| Abstract|| |
Objectives: The aim of this article is to review the factors that attract Candida albicans to denture base resin (DBR) and to verify the influence of different surface treatments, chemical modification, or structural reinforcements on the properties of DBR. Materials and Methods: Searches were carried out in PubMed, Scopus, WOS, Google Scholar, EMBASE, and J-stage databases. The search included articles between 1999 and 2020. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The keywords used during the search were “Candida albicans,” “Denture base,” “PMMA,” “Acrylic resin,” “Surface properties,” “hydrophobicity/hydrophilicity,” “contact angle,” and “surface free energy.” English full-text articles involving in-vitro studies with different acrylic resin modifications were included, whereas abstracts, dissertations, reviews, and articles in languages other than English were excluded. A meta-analysis was performed where appropriate. Results: Out of the 287 articles, 21 articles conformed to inclusion criteria. Sixteen articles were subjected to meta-analysis using random-effects model at 95% confidence interval. Results showed that DBR coatings/plasma coatings were effective methods to modify surface properties with estimated contact angle (CA) of 59.37° [95% confidence interval (CI): 53.69, 65.04]/55.87° (95% CI: 50.68, 61.06) and surface roughness (Ra) of 0.55 µm (95% CI: 0.52, 0.58)/0.549 µm (95% CI: 0.5, 0.59), respectively. Antifungal particle incorporation into poly(methylmethacrylate) DBR also produced similar effects with an estimated Ra of 0.16 µm (95% CI: 0.134, 0.187). Conclusion: The three properties responsible for C. albicans adhesion to DBR were Ra, CA, and surface free energy in terms of hydrophobicity. Therefore, the correlations between the hydrophobicity of DBR and C. albicans adhesion should be considered during future investigations for Candida-related denture stomatitis.
Keywords: Candidiasis, PMMA denture base, surface properties
|How to cite this article:|
Gad MM, Abualsaud R, Khan SQ. Hydrophobicity of denture base resins: A systematic review and meta-analysis. J Int Soc Prevent Communit Dent 2022;12:139-59
|How to cite this URL:|
Gad MM, Abualsaud R, Khan SQ. Hydrophobicity of denture base resins: A systematic review and meta-analysis. J Int Soc Prevent Communit Dent [serial online] 2022 [cited 2022 May 19];12:139-59. Available from: https://www.jispcd.org/text.asp?2022/12/2/139/342719
| Introduction|| |
Candida-associated denture stomatitis (DS) infection depends mainly on the denture base (DB) properties and the ability of Candida albicans (C. albicans) (the most common pathogen in DS) to adhere to the denture surface., Reports have confirmed that Candida adhesion to acrylic is associated with hydrophobic interactions between the two., Because C. albicans are hydrophobic, they can easily adhere to the hydrophobic poly(methylmethacrylate) (PMMA) DB. Therefore, hindering this interaction may help prevent various infections including DS. Achieving this would be of extreme benefit for elderly patients with dentures and their caretakers. The most relevant factors of a DB that influence microbial attachment are surface roughness (Ra), hydrophobicity/hydrophilicity, and surface free energy (SFE), in addition to salivary pellicles and the presence of other microorganisms.,
Higher microbial adhesion is linked to Ra and hydrophobicity of the DB material, in which roughness is capable of providing more surface area and protective hideout spot for microorganisms away from denture cleaning forces. To limit the microbial colonization, Ra of DB should not exceed 0.2 μm.,
The chemical composition of PMMA which includes carboxylate, methyl ester groups, as well as other additives, cross-linking agents, fillers, and colorants affects the hydrophobicity and SFE of the DB. Studies have reported that SFE and wettability of different denture base resins (DBRs) are related to variations in these additives. In recent years, several nanoparticles such as ZrO2, SiO2, TiO2, and diamond nanoparticles have been incorporated within the PMMA in an attempt to enhance the physio-mechanical properties of the material. These fillers were also found to increase the resistance of the material to microbial adhesion.,
Researchers have used surface coating, chemical modifications, or synthesized and incorporated fillers with antimicrobial properties within PMMA to solve the issue of Candida adhesion. However, reviews of the effect of these treatment modifications on PMMA properties with correlation to hydrophobicity are not yet available. The aims of this study were to (1) systematically review literature pertaining to the modifications of DBR and (2) to correlate the variables to Candida adhesion/biofilm formation. The null hypothesis of this study was that alteration of the DBR in the form of filler addition, chemical composition modification, or surface coating will not affect the hydrophobicity of the resin surface and therefore will not affect Candida adhesion.
