in india , as a result of the change in the age composition over the decades , there has been a progressive rise in the number and proportion of elderly , aged 60 years and above .
today india is home to one out of every ten senior citizens of the world where 75% reside in rural areas .
inadequate income is a major problem of elderly in india with nearly half of them fully dependent on others for their maintenance . as the size of
the dependent elderly population is fast growing ; there is an emerging need to pay greater attention to aging - related oral health issues . according to the national oral health survey ,
the prevalence of subjects wearing prosthesis in upper and lower dental arches in the age group of 65 - 74 years was 10.2% and 11.1% , respectively , and the most prevalent prosthesis was complete dentures .
candida - associated denture stomatitis is a common inflammatory process affecting around 60 - 65% of denture wearers and is usually found on the palatal mucosa beneath the fitting surface of the upper denture .
it has multifactorial etiology but deficient denture hygiene habit is one of the most prominent contributing factor .
there are many specialized products on the market for denture cleansing , but the dependent elderly population using dentures have decreased access to a continuous supply of such materials .
hence there is a need to introduce a few natural products to clean dentures , which are easily and economically available .
triphala ( phyllanthus emblica , terminalia chebula and terminalia belerica fruits powders in equal proportion ) , aloe vera , and cashew leaves known for their medicinal properties have been traditionally used in india as therapeutic and antimicrobial aids in various ailments and are potent antifungal products effective against candida .
aqueous , ethyl acetic , and ethanolic fractions of terminalia chebula has shown a significant inhibitory effect on candida species .
aloe vera contains six antiseptic agents as lupeol , salicylic acid , urea nitrogen , cinnamonic acid , phenols , and sulfur , and have inhibitory action on fungi , bacteria , and viruses .
there is a need to test the anticandidal efficacy of these easily available products as denture cleansers .
hence the objective of this study was to compare the anticandidal efficacy of denture cleansing tablet , triphala , aloe vera , and cashew leaves on complete dentures of institutionalized elderly .
the study population consisted of 50 institutionalized elderly wearing maxillary complete dentures residing in old age homes of mangalore city .
five groups were given either of the five measures : denture cleansing tablets ( sodium bicarbonate and sodium perborate monohydrate ) , triphala churna , aloe vera , cashew leaves , or water for cleaning their dentures .
selection of the study participants were based on the following inclusion and exclusion criteria : volunteers consenting to participate in the study and those who had a complete acrylic upper denture were included in the study . participants with partial dentures or lower dentures ; those who had used a denture cleanser within the previous 2 weeks ;
participants taking antifungal agents or antiseptic mouthwashes ; those with systemic diseases or conditions making them prone to candida infections and patients with denture stomatitis were excluded from the study . in the denture cleansing tablet group ,
the participants were advised to put the tablet into water and place denture into effervescing solution and leave it in solution for 30 min . in the triphala group , the participants were advised to clean the dentures using triphala churna . in the aloe vera group ,
the participants were provided with a freshly cut piece of the leaf , which was trimmed on the sides , and they were advised to clean the denture using the cut surface . in the cashew leaf group ,
the participants were advised to remove the midrib , and fold the leaf lengthwise with glossy surfaces facing each other , rolled into a cylindrical pack and one end was frayed off 2 - 3 mm to create a raw surface , which was used to clean the denture . in the control group , the subjects were advised to clean their dentures under running tap water using a toothbrush .
swabs for culture were taken from the palatal surface of the upper denture according to a 2  2 cm template collected before and after use of the cleanser .
the swabs were placed in a test tube containing 1 ml sterile distilled water , vortexed for 1 min . then using a 4-mm loop ,
the sample was spread in sabouraud dextrose agar medium , incubated at 37c for 48 h. swabs for culture were taken from the palatal surface of the upper denture according to a 2  2 cm template collected before and after use of the cleanser .
the swabs were placed in a test tube containing 1 ml sterile distilled water , vortexed for 1 min . then using a 4-mm loop ,
the sample was spread in sabouraud dextrose agar medium , incubated at 37c for 48 h. the colonies were identified using : 
 colony morphology : in sabouraud dextrose agar medium , the candidal colonies appear as cream , pasty , and smooth coloniesmicroscopy : in 10% potassium hydroxide mount , the candidal colonies appear oval , budding , and yeast like cellson gram staining : they appear as gram - positive oval yeast like budding cellsurease test : candida gives a negative test on carrying out urease test . 
