ORIGINAL RESEARCH


https://doi.org/10.5005/jp-journals-10015-2355
World Journal of Dentistry
Volume 15 | Issue 1 | Year 2024

A Comparative Evaluation of Anti-candidal Efficacy of Commercially Available Neem Tablets and Denture Cleansers on Complete Dentures: An In Vivo Study


Chhavi Sharma1https://orcid.org/0009-0007-0971-0550, Atibha Makhija2, Bhupender Yadav3, Ashima Singh4, Abhishek Nagpal5https://orcid.org/0000-0002-6801-0171, Omkar Shetty6

1,3,5,6Department of Prosthodontics, SGT Dental College, Hospital & Research Institute, SGT University, Gurugram, Haryana, India

2SGT Dental College, Hospital & Research Institute, SGT University, Gurugram, Haryana, India

4Department of Microbiology, SGT Dental College, Hospital & Research Institute, SGT University, Gurugram, Haryana, India

Corresponding Author: Chhavi Sharma, Department of Prosthodontics, SGT Dental College, Hospital & Research Institute, SGT University, Gurugram, Haryana, India, Phone: +91 8700566950, e-mail: Chhavi161@gmail.com

Received: 01 December 2023; Accepted: 02 January 2024; Published on: 20 February 2024

ABSTRACT

Aim: To evaluate the efficacy of commercially available neem tablets and denture cleaners on the Candida albicans (C. albicans) biofilm present over the intaglio surface of complete dentures.

Materials and methods: A total of 40 complete denture patients were selected, based on the cleansing criteria they were split into four groups (n = 10) for evaluation of efficacy of four denture cleansing methods. Group I (purified water) was taken as control group, group II had Clinsodent denture cleanser (8 hours/overnight), group III neem tablets (8 hours/overnight), and group IV Densive denture cleanser (15 minutes immersion time). Before and after the immersion procedure, samples were collected and cultured on Sabouraud dextrose agar media. The total candidal count [colony-forming unit (CFU)/4 cm2] was then determined. The data was analyzed using analysis of variance (ANOVA), Bonferroni test and paired t-tests.

Results: The results showed significant decrease in colony count in group II, that is, the Clinsodent group followed by group III (neem tablets), group IV (Densive denture cleanser), respectively. Mean change of CFU was highest in group II, that is, 138000, whereas lowest in group IV, that is, 65000. The p-value < 0.05, for groups II, III, and IV shows significant decrease in candidal count. Whereas, group I, the control group, is showing nonsignificant results.

Conclusion: In comparison to other denture-cleansing agents, Clinsodent was shown to have the highest anti-candidal efficacy. The results showed significant reduction in following order (Clinsodent>neem tablets>Densive>purified water) but none of them was able to completely eradicate the biofilm. Hence, for the total eradication of biofilm, a mix of chemical and mechanical cleaning should be employed.

Clinical significance: Poor oral hygiene in edentulous mouth contributes to halitosis, increase denture plaque aggregation and denture stomatitis. Hence, effective method of denture cleansing should be known and employed for regression of plaque adhesion.

How to cite this article: Sharma C, Makhija A, Yadav B, et al. A Comparative Evaluation of Anti-candidal Efficacy of Commercially Available Neem Tablets and Denture Cleansers on Complete Dentures: An In Vivo Study. World J Dent 2024;15(1):13–18.

Source of support: Nil

Conflict of interest: None

Keywords: Biofilm, Candida albicans, Commercially available denture cleansers, Denture stomatitis

INTRODUCTION

With hundreds of species of microorganisms in our body, the oral cavity harbors the second-largest and most diverse microbiota after the gut. Microbes inhabit the soft tissues of the oral mucosa, which is an extraordinarily complex ecosystem due to its numerous niches.1 This diversified flora is also observed in complete denture wearers, which includes fungi, bacteria, viruses, etc. We as dentists rarely evaluate and document a patient’s denture hygiene status, leading to the majority of patients having poor denture hygiene. This is mainly due to a lack of awareness about the denture cleaning methods and their consequences, which can mainly lead to problems like denture stomatitis as a sequela to denture wearing.

Candida, a yeast-like fungi that is usually present in small amounts in our mouth causing no ill effects to the host’s body. However, when there is any imbalance, there is an increased overgrowth of Candida, which can lead to fungal infections like denture stomatitis. Denture stomatitis refers to inflammation and pathological changes in the oral mucosa associated with wearing dentures.2 Though there are many factors predisposing to the development of denture stomatitis like ill-fitting dentures, poor dental hygiene, patient’s age, diabetes mellitus, dry mouth (xerostomia), etc.3 The most common factor leading to denture stomatitis is poor dental hygiene.

