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PART II
Soft Tissue Lesions
Features Denture stomatitis occurs under either complete or partial dentures and is found more frequently in women. The lesions are usually confined to the palate and seldom if ever involve the mandibular ridge. In approximately 50% of the patients, there is an associated angular cheilitis with or without an inflammatory papillary hyperplasia of the palate. A high correlation has also been established between the occurrence of this condition and wearing dentures at night. The lesions may be totally asymptomatic, or the patient may complain of a soreness and dryness of the mouth. This soreness may also be described as a burning sensation. The palatal tissue is bright red, somewhat edematous, and granular. Only the tissue covered by the denture is involved. The redness usually involves the entire area covered by the denture but may be focal in its distribution (Fig. 5-16 and Plate A, 12). When seen microscopically, the lesion is rather nonspecific. The epithelium is atrophic and may be ulcerated in areas. An intense chronic inflammatory infiltrate is present in the lamina propria and also involves the epithelium. Usually the C. albicans organism is not found in tissue specimens. The most accurate diagnostic test is a smear from the area of the lesion stained with periodic acid-Schiff's reagent. This will show the yeast and hyphal forms of Candida. DifferentiaL diagnosis The clinical picture of denture stomatitis is rather specific; few if any other diseases appear the same. Infections by other organisms, however, could be responsible for a similar diffuse redness either alone or in combination with Candida. Contact allergy to the denture base acrylic happens occasionally. In such cases, redness will not be restricted to tissue under the denture, but all mucosal sUlfaces in contact with the
acrylic will be red. Epicutaneous tests of the material will usually be diagnostic. From time to time. generalized mucositis conditions will affect the tissue under dentures. but the general distribution of these will differentiate from denture stomatitis. Some of these could be secondarily infected with Candida. Management Treatment of candidiasis is discussed on pp. 62-63. Management of denture stomatitis includes correcting denture faults, improving denture and oral hygiene, and antifungal therapy.~9 III-fitting dentures must be adjusted or replaced. The patient must remove the dentures at bedtime and place them in chlorhexidine or nystatin solution at night after proper cleaning. although some clinicians recommend dry storage. One study indicated that a hydrogen peroxide denture cleaner was as effective as using antifungal agents on the denture. 50 (On occasion, fungi will have so thoroughly impregnated the denture that it will have to be discarded and a new denture made.) Antifungal ointments and pastes may be worn with the denture during the day, and oral antifungal rinses or lozenges may be used possibly in combination with a systemic agent. A recent report indicates considerable success utilizing a miconazole lacquer applied to the tissue surface of the denture. 51 ReCUtTences are common. and it is important to ensure that levels of denture plaque are reduced. 52
Angular Cheilitis Angular cheilitis is usually a reddish ulcerative or proliferative condition marked by one or a number of deep fi sures spreading from the corners of the mouth. The lesions are most often bilateral, usually do not bleed. and are usually restricted to the vermilion and skin surface
A
c
B
Fig.5-16. Denture stomatitis. A, Only the palatal tissue contacted by an acrylic transitional partial denture is innamed. Smears containing Calldida were obtained from both the palatal tissue and the denture. B, Patchy redness covers the entire palate in a patient who wore a full denture. An exfoliative cytologic smear was positive for Calldida. C, Same patient after therapy with nystatin for I week.