 
colony morphology : in sabouraud dextrose agar medium , the candidal colonies appear as cream , pasty , and smooth colonies microscopy : in 10% potassium hydroxide mount , the candidal colonies appear oval , budding , and yeast like cells on gram staining : they appear as gram - positive oval yeast like budding cells urease test : candida gives a negative test on carrying out urease test .
numbers of colony forming units were multiplied by the dilution factor to obtain the number of colony forming units/4 cm .
the investigator and the microbiologist were blinded to the allocation of participants to different groups .
the difference in the number of colony forming units of microorganisms between first swab ( baseline before use of cleanser ) and second swab ( after use of cleanser ) was noted to assess the effectiveness of cleansers in reducing the total candida count .
one way analysis of variance ( anova ) followed by tukey 's test were used to compare the reduction of candida count between different denture cleansers .
a difference was considered to be of statistical significance if the p value was < 0.05 .
volunteers consenting to participate in the study and those who had a complete acrylic upper denture were included in the study .
participants with partial dentures or lower dentures ; those who had used a denture cleanser within the previous 2 weeks ; participants taking antifungal agents or antiseptic mouthwashes ; those with systemic diseases or conditions making them prone to candida infections and patients with denture stomatitis were excluded from the study . in the denture cleansing tablet group ,
the participants were advised to put the tablet into water and place denture into effervescing solution and leave it in solution for 30 min . in the triphala group , the participants were advised to clean the dentures using triphala churna . in the aloe vera group ,
the participants were provided with a freshly cut piece of the leaf , which was trimmed on the sides , and they were advised to clean the denture using the cut surface . in the cashew leaf group ,
the participants were advised to remove the midrib , and fold the leaf lengthwise with glossy surfaces facing each other , rolled into a cylindrical pack and one end was frayed off 2 - 3 mm to create a raw surface , which was used to clean the denture . in the control group , the subjects were advised to clean their dentures under running tap water using a toothbrush .
swabs for culture were taken from the palatal surface of the upper denture according to a 2  2 cm template collected before and after use of the cleanser .
the swabs were placed in a test tube containing 1 ml sterile distilled water , vortexed for 1 min . then using a 4-mm loop ,
the sample was spread in sabouraud dextrose agar medium , incubated at 37c for 48 h. swabs for culture were taken from the palatal surface of the upper denture according to a 2  2 cm template collected before and after use of the cleanser .
the swabs were placed in a test tube containing 1 ml sterile distilled water , vortexed for 1 min . then using a 4-mm loop ,
the sample was spread in sabouraud dextrose agar medium , incubated at 37c for 48 h. the colonies were identified using : 
 colony morphology : in sabouraud dextrose agar medium , the candidal colonies appear as cream , pasty , and smooth coloniesmicroscopy : in 10% potassium hydroxide mount , the candidal colonies appear oval , budding , and yeast like cellson gram staining : they appear as gram - positive oval yeast like budding cellsurease test : candida gives a negative test on carrying out urease test . 