When dentures are worn in the mouth, a biofilm that resembles dental plaque may form. As dental calculus, it may harden and mineralize. This biofilm is hazardous and is to be removed. Oral hygiene with denture can be maintained by using disinfectants, denture cleaners, and microwave irradiation along with mechanical removal of bacterial plaque from the denture surfaces and from the underlying mucosa.3,4 The main purpose of plaque control is to prevent denture-related stomatitis by limiting the growth of bacteria, particularly Candida albicans (C. albicans), on the dentures.

When dentures are removed from the mouth, they should be cleaned using a denture cleaner, also known as a denture cleanser for maintaining hygiene. Additionally, denture cleaners are used to remove stains and other particles that may have developed due to dietary habits, tobacco usage, coffee or tea use, etc.5 An ideal denture cleanser should be nontoxic to the internal structure of dentures, fungicidal, antibacterial, and biocompatible. It should be simple to use and capable of removing deposits.

A variety of denture cleansers are available in the market, and the majority of them include a group of alkaline peroxide. Oxidizing agent—alkaline perborate, sodium perborate, or potassium monopersulfate are the bleaching/oxidizing agents, Reducing solution—sodium hypochlorite, chelating agent—ethylenediaminetetraacetic acid (EDTA), effervescing agents—perborate, carbonate, or citric acid, additional compounds—such as dye markers that provide a color change when the cleansing process has been completed, flavors, and fragrances.6 Polident antibacterial denture cleanser tablets contain sodium bicarbonate, citric acid, sodium carbonate, sodium lauryl sulfoacetate as the active ingredients.

The denture cleansing agents utilized in this study are Clinsodent, which has potassium persulfate as an active agent which yields active oxygen on admixture with water, trisodium phosphate as alkalinity imparter, EDTA as a sequestering agent, tetra potassium pyrophosphate as a plaque remover. Densive, another denture cleansing agent used contains sodium perborate monohydrate as the cleansing agent.

Although a combination of mechanical and chemical methods is advisable for the effective removal of biofilm and maintenance of denture hygiene.7 Comparing the anti-candidal effectiveness of purified water, Densive tablets, Clinsodent, and neem tablets on complete dentures was the goal of the current study. There is limited data available which compares the effectiveness of commercial denture cleansers with herbal alternatives. Hence, neem, which has excellent antibacterial action and is commonly used by the Indian population for maintaining dental hygiene, is also taken as a study group for evaluating its anti-candidal efficacy.

MATERIALS AND METHODS

A 3-month-long study from January to March 2023 was conducted in the Department of Prosthodontics, SGT Dental College, Hospital & Research Institute, SGT University, Gurugram, Haryana, India. Institutional approval was obtained for the study, and 40 complete denture wearers were selected randomly from the outpatient Department of Prosthodontics, SGT Dental College, Hospital & Research Institute, SGT University, Gurugram, Haryana, India. Patients were explained about the study in their mother tongue, and their consent was obtained.

Inclusion Criteria

Healthy individuals with no systemic disease, and are using complete denture for >6 months. Also, those who had not cleaned their denture 24 hours prior to the intervention.

Exclusion Criteria

Patients with underlying systemic conditions and those who are wearing denture for <6 months are excluded from the study.

The swabs were collected from the intaglio surface of the upper denture (4 × 2 cm) palatal area before immersing the dentures into different groups of denture cleansers. Based on the different techniques used to clean the dentures, they were split into four groups of 10 patients each. Group I was taken as the control group, in which purified water was used (immersion time: overnight). Group II was Clinsodent denture cleaning powder (immersion time—overnight), group III was neem tablets (Neem Ghanvati-Patanjali) (immersion time—overnight), and group IV was Densive denture cleanser (immersion time—15 minutes). After immersion, swabs were again collected from the denture’s surface.

The pretreatment and posttreatment swabs were placed back into collection tubes and transported to the lab. Using a 4 mm loop, the sample was spread in the Sabouraud dextrose agar medium on the petri dish and incubated at 37°C for 48 hours. The colonies were then counted with a digital colony counter. A total of 10 samples from each group were then collected and incubated in accordance with the manufacturer’s specified immersion period, that is, for groups I, II, and III (immersion time—8 hours), for group IV (immersion time—15 minutes). A digital colony counter was used to count the colonies. The data was recorded and statistically analyzed using analysis of variance (ANOVA), Bonferroni test, and paired t-tests. The collected data was analyzed using Statistical Packages for the Social Sciences (SPSS) software (IBM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 23.0. Armonk, New York, United States of America; IBM Corp.).

