S. MAJEWSKI1, B.W. LOSTER1, A.B. MACURA2, G. WISNIEWSKA1, Z. SLIWOWSKI3, M. MAZURKIEWICZ-JANIK1, S.J. KONTUREK3

APPLICATION OF A DIAGNOSTIC-THERAPEUTIC PROCEDURE USINGIMPLANT-SUPPORTED DENTAL PROSTHESIS AS A PREVENTIVE

THERAPY FOR CANDIDIASIS OF UPPER GASTROINTESTINALTRACT IN COMPLETE DENTURE USERS

1Institute of Dentistry, 2Department of Mycology and 3Department of Physiology, Jagiellonian University Medical College, Cracow, Poland

Our previous studies demonstrated that the use of acrylic based prosthesis inedentulous patients had a direct impact on the increased incidence of oral mycosisand further episodes of mycosis in the digestive tract. This dependency is associatedwith formation of a space between the surface of the prostheses and adheringmucosal membrane, where a specific micro environment is being formed, which -as stated - creates a superior breeding ground mainly for microorganisms of thegenus Candida.

K e y w o r d s : complete denture, denture stomatitis, edentulous mouth, gastrointestinalendoscopy

INTRODUCTION

In the prosthetic treatment of edentulous and partially edentulous patients,acrylic based prosthesis are most commonly used. Our previous studies (1-3)clearly demonstrated that the use of these types of prosthetic devices had a directimpact on the increased incidence of oral mycosis and further episodes ofmycosis in the digestive tract. In particular, the existence of mutual dependenceCandida infection in the mouth and throat was confirmed (1). In edentulouspatients this dependency is associated with extensive plate prostheses and theconsequential formation of a space between the surface of the prostheses and

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adhering mucosal membrane. Within this space a specific micro environment isbeing formed, which - as stated - creates a superior breeding ground mainly formicroorganisms of the genus Candida (1, 4-9). Therefore, the oral cavity can beconsidered as a potential reservoir for gastrointestinal infection and re-infection.It was found that the factors that foster the growth of microorganisms under slabsof acrylic prostheses are: increased temperature and pH of the environment,material Alba and underlying epithelium, microaerophilic conditions and lack ofself-cleansing saliva, microscopic imperfections or defects in the acrylic plastic,disease and systemic neglect in oral hygiene. These conditions are conducive tochanging the quantitative and qualitative presence of oral microorganisms, ofwhich, a significant increase in the number of yeast-like fungi and theaccompanying use of mechanical prostheses trauma, can be regarded as the mostimportant factor in the etiology of pathological development in the lining of thedenture supporting area, known as "stomatitis prothetica mycothica" (10-14).

These assumptions, and the results of implant-prosthetic treatment (9, 15-18)as a corollary that it is possible to eliminate the plate prostheses, have become thebasis for developing a specific protocol - namely - the elimination of the causesof the infectious states observed in practice. The thesis was to undertake a studyinto the assumptions that the introduction of clinical procedures that result in theelimination or substantial reduction of plate prostheses will improve oral healthand reduce the risk further episodes of fungal infection in the digestive tract.

The goal of this work was a diagnostic and therapeutic procedure usingimplant-supported dental prosthesis as a preventive therapy for candidiasis ofupper gastrointestinal tract in the edentulous patient.

MATERIALS AND METHODS

This study was conducted among twenty edentulous patients (aged 40-70 years) who are usersof complete acrylic dentures and who have been diagnosed with extensive inflammation of themucosa. The study was approved by the appropriate Institutional Review Committe at theJagiellonian University Medical College, Cracow, Poland (No. KBET/103/B/2004) and allsubjects gave written informed consent to participate prior to inclusion. The research methodologyincluded a series of clinical and laboratory mycological tests. Interviews, general clinicalexaminations and local oral examinations were supplemented with endoscopy of the esophagus. In10 cases, laboratory tests included specimens collected from both the mouth and the esophagus.Clinical evaluation included an assessment of the denture supporting area and the state ofprosthetic additions, while symptoms of the gastrointestinal tract were initially ascertained in theinterview process. All patients involved had radiological survey to assess the state of bone anddental alveolar destruction. Swabs collected for mycological testing were taken from the liningbetween the first and second mucosal fold on the palate.