| Materials and Methods|| |
This systematic review was completed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). Focus question was generated through the PICO(S) approach and research strategy [Table 1] to systematically review the available literature. Two PICO questions were formulated as follows: first, do the modifications of DB alter the hydrophobicity and Candida adhesion thereafter? Secondly, what factors will influence the hydrophobicity of modified DBR? An electronic search of English-language dental literature on PubMed, Scopus, WOS, Google Scholar, EMBASE, and J-stage databases was conducted for articles published between January 1999 and March 2020 [Figure 1]. To identify all relevant articles, a list of keywords was used for the search. These included “Denture base,” “PMMA,” “Surface properties,” “hydrophobicity/hydrophilicity,” “contact angle,” “surface energy,” and “C. albicans.” The inclusion criteria included full-text articles in the English language, with in-vitro design, investigating heat-polymerized DBR, C. albicans adhesion, contact angle (CA), surface wettability, Ra, and/or SFE with different DB modifications (antimicrobial additives, surface coating, chemical composition modification). In contrast, papers in languages other than English, in-vivo clinical study, case reports, abstracts, short communication, letters to the editors, reviews, and dissertations and materials other than heat-polymerized acrylic resin or resin not used for DBs were excluded.
Two investigators (MMAG and RA) reviewed the articles independently according to the same parameters. Studies that (1) measured the effect of incorporated antifungal agents, surface coating, or chemical composition modifications of heat-polymerized PMMA, (2) evaluated the C. albicans adhesion and one of the following properties: CA, SFE, Ra, or hydrophobicity/hydrophilicity, (3) reported sample size, mean, and standard deviation values, and (4) included brand names and specifications of tested materials were included in this review. DB modifications were categorized as follows: control (unmodified PMMA), antifungal additive, surface coatings, and chemical composition modifications.
Data management, screening, and selection
Two independent investigators (MMG and RA) used a standardized Excel sheet to extract the data of the studies. The search was conducted in three steps. First, the titles were reviewed according to the inclusion/exclusion criteria. Secondly, the abstracts of the selected titles were screened to select those of interest for full-text analysis. At the third step, all full-text articles were analyzed. At all stages, any discrepancies between investigators were resolved by discussion. The extracted data included: the authors’ names, year of publication, materials of the study, processing method, Candida species, tests employed, presence of control group, number and dimensions of specimens, type of resin modification, results, statistical analysis and significance, and conclusions. Studies with similar methodology were selected to undergo meta-analysis. Among the scopes of this systematic review is to conduct a meta-analysis taking into consideration the diverse designs (resin modifications) of the studies and the various properties tested and to assess their effect qualitatively (surface properties) and quantitatively (number of Candida colony-forming units) [Table 2] and [Table 3].
Assessment of risk of bias
A modification of the method used in previous systematic reviews was used by two authors (MMAG and RA) to independently assess the quality and risk of bias of each study.,, The characteristics were tabulated (n=21) and the parameters were reported as “+ve” if the parameter was described in the text or “−ve” if the information was missing or unclear. The parameters assessed were: sample size calculation, the use of a control group, stating the treatment method, statistical analysis performed, reliable analytical methods, blinding of the evaluators, and correlation of the reported properties with hydrophobicity. The risk of bias was classified according to the sum of “+ve” marks obtained as follows: 1 to 3= high-, 4 to 5= medium-, 6 to 7= low-risk of bias.
Meta-analysis was performed for each treatment modality separately. Moreover, due to the variability of outcomes and methodology per treatment method, quantitative meta-analysis was done for 16 studies, whereas the rest of the studies were descriptively analyzed.
Comprehensive meta-analysis (version 3, NJ, USA) was used for analysis. Visual inspection of forest plots and χ2 tests were used to evaluate the presence of heterogeneity. Random-effects model was used when the data were found to be heterogenic, whereas the fixed-effects model was used otherwise. Egger’s and Begg’s tests were used to check for the possibility of publication bias. P-values less than 0.05 were considered statistically significant.
| Results|| |
Twenty-one studies met the inclusion criteria [Figure 1] and submitted for data extraction and result analysis. [Tables 2] and  summarize the studies’ details, methods, results, and outcomes.
Risk of bias
[Figure 2] presents the risk of bias for the included studies. Out of the 21 studies, 19 showed medium risk of bias and two showed low risk of bias. The risk of bias was mainly linked to the absence of sample size calculation and non-blinding of investigators.
Applying the inclusion criteria, out of the 21 included articles,,,,,,,,,,,,,,,,,,,,, 16 used surface coating, 4 added antimicrobial fillers, and 1 modified the chemical composition of PMMA (refer to [Tables 2] and  for details). In addition to that, several included studies compared between smooth and rough surfaces of the modified specimens., Results revealed that hydrophobicity of DBRs was affected by surface coating, antimicrobial additives, or chemical composition modifications. Therefore, the results of this study were categorized based on the effects of these modifications on the hydrophobicity of DBR and its correlations with CA, Ra, and C. albicans adhesion.