RESULTS

The mean values obtained from group I are 319000 colony-forming units (CFUs) and 300000 CFU pre- and postimmersion, respectively, group II—395000 and 257000 CFU, group III—291000, 192000 CFU, and group IV—393000 and 328000 CFU pre- and postimmersion, respectively.

The intragroup comparison was done with pre- and postimmersion count (Fig. 1). The intragroup comparison among various groups pre and posttreatment showed a significant change by reducing the candidal growth in (groups II, III, and IV), the control group, that is, the purified water (group I) showed statistically nonsignificant decrease in the candidal count.

Fig. 1: Comparison of pre- and post-Candida count of four groups

Intergroup comparison showed the maximum decrease in colony count in group II, that is, (Clinsodent>neem tablets>Densive>purified water) (Table 1). The reduction in the candidal count can be seen in the photographs (Figs 2345).

Table 1: Intergroup comparison of CFU among various studied groups at pre- and postoperative level
Group Mean Standard deviation Standard error mean F-value p-value
Pre I 319000 94044.907 29739.611 2.223 0.10**
II 395000 146685.605 46386.061
III 291000 106609.360 33712.840
IV 393000 129275.760 40880.585
Post I 300000 233449.971 73823.363 2.025 0.12**
II 257000 101220.332 32008.679
III 192000 69729.637 22050.447
IV 328000 95428.857 30177.254

**, statistically nonsignificant

Figs 2A and B: Colonies of C. albicans in group I (purified water). (A) Pretreatment; (B) Posttreatment

Figs 3A and B: Colonies of C. albicans in group II (Clinsodent). (A) Pretreatment; (B) Posttreatment

Figs 4A and B: Colonies of C. albicans in group III (neem tablets). (A) Pretreatment; (B) Posttreatment

Figs 5A and B: Colonies of C. albicans in group IV (Densive). (A) Pretreatment; (B) Posttreatment

To evaluate the anti-candidal efficacy of four treatments, Intergroup—ANOVA, multiple group—Bonferroni, and intragroup—paired t-test were used. Intragroup comparison of CFU among group I (Table 2) showed p-value > 0.05 describing nonsignificant level of candidal colony eradication with purified water after immersion for 8 hours. The intragroup comparison among different groups pre and posttreatment showed significant change by reducing the candidal growth, p-value < 0.05 (Tables 3 to 5); hence, these methods of denture cleansing can be considered effective when compared to the traditional way of soaking denture overnight in purified water. While immersion in purified water, which is the most common method for cleansing is not as effective as other methods.

Table 2: Intragroup comparison of CFU among group I at pre- and postoperative level
Mean Standard deviation Standard error mean Mean difference T-value p-value
Pre 319000 94044.907 29739.611 19000 −0.206 0.84**
Post 300000 233449.971 73823.363

**, statistically nonsignificant

Table 3: Intragroup comparison of CFU among group II at pre and postoperative level
Mean Standard deviation Standard error mean Mean difference T-value p-value
Pre 395000 146685.605 46386.061 138000 4.213 0.002*
Post 257000 101220.332 32008.679

*, statistically significant

Table 4: Intragroup comparison of CFU among group III at pre- and postoperative level
Mean Standard deviation Standard error mean Mean difference T-value p-value
Pre 291000 106609.360 33712.840 99000 4.031 0.003*
Post 192000 69729.637 22050.447

*, statistically significant

Table 5: Intragroup comparison of CFU among group IV at pre- and postoperative level
Mean Standard deviation Standard error mean Mean difference T-value p-value
Pre 393000 129275.760 40880.585 65000 3.352 0.009*
Post 328000 95428.857 30177.254

*, statistically significant

DISCUSSION

Candida is the most common fungal organism found in the oral cavity belonging to the genus of “yeast.” The accumulation of yeast cells occurs on the intaglio surface of the denture when the denture is not cleaned thoroughly or not removed while sleeping, which causes a decrease in blood flow in the denture bearing area and creates an anerobic environment that favors candidal growth.8 Care and maintenance of the prosthesis are utmost important including maintenance of hygiene. Mainly C. albicans has the predominance to attach to the irregular surface of the denture.9 In this study, purified water was taken as the control group, which showed insignificant reduction in the candidal count after 8 hours of immersion.