Precautions taken were generally adopted requirements relating to the collection of material toprepare a field study, i.e. volume and number of samples, preparation of the material fortransportation to the microbiology lab and the observation of standard precautions required whileworking with potentially infectious material.

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The assessment criteria, defined as: an increase in mycological quantity, a very ample (watercatchment), or an average mycological quantity with simultaneously occurring dyspepsiadiscomfort, was the basis for carrying out further gastroenterological research. These assessmentswere made during the clinical evaluation and analysis of material collected from the lining of theesophagus. In ten of the twenty patients studied the full application of diagnostic-therapeuticprocedure was performed; in these cases there was reasonable suspicion of the simultaneousoccurrence of a mouth and esophagus candidiasis.

After the completion of antifungal treatment (consultation with a gastroenterologist andmicrobiologist took place), the implant-supported dental prosthesis were performed to eliminate theoriginal acrylic prosthesis recorded as favoring Candida infection. After completing the implant-prosthetic treatment a re-examination by a gastroenterologist and microbiologist was completed.

RESULTS

Diagnostic and therapeutic case study of a 63 year old patient using completedentures for a period of 13 years

The patient reported complaints of the mouth and gastrointestinal tract. Aclinical examination found inflammation of the lining of the palate and floor ofmouth from the upper and lower prostheses. According to the establishedprotocol the study focused on complications of the gastrointestinal tract and adetailed assessment of the prosthetic used coupled with an assessment of thedenture bearing area. The interview revealed information of the conditionpersisting for several years and the periodically recurrence of dyspepticsymptoms. The patient wore prostheses 24 hours a day, did not use dentaladhesive, and oral hygiene and dental prostheses care was not regularlyperformed. The primary reason for the patient's seeking treatment was thedigestive tract symptoms and soft, white elevated raids covering mucosal part of

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Fig. 1. Intraoral view: The white elevated plaques covering mucosal part of the palate distally, aswell as on the periphery of disc prosthesis border

the upper plate prostheses. The intraoral survey found that dental alveolars werepartly vanished, and the mucosa of the denture bearing area showedcharacteristic inflammation covering the range of the CD prostheses. There werealso white locale raids on the mucous membrane of the alveolar and distal partsof the palate, as well as on the periphery of disc prosthesis border - especiallytowards the border of the soft palate (Fig. 1).

A palate swab was taken, in order to carry out the mycological study, whichshowed increased growth of Candida albicans in the oral mucosa of our patient.This was followed by endoscopic examination. With material taken from thelining of the esophagus, where it was found to be widespread, many fungal raidsof Candida albicans were cultured on petri plates (Fig. 2) at the level of growthabundant and very abundant. Lastly, an antibiotic sensitivelty test was performedagainst the fungal material collected from the mouth and esophagus. Essentialantibiotics used to treat fungal infections were investigated, in vivo nystatin,

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Fig. 2. Endoscopic examination-widespread, many fungal plaques on theinflamed lining of the esophagus

Fig. 3. The first stage of implanto-prosthetic treatmentA - radiological survey shows the reconstruction in mandible where 6 implants were placed andcircular bridge was seatedB - intraoral photograph taken after osseointegration of implants in mandible

pimarycin, amphoterycin B, 5-fluorocytozin, klotrimazole, miconazole,ketoconazole, tioconazole, fluconazole and itraconazole.

Prior to further prosthetic proceedings, the denture supporting area withbiological tissue material was reconstructed (using Mollosil), and afterconfirmation of fungal sensitivity, local nystatin in suspension and systematicallyacting fluconazole via syrup were administered for fungal eradication.

Ultimately, the patient was scheduled for elimination of the original acrylicprosthetic in favour of a permanent prosthetic addition, such as implant dentures.