In coating vs. CA (Supplementary Appendix 1)[Additional file 6], after exclusion of outliers, 74 groups underwent meta-analysis. Due to the considerable heterogeneity found (I2 >75%, P<0.001), random-effects model was used and the average CA after coating was found to be 59.37° [95% confidence interval (CI): 53.7–65.0]. The trim and fill method suggested inclusion of 33 more groups to remove publication bias after getting significant results of Begg’s and Eggers’ tests (P=0.002 and P=0.001, respectively).
In the plasma coating vs. CA (Supplementary Appendix 2)[Additional file 2] and coating vs. Ra (Supplementary Appendix 3)[Additional file 3], a total of 38 and 91 observations were, respectively, included in the analysis. Due to significant heterogeneity (I2 >70%, P<0.001) in both the groups, random-effects model was used. The average CA and Ra were found to be 55.87° (95% CI: 50.68–61.06) and 0.552 µm (95% CI: 0.524–0.58), respectively. In plasma coating vs. CA, Begg’s and Eggers’ tests provided insignificant results; hence, the trim and fill method was not used. However, in coating vs. Ra, the trim and fill method provided insertions of 32 more observations to avoid publication bias.
In plasma coating vs. Ra (Supplementary Appendix 4)[Additional file 4] and filler vs. Ra (Supplementary Appendix 5)[Additional file 5], 27 and 13 observations were included in the analysis. Both data sets reflected the presence of heterogeneity (I2 >70%, P<0.001) and hence the random-effects model was used for both. The estimated average Ra for plasma coating and filler addition were 0.549 µm (95% CI: 0.504–0.593) and 0.161 µm (95% CI: 0.134–0.187), respectively. Significant P-values for Eggers’ and Begg’s tests proved the presence of publication bias for both data sets. Hence, the trim and fill method suggested to insert 12 and 7 observations, respectively, to remove the publication bias.
Concerning these factors and their direct and indirect relations to C. albicans adhesion, almost all treatment modalities decreased C. albicans adhesion to modified DB in comparison to unmodified DB.
| Discussion|| |
The results of this review revealed that the different treatment modalities (filler incorporation, surface coating, and chemical composition modification) affected the Ra, CA, and hydrophobicity of the DBR resulting in Candida adhesion modification, and therefore, the null hypothesis was rejected.
Why coating? and what is the outcome?
In recent years, the DB surface has been modified with various coatings in an attempt to increase its hydrophilicity and to reduce C. albicans adhesion., These coatings can be in the form of plasma-based treatment, photopolymerized coatings, and hydrophilic polymer coatings, among others. In plasma-based treatment, partial ionization of the gas is brought up by electrical discharge which creates an environment that contains reactive species such as electrons, ions, and free radicals. Plasma treatment helps clean debris, generates reactive groups on the surface, and makes the surface more attractive to specific cells depending on the treatment atmosphere. The newly formed surface has higher SFE, improved wettability, and diminished CA, which reduces the adherence of C. albicans.,,,
Plasma treatment of PMMA in the presence of O2 gas improved the wettability of the surface even in the presence of salivary pellicle. Similarly, plasma coating in argon, argon-oxygen, and atmospheric air resulted in lower CAs. Conversely, TMS coating increased the hydrophobicity, lowered the wettability of the DB surface, and significantly reduced C. albicans adhesion. Silane-SiO2 nanocomposite films were found to improve the surface, augment the physical properties of PMMA, and increase surface hydrophobicity which decreases C. albicans adhesion.
Coating with TiO2 created smoother surfaces that are more resistant to wear and less porous, which prevent microorganisms from diffusing into the acrylic resin and colonizing on the surface. UV irradiation of TiO2 activates oxidative species that produce irreversible damage to the cells. Additionally, TiO2 coating creates a super-hydrophilic surface with “water sheathing” effect. The ability of TiO2 to improve surface wettability is essential to reduce or inhibit Candida attachment on DBR.
Surface modification with photopolymerized coating of poly(acrylic acid) (PAA) or poly(itaconic acid) (PIA) followed by UV irradiation has been achieved. The coatings decreased the CA and increased the SFE, which may have resulted from changes in the surface polar groups after coating and the acidic environment in the presence of (-OH) groups. In a similar manner, surface modification by polymerization of 2-methacryloyloxyethyl phosphorylcholine (MPC) polymer provided a statistical decrease in CA and C. albicans adhesion.
Other hydrophilic coatings like 3-hydroxypropyl methacrylate (HPMA) and polymers containing sulfobetaine methacrylate (SBMA) were found to enhance the wettability of the DB surface and to reduce C. albicans adhesion as a result of limited hydrophobic interactions.,, The CA and C. albicans adhesion were significantly reduced after coating the DBR with nanocoat or Optiglaze. This effect was brought up by changes in the carbon and oxygen content and different types of interactions. Conversely, cyanoacrylate coating increased the C. albicans adhesion with no effect on CA.