Denture cleansers are marketed worldwide for denture cleaning acts by chemical or abrasive action. The majority of denture cleansers have alkaline peroxides which is in the form of powders or tablets, when it is dissolved in water become an alkaline solution of hydrogen peroxide.10,11 These denture cleansers have sodium perborate or sodium per carbonate as a detergent; liberation of oxygen bubbles on dissolution exerts mechanical cleaning effect on the biofilm. One of the denture cleanser’s used in this study is Clinsodent has potassium persulfate as an active agent which yields active oxygen on admixture with water, trisodium phosphate as alkalinity imparter, EDTA as a sequestering agent, tetra potassium pyrophosphate as a plaque remover. As per the manufacturer’s instructions a spoonful amount of Clinsodent was mixed in water and denture was soaked for 8 hours in the group II. Group II showed the maximum reduction in colony count (Fig. 6) and provided significant results.

Fig. 6: Intergroup comparison of mean change of CFU among various study groups

Neem (Azadirachta indica) has numerous known therapeutic values along with antibacterial action. It is known to be effective against various periodontal microbes causing gingivitis, dental caries as well as periodontitis.12 Various studies revealed that leaf extracts from neem affects the hydrophobicity, cell adhesion and colonization by C. albicans. Thus, neem has a potent antiadhesive effect. In group III, two neem tablets were mixed with water and denture was soaked overnight. This group showed significant reduction in CFU removal and proved to be the second most effective method amongst different cleansers.

Ojah et al. evaluated the anti-candidal efficacy of triphala, aloe vera, neem, and denture cleanser on heat-polymerized acrylic resin. The pre to postreduction in mean Candida count was found highest in denture cleanser followed by neem, triphala, and aloe vera. Further, both denture cleaner and neem showed statistically significant reduction. The anti-candidal efficacy of denture cleanser was found to be the highest. The cost-effective Neem can be used as anti-candidal modality in place of denture cleanser.3 Densive, an alkaline peroxide cleanser (recently launched), which claims to clean the denture in 15 minutes with a unique color-changing property from green to blue depicting the action of sodium perborate monohydrate on the denture surface. It showed a significant reduction in CFU of C. albicans. Hence, this can be considered as a better alternative to overnight cleansers as it can be used chairside and is least time-consuming.

Shetty et al., conducted a study to compare the anti-candidal efficacy of denture cleansing tablet (sodium bicarbonate and sodium perborate monohydrate), triphala, cashew leaf, aloe vera and water (control) on complete dentures of institutionalized elderly, where Denture cleansing tablet and triphala churna showed a statistically significant reduction in Candida counts (p < 0.05).13 Kumar et al. conducted an in vitro study and found that the denture cleansers are effective in reducing C. albicans cells adhering to dentures. Commercial denture cleansers (Fittydent® and Clinsodent®) were found to be more effective than household denture cleansers (vinegar and diluted vinegar).14 According to Nakamoto et al., chemical denture cleansers can be divided into five groups based on their main components as—alkaline peroxides, alkaline hypochlorites, acids, disinfectants, and enzymes.15 Among these, alkaline peroxides are the most commonly used. Therefore, two alkaline peroxide cleansers—Densive (tablets) and Clinsodent® (powder)—were selected for this study. Along with this neem, which is the traditional Ayurveda medicine, known to have potential effect in controlling oral disease was used in commercially available tablet form and for the control, purified water was used.

Clinsodent removed C. albicans from the intaglio surface better than the other denture cleansers after immersion of the specimens for 8 hours and neem tablets were second and third was Densive in efficiency. Purified water was the least effective amongst the denture cleansers. The p-value < 0.05 states that Clinsodent, Densive denture cleanser and neem tablets are significantly showing a decrease in candidal count. Whereas group I which is the control group is showing nonsignificant results. None of the treatments modalities was able to completely remove Candida cells, which means that only cleansing alone with denture cleansers is not sufficient. Mechanical cleaning is essential along with chemical or natural methods for effective reduction of plaque and maintenance of denture hygiene.15,16 This is the fact that recolonization may occur as some Candida cells remain on the surface, with the use of denture cleansers only.17

The limitation of this study is that it only considered C. albicans removal as the area of interest and no research was done for removal of other microorganisms. Hence, further research is needed to test the efficiency of denture cleansers on other microorganisms present over the surface of denture.

CONCLUSION

The present study showed that there is a statistical reduction in candidal count using denture cleansing agents when compared to the traditional denture cleansing method used in India, that is, immersion in purified water. All the denture cleanser groups showed significant results when compared to the control group. Group II, which is the Clinsodent group, showed the highest reduction in candida count. Group IV showed effectiveness in minimal time; Densive could be considered as effective as other chemical cleansers, which reduce the colony count overnight and can be used as a chairside denture cleanser. Maintenance of the edentulous mouth’s hygiene is equally important as in the dentulous state. Regular cleaning of dentures is essential for maintenance of overall oral health.