Treatment by the implant-prosthetic was implemented in two stages. In the firststage teeth in the mandible were reconstructed, six implants were set in and acircular implanto-bridge was applied (Fig. 3 AB). In the second stage eight implantsin the maxilla were placed with two implanto-bridges (Fig. 4 AB, Fig. 5AB).

Mycological testing was performed again to verify the presence or absence offungal infection following treatment. Complete eradication of the mycologicalinfection resulted in a reduction in the inflammation of the mucosal lining of themouth, as well as previously reported dyspeptic ailments. In a three-year

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Fig. 4. The second stage of implanto-prosthetic treatment:A - radiological survey taken after placing 8 implants in maxillaB - intraoral photograph taken after osseointegration of implants in maxilla

Fig. 5. Intraoral photograph after the complete treatment:A - implanto-prosthetic reconstruction in mandible and maxillaB - the photograph of the palate after complete treatment. After eliminating the plate prostheses withimplant-supported dental prosthesis the inflammation of the mucous

observation period, we did not identify a relapse of infection in the mouth, whichalso correlated with the resolved symptoms of the gastrointestinal tract.

Similar diagnostic and therapeutic protocol was performed with the remainingnine patients, yielding similar results.

DISCUSSION

Patients using acrylic plate prosthesis exhibit the reservoir of microorganisms,recognized as potentially pathogenic organisms for the digestive tract. Followingmycological testing, fungal infection was discovered with the genus Candidaalbicans, whose main living area in the oral cavity is a space of mutual adherencebetween the prosthetic plate and the mucosal membrane. Based on laboratoryfindings and endoscopic examinations of 10 cases with identified inflammatorystates on the lining of the mouth and throat, the mycosis was diagnosed withsymptoms of chronic mucosal inflammation with or without erosions. This meansthat the state of inflammation of the lining of the mouth against the backgroundof mycotic infection (stomatitis prothetica mycotica) was in these casesconnected with the same candidosis recognized by the esophagus.

In addition, results obtained from clinical trials, as well as mycological andgastroenterological findings have confirmed the merits of the applicationdeveloped by the authors for the diagnostic and therapeutic proceedings in caseswhere the spark changes in the oral cavity of patients using prosthetic pieces arestrongly associated with dyspeptic history and accompanied by symptoms of thegastro-intestinal tract. In particular, it was found that treatment with implant-supported dental prosthesis, while eliminating moving prostheses, was aneffective method for the prevention of fungal infection in the mouth and throat.

Our study has confirmed earlier reports by authors (10-14) that edentulouspatients using total acrylic prosthesis present with a yeast-like accumulation offungi in the oral cavity. The infection is located between the extensive surface of theprosthetic plate and the mucous membrane, were a specific environmental niche isproduced, creating favourable conditions for the growth of these microorganisms.We confirmed the usefulness of mycolological testing of material collected from themouth region for diagnosis of upper GI pathologies. Based on the results obtained,mycological testing should be a standard procedure with acrylic prosthetic plateusers, and where permanent prosthetic implants are planned for.

Therefore, our study on 10 patients showed that treatment by prostheticimplants, can be an effective method of prevention and treatment not only offungal infection in the mouth, but can also further decrease pathological episodesin the digestive tract.

Our conclusions can be summarized as follows:1. Among denture wearers, mycological infection of the mouth is often

associated with the presence of fungi lining the esophagus;

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2. An effective method of prevention and treatment of pathological statescaused by mycological infection of the mouth and upper GI tract may be theelimination of acrylic prosthetic plates in favour of implant-supporteddental prosthesis.

Conflicts of interest statement: None declared.

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R e c e i v e d : July 24, 2008A c c e p t e d : September 30, 2008

Author’s address: Assoc. Prof. Bartlomiej W. Loster, Department of Prosthetic Dentistry,Jagiellonian University Dental Institute, ul. Montelupich 4/247, 30-155 Krakow, Poland; Tel. +48-124245442; fax: +48-124245494; e-mail: bw@loster.pl

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