. Chew CL, Phillips RW, Boone ME, Swartz ML. Denture stabilization with adhesives: A kinesiographic study. Compend Contin Educ Dent 1984; 432-8 10. Grasso JE, Rendell J, Gay T. Effect of denture adhesive on the retention and stability of maxillary dentures. J Prosthet Dent 1994; 72: 399-405. 11. Canadian denture care quality of life research; 2005. 12. Duncan JP, Taylor TD: Simplified complete dentures. Dent Clin North Am 2004; 48:625640. Coates AJ. Usage of denture adhesives. J Dent 2000; 28: 13740.
13. Shigli K. Aftercare of the complete denture patient. J Prosthodont. 2009 Dec; 18(8):688-

93. 14. Tarib NA, Bakar MT, Murat DTA, Ahmad M, Kamarudin KH. Masticatory Efficacy and Bite Force in Complete Dentures: A Study of Denture Adhesive. Hong Kong Dent J 2010;7:67-73. 15. Kulak Y, Ozcan M, Arikan A. Subjective assessment by patients of the efficiency of two denture adhesive pastes. J Prosthodont 2005;14:248-52. 16. Tarbet WJ, Silverman G, Schmidt NF. Maximum incisal biting force in denture wearers as influenced by adequacy denture bearing tissues and the use of an adhesive. J Dent Res 1981; 60(2): 115-119

17. Sheiham A, Steele JG, Marcenes W, Finch S, Walls AW. The impact of oral health on stated ability to eat certain foods; findings from the National Diet and Nutrition Survey of Older People in Great Britain. Gerodontology 1999; 16: 11-20.
18. Hung HC, Colditz G, Joshipura KJ (2005). The association between tooth loss and the

self-reported intake of selected CVD-related nutrients and foods among US women. Community Dent Oral Epidemiol 33:167-173. Rusen J, Krondl M, Csima A (1993). Perceived chewing satisfaction and food use of older adults. J Can Diet Assoc 54:88-92.
19. Bradbury J, Thomason JM, Jepson NJ, Walls AW, Mulvaney CE, Allen PF, Moynihan

PJ. Perceived chewing ability and intake of fruit and vegetables. J Dent Res. 2008 Aug; 87(8):720-5.

LEGENDS AND FIGURES Table 1: Classification of maxillary and mandibular complete dentures based of MKIS Table 2: Denture Bearing Tissues Score (DBTS) for ridge shape, tissue resiliency and location of border tissue attachment, for maxillary and mandibular arches Table 3: Classification of denture bearing tissue score (DBTS) Figure 1: Retrieved peanuts particles under (a) the upper denture base and (b) the lower denture base. Figure 2: Number of subjects according to the age and gender Figure 3: The classification of complete dentures according to Modified Kapur Index Scale (MKIS) Figure 4: The classification of patients denture bearing tissue according to Denture Bearing Tissues Score (DBTS)

Figure 5: Weight in milligram (mg) of retrieved peanut particles accumulated under dentures with adhesive (N=29). Figure 6: Weight in mg of retrieved peanut particles accumulated under dentures without adhesive (N=29). Table 5: The mean weight in milligram (mg) of retrieved peanut particles