 
colony morphology : in sabouraud dextrose agar medium , the candidal colonies appear as cream , pasty , and smooth colonies microscopy : in 10% potassium hydroxide mount , the candidal colonies appear oval , budding , and yeast like cells on gram staining : they appear as gram - positive oval yeast like budding cells urease test : candida gives a negative test on carrying out urease test .
numbers of colony forming units were multiplied by the dilution factor to obtain the number of colony forming units/4 cm .
the investigator and the microbiologist were blinded to the allocation of participants to different groups .
the difference in the number of colony forming units of microorganisms between first swab ( baseline before use of cleanser ) and second swab ( after use of cleanser ) was noted to assess the effectiveness of cleansers in reducing the total candida count .
one way analysis of variance ( anova ) followed by tukey 's test were used to compare the reduction of candida count between different denture cleansers .
a difference was considered to be of statistical significance if the p value was < 0.05 .
a total of 50 volunteers participated in the study out of which 82% were females and 18% were males .
figure 1 shows the mean reduction in candida count obtained after using different denture cleansers .
this value was obtained by calculating the difference in the number of colony forming units of microorganisms between the first swab ( baseline before use of cleanser ) and second swab ( after use of cleanser ) .
graph showing mean reduction in total candida count after using denture cleansers in colony forming units/4 cm the mean reduction in total candida count after using denture cleansing tablet was the highest , followed by triphala , aloe vera , cashew leaves , and water , with a reduction of 319.25  10 cfu/4 cm , 292.5  10 cfu/4 cm , 103.67  10 cfu/4 cm , 68.75  10 cfu/4 cm , 13.75  10 cfu/4 cm , respectively .
table 1 shows the comparison of different denture cleansers analyzed using one way anova followed by tukey 's test , and a  p value of < 0.05 was considered to be statistically significant .
there was no significant difference between the effectiveness of denture cleansing tablet and triphala ( p > 0.05 ) , and a significant difference between triphala and water ( p < 0.05 ) .
there was no significant difference between the effectiveness of aloe vera , water , and cashew leaf ( p > 0.05 ) .
the requirements of ideal denture cleansers are that they should have antibiofilm activity , exhibit bactericidal and fungicidal effects ; should be non - toxic , compatible with denture materials , short acting , easy to use ; should have an acceptable taste ; and should be cost effective .
review of literature suggests that though the antifungal and antimicrobial activity of triphala , aloe vera , and cashew leaves have been established , the potential use of these products as denture cleansers have not been evaluated . in the present study , though all the denture cleansers showed a reduction in total candida count compared with control , only denture cleansing tablet and triphala showed a statistically significant reduction .
triphala , which is an important therapeutic and antimicrobial aid in various ailments , is a combination of three tropical fruits preparation , which has been established as potent antimicrobial and antifungal agents .
the natural products used in the present study were nontoxic , inexpensive , easy to use , and readily available .
more studies are required to evaluate the long - term effects of these natural - based products as denture cleansers .
in the present study , though aloe vera and cashew leaves showed a reduction of total candida count , only denture cleansing tablet and triphala showed a significant reduction in comparison to control ( water ) .
people with less access to oral hygiene measures will be benefitted by the use of these products .
the potential use of such natural products should be further explored to reduce the microbial load and improve the overall oral health of the people .
 with an increase in the number of dependent elderly , there is a need to introduce few natural products for denture cleansing , which are easily and economically available . 
 hence the aim of this study was to compare the anticandidal efficacy of denture cleansing tablet ( sodium bicarbonate and sodium perborate monohydrate ) , triphala ( phyllanthus emblica , terminalia chebula and terminalia belerica fruits powders in equal proportion ) , cashew leaf , aloe vera and water ( control ) on complete dentures of institutionalized elderly . 
 study population consisted of 50 institutionalized elderly of mangalore , karnataka , with 10 in each group . 
 swabs were collected from the dentures before and after the use of denture cleansing tablet , triphala , cashew leaf , aloe vera , and water ( control ) . 
 thereafter , the swabs were cultured on sabouraud dextrose agar and the total candida counts were determined . 
 denture cleansing tablet and triphala churna showed a statistically significant reduction in candida counts ( p < 0.05 ) . 
 denture cleansing tablet and triphala churna were found to be more effective . 
INTRODUCTION
MATERIALS AND METHODS
Inclusion criteria
Exclusion criteria
Statistical analysis
RESULTS
DISCUSSION
CONCLUSION