ORCID

Chhavi Sharma https://orcid.org/0009-0007-0971-0550

Abhishek Nagpal https://orcid.org/0000-0002-6801-0171

REFERENCES

1. Deo PN, Deshmukh R. Oral microbiome: unveiling the fundamental. J Oral Maxillofac Pathol 2019;23(1):122–128. DOI: 10.4103/jomfp.JOMFP_304_18

2. Singh A, Verma R, Murari A, et al. Oral candidiasis: an overview. J Oral Maxillofac Pathol 2014;(Suppl 1):81–85. DOI: 10.4103/0973-029X.141325

3. Ojah P, Luniyal C, Nair C, et al. Anti candidal efficacy of commercially available triphala, neem, denture cleanser and natural aloevera leaf on heat polymerized acrylic resin. J Indian Prosthodont Soc 2021;21(2):167–172. DOI: 10.4103/jips.jips_599_20

4. Bali RK, Mathur VB, Talwar PP, et al. National Oral Health Survey and Fluoride Mapping” 2002-2003, India. New Delhi: Dental Council of India; 2004.

5. Mylonas P, Milward P, McAndrew R. Denture cleanliness and hygiene: an overview. Br Dent J 2022;233(1):20–26. DOI: 10.1038/s41415-022-4397-1

6. Jain SG, Magdum D, Karagir A, et al. Denture cleansers: a review. J Dent Med Sci 2015;14(2):94–96. DOI: 10.9790/0853-14249496

7. Oral Health Foundation. White Paper on Optimal Care and Maintenance of Full Dentures for Oral and General Health Global Task Force for Care of Full Dentures. 2018.

8. Hong G, Murata H, Li Y, et al. Influence of denture cleansers on the color stability of three types of denture base acrylic resin. J Prosthet Dent 2009;101(3):205–213. DOI: 10.1016/S0022-3913(09)60032-9

9. Pereira T, Del Bel Cury AA, Crielaard W, et al. Development of Candida-associated denture stomatitis: new insights. J Appl Oral Sci 2008;16(2):86–94. DOI: 10.1590/s1678-77572008000200002

10. Ferreira MA, Pereira-Cenci T, Rodrigues de Vasconcelos LM, et al. Efficacy of denture cleansers on denture liners contaminated with Candida species. Clin Oral Investig 2009;13(2):237–242. DOI: 10.1007/s00784-008-0220-x

11. Dhamande MM, Pakhan AJ, Thombare RU, et al. Evaluation of efficacy of commercial denture cleansing agents to reduce the fungal biofilm activity from heat polymerized denture acrylic resin: an in vitro study. Contemp Clin Dent 2012;3(2):168–172. DOI: 10.4103/0976-237X.96820

12. Lakshmi T, Krishnan V, Rajendran R, et al. Azadirachta indica: a herbal panacea in dentistry - an update. Pharmacogn Rev 2015;9(17):41–44. DOI: 10.4103/0973-7847.156337

13. Shetty PJ, Hegde V, Gomes L. Anticandidal efficacy of denture cleansing tablet, triphala, aloe vera, and cashew leaf on complete dentures of institutionalized elderly. J Ayurveda Integr Med 2014;5(1):11–14. DOI: 10.4103/0975-9476.128847

14. Kumar MN, Thippeswamy HM, Raghavendra Swamy KN, et al. Efficacy of commercial and household denture cleansers against Candida albicans adherent to acrylic denture base resin: an in vitro study. Indian J Dent Res 2012;23(1):39–42. DOI: 10.4103/0970-9290.99036

15. Nakamoto K, Tamamoto M, Hamada T. Evaluation of denture cleansers with and without enzyme against Candida albicans. J Prosthet Dent 1991;66:792–795.

16. Duyck J, Vandamme K, Krausch-Hofmann S, et al. Impact of denture cleaning method and overnight storage condition on denture biofilm mass and composition: a cross-over randomized clinical trial. PLoS One 2016;11(1):e0145837. DOI: 10.1371/journal.pone.0145837

17. Vieira APC, Senna PM, Silva WJ, et al. Long-term efficacy of denture cleansers in preventing Candida spp. biofilm recolonization on liner surface. Brazilian Oral Res 2010;24(3):342–348. DOI: 10.1590/s1806-83242010000300014

________________________
© The Author(s). 2024 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.