The main advantage of coating is that it allows surface alteration at a relatively low cost and preserves the properties of the original material., The low viscosity can produce thin films (~50 nm and <5 µm) on the surface that do not interfere with the fit of the denture., Coating PMMA with ceramic materials improves its resistance to abrasion and protects the surface from attacks of different solutions. Cold plasma treatment is performed at room temperature avoiding possible damage or warpage of acrylic resin with thermal treatments. As most of the aforementioned coatings produce hydrophilic surfaces and improve the wettability of the PMMA, their application on the fitting surface of a denture could enhance the retention of the DBs by increasing affinity to saliva/liquid molecules that would create a denture seal. In contrast, some of the coating materials require a certain preservation temperature and consumption within a short duration after preparation. Also, the durability of different coatings needs further investigation.
Roughness (Ra), hydrophobicity, resin surface chemistry, and candida adhesion
High Ra may enhance microbial retention because a rougher surface provides more area for microbial adhesion and promotes fungal adhesion and colonization.,,[37-39] Hahnel et al. did not find a linear relationship between Ra and C. albicans adhesion. However, many other studies reported that greater C. albicans adhesion is associated with higher Ra.,, Studies indicated that Ra was not altered following plasma treatment or film deposition process. Thus, these opposing results suggest that the reduced C. albicans biofilm was due to the chemical modification of the PMMA surface represented by increased hydrophilicity and SFE that was promoted by film coating. Hirasawa et al. reported that roughness of different coated specimens was not the main determining factor in Candida reduction, rather it was surface hydrophilicity that played the major role.
Incorporation of antifungal agents within DBR affected C. albicans adhesion and the development of DS. The antimicrobial efficiency of the added AgNPs is associated with ingress of water molecules into the material and the outward movement of the silver ions to the aqueous solution. Others suggested that the inhibitory effect was due to the greater antimicrobial effect of the smaller particles which provides more surface area in direct contact with the nanoparticles. PMMA containing FAp-TiO2 exhibited strong photocatalytic activity following irradiation through the production of reactive oxygen species such as (-OH) and (H2O2) which inhibit C. albicans attachment. This filler has clinical advantages especially for elderly patients through maintenance of proper denture hygiene.
The addition of nano-diamonds showed an improvement of the specimen surface, which may contribute to the significant reduction in C. albicans adhesion. Regardless of the increase in Ra at a high concentration, a reduction in Candida adhesion was detected. Moreover; the inclusion of nano-diamonds within PMMA did not alter the CAs of the modified specimens in comparison to the unmodified specimen. However, the mechanism of antifungal activity of ND was not described clearly and requires further investigations.
Chemical composition modification
The addition of phosphate into DBR by monomer substitution was reported to improve the surface hydrophilicity., The quantity of adherent C. albicans was associated with the wettability properties of the DB, emphasizing the role of acrylic resin chemistry on the initial attachment of C. albicans.
The literature reported that hydrophobicity and Ra of DBs influence the attachment and colonization of C. albicans. Therefore, to reduce Candida adhesion, the surface of the DB must be smooth, hydrophilic, and has no porosities. Improving the hydrophilicity of the DB allows contact with more liquid molecules which helps in forming the seal that keeps the denture tight to air leakage. Additionally, it has been reported that hydrophilic surfaces have fewer adherent C. albicans. Therefore, increasing the surface hydrophilicity would hinder Candida attachment.
Additionally, the intaglio surface provides the best environment for C. albicans adhesion, as it cannot be finished or polished to preserve its accuracy and fit. Therefore, surface coatings can be of great use in such situations in which the coating films are extremely thin and less likely to induce any misfit between the DB and oral tissues, affect the occlusion, or affect the texture of the resin.,, The different coating modalities mentioned earlier can reduce C. albicans adhesion and biofilm formation.
The limitations of this review could be attributed to a wide range of different treatments in each section, such as different coating materials, fillers, and minimal studies on chemical modification, which made the comparison more difficult as a result of the wide range of properties of each material and its effect on the studied properties.
| Conclusion|| |
Based on this review, it could be concluded that the hydrophobicity of DBRs and C. albicans adhesion were affected by the interrelated following factors: wettability (CA), SFE, and surface structure of DBR. Incorporation of antifungal agents or surface coating of DBR affected its hydrophobicity. Future studies evaluating the long-term biocompatibility and antifungal efficacy of different modifications are required to correlate between factors affecting the hydrophobicity and C. albicans adhesion.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Ethical policy and institutional review board statement
Patient declaration of consent
Data availability statement
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3]